' Trends in Public Health;

FLORENCE R/SABIN, M.D; F.A-PCHGA.
Chairman, Board of Health, Denver, Colo.

HE chance of a meeting of the

Western Branch of the American
Public Health Association in Denver
gives to a novice in the field the privilege
of paying tribute to one of the most
experienced public health officers: If
I understand John J. Sippy’s contribu-
tion, it was based fundamentally on his
unshakable conyiction of the impor-
tance of preventive medicine to the com-
munity, the state, and the country, a
conviction so strong that: no allure of
important positions could ever draw him
away from the actual practice of public
health in the local area. The result, it
seems to me, is that a spirit survives him
in his state expressing itself in progres-
sive and imaginative work in his chosen
field.

I will use three examples. We are
beginning elsewhere to recognize the
significance of housing to public health
but some years ago the subject was dis-
cussed at a meeting of the Western
Branch in California. Also, just now,
California is taking the leadership in
two nationally important fields, stream
pollution and air pollution. Since a
stream pollution bill failed to pass the
Colorado Legislature in 1950, a new
committee, under the leadership of Wil-
liam McGlone, undertook to make an
entirely fresh start. This committee
first studied intensively all the recent
regional reports and found that the
work of the California Commission and
the successful legislation of that state in
1949 was by far the most helpful to us.

 

"The John J. Sippy Memorial Address, presented

at the meeting of the Western Branch, American
ae Health Association, in Denver, Colo., June,
1952, : . :

The California Commission first clari-
fied the problem by sharp definitions.
They specified. “contamination” to mean
an impairment of the quality of the
waters of the state which creates an
actual hazard to public health; while to
“pollution” they gave the following
comprehensive and significant meaning,
that it includes impairment that ad-
versely and unreasonably affects waters
of domestic, industrial, agricultural,
navigational, recreational, or other bene-
ficial use; while “nuisance” they defined
as a damage to any community by odors
or unsightliness resulting from unreason- |
able practices in the disposal of wastes.

Under the new California laws the
state was divided into nine regions and
a state Water Pollution Board was
established, made up of the directors
of the appropriate governmental agen-
cies plus the directors of the nine re-
gional boards. Of the principles of the
legislation, the codrdination of all agen-
cies for the prevention and control of
pollution of the streams both from
municipal and industrial wastes was of-
first importance. The program involved
decentralization, with a case-by-case
local study of problems of pollution; it
included elimination of the rigidity of
classification and gave to what we might
call the consumer, that is municipalities
and industries, the advantage of a
knowledge of standards of discharge re-
quirements set up for each area after
thorough study. The program stressed .
both a knowledge of industrial water
use as well as the production of. indus-
trial waste; it stressed also the main-
tenance of underground waters ‘as’ well
as the protection of surface waters.

[1267]
1268

In the studies made on stream pollu-
tion by public health groups in states
not highly industrialized the emphasis
has been predominately on sewage dis-
posal. Even with our limited indus-
trialization in Colorado we have learned
the overwhelming significance of this
factor. We have but three large estab-
lished industries in the state involved in
stream pollution; beet sugar processing,
the steel industry, and mining. All three
of these groups have been working
actively with the committee. From the
beet sugar industry we have learned that
their operation, though seasonal, pollutes
the streams for that period more than
the total population of the area. More-
over, the industry is experimenting
effectively on a method of reducing their
pollution potential. Stressing the sig-
nificance of “codperation” (the keystone
of the California laws) it is our belief
that unless health departments work to-
gether with industry on stream pollution
the problem cannot be ameliorated.

Concerning air pollution, my informa-
tion comes from an article in a popular
science journal, one that we could not
well spare, namely the Scientific Amer-
ican. In the May, 1952, issue the first
article is on smog, telling of experiments
going on in Los Angeles. Here indeed
is an example of a major problem which
industrialization has brought to us. The
burning of fuels, even when they are
liquid and gaseous, discharges into the
air all sorts of organic gases and
vapors—methane, acetylene, aldehydes,
phenols, ketones, ammonia, and alcohols.
In Los Angeles some two million auto-
mobiles, buses, and trucks burn every
day nearly four million gallons of gaso-
line and oil releasing nearly four billion
cubic feet of exhaust. In addition to
this there are vast outpourings from
many types of industrial processing
plants. Moreover the wind is seldom
strong enough to dissipate this polluted
air. Los Angeles, with the aid of chem-
ists from Stanford University, has

AMERICAN JOURNAL OF PuBLIc HEALTH

Oct., 1952

formulated research to seek the sub-
stance in the air responsible for irrita-
tion of eyes, whether it is any one of
these primary substances released to the
air or some entirely new compound
synthesized out of them in the air. Does
one need a better example of imagina-
tive work in public health?

This page was written before the
May issue of the American Journal of
Public Health appeared with the very
important paper on ‘Medical Research
and Control in Air Pollution” by Gor-
don P. Larson, Director, Air Pollution
Control District, County of Los Angeles.
Here is the report of three and one-half
years of intensive study of this problem.
He reported that their group of scien-
tists have found that the present known
results of smog—reduced visibility, eye
and throat irritation, damage to crops,
and nuisance problems—arise from more
than fifty different substances released
into the air. They have found some of
these chemical compounds and have de-
veloped microchemical technics for de-
termining the concentration of many of
them. They give a most interesting
appraisal of the feasible goals of such
a study and, although the work is just
beginning, they have definite practical
results indicating that an industrialized
nation is already deeply in debt to the
California research workers on_ this
problem.

Turning to the old established public
health practices, let us consider the con-
quering of the infectious diseases of
childhood, at least so far accomplished
that the lengthened span of life now
opens up to us the problems of chronic
disease. As we come face to face with
this problem, may it not be well to con-
sider carefully all the forces that have
brought us so far in dealing with the
acute infectious diseases. As the cornet-
stone of the subject, let us ask, how
much has it been a codperative adven-
ture? Of overwhelming importance, the
foundation on which everything else
yal. 42

as research. ‘The discovery of
-, as the cause of infectious
hacteria

“ease, by Pasteur and Koch, opened
nh era of modern medicine by in-
up! ne the idea of “cause” of disease.
tro dy of what research accom-
ened is too well known to need more
than passing mention—first, through
the development of that most fascinat-
ing of biological sciences, immunology,
and second, through what I shall call
methods for “bypassing disease” through
all phases of sanitation. An interesting
example is the final conquering of yellow
fever. first through this method of “by-

sing” by eliminating the specific
mosquito and finally by the discovery of
the cause of the disease in the yellow
fever virus, and then by the application
of successful appropriate immunological
methods. When one considers research,
medical schools and research institutes
become the basic elements in the co-
operative endeavor. There the research
is catried on and students are trained
in medicine both for research and in the
spirit of research; new discoveries are
made and their application thoroughly
tested. .

In the practical application of knowl-
edge two forces have carried the load—
the public health service with its em-
phasis on prevention and the practising
physicians. I want to stress especially
two groups of clinicians—the obstetri-
cians who instituted prenatal care 35
years ago with outstanding results for
Prevention, and the remarkable work of
the pediatricians. They have carried
preventive measures effectively into the
Practice of medicine. Pediatricians have
So stressed the concept of prevention,
that working from the knowledge of im-
Mmunization and from what is known
concerning growth, 54 per cent of their
time is spent on well child care. They
are, of course, a relatively small group,
located for the most part in cities, but
their influence has been immense. In
Reneral, physicians in private practice

rested w

TRENDS IN PuBLic HEALTH

1269

carry from 80 to 85 per cent of the care
of children while the public health serv-
ices care for the rest. The public health
services do more than care for immuni-

zations and well baby clinics for the

indigent group since they are responsible
for the prevention of epidemics for the
entire community. They keep the
records, analyze the vital statistics, and
stand in a position of leadership to the
practising physicians by constantly in-
forming them of the status of each
disease. In the present state of world
tension every health department and, ©
indeed, every physician must be alert
to detect any unusual occurrence of in-
fectious disease, and for the health de-
partments this includes diseases of both
animals and plants which affect the food
supply, since it is clear that health is
one of the prime factors in the strength
of the nation.

The full realization that the conquer-
ing of infectious disease has been a co-
operative endeavor should make us
aware of the great importance of lessen- -
ing tensions between medical schools,
the organized health services, and the
practising physicians. The entire medi-
cal profession should work as a codrdi-
nated whole each recognizing the share
of the load carried by the others. In
the program for health for the last
seventy years, including the first half of
this century, more than the medical pro-
fession has been involved; indeed we
must include all the ancillary medical
services plus the specific lay and medical
organizations such as the National Tu-
berculosis Association which have con-
cerned themselves with educating the
public about disease.

With these points in mind, including
both the importance and the extent of
codperation, we turn to the subject of
chronic disease. In 1946 four national
organizations, the American Hospital
Association, the American Medical
Association, the American Public Health
Association, and the American Public
1270

Welfare Association undertook a con-
certed attack on chronic disease and
formulated their problem in saying “It
is now conservatively estimated that
about 25 million persons, more than one-
sixth of the population, have a chronic
_ disease” (J.A.M.A. 135:343-347, 1947).
Then in 1948 at a National Health
Assembly held in Washington it was
determined to form a permanent Com-
mission on Chronic Illness which held
its first meeting in Chicago in 1949
under the chairmanship of Leonard W.
Mayo. The report of this first meeting
is a document of basic importance.
Here, as with the acute infections,
_ the foundation has to be research, the
foundation that will open up the subject
of “cause.” This is a problem for the
last half of our century. For instance,
in the case of cancer, we still do not
"have enough knowledge of the normal
physiology of the cell, of the normal
processes of growth and many other fac-
tors to set the stage for research in
cancer and yet what fascinating progress
has already been made in the whole field
of general biology with bearings on the
cancer problem.

Certain practical results of present
studies are interesting. For example,
very early in the work of the American
Cancer Society emerged the idea of the
importance of early diagnosis with the
development of cancer prevention
clinics. The significance of this,’ you
will remember, was recognized at the
meeting of the American Public Health
Association in San Francisco in 1951. It
is interesting that with all the work on
tuberculosis it is only recently that very
early cases have been seen, due of
course, to the mass x-ray surveys and
the studies on nurses. As I remember it,
in the early days when we had only a
stethoscope and the finding of tubercule
_ bacilli for diagnosis, we never thought
of early cases.

It seems to me of great significance
that a meeting in 1951, sponsored by.

AMERICAN JOURNAL oF PuBLic HEALTH _ Oct., 1952

the Commission on Chronic Disease and
cosponsored by the U. S. Public Health
Service and the National Health Council
was on “Steps Toward Prevention of
Chronic Disease.” The opening sen-
tence of their report was “Can early
detection .of chronic illness and other
preventive measures match the success
achieved in controlling acute communi-
cable disease?” The group decided to
study only a limited number of diseases
—arthritis and rheumatism, blindness,
cancer and other malignant growths,
deafness, diabetes, diseases of the heart
and circulation, syphilis, tuberculosis,
and diseases of the nervous system,
especially poliomyelitis, multiple sclero-
sis, cerebral palsy and epilepsy. In
connection with chronic disease, they
stressed that certain factors are known
or believed to be important to cause and
control, namely, nutrition, heredity,
emotional factors, and occupational fac-
tors. They defined primary prevention,
which we have called “bypassing a
disease,” as keeping it from occurring
and illustrated the prevention of con-
genital syphilis by adequate treatment
of an infected mother during pregnancy.
Secondary prevention they defined as
halting the progression of disease after
early diagnosis. ,

It is clear that taking only the lim-
ited list of chronic diseases given above,
much research is already under way. We
may stress the extensive work on can-
cer, the new advances in the study of
arthritis and rheumatism, the outstand-
ing progress in Surgery of the heart both
for congenital and acquired defects, and
on diseases of the nervous system. !
want to call to your attention especially
some studies made in the Department of
Obstetrics and Gynecology of the Uni-
versity of Colorado School of Medicine
by Drs. E. Stewart Taylor, Clifton D.
Govan, and William C. Scott on oxygen
saturation of the blood of the new-born
as affected by maternal anesthetic
agents.12 They recognized that if gen-
Vol. 42

eral anesthetics are used in normal full-
term uncomplicated deliveries for no
jonger than from ten to twelve minutes
at the termination of the second stage
they will probably not increase fetal
mortality or morbidity. Nevertheless
they found that a significantly higher
percentage of the infants reached satura-
tions of oxygen above 90 per cent at one
hour when regional anesthesia was used
than when the general anesthetics were
used, and that since maternal general
anesthesia, given for relatively short
periods at the termination of the second
stage of labor, tends to prevent the early
attainment of normal blood oxygen
saturation levels in a significant propor-
tion of new-born infants, prolonged gen-
eral anesthesia for delivery should be
avoided. This is the kind of research
that seems to me to lay a foundation for
studies of prevention in connection with
injuries to the new-born.

As fast as preventive measures be-
come established, departments of public
health must make sure that they are
used. For example, does every depart-

‘Trenps IN Pusiic HEALTH

1271

ment of public health, in codperation
with the National Society for the Pre-
vention of Blindness, see that every
industry in its territory involving
danger to the eyes uses known preven-
tive measures?
_ Probably the most frightening of all
of our problems of chronic disease is
that of mental illness—frightening be-
cause of increasing numbers and the
element of weakness which it means to
the nation. Here, if we know little of
prevention, it is the responsibility of
each community to make sure that only
those patients for whom we have as yet
no adequate methods of treatment are
consigned to custodial care.

These are some of the problems of
this half century; many of you will see
them far advanced.

REFERENCES

1. Taylor, E. Stewart, Govan, Clifton D., and Scott,
William C. Oxygen Saturation of the Blood of the
New-born as Affected by Maternal Anesthetic Agents.
Am. J. Obst. & Gynec. 61:840, 1951.

. Studies of Blood Oxygen Saturation and

Causes of Death in Premature Infants. Jbid. 62:

764, 1952.

2.