Publ ic Health on the Home Front PROBLEMS, ACTIVITIES AND ACCOMPLISHMENTS of the State Department of Health for the FISCAL YEAR ENDING SEPTEMBER 30, 1945 Publ ic Health on the Home Front PROBLEMS, ACTIVITIES AND ACCOMPLISHMENTS of the State Department of Health for the FISCAL YEAR ENDING SEPTEMBER 30, 1945 WJ3TUMPKA PRINTING CO. Printers and Publishers Wetumpka, Ala. 1946 Public health workers from foreign countries visiting Ala- bama have expressed admiration for a number of features of this State’s public health system. They have had particular admiration for two of them—the separation of the public health agencies from political control and the existence of a full-time public health department in every one of the State’s 67 counties. The first feature is altogether exclusive to Ala- bama, while this State shares the second with two other states, Maryland and Delaware, the former with only 23 counties and the latter with only three. Alabama is the only predom- inantly rural state providing complete public health service at the county level to every one of its residents. What might be called “the Alabama plan” of public health organization is the coming-true of a dream of about three-quarters of a century ago, when Dr, Jerome Cochran, then a practicing physician of Mobile, envisioned a system of public health protection directed by and responsible only to the organized medical profession. That dream grew and grew in his active mind and by 1872, when the Medical Asso- ciation of the State of Alabama held its annual meeting in Huntsville, he had worked out a definite scheme of operation which he presented to his fellow-physicians. “I would like,” he said, “to have a general health law passed by the Legislature of the State, carefully prepared so as not to stand in need of frequent revision or amendment. I would have this law to invest the Medical Association of the State of Alabama with the functions, powers and respon- sibilities of a State Board of Health, and these functions I would have exercised through such organs as the Association, in its wisdom, might think best. I would have the same act of the Legislature to invest each county medical society with the functions of a county board of health, said functions to be exercised through such organs as the said county societies should, in their wisdom, determine to be best.” The scheme was revolutionary, but thoroughly sound, which fact became apparent to those who studied Dr. Coch- ran’s proposed set-up. Its thorough soundness appealed first to his fellow-physicians and in time to the State’s lawmakers, with the result that on February 19, 1875, not quite three 3 years after the plan was first publicly announced, the Gen- eral Assembly passed a law putting it into effect. Although the passing of time and changing conditions have inevitably brought minor changes in the law, the original principle of freedom from political domination through control of public health activities by the State’s organized medical profession has not been altered. Every legislative session of recent times has passed meas- ures dealing in an important way with public health, and practically all of these have added to the responsibilities of the State Department of Health. Its present functions, as a result, are manifold. The most important of them are as fol- lows: enforcement of laws affecting community and individ- ual health; investigation of the causes, modes of spread, and means of controlling and preventing all forms of illness sus- ceptible to such control and prevention; inspection of food- handling establishments; supervision of other places of busi- ness and places of public assembly which, unless properly conducted, would involve increased health hazards; supervi- sion of public water supplies to prevent them from becoming agencies in the spread of disease; adoption and enforcement of quarantine and public health laws; supervision and direc- tion of county health departments and county public health officials; assistance in an advisory capacity to the State as a whole and to individual State officials in all matters having to do with sanitation and public health; registration of births and deaths and issuance of birth and death certificates; and the performance of similar duties for the protection of the State and its people against epidemics and other health haz- ards. Seven bureaus, containing from two to four smaller units, or divisions, each, carry on the work of the Department, The State Health Officer, as the chief administrative official, is directly in charge of the Bureau of Administration (consist- ing of the Divisions of Finance, Machine Tabulation and Pub- lic Health Education and employing 61 persons) and of course has general supervision over the other six, which, however, are in direct charge of specialists in the fields to which they are devoted. These other six bureaus, each performing the type of service indicated by its title, are as follows: 4 Bureau of County Health Work (including the Division of Medical Advisory Services and the Division of Public Health Nursing), employing 15 persons. Bureau of Preventable Diseases (including the Divisions of Venereal Disease Control, Tuberculosis Control, Epidemi- ology, Cancer Control and Industrial Hygiene) employing 39. Bureau of Maternal and Child Health (including the Di- visions of Maternal, Dental and Child Hygiene and the Di- vision of Nutrition), employing 11 persons. Bureau of Sanitation (including the Divisions of Engi- neering and Inspection) employing 35. Bureau of Vital Statistics (including the Divisions of Reg- istration, Records and Analysis) employing 67. Bureau of Laboratories (including the Biologic, Research and Diagnostic Divisions) employing 60. The accomplishments of the State Department of Health as a whole represent of course the sum-total of the accom- plishments of the above-listed bureaus and divisions, each working in its own particular sphere of public health protec- tion but all fitting into the statewide public health picture. Those achievements are described in some detail in the following pages: Legislative Appropriation Averages 27 Cents Per Capita The State Department of Health received during the fis- cal year from all sources and for all purposes (exclusive of the Federal government’s Emergency Maternity and Infant Care Program, which it administered in behalf of the Chil- dren’s Bureau) a total of $1,827,266.48. This represented an average of approximately 63 cents per capita. Of this total $780,400.00 was in the form of a legislative appropriation (including a $75,000* conditional appropriation), or an aver- *This $75,000 conditional appropriation included $13,000 from the Gover- nor’s Contingent Fund for continuation of the cancer control program to the end of the fiscal year. Of this $13,000, $5,000 was unused and was returned to the State Treasurer. 5 age of slightly more than 27 cents per capita. Federal grants- in-aid made available during that 12-month period totaled $973,190.54, (exclusive of the funds provided for the EMIC Program) or about 34 cents per capita. The Rockefeller Foun- dation made available the sum of $29,300.00 for the operation of the rabies research laboratory, which has been functioning in Montgomery for the past several years as a joint project of the Rockefeller Foundation and the State Department of Health. An additional sum of $44,375.94 was received dur- ing the year in the form of fees for certified copies of birth and death certificates. In addition to these funds made avail- able for the operation of the State Department of Health and for its program of financial assistance to county health de- partments, it handled, as fiscal representative of the 67 county health departments, the sum of $368,585.00 provided by coun- ty boards of revenue and other official and unofficial bodies as the counties’ share of the cost of operating those public health units on the county level. Of the above-mentioned total of $1,827,266.48 (exclusive of EMIC Program funds) received by the State Department of Health for the maintenance of its own activities and for its assistance to county health departments, $71,986.79 was spent in the over-all public health program, for carrying on work not listed among the Department’s special activities and for general administration. Cancer control work involved an expenditure of $51,075.27* ; tuberculosis control, $207,026.36; subsidies to county health departments, $965,512.63; labora- tories (the central laboratory in Montgomery and the seven branch laboratories), $81,117.85; issuance of birth and death certificates, registration of births, deaths, marriages and di- vorces and other activities in the vital statistics field, $86,- 456.67; care of mothers and infants, dental hygiene, nutrition and similar acfvities (exclusive of the EMIC Program), $24,- 740.90; venereal disease control (exclusive of the statewide blood-testing program provided by the Henderson Act passed by the 1943 Legislature), $254,054.60; operation of the rabies research laboratory, $19,255.92; Slossfield Health Center for *The sums listed here refer to amounts actually expended during the 1944- 45 fiscal year and do not include sums encumbered during the 1944-45 fiscal year for payment in 1945-46. 6 Negroes (in Birmingham), $24,244.01; malaria control and other sanitation activities, $73,533.43; county health work (exclusive of subsidies to county health departments), $37,- 674.94; preventable disease control (exclusive of tuberculosis and venereal disease control), $11,544.19; the statewide blood-testing program, $73,116.96; training of personnel, $15,- 231.46; Tuskegee School of Nurse-Midwifery, $14,991.51; machine tabulation activities, $42,447.81; and Tuskegee Ma- ternal and Child Health Hospital Care Program, $6,888.04. In accordance with State law, the sum of $403.32 was returned to the State Treasurer at the end of the fiscal year, this hav- ing been the amount of the 1944-45 fiscal year legislative ap- propriation remaining unexpended after deduction of the sum of $82,619.82 encumbered to meet prior commitments. County Health Work The ideal of service that has always motivated the lives of the physicians of Alabama in their relationships with the State’s public health forces vouchsafed to the people of the Commonwealth protection from disease during the most try- ing period of the State Department of Health’s 66-year his- tory ; and these same self-sacrificing servants continue to stand by, prepared to remain at their posts until the emergency has passed. Though the war is over, the duration has not ended— and the shortage of manpower with the close of the fiscal year was as acute as at any time during the progress of hostilities. As a consequence, not only did combinations of counties con- tinue to operate under a common directing head but in several instances the aid of practicing physicians was enlisted in pro- viding oversight for County Health Departments. It is to this latter group that great credit is due for its contribution to the people’s welfare. At a time when there were already in- creased demands on all physicians because of the military service of many of their confreres, they assumed additional responsibilities in the field of public health with little hope of reward. Perhaps it is affrontery even to suggest that they expected anything in return since they were but upholding one of the finest traditions of medicine, that of striving to keep people well. Nevertheless, those they served and are serving owe them a debt of gratitude they can hardly pay. 7 With this foreword it may be said that, during the period covered by this report, all of the State’s 67 counties were serv- ed by local departments of health operating under the juris- diction of the State Department of Health, as provided by law—such state-wide organization at the local level having been in effect since January 1, 1938 when Bibb, the sixty- seventh and last county, provided itself with full-time health service. For the reader who may not be familiar with the public health movement in Alabama, it may be well to recall that the attainment of local protection from preventable disease by all the counties of the State marked the complete fulfillment of the plan made known in 1872 by the founder of the move- ment, Dr. Jerome Cochran, later Alabama’s first State Health Officer, who, in promoting the organization of a State Board of Health and a Board of Health for each of the counties, said: “Whenever, in the judgment of the county or municipal au- thorities, circumstances should justify some direct practical attempts towards an improved sanitary condition, the machin- ery would be ready, and could be put into working order at once.” Forty-two years elapsed between this utterance and the birth, in 1914, of Alabama’s first full-time County Health Department (Walker County), and twenty-four between Wal- ker and Bibb, but the machinery was ready and in working order. During the year 28 counties were served by individual health officers, 26 shared thirteen, 10 received oversight from practicing physicians, and, on September 30, three counties were unprovided for. Service Physicians to Resume Posts What of the future? As a nucleus, in rebuilding, it is hoped that the larger part of the number of medical health officers lost by Alabama to the Army and |sTavy will return to assume their former places or to accept positions of greater responsibility. There may be others, also, who, on returning from service, will want to engage in public health work as a career. It is doubted that Alabama Medical College will soon be able to meet the needs in the field of practice as well as 8 that of prevention but it, too, should, in time, provide material. Though combinations of counties may persist, there will not be decreased demand for medical health officers inasmuch as it is contemplated there will be assistants to those primarily responsible for the operation of district set-ups. In order that there may be efficient and economical ser- vice, as measured by the Subcommittee on Local Health Units of the Committee on Administrative Practice of the American Public Health Association, 36 units of local health jurisdiction are suggested for Alabama. Topography, land area and other factors considered, it hardly seems practical to hope for fewer groupings than 43. Assurance is given, however, that the mind of Alabama is not static; and that, as always, it will plan as seems best for the people of the State. Public Health Nursing Carries on Under Difficulties One hundred and seventy-five county public health nurses, with the assistance of 11 public health nurses employ- ed by the State Department of Health, have loyally met their share of added responsibilities during the past momentous year. Due to the superb team-work of all personnel, essential activities have been carried on under difficulties and tensions not known in normal times. This enviable record was attained despite continuous change of personnel due to shifting of nurse population. It has been difficult to maintain a field introduc- tion service due to lack of trained personnel. Despite the dif- ficulties mentioned, ten Senior Cadets completed their six months of experience with public health agencies, and five of this number were subsequently employed as public health nurses. Provision of this field experience provides much need- ed service, assists in the recruitment of public health nurses and broadens the students’ educational experience. This af- filiation will be continued in the new year. Seven public nurses completed public health nursing courses of study during the year and returned to the state for work. One nurse was trained in tuberculosis nursing at Wayne University, Detroit, Michigan, and has returned to the Sloss- field Center in Birmingham to supervise the clinic and field work at this center. One medical social worker received train- 9 ing at the Chicago School of Social Work and is now employed by the Jefferson County Health Department. One public health nurse completed the nurse midwifery course at Tus- kegee and returned to Montgomery County where she is su- pervising “Granny Midwives” and promoting better maternity supervision. Merit System Unit for County Health Work Examinations were administered in November, 1944 and April, 1945 in the following series: Clerk I and II, Typist I and II, Nurse in Public Health, and Sanitation Officer II and HI. As of September 30, twenty five persons remained on provisional appointment. Examinations have now been given in ail series except Public Health Nurse, War Emergency (which appointments are for the duration of the emergency due to the war only, and of whom no more than statutory, physical and personal qualifications are required) ; Clinic Nurse, Public Health Engineer and Scientific Aide—which classifications have been established since the last examina- tion was offered. Examinations in all series (except Public Health Nurse, War Emergency) are in preparation for admin- istration this fall. New pay scales for all classifications, and specifications in three new classifications, have been prepared and approv- ed by the State Department of Health, the Merit System Coun- cil and the U. S. Public Health Service. At present, specifi- cations covering qualifications, and the pay scale for county health service, are higher in Alabama than for any of the 14 states of this region except Texas and Florida. A complete employment record for all persons in county health service has been filed by the Merit System Unit; the guidance and efficiency record form revised; a handbook for each employee is in the hands of the printer; and the close of two years of activity shows a fine degree of understanding and cooperation on the part of all those concerned. For this reason, the Merit System Unit, the first to extend personnel administration on a merit basis to all county positions, faces with confidence reconversion to peace-time employment func- tions. 10 There has been an employee turnover in the period Sep- tember, 1944-September, 1945 of 32 per cent. To fill the 428 positions occupied during- that year 565 persons were under employment. If all who are on military leave return to re- sume their work, the following will be required to fill present needs: 23 physicians, 14 dentists (10 white, 4'colored), 2 meat and milk inspectors, 4 public health engineers, 46 public health nurses (and 41 replacements for war emergency nurses) and 10 typists. Maternity Clinics Held in 41 Counties, Despite War Eight positions on the professional staff of the Bureau of Maternal and Child Health remained vacant during the year, and this shortage caused the curtailment of many im- portant activities in that field. Particularly affected were educational, advisory, supervisory, and consultative services in the Divisions of Maternal Hygiene and Child Hygiene. At no time during this period was there an obstetrician or a pedi- atrician connected with the Bureau. Four of the vacancies required specialists with high qualifications. No optimism is felt that suitable qualified persons will be available for these positions very soon. In spite of this shortage of staff personnel and the addi- tional shortage of part-time clinicians, the record of maternity and child health activities is not much lower than that of the preceding year. Exclusive of Jefferson County, patients made 32,090 visits to the 3,321 maternity clinic sessions that were held in forty-one counties, A few clinics were discontinued because of small attendance or lack of clinicians. The child health conferences suffered less curtailment and, exclusive of Jefferson County, 4,467 children visited the 427 clinic sessions that were held in sixteen of the counties. Two new clinics were started, and these figures compare fa- vorably with those of last year. Because of its importance, prematurity again received special care. The nurse con- sultant held several demonstrations, institutes, and confer- ences with groups of physicians, nurses and midwives. It has been impossible to analyze these services by checking with vital statistics reports, but a former study clearly indicated 11 their value. This study showed that maternal deaths, still- births and neonatal deaths were fewer among clinic attend- ants than among non-clinic attendants. The county health officers and their staffs of nurses con- tinued their activities in the interest of maternal, infant, and pre-school hygiene. During the nine months ended June 30, 1945 ,the nurses made 69,893 visits to promote these services. The data for the last quarter are not yet available from the counties. County nurses made an additionl 6,992 visits to school children to follow-up the medical examinations made by the health officers. To aid in the care and treatment of crippled children 2,655 visits were made in six months. Dentists Keep Clinics Open The Division of Dental Hygiene had the services of two dentists during this period—one on full-time and one on part- time. Because of the critical shortage of dentists, many of the counties’ service programs were maintained on a very small scale; however, credit should be given to the dentists of the State who served in these clinics at a sacrifice of time and ex- pense to themselves to render a service to the children of the men in the service, underprivileged pre-school and school children, and a limited number of prenatal cases. The addition of four new clinics in counties previously without public health dental services raised the number of counties with dental clinics to forty. Only thirty-two counties had active dental clinics, leaving eight that failed to operate because of a lack of clinicians. Jefferson, Montgomery, El- more, DeKalb, Calhoun, and Etowah counties operated with dentists who were on a full-time basis. There were forty-five dentists employed on a clinic session basis and five on a sal- ary basis. A summary of the service rendered from October 1, 1944, to September 1, 1945, shows that 4,631 children were admitted to the clinics. They received 21,066 treatments con- sisting of fillings, extractions, prophylaxes, medicinal and me- chanical treatments. Complete dental service was given to 3,101 of these children, who made 7,704 visits to the clinics. 12 The above services required 4,537 hours of the dentists’ actual operating time. Routine school inspections have been eliminated until an adequate staff can be provided for this work. The usual dis- tribution of literature, posters, and educational material has been continued during the year. Talks, conferences, and lec- tures were given when the time and demand for this service were manifested. Dental inspection for select groups such as pre-school round-ups, crippled children, and 4-H Club inspec- tions were made when suitable schedules could be arranged. Nutrition Program Emphasizes Children Because one nutritionist was on leave for six months the other served on a statwide basis and usually upon request. Particular attention was given to the promotion of better nu- trition among children. This was often by individual or group conferences with parents and by cooperation with county health departments. Much attention was given to school lunch programs in cooperation with the school authorities, and a nutritionist attended the Crippled Children’s Clinics to help parents to plan diets advised by the orthopedic surgeon. Services to promote nutrition included 122 visits with 197 con- sultations to sixty health departments, 233 to other agencies, twelve to State or private institutions, eighty-nine to our va- rious health department clinics, 105 to school lunch rooms, and eighty-seven to homes. There were twenty-three talks and demonstrations to 805 persons in various groups. Special Programs The Slossfield Health Center continued giving medical services to the colored people of the Slossfield section of Bir- mingham. A major problem was the rapid turnover of per- sonnel and the difficulty of filling positions with qualified persons. After May, 1945, certain services were curtailed because the nurses were needed to help in the Jefferson Coun- ty venereal disease survey. The records show that 1,132 chil- dren made 2,382 visits to child health clinics, and 169 persons made 275 visits to the dental clinics. There were 591 ante- partum and 304 post-partum patients, who made 3,187 visits 13 to the maternity clinics. There were 415 babies born in the twelve-bed maternity hospital, and twelve were born in the homes. Twelve were stillborn, and two maternal and two neonatal deaths occurred. This project has amply demon- strated its value. The Macon County Medical and Hospital Care Program was originally intended only for the colored people of Macon County but has been expanded and has provided service to forty-seven persons from other counties other than Macon, some coming from as far as 200 miles. A few white emer- gency cases have been cared for at St. Margaret’s Hospital in Montgomery. During the fiscal year, thirty-eight children and ninety-eight maternity cases were hospitalized, and twen- ty-six major operations were performed. These cases were hospitalized for 1,652 days. This program has served a large number of critically ill patients to whom medical and hospital care would not have been available otherwise. The Tuskegee School of Nurse-Midwifery has continued with a teaching staff consisting of an obstetrician, a nurse- midwife instructor, and two nurse-midwife field workers. During the fiscal year six nurses completed the prescribed course. The field nurse-midwife delivered 154 babies and assisted in the operation of 224 maternity clinics. The Emergency Maternity and Infant Care Program con- tinued to demand more attention than any other in the ma- ternal and child health field, although the trend is now de- cidedly downward. Since its beginning in June, 1943, ma- ternity and/or pediatric medical care has been authorized for 15,222 civilian dependents of enlisted men in the armed forces. The peak of authorizations was reached in August, 1944, when 921 cases were authorized; while in September, 1945 there were 678 cases. Of the total cases authorized there remained on September 30, 1945, 4,032 not yet complete. Unfortunately, because of lack of hospital participation this much-needed care has not always been available. Sixty-one civilian and nine II. S. Army hospitals have participated in the program, and approximately 600 practicing physicians have accepted the care of these cases. We cannot say that this pro- gram is popular with the physicians but regardless of its re- 14 quirements and despised “red-tape” our physicians and hos- pitals have been very considerate and cooperative. There is more than ample evidence that very many wives of enlisted men have received good medical and hospital care during their pregnancies that they could not otherwise have received. Final figures are not available, but the program has undoubt- edly increased the number of hospital deliveries throughout the State. Venereal Diseases Meet Five-Pronged Offensive The venereal diseases continued to receive a major share of attention from the State’s public health agencies. The at- tack upon this problem has been five-pronged; diagnosis, re- porting, treatment, follow-up and education. By the end of the year there were 169 free diagnostic and treatment clinics in operation. During the past year a number of clinics had to be discontinued because there were not enough patients to warrant this service. It is not to be assumed that venereal diseases in Alabama have declined sharply, but, because of a lack of follow-up workers, many infections remain undetected. Approximately 10,012 venereal disease cases were diagnosed at these clinics during the year. Individuals treated in those clinics averaged approximately 11,392 a month, while treat- ments given totaled 423,243 for the year. Some of these clin- ics are operated by private physicians who are employed on a fee basis, while others are operated by county health offi- cers. All clinics have instituted the more rapid type of treat- ment, which lasts from eight to forty weeks; but, whenever possible, the counties are asked to refer all early cases of syphilis (less than four years in duration) to the U. S. Public Health Service Rapid Treatment Hospital in Birmingham. At that institution syphilis is treated in nine days and gonorrhea in twenty-four hours. Four Counties Covered in Blood-Testing Program The blood-testing program as required by the Henderson Act continued during the year, Houston, Dale, Morgan and Jefferson Counties were covered during the 1944-45 fiscal 15 year, and the work was begun in Calhoun, to be completed in the new fiscal year. The results of the laboratory tests in the nine counties where the testing has been completed are as follows: County White Colored Total Wilcox 2.4 17.3 14.5 Sumter ..... 3.6 24.96 20.8 Lee 1.8 19.4 11.2 Macon — 0.92 10.72 9.2 Russell 3.6 21.7 13.5 Houston 2.96 25.55 9.91 Dale —- 2.2 21.3 6.5 Morgan 2.41 27.25 6.18 Jefferson 3.07 30.86 14.16 In Jefferson County, 271,775 people were blood-tested in a forty-two day period. Three thousand and eighty-seven through August 1st were given rapid treatment with penicillin. The work in this county was the first of its kind ever to be at- tempted in a large population group. The concentrated edu- cation has done immeasurable good. On the health education front for the rest of the State the campaign against venereal disease has gone on without abatement. Motion pictures, booklets, lectures, conferences, demonstrations and other informational media were employed to present the general aspects of venereal disease to the pub- lic and to make the people of the State venereal-disease-con- scious. Tuberculosis Control Has Four-fold Task The goal of a modern tuberculosis program is not only the control but the ultimate eradication of the disease. De- spite the lean years in equipment and personnel brought on by the war, the State Health Department has organized its affairs in the tuberculosis control field during the past year in a manner which, in the next few years, should place our program on a par with those of the most progressive states in the country—a position which Alabama will rightfully de- serve. 16 A well-rounded tuberculosis control program rests on four main leg's: (1) Case finding and follow-up; (2) Treatment, including sanatorium and post-sanatorium; (3) Rehabilita- tion; and (4) the financial security of the dependents of hos- pitalized breadwinners . An evaluation of the year’s work by this department can be gauged on the above-mentioned four criteria. 1. Case Finding and Follow-up. (a) In addition to the work of the State mobile chest clinics, the reviewing of films of Selective Service rejectees and rendering a free consultation service to private physicians, the State Health Department has taken over during the past year the supervision of a 35 mm. transportable x-ray machine made available by the Tuberculosis Control Division of the U. S. Public Health Service. This equipment has been used in industrial and military facilities for the most part, although surveys were done on State employees in and about Montgom- ery, in the prisons and in the State mental hospitals. Doing surveys on select groups of supposedly well persons is profit- able, since the majority of cases found are slight in extent. The disease has been “spotted” long before symptoms could become manifest. This means that the arrest of the disease process is relatively easy within a short period of time, the cost to the community in hospitalization and support of de- pendents is diminished and the spread of the disease to others is interrupted or prevented. In addition to 9,700 persons x-rayed during the past year by the State mobile clinics, approximately 1,000 supposedly well persons a week have been examined by this 35 mm. unit. During the fiscal year approximately $136,000.00 has been made available to this Department by the Federal Gov- ernment. These funds will be utilized to purchse two 70 mm. mobile x-ray units mounted on trucks, film processing facili- ties, material for several pneumothorax refill stations, and a central register for all cases of tuberculosis in the State. They will also be used to make financial provisions for an addition- al number of trained personnel as soon as they are available. 17 (b) Follow-up. A system has been devised and is soon to be established in the counties whereby contacts of known cases of infectious tuberculosis may be adequately followed up over a period of years. In order to bring such case ma- terial up-to-date, histories on all persons examined since 1937 are being reviewed. The Alabama Tuberculosis Association has made provisions for a record analyst to contribute to our program. 2. Sanatorium Care and Pneumothorax Treatments. Despite the paucity of beds and trained personnel, the sanatorium directors and their respective staffs have perform- ed an outstanding service to the State. During the fiscal year our eight county sanatoria with a total of 545 beds have ad- mited 914 patients and have discharged 918, while 19,872 pneumothorax treatments were given, including in-and-out patients. In addition to their regular sanatorium duties, many of the medical directors have cooperated in the case-finding pro- gram. During the past year the Legislature passed the Hender- son-Smith-Simpson-Harris-Stewart bill making provision for the construction of several sanatoria in various parts of the State. Once available, this increased number of beds will help immeasurably in the conquest of tuberculosis. However, even this generous increase fails to meet the established stan- dard of two beds for every death per annum. 3. Rehabilitation. Rehabilitation has been carried out under the Depart- ment of Education, which has received additional funds to pro- vide training for tuberculosis patients in order that they may be rendered financially independent upon discharge from the sanatorium. Instruction in several vocations has been made available to properly selected candidates. One such ex-sana- torium patient is now gainfully employed by the State as an x-ray technician. 18 4. Social Security. Although this Department has enjoyed the full coopera- tion of the Departmen of Public Welfare in procuring finan- cial aid for hospitalization, still it is vital that consideration be given to the adequate support of the dependents of that person who must be hospitalized. Tuberculosis is not merely a medical problem; it is also a socio-economic problem. Thus, until such a time as communities will accept this responsibili- ty, our goal will be delayed, for patients will continue to do as all too frequently happens—leave our sanatoria against advice while still infectious in order that they may more ad- equately support their dependents. The State Health Department’s tuberculosis control pro- gram has made considerable progress during the past year. Much of this would not have been possible without the coop- eration of various agencies, especially that of the county health officers, their respective staffs and the private physicians throughout the State. Progress Made in Industrial Hygiene The Department’s industrial hygiene activities were car- ried on by a staff consisting of a medical director, an indus- trial hygiene engineer, an industrial hygiene chemist, and a clerk-stenographer. In spite of the handicap of the separa- tion of the laboratory from the office, notable work with Ala- bama industry was accomplished. The program of engineer- ing and chemical service for the determination of occupation- al environmental hazards and their control was increased and 52 different plants, employing 114,980 people, were serviced. To accomplish this 136 visits were made. Among the types of service given were 93 environmental surveys, studies and consultations, and 47 medical, nursing and dental surveys, studies and consultations. A total of 4,707 workers were af- fected by recommendations on environmental control and 10,- 940 were benefited by recommendations for improvement of health and welfare provisions, while 334 samples were col- lected for laboratory analysis, including 329 field determina- tions of physical conditions. Workers examined medically for evidence of occupational disease totaled 162. 19 Industrial hygiene activities also included a number of lectures on occupational diseases to the Alabama Society of Safety Engineers, the Personnel Managers Association, the Congress of Industrial Organizations, the interne staff of the Hillman-Jefferson Hospital, and other interested groups. Several articles were written, the most noteworthy con- tribution to the literature being an analysis of the use of alum- inum in silicosis control. This paper was written after an ex- tensive trip to various centers in the United States using this new method of treatment. The findings have proven of ben- efit to labor and management in Alabama industry. It is believed that some of the occupational disease prob- lems in Alabama have been brought to the attention of respon- sible members of Alabama industry and that a good start toward environmental control has been made during the past year. Increased Demands Upon Cancer Control Program The State Career Control Program was officially launch- ed on October 1, 1943 so the present fiscal year marks the second year of operation. No radical changes were made in the methods of operation, but there was a steady and continu- ous growth in the demand for services. As the knowledge of the program spread physicians referred more and more cases to the clinics for diagnosis and treatment. All of the clinics had difficulty in operation due to the scarcity of hospital beds and to the overcrowded staff, but in spite of these handicaps the six clinics in operation handled an increased number of patients. The records show that 485 patients were treated during the year, as compared to 264 during the first year of operation. Still too many hopeless far-advanced cases were coming in for the first time but in addition to this group many early, treatable cases wTere seen and started on proper therapy. The Field Army of the American Cancer Society contin- ued to expand its educational program. Knowledge is the only weapon in the arsenal that will send those needing diag- 20 nosis and treatment to their doctors and onto the clinics at the stage when something can be done. The Legislature rec- ognized the value of the program by voting increased funds for its operation during the next two years—a period during which some of the war difficulties will not longer apply and when even more rapid progress should be made. Certificates Decline One of the Department’s most important duties is the registration of original certificates of birth, death, stillbirth and marriage. During the year 1944-45, 137,850 such rec- ords were received, numbered and bound in volumes of 500 certificates each. This was an average of 11,488 per month, slightly less than the average of 11,762 per month last year. During the year a new system of accounting for the fees received for certified copies was put into effect. Each re- quest is written up in triplicate showing the nature of the re- quest and amount of money enclosed. One copy is filed in series and shows the final disposition of the request. It has not been possible to issue a detailed annual report since 1940; however an abridged report showing facts as to births, deaths and stillbirths has been mimeographed for the years 1941, 1942 and 1943. This is in addition to the table showing death rates for the principal causes of death prepared each month for the Journal of the Medical Association of the State of Alabama. An average of 12,640 pieces of mail dealing with vital statistics were received each month. This was about 19 per cent less than the average amount received during the pre- vious year. This decrease was due to the lessened demand for certified copies of records since the end of the war. As a result of this decrease in requests for certified copies it has been possible to reduce vital statistics personnel ten per cent and also to resume important vital statistics activities which had to be discontinued during the war. 21 Fewer Laboratory Specimens Examined During the fiscal year 1944-45 nearly 60,000 fewer speci- mens were examined in the laboratories of the State Depart- ment of Health than in the previous fiscal year; this can be accounted for in large measure by the decrease in routine diagnostic specimens tested for serologic evidence of syphilis. The loss would have been far greater had not some 68,000 blood specimens been taken and examined in connection with the State serologic survey being carried out under the Hen- derson Act. Fewer examinations were also made for intesti- nal parasites, malaria, tuberculosis, and meningitis, while an increased number of specimens were examined for enteric in- fections, gonorrhea, primary syphilis, serologic evidence of enteric infection, typhus, undulant fever, diphtheria and ra- bies. The most notable increase in examinations was in the case of specimens submitted for study in an attempt to un- cover evidence of rabies. This year twice as many animal heads were examined for this purpose as in the previous year and the great majority of them came from two counties—Mo- bile and Jefferson. In both these counties it is worthy of note that no rabies control program worthy of the name was in op- eration during most of the fiscal year, which fact undoubted- ly is responsible for this condition. However, extensive anti- rabies programs were begun in both counties in the closing months of the fiscal year and it is expected that marked im- provement will result. Other items of special interest in connection with the De- partment’s laboratory activities were: 1. The number of confirmed cases of undulant fever. 2. The isolation of a number of species of paratyphoid organisms found for the first time in Alabama. 3. The rarity of cases of malaria in which parasites were demonstrated. 4. Introduction of new technics for examination of spec- imens from suspected cases of typhus and Rocky Mountain spotted fever. 22 5. Closing of the branch laboratories in Tuscaloosa and Selma because of a shortage of competent personnel. 6. Continued loss of technically trained workers because of low salaries paid in Alabama as compared to other states. Rabies Still A Problem Rabies,* still a public health problem in Alabama, was re- ported among animals in 37 counties in 1944-45 and there were three human cases of rabies. Two of these were bitten by rabid dogs and one by a rabid fox. Though the Alabama Rabies Control Act for the suppression of rabies by vaccina- tion of dogs has been in force since 1937, all counties have not provided for its enforcement. The rabies control program is a joint project of the State Health Department and the State Department of Agriculture. In May, 1945 these agencies provided for the appointment of a Public Health Veterinarian to supervise rabies control work. This has made it possible to organize rabies vaccination clinics for dogs in all counties where rabies is prevalent. The presence of rabies among foxes in southern Alabama has made it necessary to obtain the aid of the Federal Wild Life Service as reduction of the number of foxes is the only means available for controlling the disease in this animal. Fox rabies was eliminated from Clarke County by destroying 955 foxes. It was not possible nor was it considered necessary to kill all the foxes in the county. Research studies completed in 1945 have shown that dogs receiving a single injection of commercial canine rabies vaccine maintain a high degree of immunity for one year af- ter vaccination. Dogs receiving three weekly injections of vaccine were found to be solidly immune to rabies at one month after vaccination. Other virus diseases were studied in 1945. The virus of pseudo-rabies was identified for the first time in Alabama during the past year. This virus is re- sponsible for so-called “mad itch,” a highly fatal disease of (*The studies and observations herein reported were conducted with the support and under the auspices of the International Health Division of the Rockefeller Foundation and the Alabama State Board of Health.) 23 cattle. Man is not susceptible to the disease. The virus of equine encephalomyelitis, Eastern type, was isolated in Hous- ton County in 1945. This disease is maintained in certain game birds and is transmitted to man and horses by mos- quitoes. Public Water Supplies Inspected Yearly In protecting the people of the State against water-borne diseases, the State Department of Health inspected all public water supplies at least once during the year, checking operat- ing procedures, advising and consulting with operating per- sonnel and discussing the problems of public health protec- tion with water works officials. In most instances complete reports, including recommendations, were submitted to the proper persons. Thirteen hundred and seventy reports and letters were written in regard to the public water supplies. Three hundred and fifty-nine such inspections were made during the fiscal year. These were in addition to the labora- tory examination of 14,605 water samples. Functioning as the official State agency for the checking of plans and specifications of proposed new water works and the issuance of permits for their construction, and for modi- fications, improvements and alterations in existing supplies, the Department issued permits in 1944-45 for the construc- tion of 26 new water works and new sources of supply and also issued permits for the modification of 17 existing public water supplies. Thirty-six water works projects were com- pleted during the year, representing an estimated monthly value of $1,122,900. Sixteen projects were under construc- tion at the year’s end, the total of which will cost approxi- mately $609,000. Impressive as they are as representing what has been done under the handicaps of wartime, when materials, labor and supplies are extremely “tight,” these 1944-45 projects represent only a fraction of those completed during a normal peacetime year and are expected to represent an even smaller fraction of what will be regarded as normal for a postwar year. It is estimated that the public water sup- plies now in service in this State supply water for approxi- mately one and one-half million persons, or slightly more than one half of the State’s total population. 24 Malaria Control With DDT A new approach to the control of malaria in the form of DDT as a residual insecticide was employed during the 1944- 45 fiscal year. On the basis of records which indicated ma- laria to be a particularly serious problem there, 65 precincts in the counties of Autauga, Dallas, Greene, Lowndes, Maren- go and Montgomery were included in the program. From April 1 to September 30, 15,930 pounds of DDT were used in treating 18,500 houses. As the toxicity of the applied spray diminished rapidly after three monchs, it was necessary to treat the majority of the houses twice during the season. Treated houses were inspected frequently and the DDT spray was found to be particularly effective against mosquitoes, flies and other household pests. The Department continued to assume responsibility for control of the malarial mosquito in areas contiguous to mili- tary establishments. Malaria control measures in the form of drainage, ditch maintenance and larvicidal treatment of mos- quito-breeding waters were applied in the vicinity of seven- teen military and industrial establishments, while seventy- eight others were under entomological surveillance. The war area malaria control and DDT spraying pro- grams were directed and supervised by the Department’s en- gineers with the Federal government, through the U. S. Pub- lic Health Service, contributing approximately $160,000 in personnel, materials and equipment. Other Control Methods Also Used The owning agencies of nineteen major impoundments combatted the production of Anopheles quadrimaculatus mos- quitoes on those large lakes having a combined area of 392 square miles by the application of 98,904 gallons of larvicidal oils and 359,925 pounds of paris green. Water level manage- ment and shoreline maintenance were also used extensively while house mosquito-proofing and DDT residual sprays sup- plemented other malaria control measures in the heaviest mos- quito producing areas of Wheeler and Guntersville Reservoirs. Control of mosquito production on major impoundments was, 25 on the whole, satisfactory; and, although higher Anopheles quadrimaculatus densities than anticipated were experienced on Bankhead, Guntersville, Purdy, Pickwick and Wilson Lakes, this did not, on the basis of reports received, result in a cor- responding increase in the prevalence of malaria. Minor impounded water activities included the receipt of 61 applications to impound waters, issuance of 55 preliminary permits and granting of authority to impound to 19 persons. As of September 30 there were 1,134 minor impounded water projects (each less than 100 acres in area) recorded with the Department as having been constructed since 1927. These have a total area of approximately 4,325 acres, and 173,450 persons are reported to live within one mile of their shores. Special surveys to determine the density of Anopheles quadrimaculatus were made in ten Alabama counties. This information will be correlated with reconnaissance surveys, mortality and morbidity statistics to evaluate the present as well as potential malaria problems in these counties. Sanitation Program Handicapped Shortages of sanitation officers, labor and materials greatly handicapped the Department’s general sanitation pro- gram, and it was virtually brought to a standstill, as far as new construction and repairs were concerned, by a Federal freeze-order on lumber. However, the effect of the freeze- order was partly relieved by an authorization obtained from the War Production Board granting permission for the pur- chase of a limited amount of lumber under priority rating for the construction of pit privies. During the year approval was given to the completion or restoration of approximately 6,600 installations, providing 34,130 persons with suitable excreta disposal facilities. This total included 2,936 new privies, 1,268 new septic tanks, 1,872 sewer connections, 418 restored privies and 100 restored sep- tic tanks. A statewide survey of swimming pools by the Depart- ment’s engineers was completed. Engineering reports rela- 26 tive to the construction and operation of each swimming pool, embodying recommendations for improvements, were prepar- ed and submitted through the county health departments to the owners. Sewerage System Improvement Also Hampered The restriction upon materials and equipment also seri- ously affected the improvement of sewerage systems, it being virtually impossible to construct or improve such systems ex- cept in war areas. These restrictions limited the granting of sewerage improvement permits during the fiscal year to only six, including those for sewer extensions in Slocomb, a new sewerage system for Goodrich (Tuscaloosa), a sewage pump- ing station at Dadeville, and improvements to two sewage treatment plants. New sewage projects completed during the year at an estimated cost of $470,000 consisted of five im- provements to municipal systems, three improvements to school systems and one system for a housing project. One sewerage project was under way at the end of the fiscal year. Engineering surveys were made and reports written for sewer- age improvements of seven schools and other places on which construction has not been started. Drafting Work Increases The Department’s drafting activities for the fiscal year followed closely the rapidly changing scenes leading up to the end of the war. The usual amount of routine work on charts, maps, stencils and drawings for the various bureaus of the Health Department was augmented by the additional drafting work done in connection with, first, the spread of typhus in- fected reservoirs in the State, and second, of Malaria Control in War Areas. In preparation for these special programs, a large num- ber of index maps showing beats in the participating counties were made. Later a great amount of work was done on trac- ings from aerial photographs which were used in the DDT spraying operations of the Extended Malaria Control Program. There yet remains a greater part of the mapping in this con- nection to be done. Plans were drawn and a contract let for the construction of the library shelving which was built in the 27 office adjoining the drafting room. When this was completed the technical library of the Bureau of Sanitation was moved down from the main Health Department and installed. This has greatly improved the facility of the valuable collection of technical information which has been indexed. As the typhus control program continued its expansion, plans for two additional rooms at the rear of the building were drawn up, the contract let, and at the end of the fiscal year the building of these extensions was nearing completion. That the fiscal year has been a busy one for the drafting staff is emphasized by the tangible evidence of large maps, charts and drawings completed. Approximately 1,500 prints and charts were distributed. Drawings for the fiscal year 1944-1945 were as follows: Small Charts ..... 67 Large Charts ... ... 12 Sanitary Surveys 11 Sketch Maps - 29 County Maps ..... 42 Plan and Profile (sewerage) Plan and Profile (drainage) ... 4 11 Sketch Plans . - .... 34 Stencils Misc. U. S. O. Certificates Placards ... Posters 145 70 31 13 469 Inspections Decrease There was a decrease in the number of inspections of food-handling establishments by members of the State Health Department’s inspection staff—9,976 in 1945, as compared with 11,627 in the previous twelve months. The inspection staff consisted of only five inspectors until the last quarter of the year. This is one less than for the previous year. In keeping with the exigencies of the times, inspection of food- manufacturing plants and milk and milk products plants con- tinued to receive considerable emphasis, because of the large number of potential exposures to infection through the con- sumption of products handled by such plants. Food-serving establishments in crowded defense areas also received par- ticular attention. 28 Although, fortunately, the losses in county inspection per- sonnel were not as heavy as in each of the previous three years, that phase of the health-protection program suffered considerably from the general shortage of capable, trained workers. Twenty-five counties were without inspection ser- vice at the end of the fiscal year, while 20 other counties were obliged to share their inspection personnel with one or two other counties. Thus only 22 counties faced the new fiscal year with full-time inspectors or inspector-sanitarians. This represented a decrease of two from the total of a year before. Death Brings Change in Typhus Control On February 14, 1945, Dr. Andrew J. Perolio, for several years director of typhus fever control work in the State, died. His duties were assumed by Mr. H. H. Gilmore, assistant sani- tary engineer, under the direction of the Bureau of Sanitation Director, Mr. T. H. Milford. During the year three towns working through the Health Department began rat proofing projects. These were Mobile, Brewton, and Dothan, all previously reporting large numbers of typhus fever cases. The appropriating body of one county, Houston, set up approximately $15,000 to match Federal and State funds for a countywise typhus control program. This work began in July. To date, three beats have been worked. Two other counties, Covington and Dale, have provided for a full-time man each to carry on continuous control work. During 1945, forty-two extermination campaigns in mu- nicipalities were conducted under the supervision of the Ty- phus Division personnel. The comparable figure for 1944 was thirteen campaigns. In July 1945, the U. S. Public Health Service proposed the use of DDT as a somewhat experimental aid in typhus con- trol, the idea being to destroy the rat flea which is the agent responsible for the transmission of endemic typhus fever (Brill’s disease) from the rat to man. From the nine “typhus states” the 140 counties having the largest number of reported 29 typhus cases were determined. Within the financial limits these counties are approved for DDT dusting programs where practical, as determined by the various states. Alabama had 17 counties in this category. To apply DDT dust in certain of these counties, the Health Department has been allocated approximately 45 men, transportation, the necessary DDT powder and equipment. Federal funds amounting to approx- imately $90,000 have been allocated to finance this phase of typhus control work until June 30, 1946. This work is under way, and, where possible, rat extermination procedures are incorporated with the dusting program. The tentative figures indicate considerably fewer cases of typhus fever in 1945 than in the previous year, the compar- ison being 697 to 862. Better Health Through Health Education As in previous years, health education had an important role during the 1944-45 fiscal year in the State Health De- partment’s unending and unrelenting campaign against pre- ventable disease and postponable death. Chief reliance con- tinued to be placed upon health journalism, visual education and the radio, but the other means of lifting the State’s level of health knowledge were not neglected. During that twelve-month period 589 releases were issued to the two Montgomery daily papers, the Associated Press and the United Press, which serve practically every daily pa- per in the State. In addition to these, the Department issued directly to the weekly papers and the dailies published out- side Montgomery weekly releases intended primarily for the former group, which do not have access to its regular daily releases as a result of their not being members of the above- mentioned newsgathering organizations. These weekly re- leases were aimed especially at rural readers and dealt, inso- far as practicable, with the peculiar health needs of this im- portant segment of the State’s population. The weekly feature health article State Health Chats was prepared, as in the past, for the Associated Press and made available by the A. P. to its member newspapers in all parts of the State. Articles on various aspects of public and individual health were prepared for publication in The Journal of the Medical Association of the State of Alabama, This Month in Rural Ala- bama and other publications, some intended for the general public and others appealing primarily to certain groups or per- sons of certain special interests. The Public Health News Bul- letin, which was launched in the fall of 1943 as a means of keeping staff members of the State and county health depart- ments informed regarding each other’s activities and the work of these official agencies, made its customary biweekly ap- pearance throughout the year. At the end of the fiscal year 275 copies were being made of each issue. It continued to be mimeographed. Although the work incident to preparing the 36-page illustrated booklet Public Health Is Many Things for the printers was done in 1943-44, printing delays due to the war prevented its actual publication and the beginning of distribution until November, 1944, Other activities of a jour- nalistic public health nature carried on during the fiscal year include the preparation of special reports for governmental agencies, the editing of the State Health Department’s annual reports, the distribution of numerous health booklets and pam- phlets and other similar tasks. Through the continuing courtesy of Station WSFA (Mont- gomery) the Department’s weekly radio talks were heard by residents of approximately 25 Central Alabama counties con- taining an estimated half-million potential listeners. As in previous years, these talks were mimeographed and used as health education material. A considerable number of these have subsequently been published in magazines, newspapers and health publications in Alabama and other states, reaching in that way many thousands who were not able to hear the broadcasts or read the talks in mimeographed form. Early in the new fiscal year it was decided to make the Film Library statewide by making its facilities and services available to every county health department in the State which might wish to avail itself of this opportunity. Notices of this change were sent to the 24 county health departments which were not already members, along with membership blanks, which they were requested to sign and return, and full infor- mation regarding the Film Library’s operation and the obli- 31 gations of members. Because of the difficulty in obtaining projection machines and for other reasons, only a relatively few of them returned the requisite membership agreement forms, but it is believed that others will do so as the abnormal conditions brought by the war are succeeded by the more nearly normal conditions of the postwar period. Film book- ings during the fiscal year numbered 458. Many Use Library Facilities During the year the library’s 4,000 volumes and 134 peri- odicals were used approximately 2,170 times. The library circulated 730 journals, books, pamphlets and reports to mem- bers of the staff of the Health Department, county health de- partments, students and research workers. More than 150 times the library answered inquiries ranging in variety from information on Raynaud’s disease to who wrote Thanatopsis. The most frequent requests came for articles about the Rh factor, penicillin, DDT, amebiasis, and socialized medicine. Exclusive of the 1944 periodicals which have been bound, 269 books were accessioned in 1944, among them the 1944 edition of Stitt and Strong’s two-volume Diagnosis, Prevention and Treatment of Tropical Diseases, and Charles F. Craig’s Etiol- ogy, Diagnosis and Treatment of Amebiasis. The dental sec- tion of the library was augmented in June by 18 new books on dentistry and subscriptions to 26 dental publications. Machine Tabulation Aids Public Health Work The work of the entire State Department of Health and county health departments was immeasurably assisted and, to a large extent made possible, by the Department’s system of machine tabulation, which places record-keeping and statis- tics-preparation on a mass-production basis. This system was particularly helpful during the 1944-45 fiscal year in the prep- aration of birth, marriage and death reports and records, the weekly communicable disease reports, the annual morbidity tables, the reports on the compulsory blood-testing of Ala- bamians between the ages of 14 and 50, as provided by the Henderson Act, the statistical studies of the work of the ve- nereal disease diagnostic and treatment clinics, the reports on the operation of the cancer clinics, the summaries of the cost 32 and outcome of maternity and infant care cases handled bT~ the Department under the Emergency Maternity and Infam Care Program, the reports on tests conducted by the Depart- ment’s central laboratory in Montgomery and its branch lab- oratories, and the quarterly reports of county health depart- ment activities for transmission to the U. S. Public Health Service. The Central Registry of Venereal Disease Contacts, which was formerly operated by the U. S. Public Health Service, was taken over during the past fiscal year by the State Depart- ment of Health. Important Legislation Passed A number of important laws affecting public health were passed by the Legislature during its 1945 session. The most far-reaching of these was the one providing for the construction and operation at public expense of commun- ity hospitals in those cities and towns in need of them. The bill’s primary purpose is to enable this State to receive its share of the Federal funds which are expected to be made available for hospital construction in all parts of the country under the provisions of the Hill-Neely bill, which was still awaiting action by Congress at the fiscal year’s end, with ex- cellent prospects oT eventually being passed, although with some modification. Specifically, the 1945 measure authorizes the State Board of Health to “acquire, equip, maintain and operate” public hospitals, health centers and related facilities for the treat- ment of any type of disease and also authorizes and requires the State Board of Health to set up a “master hospital plan” by which the State will be divided into .-egions, districts, or zones to be served by tire hospitals to be constructed with Fed- eral funds anticipated from the Hill-Neely bill. An advisory council, composed of State officials and outstanding private citizens, was created and authorized to approve all policies and regulations necessary for carrying out the purposes of the act. Local hospital associations are to be formed to initiate plans for needed community hospitals and health centers and 33 present those communities’ hospital needs to the State Board of Health, which is designated as the official representative of the State of Alabama for the receipt, handling and dis- bursement of hospital construction funds which may be made available by the Federal and State governments, philanthro- pic agencies and other sources. The Hill-Neely bill, as intro- duced, provided for a Federal appropriation of $5,000,000 for hospital surveys and $100,000,000 a year for five years as grants to the individual states on a matching basis, the ratio of Federal to State and local funds to be determined by each state’s per capita wealth and other factors. If, as anticipated, substantial sums in Federal funds be- come available in 1945-46, the action of the State Legislature in passing the hospital construction bill will leave Alabama in an excellent position to take full advantage of these funds. The State Building Commission, of which the State Health Officer is a member, is authorized to allocate to hospital construction part of the approximately $25,000,000 of State funds made available by the Legislature for public buildings. The 1945 Legislature also passed a bill authorizing the use of State funds to aid in the construction of seven regional tuberculosis sanatoria to relieve, as far as possible, the ex- treme shortage of hospital facilities for the treatment of vic- tims of tuberculosis who are unable, because of the expense, to obtain this treatment in private institutions. The State Build- ing Commission is authorized to designate the sum to be used in each regional tuberculosis hospital not to exceed $135,000 for building and equipment for each hospital. Other public health legislation passed at the 1945 legis- lative session included an amendment to the charter of the Hospital Service Corporation of Alabama enabling it to ex- tend its prepayment plan of hospital care to cover medical, surgical and obstetric care of hospital patients, also on a pre- payment basis, at extra cost; a law requiring school teachers, maids, janitors, bus drivers and food-handling employes of schools to be examined periodically for tuberculosis; a meas- ure requiring the Directors of the State Health Department’s Bureau of Preventable Diseases, Division of Inspection and Nutrition Division to inspect the State’s mental, penal and 34 eleemosynary institutions and report their findings to the Governor; creation of a State Commission on Education with Respect to Alcoholism, of which the State Health Officer was made one of the seven members; and of the already mentioned State Building Commission charged with deciding which new buildings are to be erected with State funds and empowered to authorize and supervise their construction; and the voting of additional funds for the State Health Department’s cam- paigns against cancer and endemic typhus fever (Brill’s dis- ease) . Alabamians continued to enjoy excellent health condi- tions during the fiscal year covered by this report, although it is too early yet to be able to show substantial proof of it, as it will be some time before the vital statistics reports for that period are available. The long-range vital statistics picture, as revealed by the latest available reports, is indeed most en- couraging. Declining Death Rates Mirror Progress These reports show that, whereas during the five-year period from 1915 to 1919, inclusive, typhoid fever claimed an average of slightly more than 28 Alabama lives every 12 months for every 100,000 persons living in this State, during the five-year period ending with 1944, typhoid fever deaths averaged less than one per 100,000 population per annum. Tuberculosis, which as recently as 1917, was killing Alabam- ians at the rate of 127 per 100,000 per annum, had an annual death rate for the 1939-44 period of slightly more than 48 per 100,000, or considerably less than half as many as in 1917. Between 1915 and 1919, inclusive, the annual death rate for malaria was 20 per 100,000 population. Between 1939 and 1943, inclusive, it was less than four per 100,000 population (about one-fifth the earlier rate). During the same period the annual death rate for pellagra declined from slightly more than 37 to only 5.7 per 100,000 population, or about 85 per cent; the annual death rate for diarrhea and enteritis (under two years) decreased from 44.3 to only 10.7 per 100,000 pop- ulation, or more than 75 percent, and the annual diphtheria death rate dropped from 8.6 to 1.9 per 100,000 population, or slightly less than 78 per cent. The Alabama infant mor- 35 tality rate declined nearly 50 per cent and the State’s ma- ternal mortality rate nearly 55 per cent between 1918 and 1944. Peace Brings Problems Peace, like the war it succeeded, has brought problems having serious health implications. The social and economic adjustments of wartime will have to be followed by the read- justments of peacetime. Widespread unemployment, which it is hoped will be short-lived, will nevertheless bring the threat of poverty, with its train of illness, undernourishment and neglect of health. There will be a strong temptation to get away from the restraints imposed by war conditions and fly to the other extreme of indulgence and self-gratification, to the detriment of physical well-being. Family life will have to be re-established, and social changes will have to be under- gone. In brief, a new world, brave and happy but fearful, came into being on August 14, 1945, It will require all our resources to keep it healthy and capable of enjoying to the full the ripe fruits of victory. All members of the State Health Department staff now on military leave—39 at the time of the most recent check-up will of course find their positions waiting for them when their periods of service to their country come to an end. (However, the Division of Mental Hygiene, which had been functioning, for a short time before this country entered the war and was discontinued when its personnel entered the ser- vice, will not be revived.) Other postwar activities definitely planned include ex- pansion of the program of environmental health protection, particularly in the fields of malaria and typhus fever control, protection of public water supplies, supervision of food-hand- ling establishments and industrial hygiene; intensification of the campaign against the venereal diseases, including exten- sion of the blood-testing program into the 57 counties which must still be covered before the main objectives of the Hen- derson Act—the completion of compulsory blood-testing in every county of the State—will have been attained; provision 36 of diagnosis and treatment for more and more Alabamians suffering from cancer; expansion of the Department’s ma- ternal and child welfare program to carry this valuable ser- vice to more and more women and children; enlargement of the Department’s laboratory services in both the diagnostic and biologic fields; and provision of more nearly adequate housing for the Department’s staff, with a resultant increase in efficiency, convenience and economy. 37