Public Health Administration and Organization 
for the 
Territorial Board of Health 
Territory of Hawaii 
Recommendations of the Committee on Public Health Administration 
A 
Postwar Planning Committees on Health _ 
Chamber of Commerce of Honolulu 
1946 POSTWAR PLANNING HEALTH COMMITTEES 
of the 
CHAMBER OF COMMERCE OF HONOLULU 
Steering Committee 
Charles L. Wilbar, Jr., M. D., Chairman 
Nils P. Larsen, M* D, 
R, G, Nebelung, Dr. P. H. 
Vivian Johnson, M. A. 
COMMITTEE ON PUBLIC HEALTH ADMINISTRATION 
Robert H. Onstott, M. D,, Chairman 
Subcommittee on Lav's and Regulations 
Mrs. David Y. K. Akana, Chairman F. A. Schramm 
Ronald W. Jamieson C. Nils Tavares 
Subcommittee on Organization and Operating Policies, 
Territorial Board of Health and Official County Health Agencies 
Thomas M, Mossman, M. D., Chairman Kaarlo W. Nasi 
Laura A. Draper R» G. Nebelung 
Thomas H. Richert, M, D. 
Subcomnittee on Inter-Agency Relationships 
Mrs. Marjorie Abel, Chairman 
Lome W. Boll 
Kum Pui Lai 
Joseph W, Lam, M. D, 
Ferris F. Laune 
Samuel M. Wishik, M, D* 
Subcommittoe on Personnel and Fiscal Policies and Practices 
Randolph Lee, Chairman 
Samuel D. Allison, M. D. 
Robert W. Beasley 
Harold W, Boss FOREWORD 
Because of the nature, quality and direction of economic and 
social changes that are taking place now and may be expected in 
the future, the reorganization of our official health agency 
administrative machinery and the development of new programs based 
upon community needs is indispensable for both the well-being of 
society and the welfare of the individual. 
Our organized facilities and services designed to prevent and 
mitigate illness have had for the most part an irregular rate of 
growth, which has produced definite gaps in our programs and made 
more cumbersome the supervisory machinery for rendering both old 
and new services. This report of the Committee on Public Health 
Administration brings into sharp focus certain measures which are 
clearly indicated to insure more economical and efficient operation 
of this agency. The committee, in making its recommendations, has 
tried to keep in mind the need for developing a simplified and 
orderly arrangement of duties and functions. 
A review of the publication will, in numerous sections, arrest 
the eye of the casual observer; and the trained observer will find 
much interest in the contents of the report. 
F, J. Pinkerton, M.D., Chairman 
Public Health Committee 
Chamber of Commerce of Honolulu PREFACE 
Administrative organizations, policies and procedures in any 
field are merely the reflection of program content as influenced by 
local conditions, personalities, and many other less tangible factors. 
In submitting the follov/ing report the committee has attempted to 
toko most of these factors into consideration. Yet public health is 
a constantly changing scene, and what may be the best judgment today 
is not necessarily so tomorrow. Professional personnel are indivi- 
duals, Organizations and programs which are efficient and smooth- 
working with one set of individuals may be totally unsuited to 
another staff who have different personality traits and ambitions. 
Organizations and programs, therefore, must be reasonably flexible. 
We believe the principles involved in the report are sound; 
however, it is hoped that the report will be interpreted in the light 
of the constantly changing influences and personalities. It is not 
a fixed blueprint, Sound advances in public health are evolutionary. 
ROBERT H. ONSTOTT, M.D., Chairman INTRODUCTION 
This publication of the Committee on Public Health Administra- 
tion, which is the result of long hours of study and conferences on 
the part of committee members, points out a number of improvements 
and changes in organization which are suggested for the official 
public health agency of the Territory. Some of these changes can be 
put into effect by action of the Board of Health, others require 
legislative action and additional appropriation of funds. 
As is pointed out in the introductory note of the narrative 
report of the committee, the field of public health is anything but 
static, so that changes suggested today in the organization picture 
of the health agency might not be entirely applicable a year from now. 
This changing picture in public health, as v/ell as the need for 
different emphases on the various branches of a public health program 
brought about by differences in total population, concentration of 
population, wealth of a community, racial and sex make-up of a 
community, are causative factors of the wide diversity of public 
health organizations throughout the country. No two state or 
territorial health departments have the same departmental organiza- 
tion and health departments on the county levels are dissimilar in 
their organizational details. 
This report, I believe, can be most helpful as a guide in 
improving public health organization in the Territory, especially in 
regard to its indications of major principles involved in public 
health organization. 
On behalf of the Steering Committee, I should like to express 
appreciation to those groups and individuals who have participated 
and cooperated in providing material for this report. 
Charles L. Wilbar, Jr., M.D. 
Chairman, Steering Committee PUBLICATION PROCEDURES AND RESPONSIBILITY FOR REPORTS 
Reports of the postwar planning health committees are prepared by 
the several study groups with the aid of the Public Health Committee 
staff of the Chamber of Commerce, Staff members meet regularly with 
the groups during the course of study, Alice L. Spillane has served 
as the liaison field worker between the steering group and the study 
committees. 
A tentative final report in outline form is submitted to the 
Steering Committee for review. The study group chairman then meets 
with the Steering Committee which advises, offers suggestions regard- 
ing changes, and then refers the project back to the study group for 
further consideration. The final revision is resubmitted to the Steer- 
ing Committee for approval both in outline and narrative forms. The 
purpose of the outline is to enable anyone to readily appraise the 
present status of a particular program and the recommendations of the 
study committee without having to peruse the entire report. Each 
finally revised report will include any dissenting opinions of the com- 
mittee members v/hich they may request be published. Reports are 
issued as the work of the particular committee preparing them. 
Individual recommendations nay be considered to represent the views 
of the committee as a whole. 
R. G. Nebelung, Dr, P,H, 
Executive Director 
Public Health Committee TABLE OF CONTENTS 
Pa^e 
Outline of Suggested Recommendations ....... . . 1 
Organization of the Board of Health 13 
Organization of the Department of Health 14 
1. The Bureau of Local Health Services 15 
a. The Division of Public Health Nursing 15 
b. The Division of County Health Officers and Govern- 
ment Physicians , 15 
2. The Bureau of Preventive Medicine. . 16 
a. The Division of Laboratories 17 
b. The Division of Tuberculosis Control IS 
c. The Venereal Disease Control Division, 18 
d. The Division of Maternal and Child Health and Crip- 
pled Children IB 
e. The Division of Epidemiology IB 
f. The Division of Mental Hygiene 19 
g. The Division of Nutrition. 19 
h. The Division of Geriatrics and Cancer Control. ... 19 
i. The Division of Dental Health. 20 
j. Other Divisions 21 
3. The Bureau of Sanitary Engineering 22 
4. The Bureau of Central Administration 23 
a. The Division of Business Management 23 
b. The Division of Personnel Administration 24 
c. The Division of Public Health Statistics 24 
d. The Division of Public Health Education 25 
A Bureau of Medical Services 25 
General Considerations ...... 26 
Physical Facilities 26 
Appropriations. 27 
School Health .......... 2B 
Communicable-Disease Hospitalization 28 
Postgraduate Medical Education 29 
Indigent Medical Care 29 
Personnel Classification, . . 29 
Inter-Agency Relations 30 
Public Health Laws and Regulations. 31 Committee on Public Health Administration 
Postwar Planning Committees for Health 
OUTLINE OF SUGGESTED REGOMMENDATIONS 2 
Long-range Ucnectiveg or Action 
Suggestions and Recommendations for 
Health's regulation-making 
power under section 2015, R.L.H. 
1945, as amended, to specifical- 
ly named subjects be cured, 
because too many subjects worthy 
of regulation fall in the gaps 
between the named subjects. 
3. The President be freed from the 
details of internal administra- 
tion, that he may be able to 
devote himself to public rela- 
tions, policy-making, observa- 
tion and analysis of Board of 
Immediate Action 
Chap. 50; Sec. 2657-2658, Licen- 
sing of Naturopathic physicians 
Chap* 51; Sec, 2701-2781, Abate- 
ment of nuisances 
Chap. 54-J Sec. 2855, Examination 
fee 
Chap. 56; Sec. 2951-2956, Sals 
of Poisons 
Chap. 57; Sec. 3001-3004, Radium; 
use for medical and surgical 
purposes 
Chap. 58; Sec. 3051-3058, 
Undertakers, embalraers, 
funeral directors 
Chap. 59; Sec. 3073, veterinary 
medicine and surgery and den- 
tistry report of board of 
examiners to Board of Health 
Chap. 60; Sec. 3101-3128, 
Vital Statistics (births, deaths 
marriages) 
II. Territorial Board of Health 
Responsibility for administra- 
tion of program to protect and 
preserve the health of the people 
in the Territory vested in the 
Territorial Board of Health. 
Present Situation 
(Services and Resources) 3 
Long-range Objectives or Action 
Suggestions and Recommendations for 
Health operations, and of the 
total health situation in the 
Territory, broad program making, 
and keeping in touch with the 
best thought on public health 
in the Territory and elsewhere. 
4-. A Bureau of Local Health Services 
be established. 
5. The health officers of the 
counties of Hawaii, Maui and 
Kauai be experienced, qualified 
physicians; and, under the di- 
rection of the President and 
Chief of the Bureau of Local 
Health Services, have full power 
and responsibility for the ad- 
ministration of the public-healti 
programs in their counties. 
6. The Chief of the Bureau of Local 
Health Services have direct 
supervision of the operating 
program in the City and County 
of Honolulu and should supervise 
the activities of the several 
county health officers. 
7. The specialists and the directors 
of the various bureaus and divi- 
sions (except the Chief of the 
Immediate Action 
1. Board of Health 
Nine members including 
Attorney General as ex-offi- 
cio member; members appoint- 
ed by Governor for 4- year 
term; members to serve with- 
out pay, except President 
who is executive officer of 
the Board. 
2. Program and Personnel 
President and Executive 
Officer; Director of Public 
Health 
a. General Admini strati on: 
1) Finance 
Chief Clerk 
Budget Officer 
Business transactions 
of Board of Health; 
total budget for 
194-5 fiscal year was 
11,124., 54-2.69 
2) Personnel 
Personnel administra- 
tor—Responsible for 
recommendations re; 
position classifica- 
tions; employer- 
employe relationships; 
piacement; training; 
promotions; termina- 
tions, etc. 
* As outlined In 1944-194-5 Annual 
Report to the Governor 
Present Situation 
(Services and Resources). Long-range Objectives or Action 
4 
Suggestions and Recommendations for 
Bureau of Local Health Services) 
be merely consultants to the 
health officers of the counties 
of Hawaii, Maui and Kauai and 
not exercise authority over them 
except at the direction of the 
President through the Chief of 
the Bureau of Local Health Ser- 
vices, 
B. The government physicians in the 
counties of Hawaii, Maui and 
Kauai be under the direction of 
the health officer for the 
county; in the City and County 
of Honolulu, under the direction 
of the Chief of the Bureau of 
Local Health Services. 
9. The Bureau of Local Health Ser- 
vices include a division of 
public health nursing which 
should be headed by a director 
and should include an assistant 
director for education. 
10, There be a Bureau of Preventive 
Medicine which should be under 
the direction of its director 
and include the following 
divisions; laboratories, tuber- 
culosis control, venereal 
disease control, maternal and 
Immediate Action 
Total number person- 
nel: 
650 full-time 
42 part-time 
3) Public Health Educa- 
tion 
Acting Director 
Assft. to Director 
Secretary 
Tcchnician-clerk 
(part-time) 
Program includes news 
releases; distribution 
of films, pamphlets; 
radio releases and 
programs; talks to lay 
groups; assistance to 
department staff on 
preparation of talks, 
articles, etc.; pub- 
lication of "Health 
Messenger”, 
4.) County Health Admi- 
nistration 
Administration and 
supervision of public 
health program on 
other islands, 
b. Bureaus and Divisions 
1) Bureau of Vital Sta- 
tistics 
Acting Registrar Gen- 
eral 
Present Situation 
. iSffXYiaaa. md Respurges) 5 
Long-range Objective5 or Action 
Suggestions and Recommendations for 
child health and crippled 
children, epidemiology, mental 
hygiene, nutrition, geriatrics 
and cancer control, a division 
of dental health, and industrial 
hygiene, each of which, in turn, 
should be headed by a director, 
11, There be a Bureau of Sanitary 
Engineering under the direction 
of its director which should 
include divisions as follows: 
water, sewage and general sani- 
tation; milk and food handling 
establishments; housing; pure 
food and drug; rodent control; 
and insect control; each of 
vdiich, inturn, should be headed 
by a director, 
12. There be a Bureau of Central 
Administration, under the direc- 
tion of its director, which 
includes the following divisions 
business management, property 
control, personnel administra- 
tion, public health statistics, 
and public health education, 
each of which, in turn, should 
be headed by a director. 
Immediate Action 
Statistical and Cleri- 
cal staff. 
Program has three 
major functions: 
a) Registration and 
preservation of all 
vital records. 
b) Compilation and ta- 
bulation of vital 
statistics. 
c) Issuance of certi- 
fied copies and 
performance of 
searches of records 
for data requested 
by the public. 
2) Bureau of Sanitation 
Director; Ass1t, Di- 
rector; Clerical Staff 
a) Division of Sani- 
tary Engineering: 
65 sanitary 
inspectors. 
Program: investiga- 
tion and control 
of rater supply 
areas, drainage 
and sewerage, and 
housing. 
Present Situation 
(Services and Resources) 6 
Long-range Ob.iectives or Action 
Suggestions and Recommendations for 
1Z., The Legislature grant a single 
departmental appropriation for 
the Board of Health, based on a 
budget, and allocable by the 
Board of Health to its various 
uses according to its best 
judgment. Quarterly allotments 
would be made on the basis of 
detailed budgets and at the end 
of each biennium the Board shouli 
be required to report to the 
Governor and to the Legislature 
its use of the appropriation. 
13. The Board of Health be provided 
with a new building in Honolulu, 
which would include a new healtl 
center. The Kapahulu and Lana- 
kila Health Centers be continued 
and devoted exclusively to the 
local health program; Board of 
Health facilities at Hilo, 
Wailuku and Lihue, now inade- 
quate, be expanded and improved; 
modern, clean and attractive 
Board of Health facilities be 
established at strategic loca- 
tions in each county as the 
local health centers. 
Immediate Action 
b) Public Health En- 
gineering Labora- 
tory; 
Staff 3. 
Program; sampling 
of potable and non- 
potable water, 
sewage; determine 
bacterial and che- 
mical analyses for 
food, drug, milk 
and others. 
c) Division of Pure 
Food and Drugs: 
Food Commissioner 
& Analyst. 
Staff U. 
Program; regulatoiy 
control of food 
and drug consumed 
in the Territory. 
Enforcement of 
territorial laws 
re; food, drugs, 
cosmetics; inves- 
tigation of com- 
plaints; licensing 
of poison dealers 
and itinerant 
vendors. 
Present Situation 
(Services and Resources) 7 
Long-range Objectives or Action 
Suggestions and Recommendations for 
15. A school health section be estab 
lished in the Bureau of Local 
Health Services or in the 
Maternal and Child Health Divi- 
sion. 
16, Whenever the hospitalization of 
any person is required by law 
for contagious disease, the 
Board of Health pay the expenses 
of such isolation or hospitali- 
zation or make available T/ithout 
cost the facilities for such 
isolation or hospitalization. 
17. The medical care program for in- 
digents, now divided between the 
Board of Health and the Depart- 
ment of Public Welfare, be made 
less cumbersome in its operation 
18..Board of Health positions con- 
tinue to be classified by the 
Personnel Classification Board 
of the Territory; but that the 
Board of Health and Personnel 
Classification Board seriously 
consider the appropriateness of 
various classifications and job 
descriptions and of commencing 
in the near future the limited 
use of the P-B classification. 
Immediate Action 
d) Division of Indus- 
trial Hygiene; 
Director (Ass*t. 
Director of Bur- 
eau) . 
Five major aspects 
of program; (l) 
collaborate with 
other health and 
safety programs in 
development of 
practices on and 
off worksites to 
increase and im- 
prove working con- 
ditions and health 
of workers; (2) 
assist in promot- 
ing medical exami- 
nations for per- 
sons to be employ- 
ed in hazardous 
occupations; (3) 
arrange separation 
of persons report- 
ed by physicians 
as having symptoms 
of industrial ill- 
ness and assist in 
arranging treat- 
ment of such per- 
sons; (A) survey 
hazardous indus- 
trial conditions 
Present Situation 
(Services and Resources) 8 
Long-range Objectives or Action 
Suggestions and Recommendations for 
Immediate Action 
and make recom- 
mendations for 
their control; 
(5) educate public 
workers, manage- 
ment and profes- 
sional personnel 
toward better 
protection of the 
health and welfare 
of workers. 
e) Division of Rodent 
Control: 
Director; Staff 
203. 
Program: eradica- 
tion of plague 
and control of 
rodents by cor- 
rection of har- 
borage and food 
conditions fos- 
tering infesta- 
tion; enf orcemeni. 
of ratproofing 
measures; sup- 
pression of ro- 
dents by trapping, 
poisoning, gas- 
sing, and other 
methods. 
f) Division of Mos- 
quito Control: 
Director; Staff 
156. 
Present Situation 
(Services and Resources) 9 
Long-range Objectives or Action 
Suggestions and Recommendations for 
Immediate Action 
Program: control i 
of mosquitoes by 
destruction of 
adult Aedes mos- 
quito; cleanup 
campaigns; rock 
and tree-hole 
filling; roof 
gutter drainage; 
insecticiding; 
storm drain lar- 
viciding and 
other methods. 
Educational pro- 
gram: Utilize 
radio5 press, and 
other methods; 
cooperate vrith 
Department of Pub- 
lic Instruction to 
include unit on 
mosquito control. 
3) Bureau of Communicable 
Diseases; 
Director; Government 
Physicians; Acting Di- 
rector of the Bacter 
riological Laboratory, 
Program: control of 
communicable diseases 
other than tuberculo- 
sis and the venereal 
diseases. 
Present Situation 
(Services and Resources) 10 
Long-range Objectives or Action 
Suggestions and Recommendations for 
Immediate Action 
a) Division of Bacte- 
riological Labora- 
tories; 
Setting of standards 
for laboratory own- 
ers, directors and 
technicians desirinj 
Board of Health cer- 
tification. Inves- 
tigation and licen- 
sing of labs con- 
ducting prenatal 
and serological 
tests. Functions of 
lab include exami- 
nation of specimens 
of suspected cases 
of communicable 
diseases for physi- 
cians and health 
officers; periodic 
examination of 
water samples from 
public and insti- 
tutional water sup-; 
plies, swimming 
pools and beaches; 
examination of sam- 
ples of ice, water 
•and sewage and in- 
dustrial wastes, 
milt, frozen des- 
serts, poi and othei 
foods; examination 
Present Situation 
(Services and Resources) Long-range Ob.iactives or Action 
Suggestions and Recommendations for 
Immediate Action 
of blood specimens| 
investigations and 
research in connec- 
tion with outbreaks 
of disease. 
4.) Bureau of Venereal Di- 
seases 
Director; Medical and 
Nursing staff. 
Program: control of 
venereal diseases 
through case-finding 
epidemiology; treat- 
ment and education. 
5) Bureau of Tuberculosis: 
Director; Medical and 
Nursing staff; other 
personnel, 
Program: control of TB 
through case finding 
and diagnosis; con- 
sultation services to 
physicians in private 
prac ti c e; educational 
and statistical re- 
search, 
6) Bureau of Mental Hygiene 
Acting Director; Child 
Psychologist; other 
professional staff. 
Programs psychiatric, 
consultation and edu- 
cational services. 
Present Situation 
(Services and Resources) 12 
Long-range Objectives or Action 
Suggestions and Recommendations for 
Immediate Action 
7) Bureau of Maternal and 
Child Health and Crip- 
pled Children 
Program! maternal and 
child health con- 
ferences; school 
health services; su- 
pervision of child- 
ren's boarding homes; 
crippled children*s 
clinics; classes for 
parents, and raatema. 
and pediatric care 
for military depen- 
dents . 
Director; Medical, 
nursing and nutrition 
staffs• 
Present Situation 
(Services and Resources) 13 
REPORT OF THE COMMITTEE 
ON PUBLIC HEALTH ADMINISTRATION OF 
THE CHAMBER OF COMMERCE POST-WAR PLANNING COMMITTEE 
Organization of the Board of Health 
As a result of Act 43 of the 1943 legislature, the position 
of Commissioner of Health as the full-time executive of the 
Department of Health was abolished, and the responsibilities of 
that position were vested in a President of the Board of Health, 
who seivos as chairman of the meetings of the Board, and who acts 
as its Executive Officer, The Commissioner of Health was required 
by statute to be a licensed physician, or both a doctor of medicine 
and a doctor of public health, with five years’ training or ex- 
perience in the administration of public-health programs. These 
professional qualifications are not required by statute for the 
position of President of the Board of Health; indeed, should the 
Governor so desire, an inexperienced layman could be appointed as 
the President, 
Only in one state in the United States is there a state health 
officer who is not a physician, and there are few such health 
authorities who do not have special training or qualifications in 
the field of public health administration. In the one excepted 
state the incumbent holds a post-graduate degree in public health 
administration. It is considered wise that qualifications of 
training and experience be stipulated by law, and a revision of the 
law in this regard is advocated. 
The merits of an executive Board of Health, vs. a Board of 
Health having stipulated duties reasonably confined to the field 
of promulgation of regulations and establishment of policy and 
procedure is controversial. In some states, revolving about the 
temperament and personal ambitions of the members of such an 
executive board, programs have suffered materially through insist- 
ence of the board that minutia of operations come before it. 
The current division of responsibility between the Board of Health 
and the President, as executive officer of the department, is con- 
sidered to be healthy and should be commended. That this is so 
is due in measure to the fact that the Board of Health has re- 
frained from exercising all of the power given it by the legisla- 
ture, relying on the President of the Board to be in fact the 
executive of the department. A stipulation in the law covering 
the division of responsibility and authority between the Board of 
Health and executive officer of the department would insure 
continued smooth operation. 14 
Organization of the Department of Health 
Certain changes are recommended in the organization of the 
Department of Health, directed principally at the objective of 
freeing the executive officer of many of the details of the in- 
service operation and allowing him to concentrate on the important 
subjects of public relations, policy making and program planning. 
Without being seriously tied down with the machinery of day-to-day 
administration the executive should be able to represent the 
department at national and local meetings, and spend a considerable 
part of his time in the field, observing the operation of the 
various programs and analyzing the health problems of the community. 
Basic in advancing the public-health program in Hawaii is the 
appointment of qualified, experienced physicians as the health 
officers of the Counties of Hawaii, Maui and Kauai. These officers, 
acting under the executive of the department and the Board of 
Health, should be delegated full power and responsibility for the 
administration of the public-health programs within their respect 
tivo jurisdictions. All policies and operating procedures of the 
department in their jurisdictions should be administered by them. 
They should be in active charge of all general and specialized 
programs carried out by the personnel of their departments and, 
in turn, the personnel should look to them as their administrative 
directors. The health officers of the noutsidefl counties will be 
responsible to the executive officer of the department through the 
Chief of the Bureau of Local Health Services, to be described later. 
In the City and County of Honolulu, because it comprises 10% 
of the population of the Territory, and because of the duplica- 
tion of specialist personnel required to establish an integral 
public-health department, no separate health officer for this area 
is advocated at this time; however, the supervision, integration 
and responsibility for the operation of this program should be 
delegated to the Chief of the Bureau of Local Health Services and, 
under the supervision of the executive and Board of Health, he 
should function in all ways parallel to the health officers of 
the ’’outside'* counties. 
In the "outside" counties, the various specialists throughout 
the bureaus and divisions of the department should act as consul- 
tants to these local health officers, but the authority and 
responsibility for the operation of the various special programs 
should be vested in the local health officer. All activities of 
the consultants from the central department while visiting those 
areas, or in the conduct of their correspondence, should be in a 
manner agreeable to the local health officer under the supervi- 
sion of the executive of the department. 15 
In the City and County of Honolulu, the various specialists 
throughout the bureaus and divisions of the department should have 
direct responsibilities in the operation of the program in addi- 
tion to their planning and supervisory duties at a Territorial 
level. In so far as they assume operational responsibility in the 
program for the City and County of Honolulu, they should be 
directly responsible to the Chief of Local Health Services. 
Personnel formerly carried on budgets and organization charts of 
the various bureaus and divisions, but who functioned exclusively 
in the health program for the City and County of Honolulu, should 
be transferred to a budget for the City and County and should be 
administratively set up in the Honolulu organization. Under the 
Chief of Local Health Services, there will be required a Chief of 
Public Health Nursing for the City and County of Honolulu and a 
Chief Sanitary Officer. Other adjustments may be necessary in or- 
ganization and assignment of personnel in the Oahu program. 
The Territorial Department of Health should be divided into 
four major bureaus: 
1. The Bureau of Local Health Servicegr headed by a Chief, who would 
directly supervise the health officers of the "outside11 counties, 
and be in active charge of tho public-health program for the City 
and County of Honolulu. He would be responsible for the coordina- 
tion of the activities of the divisions of the department, through 
their respective bureau chiefs, both in the operating program in 
the City and County of Honolulu and in their consultative functions 
to the health officers and subordinate staff of the departments 
in the "outside" counties, The establishment of this bureau, 
centralizing therein the administrative phases of the health program 
in the four counties, is of fundamental importance. It is suggested 
that the position of Assistant Health Executive be redefined as 
Chief of the Bureau of Local Health Services. 
Subordinate divisions would be: 
a, Tho Division of Public Health Nursing, which would be 
headed by a Director, and would have an Assistant Director who 
would serve as educational director. Within this division would 
be grouped the specialized consultants in such fields as venereal 
disease nursing, tuberculosis nursing, orthopedic nursing and 
maternal and child health nursing. 
b. The Division of County Health Officers and Government 
Physicians, which would be headed by the Chief of the Bureau of 
Local Health Services and would supervise not only the county 
health officers, but also, through them, the government physicians 
of the various counties, bringing about a closer integration of 
the work of the government physicians into the public-health 
program. 16 
2. The Bureau of Preventive Medicine. With the general advances 
in the specialized fields of public health, and particularly 
since the advent of federal grant-in-aid programs in specified 
fields, there has been a tremendous expansion of such programs 
over the past ten years; for example, venereal-disease control, 
maternal and child health, nutrition, mental hygiene, industrial 
hygiene, cancer control and dental health. With the increasing 
awareness and interest of the public and, particularly, of 
legislators, in the continued promotion of such work, further 
expansion may be anticipated. Only within the last year have 
federal grants in aid become available in the field of tuber- 
culosis control, and several bills are now pending before the 
Federal Congress which would carry further grants in such fields 
as mental hygiene, dental health, industrial hygiene, cancer 
control, and others. 
In order to benefit to the utmost from such grants, the Terri- 
torial Board of Health must be ready to develop comprehensive 
plans, budgets and reports for the various federal agencies. 
These, together with the multitude problems of program planning 
and administration, have multiplied the supervisory work of the 
Department; and the time has been reached when it is impossible 
for the health officer himself to supervise adequately all such 
specialized programs. 
To meet this problem many states have grouped these programs 
in a bureau commonly called the Bureau of Preventive Medicine, 
with a bureau chief who has had broad experience in one or more 
of the specialized fields, and who has demonstrated himself to be 
a capable administrator. This chief is then delegated the author- 
ity and responsibility for the supervision of these special pro- 
grams. This has proved to be not only a tremendous advantage in 
meeting the various federal requirements, but has been reflected 
in the improvement of the individual programs themselves. Prob- 
ably more important, it has given definite coordination and con- 
tinuity to the several specialized programs, and has stimulated a 
closer integration and planning of the various programs as they 
are placed in actual operation in the several local jurisdictions. 
The establishment of such a bureau is strongly recommended, 
and is a second fundamental change recommended in the organization 
of the department. 
The position of chief of the Bureau of Preventive Medicine 
would be a new position. The chiefs of the bureaus of Local 
Health Servicesand Preventive Medicine, together with the chief 
of the Bureau of Sanitary Engineering, would then handle much of 
the detail of administration and program analysis and planning, 
which now comes to the executive officer of the department. It 
is only through this reorganization and creation of one additional 17 
top executive position that the hands of the executive officer 
can be properly freed from the multitudinous detail which now 
comes to him. Within this bureau would be grouped the following 
divisions: 
a. The Division of Laboratories, headed by a physician, 
who should be required to have special training in the field of 
laboratory medicine, a certificate from the American Board of 
Pathology, and progressive experience in tissue pathology, bac- 
teriology and serology. The Division of Laboratories would be 
responsible for all laboratory analyses performed by the de- 
partment. The laboratory would have no direct responsibilities 
in the administration of programs involved in such laboratory 
analyses. On the other hand, divisions such as Food and Drug, 
Milk Sanitation, Water Sanitation, and so forth which have 
formerly made little distinction between the operation of the 
specialized program and the incident laboratory examinations, 
would no longer hold any responsibility for the laboratory 
examinations; but would base administrative actions on laboratory 
reports received from the Division of Laboratories. The Director 
of Laboratories would cooperate with other division heads under 
supervision of the bureau chiefs in special epidemiological 
studios. The laboratory would be equipped for tissue pathology, 
and the Director of Laboratories would serve as a consulting 
pathologist, without fee, to any practicing physician in the Terri- 
tory, under a plan approved by the Territorial Medical Society. 
The Board of Health laboratory would also analyze specimens or 
tissues, toxicologically or pathologically on the request of any 
competent officer of Government—the sheriff, coroner, county 
health officer, government physician, autopsy surgeon or others 
and the Director of Laboratories would be available for consulta- 
tion. 
The committee is not prepared to make final recommendations 
with regard to a coordinated system of forensic medicine in the 
Territory, On the basis of facts available to the committee, it 
appears that this is a subject which should receive careful 
consideration from the various interested agencies. It would 
appear that rath the ‘establishment of a Division of Laboratories 
in the Board of Health, and with available personnel who are well 
qualified in the fields of pathology and toxicology, the facilities 
of this Division of Territorial Government might well be used as 
a nucleus for a well-integrated forensic medicine setup. 
Two classes of necropsies are involved: 
l) Sudden deaths when a person was in apparent good health, 
deaths unattended by a physician, and deaths wherein the cause 
has not been verified but no criminal evidence is involved. 18 
2) Sudden or violent deaths, or deaths under circumstances 
suggestive of foul play, and where criminal evidence is or may 
be involved. 
In the first class of deaths, the determination of cause is 
primarily a matter of health importance. In the latter class, 
factors of health importance are present, but the primary interest 
falls within the province of the sheriff and public prosecutor, 
A coordinated program, however, may eliminate duplication of 
function and facility and result in public economy and efficiency. 
It is therefore recommended that all interested agencies study 
the problem and analyze the merits of such a system. 
b. The Division of Tuberculosis Control, which would 
continue to function in its present capacity—that of operating 
the tuberculosis control program for the City and County of 
Honolulu, and serving as consultants in the programs in the Hout- 
side" counties. 
In the tuberculosis-control program, perhaps to a greater 
degree than in any other program of the Board of Health, cordial 
and close cooperative relations are necessary with other official 
and voluntary agencies in the field. The program of the health 
department, the various tuberculosis sanitoria, the tuberculosis 
societies, the welfare department, and welfare agencies are 
necessarily interwoven. 
A clear understanding on the part of all agencies concerning 
their respective responsibilities and fields of activity, and a 
smoothly operating manual for the various agencies may be of 
assistance in this regard. 
c. The Venereal Disease Control Division, which would 
continue as presently constituted. 
d* The Division of Maternal and Child Health and 
Crippled Children, which would continue to function as presently 
constituted, with the exception of the removal from that division 
of the present nutrition services which would be established as 
a separate division of the Bureau of Preventive Medicine. 
e. The Division of Epidemiology, which would be developed 
around the present Bureau of Communicable Disease Control. It 
would be the function of this division to administer the communi- 
cable disease morbidity and mortality reporting services in 
cooperation with the Division of Public Health Statistics, and to 
conduct epidemiological investigations and studies relevant to 
the occurrence and control of communicable diseases in the Terri- 
tory. Close cooperation must exist between this division and 
those divisions interested in specific disease problems. The 19 
director of necessity would be unusually skilled in epidemiology, 
biostatistical analysis, and the orderly presentation and inter- 
pretation of statistical material concerning the occurrence, in- 
cidence and prevalence of disease problems in the community. 
Based upon the work of this division and interpretations to the 
chief of the Bureau of Preventive Medicine, the operating program 
of the department would be moulded to meet problems as they present 
themselves. 
f. The Division of Mental Hygiene, which would continue 
as constituted, laying constant stress on the preventive aspects 
of the program. 
g. The Division of Nutrition, which would be developed 
around the nutrition services now in the Bureau of Maternal and 
Child Health, with augmentation of personnel and broadening of the 
program to provide nutritional consultation to all public or non- 
profit action agencies having an interest in the field of diet 
and health. Such a division is one of the basic divisions of the 
modern health department and should be materially strengthened. 
Adequate knowledge of food values, intelligent selection of 
foods and the actual development of proper dietary practice are 
factors of primary importance in the public health of the commu- 
nity. The health department should be the backbone of this 
community nutrition service, cooperating with all community 
agencies having an interest in nutrition. 
The division should establish minimum dietary standards for 
various rqcial groups, age groups and occupational groups, in the 
light of their dietary preferences, and should work with relief 
agencies to the end that food allowances are adequate. Promotion 
of proper dietary practice in the schools through precept and 
practice is fundamental. In the treatment of certain metabolic 
diseases the institution of a special dietary service to physicians 
upon request might well bo considered. 
h. The Division of Geriatrics and Cancer Control. With 
the reduction in mortality rates in the younger age groups, 
degenerative diseases are becoming of more and more concern to 
official health agencies. Cancer and other degenerative diseases 
are annually accounting for a larger proportion of deaths. At the 
same time, due to advances in medicine, cancer, heart disease, and 
the other degenerative conditions are no longer looked upon as 
"inevitable.” They are, in reality, preventable diseases—if 
recognized in incipiency and if early and proper medical therapy 
and guidance are available. The dissemination of these facts is a 
field of fruitful endeavor in the field of public health education. 
At the same time, it appears that certain public medical facilities 
and programs will be necessary. 20 
Taking cancer, for example, the early recognition of the 
disease or pro-cancerous conditions, with the institution of pro- 
per medical treatment early, will unquestionably cure or prevent 
a large proportion of such cases. An educational program alone, 
however, will accomplish little in attaining the objective. Along 
with this we must have physicians who arc interested in the pre- 
ventive phases of the problem and who have sufficient knowledge 
and interest to conduct competent examinations in the field. 
Many such examinations are time-consuming and expensive. Persons 
who are in apparent health will seldom undergo such examination 
even after being convinced that they should, if the cost of the 
examination is such as to be a financial burden. It is therefore 
basic in the establishment of a cancer-control program that a 
clinic be established under independent or health department aus- 
pices, equipped with the necessary diagnostic equipment, and 
staffed by a group of physicians having special interest and com- 
petence in such work. 
The director of the program should have extensive experience 
in cancer-control work, and be adequately qualified by special 
training in internal medicine, radiology, and pathology. He 
should be employed on a full-time basis. Other members of the 
group might well be practicing physicians employed on a consulta- 
tive basis in the fields of internal medicine, radiology, pathology 
and surgery. The clinic should be available on a consultative basis 
without charge, for physical, x-ray, pathological or other diagnos- 
tic procedure, and in the case of medical indigency, should be 
prepared to carry out curative procedures at local hospitals and in 
the clinic. Such a program, of necessity, would require close 
cooperation between the health department and the medical profession 
through the medical society. There arc established patterns of 
operation which might well bo taken as guides in the field of 
Cancer Control. 
The general field of Geriatrics is newer, but is becoming 
recognised as a field meriting the attention of health departments. 
Cancer control is a part of the broad field of geriatrics, and 
during the developmental stages, the entire field should be 
covered by one division. 
i. The Division of Dental Health. Recent £elective 
Service rejection rates have pointed out the serious reed for 
increased attention to dental health. The subject has not been 
ignored in the Territory as the Department of Public Instruction 
has a basic program in the public schools, and treatment, facilities 
are available for indigent at Paloma Settlement. However, neither 
dental health nor its broader aspects such as the etiology and 
prevention of dental caries have ever received the attention of 
the Health Department. 21 
The Health Department should include a Division of Dental 
Health, headed by a dental surgeon who has training and ex- 
perience in public health and preventive dentistry. The program 
of the division should bo developed with the full cooperation 
of the Dental Society and the Department of Public Instruction, 
Because of the heterogenous population and certain unique 
environmental factors, the opportunity is present in Hawaii for 
valuable epidemiological studies in the causes and prevention of 
dental caries. 
j• Other Divisions: 
Industrial Hygiene formerly has been concerned with 
the prevention of industrial accidents, the recognition of and 
elimination of industrial hazards which might lead to occupational 
disease resulting from exposure to toxic materials. In recent 
years, however, the subject has taken on new significance. No 
longer is communicable disease and the general health of the worker 
an individual problem. Industry has recognized a total interest 
in the health of the worker, and industrial hygiene programs are 
becoming known as industrial medical programs. The prevention of 
industrial accidents and, to a degree, the prevention of industrial 
disease arising out of exposure to toxic materials is an engineering 
problem. A minimal program of this nature is carried out by the 
Board of Health in the Division of Sanitation. Hawaii, not being 
heavily industrialized, has few problems of industrial disease as 
represented by lead, heavy chemicals, silica, industrial solvents, 
and so forth. Exposure to bagasse dust in other areas has given 
rise to pulmonary disease. This subject has not been adequately 
investigated in Hawaii, If the Health Department is to assume its 
total responsibilities in the field of industrial medicine, the 
work should be centered in an Industrial Hygiene Division in the 
Bureau of Preventive Medicine, headed by a physician who has had 
broad experience and training in industrial medicine. Preliminary 
studies should be made by the Board of Health to define the 
problem in Hawaii and to determine whether the magnitude and scope 
of the problem is such as to demand immediate attention. 
Hawaii is the gateway to the Orient; fortunately, however, to 
date it has had little experience with the exotic diseases of the 
tropics. Particularly in the postwar world, with the rapid ex- 
pansion of world commerce, the possibility of introduction of such 
diseases into Hawaii is not too remote, The physicians of Hawaii 
should have thorough knowledge of the world incidence, the signs 
and symptoms of all such diseases so that they may recognize them 
immediately. In the absence of day-to-day contact rath these 
diseases, refresher courses and lectures in such subjects are of 
public-health importance„ 22 
3. The Bureau of Sanitary Engineering as presently constituted, 
with minor revisions, would constitute the third major bureau of 
the department, and should be composed of the following divisions, 
each under the direction of a professional directors 
A. The Division of Water, Sewage and General Sanitation 
B, The Division of Milk and Food Handling Establishments 
C, The Division of Pure Food and Drug 
D, The Division of Rodent Control 
E. The Division of Insect Control 
F. The Division of Industrial Hygiene and Housing {until 
such time as a Division of Industrial Hygiene is 
established in the Bureau of Preventive Medicine) 
Each of these divisions would function as indicated by title 
under the direction of the Bureau Chief. 
In grouping the several functions of the Bureau of Sanitation 
into the several divisions, attention has been given to the pro- 
fessional qualifications required for the professional head of the 
several divisions. 
The Division of Water, Sewage and General Sanitation should be 
headed by a sanitary engineer. It is suggested that the Bureau 
Chief head this division until such time as the volume of work in 
the Bureau and the Division demands additional personnel. 
Milk Sanitation, aside from the veterinary aspects such as 
tuberculosis, brucellosis and mastitis in the herds, is a specialized 
problem in sanitation requiring knowledge of milk processing equip- 
ment, milk bacteriology, milk-processing and distribution methods. 
At the present time, the most competent courses of instruction in 
this field are in schools of public health engineering; unfor** 
tunately, schools of veterinary medicine have largely slighted 
this subject. It is not important whether the director of such a 
division be a veterinarian, a sanitary engineer, or a biologist or 
bacteriologist, so long as he is qualified by education and ex- 
perience to administer an effective milk control program. The 
field of food handling, including abattoir, grocery and restaurant 
sanitation, is closely allied to milk control so far as the basic 
education and training of the division chief is concerned; and, 
if anything, requires less highly trained skills. It is therefore 
proposed that the chief of this division have fundamental training 
and experience in milk sanitation. 
In staffing the Divisions of Rodent Control and Insect Con- 
trol, it is not considered essential that either such position be 
filled by a sanitary engineer, although such is general practice 
in most health departments. Rodent Control is a biological 
problem, involving not only rat-proofing but trapping, poisoning 23 
and other biological fields. An individual with a well'-rounded 
background in public health, but with special training in biology, 
bacteriology and administration should be able to carry on the 
program competently. In the field of insect control; since there 
is no anopholene or salt-marsh mosquito breeding in the Territory, 
the control program will hove few engineering aspects. From this 
standpoint the division might well bo headed by an entomologist; 
under any circumstances a well qualified entomologist will be 
necessary in the division. 
As suggested previously, it may be determined that the 
Division of Industrial Hygiene should be transferred to the Bureau 
of Preventive Medicine, with a physician in charge> Until this 
time, no change is contemplated in the present sevip with a well 
qualified sanitary engineer in charge, giving additional attention 
to housing. It may eventually prove desirable to establish a 
Housing Division, particularly when Industrial Hygiene is trans- 
ferred to the Bureau of Preventive Medicine, 
A. The Bureau of Central Administration, It is recommended that 
those activities of bhe Department which are of general service 
to all Damans and Divisions be grouped together in a Bureau of 
Central id^dniaeration, Public health statistics, public health 
education, budget control and accounting, property control, and 
personnel adirministration are such functions. 
It is recognized that there is a wide disparity of function 
in certain of these activities, and that the division directors 
must of necessity have a considerably wider latitude of action with- 
in this bureau than would be necessary in other bureaus. At the 
sane time, each function is of such nature that it is normally 
headed by a non-medical person; and there are close parallels in 
methodology between accounting and public-health statistical pro- 
cedure or the production of public-realth educational materials 
and the general duplicating work of the department. Toe, these 
fields arc those in which non-medical public health administrators 
are trained and have experience; therefore it should be reasonably 
easy to employ a bureau chief who would have the broad training 
and experience necessary to supervise these activities in spite 
of the seeming wide range of fields involved. Within the bureau 
should be the following Divisions: 
a. The .Division . of FuniKe3.s ..Mmaj?enGnt, iopresenting in 
pa~t the functions o.f the pro sc nr. Ihio.t dlor;-* and Budget Officer. 
The procurement of cquApneab and supplies-- two m A iterance of 
storerooms and invent a ales, +ho 2is.intora.arc of buildings, business 
machines. motor vehicles and 'other equipment is an Law,v’tant and 
rather specialized field in .She department, The estab": : s;’went of 
such a division would. pernio instituting a system of centralized 
purchasing and supply, taking advantage of bulk-price discounts, etc. 24 
General duplicating and multilithing should be a function of this 
division. The more general use of multilithing for reproduction 
of forms, reports and similar materials should substantially 
reduce the printing expense of the department. The establishment 
of an orderly system for the maintenance of mechanical equipment 
should also result in a considerable saving through control of 
loss by deterioration. 
b. The Division of Personnel Administration as presently 
constituted, and with expansion as necessary to serve adequately 
the department in the recruitment and placement of personnel, with 
a broad program of in-service training in cooperation with the 
other divisions of the department. 
c. The Division of Public Health Statistics, which would 
include the work of the present Bureau of Vital Statistics, but 
would be broadened to incorporate morbidity reporting and the 
tabulation, analysis and reporting of all reports and statistics 
of public-health interest. 
All work relating to the collection, organisation and analysis 
of statistical data in the department would thus be brought together 
within a single unit. The division would handle not only deaths, 
births, stillbirths, marriages, divorces, but also morbidity data 
and reports of health-department activities. 
The organization of the division would normally break down 
into three sections: (1) Registration and Records, (2) Tabulation,, 
and (3) Analysis and Reports. The Registration and Records Sec- 
tion would function in the promotion of complete and accurate 
registration of all events of public-health significance, and 
provide accessible filing and permanent safekeeping of these records. 
It also would issue certified copies of basic records and prepare' 
record transcripts for the Federal Bureau of Census. The use of 
microfilm equipment for the maintenance of working files has 
proved most satisfactory. Legally acceptable certified copies 
may be prepared from such film with efficiency, thus eliminating 
many long and tedious searches of the original records. 
The Tabulation Section can most efficiently function through 
use of electrical accounting machines based on conventional punch 
cards. 
The Analysis and Reports Section would analyze the data avail- 
able in the Records Section and present analyses in such way that 
they will be of maximum value to the department and allied agencies* 
Valid analysis of data not only requires the application of appro- 
priate statistical principles to the material already collected, 
but also calls for the use of such principles in determining the 
character of the primary records and the procedures to be employed 25 
in collecting the initial records. These functions, as well as 
the preparation of final tabulated reports, the computation of 
statistical constants, and the interpretation of the resulting 
analyses, would be performed by this section. 
Efficient accurate procedures have been developed for such 
functions as an up-to-date, functioning tuberculosis register, 
a venereal disease central registry, communicable disease regis- 
tries, laboratory reporting system, and so forth. Such data not 
only is available for routine reports, but it is in such form that 
special studies are easily instituted. Well-developed procedures 
are also available for the efficient processing of all types of 
birth and death reports. 
d. The Division of Public Health Education, which should 
be enlarged to offer a total community health-education program, 
and in cooperation with the Division of Personnel Administration 
and the several Division Chiefs, an in-service program of pro- 
fessional training. Community organization work, library and 
reference service and editorial service would be included. Public 
health education, which is a keystone in the public health program, 
is of paramount importance. The personnel of this division should 
consist of a minimum of the following personnel! a director, an 
editorial associate, two health-education consultants, two health 
educators, and office personnel of approximately four stenographers 
and clerk-typists. 
In developing an expanded program of public health education, 
the resources of the health department should not be considered 
a limiting factor. The program should be jointly planned with 
the numerous other public and private welfare and educational 
agencies, with close integration of the programs of the various 
official and non-official agencies in the field. 
In addition to the well-established techniques in the field 
of public health education, some of the newer methods are deserving 
of serious consideration. 
A Bureau of Medical Services. With the present trend in the federal 
legislation and the increasing interest of influential groups of 
citizens in matters affecting public health and medical care it 
is almost certain that substantial federal aid will become avail- 
able to the states and territories in new fields. In the field of 
physical facilities for health, departments and hospitals, one such 
piece of legislation has progressed to the point of almost cer- 
tain passage. This legislation, to be administered fnroagh. the 
United States Public Health Service, will make f arce -.reliable 
as grants in aid for studies and surveys in t-he f ctl d of health- 
center and. hospital-bed needs, and will also make substantial 
funds available for grants in aid in the construction program. 26 
The legislation requires that the program be administered through 
one single department of the state government, and also requires 
that plans bo submitted to and approved by the United States 
Public Health Service, 
Anticipating such legislation, surveys of health-center and 
hospital-bed needs have been started in 19 states and the District 
of Columbia, legislation authorizing surveys has been passed in 
8 other states, while in three additional states such surveys are 
being started through official action of their respective governors. 
These surveys, coordinated through the Commission on Hospital 
Care, will unquestionably be accepted by the United States Public 
Health Service as basic units of the state plan in the allocation 
of funds. 
Because the State or Territorial Health Department is usually 
the one agency of state government in the medical field, and be- 
cause of the long, mutually cordial relationships which exist be- 
tween the various boards of health and the United States Public 
Health Service, it would appear logical, and in fact highly 
desirable, that the Board of Health bo the agency designated in 
the Territory of Hawaii to administer these grant-in-aid programs. 
It is therefore proposed that a Bureau of Medical Services 
be approved in principle, to be composed of such divisions as 
prove necessary to accomodate possible expansion in the fields of 
hospital surveys, grants in aid for the construction of health 
centers and hospitals, and so forth. 
GENERAL CONSIDERATIONS 
Physical Facilities 
In spite of the construction of two health centers in 
Honolulu under grants from the Federal Works Agency, the facilities 
in Honolulu for housing the various bureaus and divisions of the 
Board of Health, arc grovssly inadequate, A new building for the 
Board of Health, adequately designed to accommodate all of the 
departments, is urgently needed. The facilities at the Kapahulu 
and Lanakila Health Centers should be available for use in the 
local health program exclusively. In addition, the new building 
for the contra! department should have a section devoted to the 
local, health department functions for Honolulu, thus in effect 
creating three health centers in Honolulu, and adequate facilities 
for the central department. 
In Hilo, Wailuku, and Lihue, the facilities for the county 
health departments are very inadequate, and in each instance new 27 
facilities should be provided. In addition, modest but modern, 
clean, and attractive facilities should be strategically located 
in several districts of each county, serving as health centers for 
the rural areas of the Territory. Appropriations from the Terri- 
torial legislature for this purpose should be sought. It is 
entirely probable that federal grants in aid may be available to 
assist in this program. 
Appropriations 
By legislative action all funds appropriated to the department 
are earmarked for specific bureaus or divisions, and may not be 
transferred for use in another division ¥/ithout extensive justifi- 
cations and approval of the Governor. On the other hand, federal 
grant-in-aid funds from several sources are available for use 
within any division or bureau of the department, upon budget 
approval, and arc available for expenditure by the department with- 
in the limit of the allotments. This is not true with territorial 
funds, as funds appropriated to an individual division revert to 
the general fund unless extraordinary action is taken on the part 
of the Governor, authorising the specific transfer of funds. 
The inability of the Board of Health to transfer territorial 
funds from one division or bureau to another, as they may do with 
federal funds, is a great handicap) to efficient administration. 
The Territorial Board of Health is an executive board having full 
power to govern the activities of the department, and the President 
of the Board is a bonded officer. All legislative appropriations 
made in support of the Board of Health should, in the interest of 
economy and efficiency, and after budget estimates are submitted 
by bureau and division, be appropriated in a single departmental 
appropriation for use as authorized by the Board of Health. 
Supporting schedules by activity would continue to be sub- 
mitted whenever budget estimates are prepared for the legislature. 
Granting of quarterly allotments to the department would continue 
to give the necessary budgetary control by the Bureau of the 
Budget. Although the request for quarterly allotments would be 
made for the entire department, a supporting schedule, detailed by 
activity would be submitted. 
The accounting system would provide for a single appropriation 
ledger which would reflect a summary of allotments and the expendi- 
tures mace against the allotment quarterly. Such a plan would 
make possible a mono efficient system of processing claims, and 
the abolishing of separate activity ledger controls would eliminate 
existing voluminous detail. 28 
School Health 
There are many divisions in the health department, including 
Health Education Division, Maternal and Child Health Division, and 
Sanitation Division, which have interest in school health programs. 
There are undoubtedly several divisions in the Department of Public 
Instruction which have similar interests. In order that there may 
be a well-rounded comprehensive school-health program it would 
appear necessary that an adequate interdepartmental administrative 
mechanism be established. Several possibilities are available. A 
joint committee with representatives from the interested divisions 
of the Board of Health and Department of Public Instruction might 
be established as a permanent operating agency; or the Department 
of Health and Department of Public Instruction might establish 
coordinating sections in their respective agencies, each section 
representing the total interests of the respective departments in 
the program. Under this latter plan a school health section should 
be established in the Bureau of Local Health Services or in the 
Maternal end Child Health Division; and, the section head 1 
should have experience and training not only in the broad aspects 
of public health but also in the field of education. He would be 
responsible for the necessary stimulative and’ liaison work with 
the Department ol Education. The various responsible bureaus and 
divisions of the Hoalth Department would be charged with the 
detailed working program. 
Communicable-Disease Hospitalization 
At the present time, regulations of the Board of Health do or 
should require isolation and hospitalization of certain communi- 
cable diseases. The provision of communicable-disease hospital 
beds however, has been left to the various voluntary hospitals of 
the community; this leaves much to be desired. In the first place, 
the construction and maintenance of a communicable-disease unit 
by a voluntary hospital is a marked financial liability, and where 
each voluntary hospital attempts to maintain beds for commuricable 
disease this liability is multiplied. At the same time, because 
such units are usually operated at a considerable financial loss, 
no voluntary hospital can be expected to build, equip, and main- 
tain a communicable-disease unit of highest quality. 
There is also constant friction arising between patients and 
hospitals. Patients who feel (rightly or wrongly) that there is 
no physical necessity for hospitalization are reluctant to pay 
large hospital bills just because the regulations of the Beard of 
Health may require such hospitalization to protect the public 
heal-.I, The public may legitimately expect the official agency 
such hospitalization in the interest of the public health 
to provide this hospitalization without undue expense to the 
individual. No recommendations are made as to the location of 
such facilities, or as to the ultimate management of such hospital 29 
beds; however, it is believed that the Board of Health should study 
the primary responsibilities involved and make suitable arrangements. 
Postgraduate Medical Education 
It was suggested in a previous section relating to the subject 
of tropical diseases that it is important from a public-health 
standpoint that physicians be in a position to diagnose diseases 
foreign to their usual experience, and refresher courses and 
lectures were indicated. In other fields public health is a growing 
subject; in these fields too, it should be the responsibility of 
the Board of Health to keep the physicians of the community informed. 
It is therefore recommended that the Board of Health take cognizance 
of these facts and finance a well-planned program of postgraduate 
education for physicians, nurses, and other interested groups in 
the Territory. The programs should- be planned jointly with the 
various professional groups. 
Indigent Medical Caro 
At present government physicians are employed by the Board of 
Health, and to a limited degree function in the operation of the 
public-health program. To a larger extent, however, they are 
responsible for furnishing medical care to the indigent. The 
individual government physicians are largely responsible for all 
phases of the indigent medical care program as financed by the 
Department of Welfare which creates an anomalous situation of 
divided authority and responsibility which cannot help being 
cumbersome and confusing. It is therefore highly desirable that 
this subject receive careful consideration by the departments 
involved, or by a referee, and that governmental authority and 
responsibility for total indigent medical care be centralized 
within one department of the government. 
Personnel Classification 
The committee has not studied in detail all of the existing 
position descriptions and classifications assigned to the various 
positions within the Department of Health, The subject has been 
investigated to the degree that several discrepancies have been 
encountered in qualifications of experience and training and in 
classification. In general, it may be stated that there is a feeling 
that tho specified qualifications for many of the more responsible 
positions in the Department of Health are too low. This is also 
true in many subordinate types of positions, such as those of 
sanitary inspect, 
It is believed that the classifications of some of the more 
responsible positions in the department also are too low and there 
are instances of inequality in the assignment of classification to 
positions requiring equal experience and training. 30 
A detailed review of position descriptions and classification 
of positions in the department is of utmost importance. Qualifi- 
cations for such positions should be sufficiently high to assure 
that new employees are capable of performing outstanding service. 
Classifications must be high enough to attract competent persons 
to public service. Limiting specific recommendations, it would 
appear essential that the following specified positions be described 
and classified at the minimum grades indicated: 
P-8 Chiefs of the Bureaus of Local Health Services, 
Preventive Medicine, Sanitary Engineering, and 
Medical Service, if and when established. 
P-7 Directors of the Divisions of Laboratories, Tubercu- 
losis Control, Venereal Disease Control, Maternal 
and Child Health, Epidemiology, Mental Hygiene, 
Geriatrics and Cancer Control, Dental Health and 
Industrial Hygiene, if and when the last-named 
division is established. 
Inter-agency Relations 
The committee considered at some length the present general 
structure of inter-agency cooperation. Several areas were pointed 
out as being examples of lack of coordination. In one instance 
another subcommittee--that on Healthful Housing--pointed out //hat 
appeared to them to bo a lack of proper coordination between some 
four agencies dealing with housing. It is felt, however, that the 
machinery for cooperation exists in most cases if the individuals 
involved choose to use it. No detailed review of the various 
relationships necessary in each field of public health has been 
attempted. The committee feels that it cannot go beyond a strong 
recommendation that a.11 possible channels be used to increase 
coordination. 
Two specific recommendations are made: 
1. As soon as possible, the Oahu Health Council should begin to 
function as an active force in increasing inter-agency coordination. 
Member agencies should be made aware of the policies, function and 
methods of operation of other agencies with whom they might have 
contact. As an example, voluntary welfare agencies should be aware 
of the fact that public health nurses and nutritionists of the Board 
of Health care available to help them in health problems or staff 
education. 
2. Each agency should have a manual of operating policy and procedure 
with •pertinent dotal] corcorning'the various operating programs of 
the agency and including a description of the division of responsi- 
bility between that agency and other agencies in the various fields 
of public health. The manuals should be kept up to date through 31 
periodic revisions as necessary. Sample forms, correctly executed, 
should bo included. Such manuals would be of value in staff edu- 
cation, and an interchange of such manuals between agencies would 
appear to be particularly valuable in understanding and working 
out inter-agency problems. 
Public Health Law and Regulations 
The Revised Laws of Hawaii, 194-5, and the Session Laws of 
Hawaii, 1945, have been reviewed by the committee in so far as they 
relate to the overall administrative problems in the health 
program. Pertinent comment on certain phases of the law are 
incorporated in other paragraphs of this report. This committee 
has not analyzed in detail the various laws as they pertain to the 
operation of specialised programs; this falls within the scope of 
the several subcommittees studying these specialized problems and 
programs. 
In relation to the proposed reorganization of the bureaus and 
divisions of the Board of Health, it would appear clear in the law 
(Ch.35, Sect. 2001-2012, RLH 1945) that the Board of Health has all 
necessary authority for such reorganization. At the same time, 
certain bureaus of the department have been created as such by acts 
of the legislature. Specifically, bureaus of Crippled Children, 
Mental Hygiene, and Vital Statistics are designated by law, as is 
the position of Food Commissioner. 
It is the usual practice in health departments to term the 
major subdivisions as "bureaus”, each composed of "divisions”.- If 
this practice were followed in Hawaii, it would probably require 
legislative action in regard to the title for the above listed 
functions. 
The Laws of the Territory of Hawaii, as they pertain to the 
health program, are an accumulation of legislative acts extending 
over the history of the Territory. While the existing body of 
laws appears to be reasonably adequate in scope, there are many 
laws on the statute books which are no longer significant in all 
detail in the light of modern medical and public health knowledge 
and practice. There are other areas in which legislation appears 
very weak. As an example, the powers of the Board of Health to 
make and enforce regulations are defined in numerous sections of 
the law. In each instance, the field in which riles and reguja- 
tions may be adopted are specifically set forth in the law, and 
there are no general provisions authorizing rules me. regulations 
in ether fields of public health importance not specifically covered 
by law. There appears to be inadequate authorization in law, either 
specific or general, for regulations governing the control of com- 
municable diseases, swimming pods, rodent control, quarantine, 
examination of school children, embalming, funeral pallors, fumiga- 32 
tion, ice cream manufacture, and a variety of other subjects of 
public-health significance* 
Many chapters and sections of the lay go into minute detail 
concerning the operation of the public-health program; others 
define the scope of the problem, charge the Board of Health with 
responsibility, and authorize rules and regulations to govern. In 
the first instance the law is frequently in need of revision because 
of constantly changing circumstances, while in the latter instance 
modification of rules and regulations satisfactorily and completely 
cover the problem. 
It is recommended that Title 6 of the Revised Laws of Hawaii 
194-5, as amended, be completely rewritten, culling out the archaic 
material and broadening the scope as would appear necessary. In 
this the general principle should be adopted that it is the purpose 
of the law to vest responsibility and authority in the Board of 
Health, giving the Board of Health rather broad powers to make regu- 
lations; but that so far as the detailed programs are concerned 
these matters be left for incorporation in the rules and regula- 
tions of the Board of Health, and hence readily susceptible to 
revision with changing circumstances. The authority of the Board 
to make rules and regulations should be sufficiently broad that 
new problems may be met legally and promptly without the necessary 
delays incident to obtaining revision of law. 
In this regard, it would appear proper that the Board of Health 
and the Attorney General of the Territory, working together, should 
prepare the text of a proposed rocodification of the Public Health 
Law of the Territory, as well as the text of a proposed set of 
regulations of the Board to be promulgated thereunder, and that 
such a law be an administration-sponsored measure at the next 
regular session of the Territorial legislature. 
The regulations of the Board of Health are in process of being 
so reorganized and published as to bo available to all interested 
parties in one volume which may be easily kept up to date by 
additive revision. This is most commendable, and should be carried 
to completion at an early date.