Child Health Services in Florida Report of The Florida State Pediatric Association Study of Child Health Services Made with the cooperation of the Florida State Board of Health Published by The Florida State Board of Health .Florida Study of Child Health Services State Chairman: President, 1944-45: George L. Cook, M.D. Executive Secretary; Stella Lackey STATE STUDY COMMITTEE James R. Boulware, Jr., M.D. Margaret Bristol Hugh A. Carithers, M.D. Sylvia Carothers George L. Cook, M.D. Bryant S. Carroll, D.D.S. Banks H. Goodale, M.D. L. J. Graves, M.D. Luther W. Holloway, M.D Marion T. Jeffries Wilson T. Sowder, M.D., M.P.H American Academy of Pediatrics Nation-Wide Study of Child Health Services Made with the cooperation of the U. S. Children’s Bureau and the U. S. Public Health Service COMMITTEE FOR THE STUDY Warren R. Sisson, M.D., Chairma. Allan M. Butler, M.D. Harvey F. Garrison, M.D, Henry Helmholz, M.D. Lee Forrest Hill, M.D. Joseph I. Linde, M.D. Arthur H. London, Jr,, M.D, Joseph S. Wall, M.D. James L. Wilson, M.D. John P. Hubbard, Director ADVISORY COMMITTEE Joseph S. Wall, M.D., American Academy of Pediatrics Martha M. Eliot, M.D,, U. S. Children’s Bureau George St. J. Perrott, U. S. Public Health Service CONTENTS Chapter page I. INTRODUCTION 1 II. TOTAL VOLUME OF CHILD HEALTH SERVICES A. Medical care 4 B. Dental care 5 HI. HEALTH SUPERVISION 5 IV. PRIVATE PRACTICE A. Physicians Number, type and training 6 Services 8 B. Dentists Number, type and training 10 Services 10 V. COMMUNITY HEALTH SERVICES A. Medical well child clinics 12 B. Mental hygiene services . 13 C, Services for the physically handicapped 13 D. Public health nursing services 15 E. School health services 16 F. Communicable disease control 16 G. Dental services 17 VI. HOSPITAL FACILITIES AND SERVICES A. General hospitals 17 B. Special hospitals admitting children . 20 C. Outpatient services for children 20 VII. CONCLUSIONS AND RECOMMENDATIONS 20 APPENDIX TABLES : 26-31 personnel, without which it is probable data could not have been gathered. Contributions from the county chapters of the National Foundation for Infantile Paralysis paid most of the other expenses. Acknowledgment with gratitude is made to the chairmen of the many chapters and especially to Mr. Ma- rion T. Jeffries, state representative of the National Foundation for Infantile Paralysis. Thanks are also given the Florida State Tu- berculosis Association and Mrs. May Pyn- chon, its executive secretary. Appreciation is expressed for the aid given by the Florida Medical Association, the Florida State Den- tal Society, the Florida State Hospital Asso- ciation, the State Department of Education, state and local welfare agencies, parent- teacher organizations, the Florida Crippled Children’s Commission and other organiza- tions which assisted in verifying, clarifying and supplementing data from localities. The Florida Pediatric Association expresses ap- preciation for the part the Florida Children’s Commission has taken in respect to recom- mendations suggested for the improvement of child health services in Florida. The plans the commission is inaugurating to activate the recommendations by bringing this report to the people on the local level are of inestim- able value. In the fall of 1944, the American Academy of Pediatrics undertook a far reaching proj- ect based on the conviction that physicians themselves should assume greater responsi- bility in planning medical care for children.1 The stated objective was: “To make avail- able to all mothers and children of the United States all essential preventive, diagnostic and curative medical services of high quality which, used in cooperation with other services for children, will make this coun- try an ideal place for children to grow into responsible citizens.” FOREWORD To achieve such an objective, more com- plete information as to existing facilities was necessary in order to devise the most effec- tive plans. To obtain this complete picture, a nationwide study of child health services was undertaken on a national, state and local level. The U. S. Public Health Service and the U. S. Children’s Bureau cooperated.- The Florida Pediatric Association was one of the first groups to get its study underway. This report summarizes the results of the survey in Florida. The Florida State Pediatric Association expresses thanks to the State Board of Health, especially to Dr. Wilson T. Sowder, the State Health Officer, and to Dr. Lucille J. Marsh, formerly director of the Bureau of Maternal and Child Health. They made pos- sible office space, equipment and the loan of Particular attention is directed to the fact that the central office staff of the Academy study prepared the schedules, outlined pro- cedures for conducting the work, maintained consistent supervision and tabulated all data for the study. The Florida Pediatric Asso- ciation thanks Dr. Warren R. Sisson and the Academy Committee for the study of which he is chairman, Dr. John P. Hubbard, direc- tor of the study, the U. S. Public Health Serv- ice and the U. S. Children’s Bureau for their invaluable assistance. 1. Journal of Pediatrics 25:625 (Dec.) 1944 2. At the national level the U. S. Children’s Bureau and the TJ. S. Public Health Service contributed the full time services of medical and statistical personnel, office space and equipment. The study has been financed from the limited reserve fund of the Academy, with generous finan- cial contributions from the National Foundation for In- fantile Paralysis, the National Institute of Health (Re- search Grant), the Field Foundation and a number of commercial firms. George L. Cook, M.D. FIG. I. COUNTY GROUPS IN FLORIDA Distribution of schedules to physicians, dentists and community health agencies was begun in June 1946. A few pediatricians who started practice after the first distribution of schedules reported for a later month. Hospital and community health service records covered a full year. Pediatricians re- ported for a twenty-eight day period. A one day record was requested from each general practitioner and specialist, other than pedia- tricians, in private practice, one-seventh of the practitioners reporting for each of the days of the week. For nonreporting prac- titioners, adjustment was made on the basis of a special study. Hence, unless otherwise indicated, the figures represent service for all physicians in specified areas. Since this was a national as well as a state study, duplication of data had to be avoid- ed.5 The lists of physicians and dentists in private practice in Florida were made up of the names of those who were residents of the state in the spring and summer of 1946. Because this is a study of child health services, the estimate of child wras used as a basis of comparison, rather than the entire population (Appendix-A) .7 This study was not intended to include an analysis of the quality of medical services rendered children. It is hoped that interested people of local areas will determine, to as great an extent as possible, the quality of health services given. It is probable that the frequency data will imply better conditions than actually exist. Figures alone cannot tell the story. Chapter I—INTRODUCTION The factual material for the study of exist- ing facilities for medical child health services was obtained through four major sources: (1) physicians, (2) dentists, (3) voluntary and official health agencies, and (4) all hos- pitals admitting children and maternity cases.3 Eighteen different types of schedules were prepared by the central staff of the Academy study for distribution in each of the forty- eight states. Some schedules could be mailed, but others required field visits to obtain need- ed information. In order to insure as com- plete a response to the schedules as possible, a campaign of publicity was begun one month preceding distribution. This was carried out first through meetings with different state organizations, namely, the Florida Medical Association, the Florida Hospital Associa- tion, groups of officers of public health units and chairmen of county chapters of the Na- tional Foundation for Infantile Paralysis; the second, by local meetings with dental and medical societies. The purpose and scope of the questions were presented to these groups. Since some pediatricians did not attend the state meetings and because others did not start practicing until later in the summer, the executive secretary made field trips to inter- view them, acquainting each with the facts of the study as well as enlisting their help in getting complete data. The planning of better medical or health services for children should be made by those most interested and closest to the problem. It was decided that in all localities where they were available, pediatricians should as- sume the responsibility of collecting special data and of enlisting the cooperation of phy- sicians, dentists and community agencies. In many areas there was no pediatrician. In these localities the assistance of the many general practitioners who evince special in- terest in children was obtained. Much of the credit for the excellent response to the in- quiries is therefore due the pediatricians and general practitioners who devoted time and energy to the completion of data from their respective localities.4 The State Board of Health appointed one full time worker for the collection of data from the hospitals. Comparison with Other States The data for all states had not been com- pleted at the time this report was prepared. A fairly representative group of states was therefore selected for use as a basis of com- parison. The academy staff conducting the study 5. Inasmuch as the study in Florida was being conducted simultaneously with a national study, out-of-state physi- cians who practiced a few of the winter months in Flor- ida were counted in the states of which they were resi- dents. 6. In this report “children”, unless otherwise qualified, refers to persons under 15 years of age, including the newborn. 7. Population under 5 years of age, as of July 1, 1945, was estimated for each county on the basis of the number of births for each of the five calendar years 1940 through 1944. Survival rates for each year of age were applied to the number of births occurring in each of the years. The figures obtained by the application of survival rates to the births occurring in each of the five years 1940 through 1944 were added for each county, and these totals were corrected for underregistration of births. The num- ber of children aged 5 through 14 years was estimated for each county on the basis of changes in school enrollment since 1940. The ratio of elementary public day school en- rollment as of June 1945 to that of June 1940 was used to project to 1945 the 1940 census population in this age group. In both cases the figures for all states were adjusted to tally with the estimated population of the entire United States for the specific age group for July 1, 1945. 3. In order to produce a report brief enough for practical use in the state, a large mass of data collected in the course of the study has necessarily been referred to only briefly or omitted entirely. 4. Ninety-five per cent of the pediatricians each reported data for a twenty-eight day period. Seventy-three per cent of other physicians in private practice responded. Sixty-one per cent of the dentists in private practice responded. 1 explains : “In the selection, an attempt has been made to obtain an approximate sample of the whole country based upon such consid- erations as geographic location, size of State, per capita income, population distribution between metropolitan and rural counties, and the relative number of available physicians, dentists and hospital beds. Although this group of States may be said to represent ‘a little United States,’ it is not a true sample in the strict sense of the word because the selection was conditioned by the necessity of having to exclude States that had not yet finished collecting their data at the time the sample was chosen. The States selected are: Oregon, Montana, New Mexico, Illinois, Alabama, North Caro- lina, New Hampshire, and a new ‘State’ which has been ‘admitted to the Union’ for this pur- pose, composed of Maryland, the District of Columbia, and two counties of Virginia. 8 These eight selected States contain about five and one-half million children or approxi- mately 15 per cent of the Nation’s children,” Comparisons in some cases are made with the eight selected states individually and in other instances with the highest, lowest and average values for a particular item among these selected states. It is well to empha- size that the highest record attained by any state does not necessarily set a standard for adequate care. It rather indicates what has been accomplished under favorable condi- tions. Comparison Within Florida Distribution of medical services for chil- dren in Florida reveals glaring inequalities. The fact that some of the counties have low health care rates within their borders does not always mean the services are not avail- able. Metropolitan areas or counties con- taining fair-sized cities often become medi- cal centers for a larger area than the imme- diate county. Hospital and physicians’ serv- ices of these densely populated counties may provide some needed care for children from other counties. This fact reduces the in- equalities which county tables indicate. This being true, instead of studying services by counties individually, grouping of counties as to their location near or isolated from medi- 8. This new “State” was devised primarily for presenting hospital data, since facilities in the District of Columbia serve surrounding counties. FIG. 2. pep; capita effective, buying powep, e>Y STATE. 2 cal centers has been used. Under this group- ing, metropolitan counties are those which include the metropolitan districts of 50,000 or more population. Counties contiguous to the metropolitan counties are classified as adjacent. Other counties are classified as isolated and are subdivided into those with an incorporated place of 2,500 or more popula- tion (semirural) and those without such a place (rural).9 The Economic and Health Setting of the Child The economic standing of an area deter- mines to a great degree the medical facilities of that region. The Florida per capita in- come of $974 in 1946 is exceeded by thirty- three states.10 Figure 2 shows the per cap- ita buying power of the states. Comparison of figures 1 and 7 reveal the high correlation between the economic status of and the health services provided in the counties of Florida. Figure 7 does not indi- cate the number of health services received by children in other than their home coun- ties. As mentioned in a foregoing paragraph, children of outlying counties receive rela- tively better care than data for an individual county indicates. Children under fifteen years of age com- prise about 25 per cent of the total popula- tion of Florida. The ratio of child popula- tion to total population is lower in this state than in twenty-four other states. About 51 per cent of the children live in isolated (semi- rural and rural) counties. The age-adjusted death rate for Florida in 1940 was 12.3 per 1,000 population J1. This rate is higher than the rates in thirty-eight of the other states. During the five-year period 1941-1945, an average of 47 out of 1,000 children born alive in Florida died during the first year of life. Average infant mortality for the United States in the same period stood at 40.7 per 1,000 live births. In comparison with other states Florida ranked thirty-third in infant mortality during the 1941-1945 period. Fig- ure 3 shows the trend of infant mortality rates for Florida compared with that of the RECORDED MATERNAL DEATH RATES, US. AND FLORIDA 1917-1947 RECORDED INPANT DEATH RATES U.S.AND FLORIDA 1917-1947 Fig-. 3 Trend of Infant and Maternal Mortality United States and Florida 1917-1947 United States for the period 1917-1947. Con- sistent improvement has occurred from 105.9 in 1917 to 37.0 per 1,000 live births in 1947. The maternal mortality rate has also shown much improvement. Figure 3 shows that Florida maternal death rate has dropped from 11.6 in 1917 to 2.1 per 1,000 live births in 1947. During the five-year period 1941 1945, there was an average of 3.9 maternal deaths per 1,000 live births in Florida, as com- pared with a maternal mortality rate of 2.5 for the United States in the same period. Only two other states had higher maternal death rates for those five years. During 1945, 70 per cent of the births oc- curred in hospitals, giving Florida thirty- second place in the country and sixth place in comparison with the eight selected states. Metropolitan counties have a much higher rate of births in hospitals than do the other counties. In metropolitan counties 85 per cent of the births were in hospitals, in adjacent 9. For a more detailed description of the classification by county group, see Hubbard, John P.: Pennell, Maryland Y.; and Britten, Rollo H.: Health Services for the Rural Child—Availability of Hospitals, Physicians, and Dentists in Service Areas. Submitted for publication in the Journal of the American Medical Association. 10. Calculated from estimates of income made by Sales Management for 1944-46. Sales Management, Vol. 54, No. 10, May 15, 1945 and corresponding issues 1946 and 1947. Copyright 1947, Sales Management, Inc.; further reproduc- tion not licensed. 11. The rates were adjusted to the age composition of the entire country. Data for 1940 are used since that is the last year for which population data by age are available. 3 counties 65 per cent, in isolated semiiuial counties 63 per cent and in isolated rural counties 43 per cent. The rate of births of nonwhite babies born in hospitals in 1945 was about 32 per cent of the rate of white babies born in hospitals. This ratio has steadily increased through the years. It is interesting to note the compari- son in the rate of increase in the number of white and nonwhite babies born in hospitals for the decade of 1935-1945. In 1945 the rate of hospitalized births of white children was 21/2 times what it was in 1935. The rate of hospitalized nonwhite births was slightly more than 4 times what it was in 1935. At this point it is logical to consider how Florida ranks in other studies. In one study, after evaluation of many factors as to health and sanitation, Florida places thirty-third in comparison with other states.12 Chapter II—TOTAL VOLUME OF CHILD HEALTH SERVICES A. MEDICAL CARE No exact standard has yet been set up to meet the actual need for medical care exist- ing in the nation. Much more care is un- doubtedly needed than has yet been provided in any area. Nevertheless, for the purpose of this study, it is appropriate to consider some standard of attainment. A composite picture of the total volume of medical care has been developed through the study. Phases of the study which make up the picture are based on both visits and hospital days13 rendered to children: (a) in private practice (home and office) ; (b) in clinics14 and (c) in hospitals.15 Using this picture in relation to the number of children in the state, one can determine the number who are actually under medical care for one day. A method was devised to determine the number of chil- dren under medical care for an average day in Florida. A one day period in a hospital was given the same weight as a visit to a physician or clinic. This form of evaluation may minimize the true worth of hospital care. Comparison with the eight selected states is made to measure differences between high- Fig. 4. Total Volume of Medical Care for Children on One Day per 1,000 Children in Florida—Com- parison with Eight Selected States est, lowest and average attainments. Comparing the record of the state of Flor- ida with the highest record among the eight selected states 16 may indicate, to some ex- tent, what improvement could be made. Chil- dren of Florida receive 35 per cent less care, as defined in the foregoing paragraph, than children of the state with the highest record. Figure 4 shows the highest, average and low- est record in comparison with the record of Florida. Florida ranks below the average of the eight selected states in all phases of the study, private practice, clinics and hospi- tals.17 When one considers that the average includes some very low rates of accomplish- ment, it is evident that there is great room for improvement. Since, as mentioned previously, all children of any county are not always dependent upon the facilities within the respective county for health care, a composite picture of the two large groups of counties is presented. Metro- politan and adjacent counties combine to form 12. Hirschfeld, G., and Strow, C. W.. Comparative Health Factors Among the States, Am. Soc. Rev. 11:42 (Feb.) 1946. 13. Since for this purpose, equal weight is given to a physi- cian’s visit, a clinic visit and a day of hospital care, it may he felt that the importance of hospital care has been underestimated in the figures for total volume. 14. Outpatient departments, medical well child clinics, mental hygiene clinics and community health services for crippled children. 15. Days of care in institutions for the feeble-minded excluded. 16. See Chapter I, Introduction, for description of these eight states. 17. The assumption is made that the need for medical cape in terms bf service per 1,000 children is the same in dif- ferent parts of the state and in the individual states with which comparison is made. 4 one group and semirural and rural counties combine to make the isolated group. In metropolitan-adjacent counties the ratio is 12.5 visits per 1,000 children, while in iso- lated counties 9.4 visits per 1,000 is shown.18 Children of isolated counties receive 25 per cent less care than those of the metropolitan- adjacent group. The analysis of services in each group is given in Table 1. TABLE 2. NUMBER OF CHILDREN UNDER DENTAL CARE PER 1,000 CHILDREN ON ONE DAY COMPARISON WITH EIGHT SELECTED STATES Private Dental Total practice clinics Florida 2.2 2.1 0.08 Eight states Highest 5.3 5.2 0.28 Average 3.1 3.0 0.12 Lowest 0.9 0.9 0.01 TABLE 1. NUMBER OF VISITS PER CHILDREN ON ONE DAY 1,000 County group Total children under medical care Visited by physi- cians(a) Visiting clinics In hospitals Metropolitan- adjacent 12.5 10,4 0.5 1.94 Isolated 9.4 7.9 0.18 1.34 (a) Office and home. parison of Florida rates per 1,000 with those made in the selected states. Children of outlying counties in Florida had but 54 per cent of the amount of clinical dental service provided in the metropolitan coujities. Summary 1. Florida provided only about two-fifths the amount of dental care for children as did the highest of the selected states. 2. Clinic dental services cared for so few children that it is evident that many children have no dental care, either in private prac- tice or in clinics. Included in Table 1 is the number of chil- dren who were attended for health super- vision by physicians or within clinics.19 Of the total number (exclusive of the newborn) under medical care, 23 per cent are for health supervision of well children. Additional in- formation regarding health supervision will be discussed in following chapters. Chapter III—HEALTH SUPERVISION 20 Parents are becoming more keenly alert to the need of consistent health supervision of their children. This changing attitude has been due in great part to the combined ef- forts of the medical profession and public and private agencies, with the assistance of press, radio and school. They are learning that no child should “just grow,” as did Topsy. Too many of the conditions of child- hood determine the sort of adults the chil- dren will become for parents to ignore them. Feeding and care, hygiene habits, emotional and social adjustments are all phases of growing up which should be supervised. It is well, then, to observe the rate of health supervision provided today. Of the total number of visits to children for health supervision in Florida made by private practitioners, general practitioners care for 61 per cent, pediatricians care for 33 per cent and other specialists care for 6 per cent. Considering the ratio of well child visits to the total child visits for each type of practitioner, general practitioners devote 23 per cent of their practice among children to the well child;21 pediatricians devote 50 per cent of their practice to the well child; other specialists report 9 per cent of the children they care for are well children. Com- parison of the percentage of practice among Summary Comparison with eight selected states is made to measure the difference between the highest, lowest and average records attained. 1. In spite of the fact that even the high- est attained record of the eight selected states does not reflect the entire medical and health need, Florida is deficient, compared with the highest record of these states. 2. Children of metropolitan-adjacent coun- ties receive considerably more care than those of outlying counties. 3. About one-fourth of the medical care is for health supervision of well children. B. DENTAL CARE There were 2 children per 1,000 children in Florida who were under dental care on an average day. The study of the eight selected states showed a wide range in the number under dental care per day, with 5.3 per 1,000 in the highest to less than 1 per 1,000 in the lowest state. The study revealed that less than 4 per cent of the total volume of dental care was given in dental clinics. Table 2 shows the com- 18. In comparison by county group, data for special hospitals and for mental hygiene and physically handicapped serv- ices are excluded. 19. Hospital care, a part of total volume, was excluded from well child care. 20. The term “health supervision” refers to supervision of well children. 21. Including the newborn. 5 children devoted to the well child in Florida and the eight selected states is given in Table 3. TABLE L HEALTH SUPERVISION GROUP BY COUNTY Number of children Ratio of rate in Florida per 1,000 children metropolitan counties under 5 years of age counties Metropolitan 5.39 — Adjacent 5.31 .99 Isolated semi- rural 3.86 .72 Isolated 2.28 .42 TABLE 3. PER CENT OF TOTAL VISITS TO CHILDREN Visits Eight selected states made by: Florida Highest Average Lowest General practitioners 23 33 26 19 Pediatricians 50 61 54 33 of health supervision given through well child clinics as indicated in figure 5. Comparison relating to the amount of health supervision by county group is given in Table 4. Children of outlying counties re- ceived less than one-half as much well child supervision as children in metropolitan coun- ties. As mentioned previously, private and pub- lic health agencies also contribute toward the supervision of the well child. Health clinics for infants and young children have been con- ducted by them at community health centers. Data as to the combined practice of physi- cians and health centers are discussed in the following paragraphs. Most of the well child cinics care for children from 1 month to 5 years of age. The following comparisons are limited to those ages. As shown in figure 5, about 4 out of 1,000 children under 5 years of age2- in Florida are under health supervision on one day. This is about 55 per cent of what has been attained in the highest of the eight selected states. Attention is directed to the small proportion Summary 1. About three-fifths of the health super- vision by private physicians is done by gen- eral practitioners. 2. There is a wide difference in the per- centage of practice devoted to well child su- pervision, in that general practitioners re- ported 23 per cent of their practice with chil- dren is for the well child; pediatricians re- ported 50 per cent; other specialists reported 9 per cent. 3. The rate of number of children 1 month to 5 years of age seen for health supervision in Florida is about one-half the rate in the highest selected state. 4. The lowest rate of health supervision in Florida is in isolated counties. Chapter IV—PRIVATE PRACTICE A. PHYSICIANS Number, Type and Training In the summer of 1946, there were 1,412 physicians in private practice in Florida. HIGHEST AVERAGE FLORIDA LOWEST Fig. 5. Children Receiving Health Supervision on One Day per 1,000 Children in Florida—Comparison with Eight Selected States 22. Because of the age groups in Census data the estimated population under 5 years of age is used in calculating rates. Fig. 6. Number of Children per Physician in Priv ate Practice in Florida and Eight Selected States 6 FIG. 7. COMPOSITE PICTURE OF CHILD WEALTH SERVICES IN FLORIDA. Physicians devoting full time to public health, institutional work, industrial practice and re- search were not counted as being in private practice. Physicians listed in private prac- tice in other states and spending but a few months in Florida were not included in the count of private practitioners in this state. Because the purpose of this study is to learn more about the facilities for child health services, the count of children rather than the total population has been used in differ- ent ratios. There were 395 children per phy- sician in the state at the time of the study. In comparison with the eight selected states, three of the states rank lower than Florida. The average of these sample states was 338 children per physician and the state ranking highest had 219 children per physician. Fig- ure 6 shows the position of each of the se- lected states and Florida with respect to this ratio. In Florida, the best record is in one county with 196 children per physician. Four of the Florida counties had no physician. In only seven counties was the ratio better than the average of the eight selected states. In seventeen counties the ratio was more than 1,000 children per physician. A high corre- lation between the economic status of a coun- ty and the rate of physician-child ratio can be observed in figure 7. Table 5 indicates both the actual number of physicians and the child-physician ratio by county group. No accurate count of the number of physi- cians in private practice today, 1948, is avail- 7 TABLE 5. NUMBER OF PHYSICIANS AND CHILD-PHYSICIAN RATIOS BY COUNTY GROUP Number of Actual number Florida children per of counties physician physicians Metropolitan 276 735 Adjacent 470 148 Isolated semi- rural 474 474 Isolated rural 1,111 55 TABLE FLORIDA 13 ing this special type of clinic. There are now six schools operating in the state especially designed for the education and treatment of these exceptional children. These schools have physical therapists who provide needed treatment under medical supervision. Three of the schools have monthly clinics conducted by orthopedic and pediatric physicians. The association is also interested in setting up speech clinics for deaf children and others who have speech defects. Such plans are handicapped by the lack of trained personnel to teach speech correction. Services for the Blind No clinics were held for the visually handicapped children. The Florida Council for the Blind assisted in locating children with poor vision and urged that they consult an ophthalmologist. Towns, villages and counties reported that in some cases check-ups and examinations could be arranged at the State School for the Blind. They also reported that service clubs frequently paid for examinations by private practitioners, and for glasses needed. No concerted, well integrated program for visu- ally handicapped children had been developed in Florida at the time of the study. Rate cf Service.—A comparison of special services is given in figure 13 with ratios of the selected states. The number of visits to clinics per 1,000 children is given to indicate the contrast between the highest and lowest attained records. Fig. 11. Rate of Service in Medical Well-Child Con- ferences in Florida (visits per 1,000 Children Under 5 Years)—Comparison with Eight Selected States gram through the employment of needed medical and other personnel. Before a child may receive treatment through this service, his parents or guardian must have been declared medically indigent by a juvenile court.29 The professional staff for crippled chil- dren’s clinics is composed of a pediatrician, an orthopedic surgeon, a physiotherapist and nurses. An auxiliary staff of lay persons as- sist at these clinics. A nursing group of five experts follow up cases in their respective areas, see that children receive necessary treatments through clinical, hospital or phys- iotherapy care. There were 264 sessions held in the state in 1945. The average number of visits per child attending the clinics was 2.5 per year. Sessions were held in thirty- three counties, to which children from nearby counties could be transported. Figure 12 shows the location of clinics held in 1945. Some services have been rendered the chil- dren having cerebral palsy. A school in Broward County has for a number of years had facilities for the education and treat- ment of such patients. The Florida Association for Crippled Chil- dren and Adults, Incorporated, has been ac- tive in promoting programs for the care of children suffering from cerebral palsy. They have assisted in setting up clinics and schools to improve the care for such handicapped children. In 1945 two counties reported hav- 29. Before children may receive treatment from the commis- sion, the juvenile court must, upon petition and after full investigation, certify to the commission that the parents or guardian of such children are financially unable to provide for such care and treatment. Fig. 13. Rates for specified community health services (visits per 1,000 children per year) —Com- parison with Eight Selected States 14 FI G. 12. LOCATION OF CLINICS PROVIDING SERVICES FOR CRIPPLED CHILDREN IN FLORIDA TABLE 16. NUMBER OF CHILDREN PER PUBLIC HEALTH NURSE, COMPARISON WITH EIGHT STATES Florida 2,699 Eigdit states Highest 1,300 Average 2,600 Lowest 5,000 habits. The general shortage of nurses dur- ing and since the war has affected the nurs- ing program in Florida as it has in other states. Many of the vacancies exist because no nurse can be found. Of the nurses who reported facts as to their training, only 32 per cent had had one full year of academic training in public health. In 1945 there were nineteen counties in Florida without any full time public health nurse. Some of the counties reported visits to adjoining counties for special emergen- cies. When a nurse reported giving full time service in one county with slight assistance in another, she was counted as a full time nurse for the county where her headquarters were. Public health authorities estimate that 1 D. PUBLIC HEALTH NURSING The work of the public health nurse is rec- ognized as one of the fundamentals of a well rounded community health program. It is she who deals directly with the people, analy- zing their needs, executing the programs drawn up, determining and influencing the attitudes of the people and deciding how best to convey ideas of hygiene and better health 15 nurse per 2,500 population is needed for an adequate program.30 This estimate would mean about 1 nurse for 800 children. Florida falls short of this standard with an average in the state of 1 nurse per 2,699 children. The comparison with the eight selected states is given in Table 16. had to be set up by which to judge whether or not medical school services were given. A school was classified as having medical school services if: (1) all pupils are examined once a year, (2) certain grades are examined once a year, or (3) referrals by nurses or teachers are examined once a year. In the third type of care, attention is directed to the fact that such referrals do not mean emergency cases, but rather imply a consistent program of examination, depending upon the nurse or teacher to screen the pupils for selection of children needing examinations. Data from the numerous towns, villages and counties were not complete enough to give an exact picture of school health serv- ices. Because of this fact, it is necessary to view the data obtained negatively. Of the sixty-seven counties, for instance, twenty- eight reported no medical school services in even one school of the county. In the re- maining counties at least one school had some medical service. It is well to keep in mind that an indication of medical services given in schools in a county (Appendix B) does not necessarily mean that all schools have the service. In some counties the public health officer, who is a private practitioner, was the school physician. Two cities reported that the Board of Education appoints the physician. Of the 196 nurses reporting school serv- ices, 181 were public health nurses conduct- ing a generalized program in the county or area. F. COMMUNICABLE DISEASE CONTROL For this study a report was not made on how the actual number of cases of diseases compared with the number of immunizations given in the state.31 Reports of the official community agencies, however, indicate the rates of children immunized by them per 1,000 children. Table 19 shows these rates per specific disease. Because smallpox immunizations for adults were included in the data from fifteen coun- ties, the first average is not exact. Rural areas reported half as high a rate per 1,000 TABLE 17. NUMBER OF CHILDREN PER PUBLIC HEALTH NURSE BY COUNTY GROUP County group Metropolitan 2,009 Adjacent 5,396 Isolated semirural 2,775 Isolated rural 5,090 The county groups in Florida differed con- siderably in respect to the number of chil- dren per public health nurse. Table 17 indi- cates this ratio by county group. Figure 13 shows the number of home visits per 1,000 children made by public health nurses in Florida in comparison with the eight selected states. Table 18 compares the rate of visits by county group. This table reveals that metropolitan counties vary con- siderably from the other county groups in respect to nurses’ home visits. No report was given regarding the number of home visits made to nonwhite children. It is understood that where public health nursing is available, the nonwhite children are considered and cared for to the same de- gree as the white children. TABLE 18. NUMBER OF HOME VISITS TO CHILDREN PER 1,000 CHILDREN BY COUNTY GROUP County group Metropolitan 255 Adjacent 179 Isolated semirural 177 Isolated rural 189 E. SCHOOL HEALTH SERVICES The problem of administration of school health services differs from state to state. Some place the responsibility upon the De- partment of Education, others upon the De- partment of Health, and others carry on a cooperative plan, using both departments. In Florida most of the school health services were administered by public health agencies. In a study such as this, some standards TABLE 19. NUMBER OF CHILDREN PER 1.000 CHILDREN IMMUNIZED FOR SPECIFIC DISEASES Smallpox 68 Diphtheria 69 Whooping cough 17 30. This rate includes bedside nursing needed in an adequate program of public health nursing. The American Public Health Association, after a detailed study of the locai health picture in the United States, established a quanti- tative standard of 1 public health nurse for 5,000 people. Reported by the Federal Security Agency—The Local Health Unit Story, June 1948. Based on this standard, the shortage of such nurses in Florida and other states is cut in half. 31. Physicians were not asked to record the number of im- munizations given in their private practice. The data for community health agencies are subject to underreport- ing. Also the reports of diseases to the State Board of Health are considered incomplete. 16 children immunized for smallpox as did the metropolitan counties. Nineteen of the coun- ties in Florida reported no information re- garding the number of immunizations given. G. DENTAL SERVICES The effect of caries on the health of the child places it as one of the major diseases to be considered if child health is to improve. With the control of this disease in mind, schools and public health agencies in differ- ent states have set up dental programs. Some of the plans include only class instruction; others include dental examinations of all school children, notices and bulletins to par- ents, and a follow-up by nurse or teacher to ascertain the number of corrections made. These programs attest to the recognition of the need which exists, but in general fall short of sufficient provision for correction. It is recognized that dental examination of the children for caries is a beginning. Without corrective measures being carried out, the examinations are of little value. For the pur- pose of this study, therefore, community den- tal service is defined as one providing dental care other than examination. In Florida, for some years the State Board of Health has had a Bureau of Dental Health. The program for 1945, as explained by the director, “called for promotion of dental health on a statewide basis and provided den- tal health education for everyone in the state and correctional service for indigent mater- nal and preschool cases and elementary school children.” The personnel of this bureau was limited to a director, a field den- tist and one secretary. Two dentomobiles were used in the coun- ties, usually in cooperation with a county health unit. Ten counties received visits from three to eight weeks by the dentomo- bile units. Six counties availed themselves of the care afforded preschool children through the Maternal and Child Dental Cor- rective Clinics. Three county health de- partments operated dental clinics in connec- tion with general health programs. Figure 13 gives the rate of visits to dental clinics during the year of the study, compared with records of the selected states. The rate of service in the highest state was slightly more than SVa times the rate of service in Florida. Summary 1. Three out of five counties reported no well child clinics with continued supervision. 2. With an average of 18 patients per ses- sion of about two hours’ duration, the well child clinics were not overcrowded. Florida showed about the same rate of service as that shown in the average of the selected states. 3. No concerted program for mental hy- giene had at the time of this study been de- veloped in the state. A program has now been started with three clinics in operation. 4. The rate of service for the physically handicapped child in the highest of the se- lected states was 2J/2 times the rate of serv- ice given in Florida. No clinics were held for blind children. 5. There was one public health nurse per 2,699 children in Florida compared with an accepted standard of one public health nurse per 800 children. The highest record of the selected states was one public health nurse per 1,300 children. 6. Many counties had no full time public health nurse. Counties differed consider- ably in the public health nursing care pro- vided for children. 7. More than two-fifths of the counties had no elementary schools within their bor- ders conducting a medical school service pro- gram. One hundred and ninety-six nurses reported health work in school, but most of them were conducting a generalized program which included school nursing services. 8. The rate of services in dental clinics in the highest of the selected states was 3!/2 times that of Florida. Chapter VI—HOSPITAL FACILITIES AND SERVICES-3 2 A. GENERAL HOSPITAL The preservation of health in any commu- nity depends to a large extent upon the hos- pital facilities available within or near it. Hospitals have become essential instruments in public health, acting with increasing fre- quency as medical health centers providing, through clinics, diagnostic, preventive and curative care. An adequate number of phy- sicians for a community is also determined in large measure by the facilities afforded by available hospitals. Added to these facts is the ever present need for training future nurses and physicians in hospitals. 1. Facilities and Services for Children (Other Than the Newborn) At the time of this study, there were 107 32. In this report the term “hospitals” is limited to those caring for children, including the newborn. No institu- tion is included having less than 5 beds for regular inpatient care. Federally owned hospitals are excluded. 17 general33 hospitals in Florida caring for chil- dren. Twenty-three of these hospitals had pediatric units.34 The state of Florida had no pediatric hospitals. Of the 107 general hospitals, 50 per cent were between 25 and 100 beds in capacity. The study revealed that the general hospi- tals had 6,396 hospital beds, or an average of 11.4 beds per 1,000 children. In actual fact, only 404 beds were set aside for the exclu- sive use of children, or 6.3 per cent of the total number of beds. In figure 14 and Table 20, comparison with the eight selected states is made. The discrepancy, in terms of total beds per 1,000 children, between the record of the highest state and that of Florida was 45 per cent. Considering the number of beds per- manently set up for children, there was a greater variance, or a discrepancy of 65 per TABLE 20. NUMBER OF HOSBITAL BEDS PER 1,000 CHILDREN AND PERCENTAGE OF BEDS SET ASIDE FOR CHILDREN Per 1,000 children Total Pediatric beds beds Percentage of total beds permanently set up for children Florida 11.4 0.7 6.3% Selected states Highest 20.6 2.0 9.8 Average 12.5 1.2 9.4 Lowest 5.7 0.5 4.3 Fig. 14. Beds (total) in General Hospitals per 1,000 Children in Florida and Eight Selected States politan-adjacent counties and 25 child admis- sions per 1,000 children in isolated counties. Some of this variance can be explained by the number of children from outlying coun- ties who were referred to the larger medical centers where there are many specialists and highly skilled professional services. Hospitals of 100 beds or more had more than half the child admissions made in the state. Small hospitals, having 5 through 24 beds, cared for 17 per cent of the child admissions in the state. Fifty-three of the general hospitals cared for white patients only; 9 were exclusively for nonwhite; 45 were for both white and nonwhite patients. Complete records of ad- missions of white patients compared to non- white patients were not supplied. 2. Care of the Newborn35 An analysis of the number of all the chil- dren cared for in general hospitals shows that 63 per cent of the child patients were newborn. This ratio did not differ greatly between the metropolitan-adjacent county grouping and the isolated county grouping. cent. A number of hospitals in Florida ex- plained, in the course of the study, that they did not have sufficient personnel to care for children and therefore tended toward the acceptance of adults instead of children. There was a wide variance between the average number of beds in hospitals when comparing metropolitan-adjacent counties with isolated cunties. There were 14.8 beds per 1,000 children in the former group and 8.1 beds per 1,000 children in the latter. Hos- pitals of isolated areas had little better than half the rate of beds for children as had the metropolitan-adjacent counties. Child admissions to hospitals totaled 16,757 in 1945, or a rate of 30 admissions per 1,000 children. The highest record of the selected states was 83 admissions per 1,000 children. A comparison of the rate of child admis- sions to hospitals between the two broad coun- ty groups reveals that there were 35 child admissions per 1,000 children in the metro- 33. For the purpose of this study “general” is taken to include maternity and pediatric. A few hospitals cared for the newborn but not other children. 34. A unit of 5 or more beds permanently set aside for the care of children in hospitals with 25 beds or more. 35. Data on the proportion of births in hospitals were pre- sented in Chapter I of this report. 18 At the time of the study there were 1,300 bassinets and 149 incubators in the general hospitals, 3. Characteristics of Hospitals Caring for Children As was mentioned previously in this re- port, the quality of care has not been an- alyzed in this study. There are, however, numerous characteristics which have been associated with good quality of hospital care for children. Items such as space, organiza- tion of pediatric care, medical staff, nursing and special procedure are considered in rela- tion to the amount of service provided by hospitals which have them. the newborn, indicating the proportion of births in hospitals with specified characteris- tics. This table reveals that 99 per cent of the births occurring in hospitals were in those with a graduate nurse on duty at all times in the nursery. This high average is in contrast with the provision for a special formula room indicated by the fact that only 66 per cent of the births occurring in hos- pitals were in those with a room used exclu- sively for formulas. The Very Small Hospitals.—In some areas the only hospital available is necessarily small in size, 5 to 24 beds. Seventeen per cent of the child admissions to general hos- pitals in the state occurred in these small hospitals, and approximately 16 per cent of the babies born in hospitals were born in smaller hospitals. Table 23 indicates the de- ficiency of facilities in these hospitals com- pared with those of 25 beds or more. In many of the smaller hospitals not hav- ing a clinical laboratory, it was explained that the clinical laboratory of the physician was used, or specimens were sent to the near- est city or to the State Board of Health. TABLE 21. PERCENTAGE OF CHILI) ADMIS- SIGNS OCCURRING IN HOSPITALS WITH SPECIFIED CHARACTERISTICS (a) COMPARISON WITH EIGHT SELECTED STATES Characteristics Florida Eight states Highest Average Lowest Separate pediatric units 64 91 73 51 Graduate nurse on duty at all times in pediatric unit 62 71 61 41 Any house staff 51 90 56 8 Clinical laboratory 90 97 89 72 Selected clinical laboratory service (b) 77 96 83 35 Separate ward for infants other than the newborn 23 79 52 18 Average percentage 61 88 70 39 (a) Hospitals of 25 beds oi • more. (b) Blood level for sulfonamides, sedimentation rate, blood culture and serum protein. TABLE 22. PERCENTAGE OF HOSPITALIZED BIRTHS OCCURRING IN HOSPITALS WITH SPECIFIED CHARACTERISTICS (a) COMPARISON WITH EIGHT SELECTED STATES Characteristics Florida Eight states Highest Average Lowest Any house staff 52 Graduate nurse on duty at all times 90 58 4 in nursery 99 Room used exclusively 98 91 77 for formulas 66 Nursery for full term or suspected sick newborn sep- 94 78 29 arate from well 14 66 37 0 Average percentage 58 87 66 28 - (a) Hospitals of 25 beds or more. Table 21 indicates the percentage of child admissions to general hospitals with speci- fied characteristics and comparison with the corresponding percentage for the eight se- lected states. Considering the average per- centages for the table of characteristics, one sees that Florida is below the highest of the selected states, a discrepancy of slightly more than 31 per cent. But studying the charac- teristics separately, one finds the widest dif- ference is the separate ward for infants other than the newborn. This table reveals that only 23 per cent of the admissions of children to hospitals were made in hospitals with sep- arate wards for sick infants. Numerous hospitals in Florida explained that when an infant is sick, a private room, not perma- nently set up for such patients, was used. Only about one-half of the admissions of children were made to hospitals having a house staff. Newborn.—Table 22 gives data regarding TABLE 23. PERCENTAGE OF LARGE AND SMALL HOSPITALS WITH SPECIFIED CHARACTERISTICS Hospitals Hospitals Characteristics 5-24 beds 25 or more beds Registered by AMA Clinical laboratory 37 85 in hospital Separate nursery for 33 74 newborn only Graduate nurse on duty at all times in 78 99 newborn nursery 61 97 With pediatric unit (a) — 35 Average percentage 41.8 78 (a) By definition. 19 4. Facilities for the Care of Acute Poliomyelitis A well organized plan of cooperation and service was developed to provide sufficient care for children suffering from poliomyeli- tis in the state in 1946, during the time of the study. The National Foundation for In- fantile Paralysis and the State Board of Health with the cooperation of the medical profession worked out efficient plans to en- able a stricken child to be taken to the near- est hospital for diagnostic care. From there children who needed treatment were trans- ported to hospitals where a special setup had been provided for such patients. These hos- pitals were located so that care was available in every area of the state. Of hospitals hav- ing 25 beds or more, 87 per cent admitted pa- tients with acute poliomyelitis. Thirty-two per cent of these larger hospitals rendered complete care. Thus if one hospital failed to have complete facilities needed for specific problems, the children were transported to one which did. 5, Convalescent Care for Poliomyelitis Most of the hospitals which cared for pa- tients in the acute stage of poliomyelitis had no facilities for convalescent care. The Na- tional Foundation for Infantile Paralysis ar- ranged for such care in five of the larger hospitals. These hospitals were located so as to serve different areas of the state. Some families applied to the Florida Crippled Chil- dren’s Commission for assistance. Children from these families were cared for in one of the four orthopedic hospitals or convales- cent homes sponsored by the commission. Convalescent care was therefore readily available to any child in need of it, no matter where he lived in the state. Summary 1. Florida general hospitals had an aver- age of 11.4 beds per 1,000 children, a little better than half the rate in the highest of the eight selected states. 2. Metropolitan-adjacent counties had al- most twice as many beds per 1,000 children as did the isolated counties. 3. About 6 per cent of the beds in general hospitals were assigned permanently to chil- dren. 4. Admissions of children to general hos- pitals for the year of the study, on the basis of the number of admissions per 1,000 chil- dren, were only 36 per cent of those in the highest of the eight selected states. The rate of isolated counties was 29 per cent less than the rate in metropolitan-adjacent coun- ties. 5. Comparing hospitals on the basis of characteristics which are needed for good quality of care, Florida data reveal a much lower rate than the highest attained record of the eight selected states and one which does not reach the average of the sample states. B. SPECIAL HOSPITALS ADMITTING CHILDREN Of the 6 special hospitals admitting chil- dren, 1 was for patients with cardiac condi- tions, 1 was for feeble-minded and epileptic children, and 4 for those requiring ortho- pedic care. The locations of these special hospitals are shown in figure 15. Excluding the Farm Colony36 for feeble- minded and epileptic children, the total days of care in special hospitals was 58,177 for the year. The Farm Colony reported 237,757 days of care, which included custodial as well as hospital care. The special hospitals, excluding the Farm Colony, provided annually an average of 104 days of care per 1,000 children in the state. The highest rate of the selected states was 246 days of care per 1,000 children in a year; the average of these states was 91 days; the lowest was 15 days. Florida ranks above the average, but shows a discrepancy of 57 per cent with the state having the highest record among the eight selected states. C. OUTPATIENT SERVICES FOR CHILDREN There were only 14 outpatient departments reported in Florida, all of which were in hos- pitals. Two of these hospitals had separate pediatric clinics. The total number of visits of children to outpatient departments for one year was 16,486.3 7 Chapter VII—RECOMMENDATIONS AND CONCLUSIONS 1. Florida Children’s Commission The pertinent facts revealed by the Florida study of available facilities for medical and health care of children give evidence that inequities and deficiencies exist. Florida ranks below the average of many other states in relation to the amount and distribution of health services provided for children. It is 3G. The Farm Colony is the State Institution for the care of feeble-minded and epileptic children. 37. For the purpose of determining the total volume of medi- cal care, it was necessary to include some figures for out- patient services for children ; if not reported, these were estimated as 10 per cent of the total number of outpatient visits by persons of all ages. 20 FI G. 15. LOCATION OF SPECIAL HOSPITALS ADMITTING CHILDREN IN FLORIDA believed that when local groups are aroused to the health needs of their children and have organizations set up to promote and carry out health programs, one of the prime difficulties will be overcome. The Florida Children’s Commission, ap- pointed by the Governor, has included better health care for children as one of its objec- tives. The commission recognizes the influ- ence of health factors on the development of the growing child in relation to character, mental training and social adjustments. To implement such a program, a Children’s Com- mittee in each county assumes responsibil- ity for leadership on the local level. With such a body already organized or in the process of formation, it is believed that it is one of the logical groups with which the pediatricians and other physicians can work to achieve the goals set for better health services for children. It is suggested that a pediatrician or, in counties which have no pediatricians, a general practitioner who takes a special interest in children, should be appointed, as a consultant to or member of the Children’s Committee. It is recommend- ed on the state level, that a pediatrician be appointed to the Children’s Commission. His knowledge of and experience with the grow- ing child should be of inestimable value to the commission. 21 2. Training of Physicians in Child Health Sixty-six per cent of the physicians’ visits to children in Florida were made by general practitioners. Yet, 43 per cent of them re- ported that they had had none or less than one month’s special training in pediatrics. It is believed that the majority of general practitioners would avail themselves of any feasible plans for added training. It is rec- ommended that seminars be arranged at strategic locations in the state, so that the physicians would find it convenient to attend. These meetings would be for the purpose of discussing developments and strides made in methods of diagnosis, prevention and treat- ment of diseases of children. Such seminars could be sponsored by the Florida State Pedi- atric Association in cooperation with the Florida State Board of Health 3. Physicians’ Services to Children On the average, the general practitioners reported that 25 per cent of their patients were children but that less than one-fourth of these were well children. Further analysis showed that 31 per cent of the general prac- titioners saw no children on the day assigned them. It is recommended that in localities where there are no pediatricians, a greater number of general practitioners devote more time to well children. 4. Expansion of Community Health Services Only twenty-eight counties reported hav- ing well child clinics. Two-fifths of the coun- ties had no medical school services. A marked deficiency in programs for the immuniza- tion of young children against dread diseases was revealed in the study. Many counties were without full time public health nurses. A concerted effort on the state and local levels should be made to provide adequate community health services. It is recom- mended that the number of well child clinics for the supervision of medically indigent38 children from the ages of 1 month to 5 years of age should be increased. These clinics should be so distributed that all such chil- dren can obtain health supervision. Pro- grams for medical examination of preschool and elementary school chidren should be in- stituted. Such programs should include a follow-up system39 to insure correction of de- fects as far as possible. The decision regard- ing whether or not corrections have been made as far as possible should be made by the family physician. Parents should be no- tified in respect to the findings of the medi- cal examiner and in case of defects, referred to the family physician for correction. Medic- ally indigent children should be the respon- sibility of the public health agency. It is further recommended that correction of de- fects should be compulsory, insofar as pos- sible.40 If preventive medicine is to be expanded, an immunization program is needed in every county. It is recommended that before a child is enrolled in his first year of school he should be immunized against typhoid fever, smallpox, diphtheria, tetanus and whooping cough. Children should be referred to the family physician for such immunizations, ex- cept in cases of the medically indigent. Chil- dren from families who are unable to pay for immunizations should be the responsi- bility of the public health agency. The par- ent should be notified regarding the number and types of immunizations given and warned that in cases of exposure to a disease, further immunization may be called for. It is rec- ommended that the State Board of Health carry on an intensive educational program for parents of young children in respect to the need for immunizations. One of the major qualifications for a pub- lic health nurse is that of one full year’s training in public health. In the year 1945, ony 32 per cent of the nurses in this field in Florida had had this required training. It is recommended that the present plan of provid- ing post-graduate training for employees be continued, and when possible expanded. In- sofar as is feasible, with the existing short- age of nurses in the nation, it is suggested that new appointees to the public health nursing staff meet the qualification of one full year’s training in public health nursing. 5. Rheumatic Fever Program The study did not reveal the facts pertain- ing to the prevalence of rheumatic fever among children in Florida. It is the concen- sus of the pediatricians in the state that the more severe stages of the diseases are seldom found among the children in Florida. Never- theless, the earlier stages of the disease are serious in the effect they have upon the 38. The classification in respect to which families are medi- cally indigent should be the responsibility of the social or public health agency which sponsors the clinics. 39. A follow-up system should include a file of individual health cards of the children examined. Each card should record the findings of the medical examiner and notation as to corrections made. This card should go with the child when he is transferred to another school. 40. When the findings of the medical examiner indicate de- fects, the respective child should have a certificate from the family physician or public health agency, as the case may be. This certificate should indicate that correction of defects, insofar as the attending physician deems pos- sible, has been made before the child enrolls in school. 22 growth and health of the child. It is sug- gested that a special study of the prevalence of rheumatic fever among children in the state be made. This study could be spon- sored by the Florida State Board of Health. Plans for improving the care of children suf- fering from this disease, could be based on the findings of the special study made. 6. Expansion of Hospital Facilities According to the findings of the study, most of the hospitals admitted children. The lack of personnel and facilities resulted in a minimum number of children being able to obtain such needed service. Only 404 beds were permanently set up for the exclusive use of children and most of them were in the largest hospitals. It is recommended that the Hospital Planning Division of the Flor- ida Improvement Commission plan for needed hospital facilities for children. It is believed that such plans could be more rapidly ef- fected by enlarging present hospitals by plac- ing special emphasis upon more pediatric beds and basic needs for laboratories, diag- nostic equipment and all other features which assist in providing the highest quality of medical care for children. It is further rec- ommended that medical centers should be so located that required hospitalization for chil- dren from all counties would be readily avail- able. 7. Premature Infants When expanding facilities in hospitals, spe- cial attention is directed to the need of better care for premature infants. It is recom- mended that all larger general hospitals and small hospitals, which serve a wide area, should have a separate nursery for premature infants. To implement the program of bet- ter care for the premature infants, several medical centers at strategic locations in the state_should have facilities for training grad- uate nurses in this highly specialized type of care. Such a course of training would necessarily be of short duration but is highly desirable if infants in outlying counties are to have the required care. 8. A Long Term Program There is little doubt but what the general improvement of child health services in Flor- ida will evolve slowly and step by step. Nevertheless, it is gratifying to note the changes which are already taking place. All except five counties in Florida now have ac- credited public health agencies. There are now more physicians, dentists and public health nurses in the state than there were at the time the study was made. School and public health agencies are striving to work out better plans for medical school health services. Dental programs for the medically indigent children have expanded. Mental hygiene is now a recognized program with four clinics in operation. With groups in each county aroused to the necessity of enlightening parents regarding the medical needs of their children and with the cooperation of medical, dental and public health agencies, many of the goals on both the state and local level can be achieved. 9. Recommendations on Dental Services for Children There is a high correlation between good teeth and good health. Diseased teeth among children affect their health and, in turn, childhood diseases affect the teeth. The problem of providing adequate dental care for children is one of the most serious phases of any plans designed for the improvement of child care. The Florida State Dental Society is considering recommendations for more dental care for children. The State Board of Health has plans now in operation to meet the dental needs of a greater number of chil- dren among the medically indigent. 23 Appendix Tables Appendix A. County Group Child Population Private Practitioners Number of beds in general hospi- tals Under 15 years Under 5 years Number Number per 1,000 children Physicians Den- tists Physi- cians Den- tists Total General pi’acti- tioners 1 Whole state 558,854 219,262 1,412 866 604 2.53 1.08 6,396 2 Alachua 3 11,493 4,519 23 19 9 2.00 0.78 1 116 3 Baker 2 2,778 1,049 1 1 o 1 0.36 — 0 4 Bay 3 12,624 3,936 16 14 8 1.27 0.63 66 5 Bradford 2 4,081 1,620 3 3 2 0.74 0.49 0 6 Brevard 4 4,212 1,516 7 6 5 1 1.66 1.19 46 7 Broward 2 11,857 4,534 48 24 17 4.05 1.43 193 8 Calhoun 4 3,121 1,404 4 4 1 1.28 0.32 0 9 Charlotte 4 771 296 2 2 1 2.59 1.30 0 10 Citrus 4 1,598 595 4 4 1 2.50 0.63 0 11 Clay 2 2,524 1,061 3 ! 3 0 1.19 — 7 12 Collier 4 1,197 473 1 1 0 0.84 — 0 13 Columbia 3 5,751 2,523 9 7 4 1.56 0.70 57 14 Dade 1 65,966 25,793 336 154 134 5.09 2.03 1,156 15 De Soto 3 2,353 945 6 6 3 2.55 1.27 1 24 16 Dixie 4 2,274 1,308 1 1 1 0.44 0.44 0 17 Duval 1 65,990 25,053 165 80 75 2.50 1.14 798 18 Escambia 3 29,435 13,042 40 21 18 1.36 0.61 247 19 Flagler 4 601 237 1 1 0 1.66 - 0 20 Franklin 3 2,056 786 4 4 2 1.95 0.97 0 21 Gadsden 3 8,954 3,569 10 10 4 1.12 0.45 30 22 Gilchrist 4 1,566 712 0 0 0 J — - 0 23 Glades 4 610 249 1 1 0 1.64 - 0 24 Gulf 4 2,795 1,298 5 5 0 1.79 28 25 Hamilton 4 3,296 1,449 2 2 0 0.61 — 0 26 Hardee 2 2,653 1,086 4 4 2 1.51 0.75 15 27 Hendry 4 1,741 712 1 1 1 0.57 0.57 24 28 Hernando 4 1,541 634 3 3 2 1.95 1.30 25 29 Highlands .... 3 3,372 1,364 5 4 4 1.48 1.19 45 30 Hillsborough 1 51,528 20,938 130 68 53 2.52 1.03 917 31 Holmes 4 5,202 2,226 3 3 1 0.58 0.19 6 32 Indian River 3 2,441 885 5 5 2 2.05 0.82 18 33 Jackson 3 13,350 5,633 11 10 3 0.82 0.22 62 34 Jefferson 3 4,137 1,851 1 1 0 0.24 — 0 35 Lafayette 4 1,479 565 1 1 0 0.68 — 0 36 Lake 3 6,926 2,480 14 12 7 2.02 1.01 96 37 Lee 3 5,055 1,888 13 10 6 2.57 1.19 45 38 Leon 3 11,538 4,797 20 14 11 1.73 0.95 48 39 Levy 4 3,491 1,431 3 3 0 0.86 - 0 40 Liberty 4 1,011 368 o 0 0 — — 0 41 Madison 1 3 6,245 2,998 6 6 2 0.96 0.32 14 42 Manatee 1 2 7,041 2,712 11 8 6 1.57 0.86 106 43 Marion 3 8,599 3,182 17 12 9 1.98 1.05 72 44 Martin 4 1,439 525 3 3 1 2.08 0.69 33 45 Monroe I 3 4,615 1,772 5 5 5 1.08 1.08 68 46 Nassau ! 2 3,915 1,581 5 5 2 1.28 0.51 28 47 Okaloosa I 4 4,970 2,023 4 1 4 2 0.80 0.40 17 48 Okeechobee .. I 4 1,020 468 0 0 0 - — 0 49 Orange 1 3 18.998 I 7,250 79 40 45 4.16 2.37 369 50 Osceola 1 3 2,014 691 3 3 2 1.49 0.99 58 51 Palm Beach I 3 19.134 7,045 ! 78 43 25 4.08 1.31 282 52 Pasco 1 2 4.074 I 1,535 5 5 2 1.23 0.49 20 53 Pinellas 1 1 19,391 1 6,958 I 103 66 52 5.31 2.68 421 54 Polk 1 2 26.333 9,905 I 59 44 16 2.24 0.61 256 Child population, physicians, dentists, hospital beds and rates, by county in Florida 26 Appendix A (cont’d). Child population, physicians, dentists, hopital beds and rates, by county in Florida County group Child Population Private Practitioners Number of beds in general hospi- tals Under 15 years Under 5 years Number Number per 1,000 children Physicians Den- tists Physi- cians Den- tists Total General practi- tioners 55 Putnam 3 5,256 1,840 9 9 7 1.71 1.33 55 56 St. Johns 2 4,914 1,842 10 8 8 2.04 1.63 153 57 St. Lucie 3 3,937 1,542 8 8 3 2.03 0.76 47 58 Santa Rosa .... 4 5,502 2,030 5 5 1 0.91 0.18 0 59 Sarasota 3 4,131 1,554 19 16 9 4.60 2.18 84 60 Seminole 3 5,873 2,067 • 13 10 4 2.21 0.68 32 61 Sumter 4 3,361 1,300 4 4 1 1.19 0.30 0 62 Suwannee 3 5,924 2,514 5 5 1 0.84 0.17 0 63 Taylor 3 3,263 1,304 4 4 2 1.23 0.61 0 64 Union 4 1,887 812 1 1 0 0.53 0 65 Volusia 3 12,029 4,090 42 32 18 3.49 1.50 199 66 Wakulla 4 2,086 953 0 0 i 0 0 67 Walton 3 5,174 2,007 3 3 3 0.58 0.58 13 68 Washington .. 4 4,388 1,916 5 5 1 1 1 1.14 0.23 0 Notes 1. Child population, estimated as of July 1, 1945. 2. Physician and dentists in private practice in Spring and Summer, 1946. 3. Beds in general hospitals in 1945. 4. See Fig 1 for classification by county group. Appendix B. Physicians, by type of specialty, and number of dentists in each county and each city with 10,000 or more population in Florida in Spring and Summer of 1946. County and city Number of physicians S Total to General w Practitioners “ Pediatricians Other specialties to Number of dentists _ > u < (5) Psychiatry and 3 neurology ~ Surgery(except orthopedic) Orthopedic 3 surgery Obstetrics and 3 gynecology _ Ophthalmology o and w otolaryngology 'rj >> cs £ >5.2 be be ki o o ® 'o'o'S 03 C Was (11) 54. Balance o 55. Leon 20 14 1 1 4 11 56. Tallahassee .. 20 14 1 1 4 11 57. Balance o 58. Levy 3 3 0 59. Liberty 0 60. Madison 6 6 2 61 Manatee 11 8 1 1 2 6 62. Marion 17 12 2 2 1 9 63. Martin 3 3 1 64. Monroe 5 5 65. Key West .... 5 5 5 66. Balance 0 67. Nassau 5 5 9 68. Okaloosa 4 4 2 69. Okeechobee 0 0 0 70. Orange 79 40 7 5 3 10 1 4 8 1 45 71. Orlando 70 33 7 3 3 10 1 4 8 1 41 72. Balance 9 7 2 i 4 73. Osceola 3 3 2 74. Palm Beach 78 43 2 13 8 4 5 3 25 75. W. P. Beach 1 53 24 2 11 4 4 5 3 16 76. Balance 25 19 2 4 9 77. Pasco 5 5 ! 2 78. Pinellas 103 66 2 16 1 7 2 1 6 2 52 79. St. Petersburg 84 49 2 15 1 6 2 1 6 2 43 80. Clearwater .. 12 10 1 ! 1 7 81. Balance 7 7 ! 2 82. Polk 59 44 2 3 ! 3 2 4 1 16 83. Lakeland 29 16 2 3 1 3 2 2 1 9 84. Balance 30 28 1 2 7 85. Putnam 9 9 1 > 7 86. St. Johns 10 8 : 1 1 8 87. St. Augustine! 10 8 1 1 1 8 88. Balance 1 : 0 89. St. Lucie 8 8 i ■ '} 3 90. Santa Rosa 5 5 i j i 91 Sarasota 19 16 1 1 1 1 9 92. Sarasota 18 15 1 1 I 1 9 93. Balance 1 1 1 . 94. Seminole 13 10 1 1 1 1 4 95. Sanford 12 9 1 1 1 1 4- 96. Balance 1 1 ! 97. Sumter 4 4 1 * 1. 98. Suwannee 5 5 1 . ; 1, 99. Taylor 4 4 ; 1 2. 100. Union 1 1 1 o. 101. Volusia 42 32 1 i 2 1 4 18. 102. Daytona : Beach 31 22 1 i 2 1 4 12 103. Balance 11 10 1 ! <3, 104 Wakulla 0 0 i . 0 105 Walton 3 3 I 3 106. Washington .... 5 5 : 1 , : r. Notes : ’ j ■ V 1. Of the number of dentists reporting type of practice, 91 per cent were general practitioners. 29 Appendix C. Community health services for children during one year in each county and city of 50,000 or more population in Florida in 1945. County Medical well child clinics Dental clinics Public health nursing School health services Location of clinics Number of sessions Number of centers Number of dentist-hours Number of full-time public health nurses 3 Medical service 77 Nursing service S only 77 Mental hygiene 12 Service 77 Orthopedic IS and plastic C/j ervices ha 1 u 3 > o V X (13) for physica ndicapped X c £ .2 ® 1 > (14) | (15) lly tt z (16> Off. (1) Vol. (2) Off. (3) Vol. (4) Off. (5) Vol. (6) Off. (7) Vol. (8) 1 Whole state 2,975 8,598 1,365 199 8 2 Alachua 45 5 10 * * 3 Baker 30 1 136 1 * [ 4 Bay 10 1 4 * * 5 Bradford 50 2 1 * 6 Brevard 1 * * 7 Broward 79 3 6 * * 8 Calhoun 1 | 9 Charlotte R 1 * 1 i 10 Citrus * 1 1 11 Clay 1 * 1 12 Collier 13 Columbia 1 * * 14 Dade 151 2 2,080 37 2 * * 15 Miami X NR X X 2 * * ! i IB Balance X NR X X * 1 i 17 De Soto 1 * - ! ! 18 Dixie * 1 ' I 19 Duval 349 11 120 | 24 * * 1 1 20 Jacksonville 200 1 18 * * 1 ! 21 Balance 149 10 120 6 ♦ 1 ! 22 Escambia 88 6 1 * 1 1 23 Flagler 1 24 Franklin 50 2 90 1 * I ! 25 Gadsden 153 5 5a * * 26 Gilchrist 1 1 I ' 27 Glades 4 1 1 * I 1 ! 28 Gulf 29 1 1 ♦ * 29 Hamilton I I 1 i 30 Hardee 1 * 1 1 1 31 Hendry ! 32 Hernando * I I 1 I 33 Highlands 85 2 ‘150’ 2 * 1 1 1 1 34 Hillsborough 656 19 1,820 25 2 *, I * 1 1 35 Tampa X NR X X X * | * i l I 36 Balance X NR X X X * 1 ( ! ! 37 Holmes 56 1 * 1 ! 1 38 Indian River 1 * I 1 ! 1 39 Jackson 2 * 1 * 1 1 40 Jefferson 24 li 120 1 * 1 1 1 ! 4l Lafayette 1 1 ! 1 42 Lake 18! 51 200 4 * 1 ! 1 ! 43 Lee 1 | 1 1c | * I ! ! 44 Leon 721 NR | R 7 * I * ! ! I 45 Levy 501 1! 1 * I I 1 ! 46 Liberty b! * I 1 1 i 47 Madison 221 51 ‘148’ 1 l! * 1 * 1 1 I 48 Manatee ■ i 11 * 1 I I I 49 Marion 1 * ! ! I i 50 Martin I 1 t ! 51 Monroe 771 11 1461 1 6! * 1 * 1 1 i 52 Nassau 131 41 i 21 * 1 1 1 ! ! 53 Okaloosa ' 1 11 * ! ! 1 I 54 Okeechobee I 11 1 I 1 1 55 Orange 1681 71 48R| ! io’ * ! * I 1 1 30 Appendix C (cont’d). Community health services for children during one year in each county and city of 50,000 or more population in Florida in 1945. County Medical well child clinics Dental clinics Public health nursing School health services Location of clinics Number of sessions Number of centers Number of dentist-hours Number of full-time public health nurses Medical services g Nursing service only i-1 Mental hygiene Service Orthopedic and plastic w rvices hai o a . £ m « (13) for pi rdicapi X <1> V ft cn (14) rysical red 1 c o M > (15) ly t* .5 ee X (16) Off. (1) Vol. (2) Off. (3) Vol. (4) Off. (5) Vol. (6) | Off. (7) Vol. (8) 56 Osceola 1 57 Palm Beach I ' 1365 3 1 * 58 Pasco 1 59 Pinellas ' 1301 4 ‘714’ 10 1 * * 60 St. Petersburg X NR X 10 1 * * 61 Balance X NR X * 62 Polk 2401 1 102 1 * 63 Putnam 1 ‘174’ 1 * 64 St. Johns i 41 1 2 2.200 * 65 St. Lucie 1 i ■ . * 66 Santa Rosa 1 | 1 I 1 * 67 Sarasota | ! 11 68 Seminole 961 i 3 80! 3 * 69 Sumter 18) 1 1 * 70 Suwannee ! | ! , 71 Taylor 1 ! i 80! ! i * 72 Union | i 1 : 73 Volusia | 1381 5 R i 6 1 * 74 Wakulla t 501 1 3 | 35 1 ! 1 i * 75 Walton ! 1 i I ! 1 * 76 Washington 1 1641 1 5' ! i i * 1 Notes 1. Data uiven tor a specific service in a city of 50,000 or more population, if reported separately. 2. Blank space indicates that specified service is not given in particular location, although services may be available else- where to residents of that county or city 3. X Indicates that allocation of particular service between city and county not reported. 4. * indicates that specified service is given or clinic is located in particular county or city. 5. NR indicates not reported. t>. R indicates dental services (other than examinations) in particular county or city are provided through organized re- ferral to private offices. hours of which are not included. 7. a indicates one or more of these nurses serve other counties. 8. b indicates nursing service available from another county. i). c indicates nurse employed by the U. S. Indian Service listed only n county of headquarters although service may be available for other counties. 10. Figures shown in quotes are statistical estimates.