A SURVEY OF THE HEALTH DEPARTMENT OF MONTGOMERY COUNTY, MARYLAND. BY Senior Surgeon M. V. Ziegler, Director, * i U. S. Public Health Service.District No. 2. WASHINGTON, D. C. 1940 CONTENTS Pagf. Scope of Survey and Sources of Information ............. 1 General Description ....... Population.,« ....... • 2 County Commissioners 3 Financial Resources 3 Offices U Health Department U District Nursing* 5 Public Health Personnel 5 Full Time 5 Fart Time 5 Personnel of Other Agencies 6 Health Committees 7 Public Health Program. 7 Vital Statistics B County Registrars ..... B Communicable Disease Control,,... 10 Diphtheria Control 10 Venereal Disease Control 12 Tuberculosis Control 14- Hospitalization. 15 Maternal Hygiene 15 Dental Care 16 Midwives IB Page Infant and Child Hygiene 19 School Hygiene 21 Dental Care 21 Crippled Children 23 Hospitalization 24* Laboratory ,. 2 A Environmental Sanitation 25 Public, Semi-public, and Private water Supplies 25 Urban and Suburban Sev/er Systems and Rural Sanitation........, 25 Milk Sanitation 27 Food Sanitation 28 Children ’ s Boarding Homes, 28 Garbage Disposal and Hog Farms 29 Other Activities,, 29 Medical Care , ... 29 Physicians,,..,, 29 County Aid Board, 29 Hospitals ... 30 Mental Hygiene 30 Personnel Requirements ............ 31 Recommendations: Budget Recommendations 33 Organization and Facility Recommendations 33 Administrative and Functional Recommendations 36 REFERENCES Qualifications for Public Health Personnel Recommended by the Conference of State and Territorial Health Officers. 1938. Ordinance Regulating Eating and Drinking Establishments Recommended by the U, S, Public Health Service, 1940* Frozen Desserts Ordinance Recommended by the U, S, Public Health Service, 1940. iiilk Ordinance (Public Health Bulletin No, 220 - 1939 Edition) Recommended by the II, S, Public Health Service, An Ordinance Providing for the Sanitary Disposal of Human Excreta (Supplement No, 108 to the Public Health Reports). A SURVEY OF THE HEALTH DEPARTMENT OF MONTGOMERY COUNTY, MARYLAND * Senior Surgeon M, V. Ziegler, Director U, S* Public Health Service District No, 2 By At the request of the Brookings Institution a survey of the Health Department of Montgomery County (Maryland) was made by the U, S, Public Health Service during July and August 194-0. The survey included (l) scope of activities and the accomplishments, (2) the extent and character of the health problem, and (3) the organization and available resources. The standards set in the Appraisal Form for Local Health Work, prepared by the Committee on Administrative Practices of the American Public Health Association, were used to evaluate the services rendered by the Health Department. Statistical data used concerning cases registered and visits made were taken from the report of activities made by the County to the Maryland State Health Department for the calendar year 1939. The recommenda- tions for extension and improvement of the health services performed were not based alone upon the scores attained. Information was secured from a study of special reports and the observation of activities. The State Health Officer, the Directors of the several Divisions of the Maryland State Health Department, and the Montgomery County Health Officer and his staff were most generous in giving their time and in making available to representatives of the Public Health Service records and re- ports pertinent to the survey. In the interests of brevity, emphasis has been placed in the report only on the objective health needs of the area. * A part of the factual data contained in this Survey was assembled by Assistant Surgeon David 3* Wilson, Assistant Public Health Engineer P. A, Stephens, and Public Health Nursing Consultant Olive M,. Whitlock, GENERAL DESCRIPTION Montgomery County is located in the south central part of the State, bordering on the Potomac River and the District of Columbia, It has an area of 4-90 squs.re miles. The terrain of.the county is well-drained, rolling, fertile farm land. Its proximity to Washington accounts for the rapid increase in population during the past ten years. Table I Population of Montgomery County 1920—194.0 Year Population Percentage — Increase 1920 34-,921 1930 49,206 40.9 1940 81,444 65.5 Of the population, 89 percent are white, 86 percent are native born and 3 percent are foreign born? 10 percent are colored5 1 percent or less are of other races. The age distribution compared with the State of Maryland and the United States as a whole is shown on the table below: Table II Age Distribution of Population Age Group Percentage County Percentage State Percentage U. S. Under 5 9.8 8.9 9.3 5 - U 20*5 19.4 20,1 15 - 24 16.3 17.8 18.3 25 - 34 14.1 15.7 15.4 35 - 44 14.3 14.2 14.0 45 - 64 18.9 18.1 17,4 65 and over 6,1 5.9 5.5 A large part of the population have interests in the District of Columbia, chiefly in Federal Government employment. Those not employed in the District of Columbia follow the usual urban and rural community pursuits, A considerable portion of the population of Montgomery County lives in unincorporated towns or villages, particularly in those areas of the county adjacent to the District of Columbia. This creates a rather peculiar public health problem, particularly in the field of sanitation. many of the people living in the suburban areas belong to the higher economic group, presenting a different public health problem from those in other sections of the county where there is a lower economic status. The group with very low income is smaller than is found in most counties. In between these two groups there is a large relatively prosperous popula- tion. From the conditions mentioned above it can readily be seen that ample resources could be made available for an efficient health service, One of the primary problems of the health department is convincing the citi- zens of the need for the application of public health measures. People in comfortable financial circumstances feel that their family physicians are able to provide for their health protection. It is, therefore, incumbent upon the health department to demonstrate the effectiveness and necessity for organized health work. It is obvious that any population group requires the services of a well organized and functioning health department. The government functions of the county are discharged by five elected commissioners with authority to levy all taxes and make all appropriations. FINANCIAL RESOURCES The total assessed valuation of the county is $135>245>920, The regular county levy is $1,*50 on each $100 assessed valuation. The sum of $2,300,550,64 ($34.39 per capita) was appropriated for the fiscal year 1939 for all county government services. During 1939 the sum of $25,020 was made available for the expenses of the health department. Funds from other public and private sources available to the health department amounted to the sum of M24.,215• The aggregate sum available for health work from all sources in Montgomery County in 1939 amounted to 04-9 >23$ (60 cents per capita) which was apportioned as follows: Table III Source of Funds for Health Services County Commissioners , $25,020 County Education Department (Dental Services) 670 Maryland State Department of Health (exclusive of branch laboratory) 17,160 Montgomery County Tuberculosis Association.... 4-,295 Lay Committees - Federation of Parent- Teachers Association 1,090 Private Donor - Demonstration District 1,000 Total . .$4-9,235 It will be noted that only two cents of the county levy is devoted to the support of the county health department. Considering the taxable valuation of the county and the total amount available for operating the county government, it is believed that two dollars per capita would be a conservative amount to be made available for health service in Montgomery County* For the fiscal year 194-2 a smaller amount is requested, viz, $1,2$ per capita. HEALTH DEPARTMENT OFFICES The offices of the health department are located in the county court house. The Health Officer’s office and the X-ray laboratory are located on the second floor in the new court house building. The State Health Department branch laboratory is also located on the same floor. The office for the nurses is on the third floor in the old court house. The office of the sanitation division is located on the second floor of the old 5 court house building. The old and new court house buildings are connected. The separation of the offices of the health department seriously interferes with the efficiency of the department, particularly with regard to informa- tional services, telephone communications, filing, and centralization of clerical services. The present office space is inadequate. Provision should be made for adequate office space, including suitable space for holding conferences and examinations which would afford some degree of privacy. District nursing offices are located at Bethesda, Silver Spring, Takoma Park, and Olney, These district offices are the headquarters for the district public health nurses and serve as health centers. Conferences and clinics in connection with maternal and child hygiene activities are held periodically at these points. PUBLIC HEALTH PERSONNEL The staff of the Montgomery County Health Department consists of IB full-time and 25 part-time employees. The full-time personnel is as follows: Health officer 1 Supervising public health nurse 1 Public health nurses 8 Sanitarians 3 Clerks 3 Laboratory assistant 1 Laboratory assistant (l/2 salary)! The regular health department staff is augmented by the services of a bacteriologist and a laboratory assistant (l/2 salary) who are paid by the State Health Department and are on duty in the branch laboratory. The part-time employees comprise 23 physicians, one dentist, and one nurse. The physicians serve in venereal disease, tuberculosis, and maternal hygiene clinics and in connection with the medical inspection of school children. The dentist performs dental inspections and some corrective work in the county schools. The colored nurse, paid by the State Venereal Disease Bureau, serves in the colored venereal disease clinics. All of the part-time employees are paid on a clinic session or hourly basis. The personnel of the health department paid from county funds are appointed by the Health Officer with the approval of the Board of County Commissioners. That part of the personnel of the health department who re- ceive a part of their salaries from the State grant-in-aid funds are selected by the Health Officer and. appointed after consultation with the Maryland State Department of Health, The staff personnel are energetic workers; however, some employees are performing services for which they are not properly qualified, A number of the employees do not meet the minimum professional qualifications with respect to education, training, and experi- ence as recommended by the Conference of State and Territorial Health Officers, PUBLIC HEALTH PERSONNEL EI.TLOIED BY OTHER OFFICIAL AND NONOFFICIAL AGENCIES The Montgomery County Board of Education, the Montgomery County Chapter of the American Red Cross, and the Metropolitan Life Insurance Company, each employ a public health nurse. These nurses are not under the supervision of the local health department5 however, they cooperate in the several phases of the public health nursing program in the county. HEALTH COi H UT TEES It is the policy of the Montgomery County Health Department to have each district nurse organize a functioning lay committee in her respective district. This lay committee assists the nurse to organize programs, hold clinics, and solve any problems relative to health that may arise in that district, A member is chosen from each district committee to join with representatives of the other districts to form a county council. The county council was instrumental in securing facilities for the operation of the present dental clinics sponsored by the health department. The council also assists in providing transportation for patients to all types of health department clinics. There is an advisory health committee composed of representatives from medical and dental societies, voluntary health organizations, civic organizations, county commissioners, board of education, and representative citizens. This committee considers from time to time matters pertaining to the content and scope of the health program in Montgomery County and assists the Health Officer with the development of his program. The committee endeavors to create a public health consciousness through the respective agencies to the end that the citizens will require the constituted authori- ties to make provisions for application of proven health measures. PUBLIC HEALTH PROGRAM The program of the county health department embraces vital statis- tics; communicable diseases, venereal disease and tuberculosis control; maternal, infant, preschool and school hygiene; laboratory services; and sanitation. Each of these services v/ill be discussed separately. The health department is conducting a demonstration with one nurse in the Olney area, comprising 1,700 people, to demonstrate the effectiveness of the generalized public health nursing service, including bedside nursing care, A private donor and the county tuberculosis association support this demonstration. Vital Statistics The records of births and deaths are valuable in the planning of a public health program and are of inestimable value to the other divisions of the county and State governments. These statistics should be sufficiently detailed and current to furnish accurate information of the health conditions in the county. The Health Officer is County Registrar and is the custodian of copies of birth and death records. The local registrars collect the birth and death certificates and make copies of each certificate. The originals are forwarded each month to the State Registrar by the local registrar and at the same time the local registrar forwards copies to the County Health Officer (County Registrar), Under this system it is possible for a delay of thirty days to occur before the County Health Officer has information as to the births or deaths that have occurred during the first part of the month. The delay might be obviated if the State Registrar would instruct the local registrars to forward to the County Registrar either the original certificates or copies of such certificates within forty-eight hours of their receipt. The appointment of the County Registrar as special agent of the Vital Statistics Division of the Bureau of the Census would facilitate the expeditious collection of the birth and death certificates. Such an appointment would permit the Health Officer to place in the hands of the local registrars self-addressed franked envelopes for immediate submission of birth and death certificates. The special agent would also query* the certificates for incompleteness, corrections, and the exact causes of death. There is some delay in obtaining from the District of Columbia Health Department transcripts of birth certificates for Montgomery County babies born in Washington, D. C, The Stats Registrar’s office is the channel through which transcripts of non-resident births are handled. The State Registrar makes a special effort to expedite the handling of transcripts for births and deaths in Montgomery County, The vital statistics are tabulated and analysed by the Maryland State Department of Health, The death rate for Montgomery County for the last two years is as follows: Total White Negro 193S deaths per 1000 population 11,1 10,5 15#3 1939 deaths per 1000 population 12,5 11.7 17,7 These rates were computed on the 1930 population figures. The State’s annual vital statistics report is not available before the last quarter of the follow- ing year; however, a provisional annual report, corrected for residence within the State, is made available to the county less than one month after the close of the year, A monthly mortality summary for the county likewise corrected for residence within the State of Maryland is made available to the County on the fifteenth of each month, A recent test raa.de on the completeness of birth registration in Montgomery County indicated that the registration of births was 9A*5 percent complete. If the several offices of the Montgomery County Health Department were centralized into one unit, it would be possible for one clerk to be designated as statistical clerk to perform administrative statistical services for the health department. This service would include the current analysis of births and deaths for the various areas and districts in the county for the information and use of the Health Officer and the members of his staff in carrying on the health programs suitable for each locality. Communicable Disease Control During 1939? 779 cases of communicable diseases were reported in Montgomery County, The quarantine laws and regulations were satisfactorily enforced. Epidemiological investigations are not being made on all of the known or suspected cases or contacts to cases of communicable diseases reported to the health department. Home visits are made by the nurses to all reported cases of diph- theria, scarlet fever, meningitis, typhoid fever, and poliomyelitis. The cases visited are given instruction by the nurse regarding care and isolation. Visits to reported communicable disease cases other than those mentioned above are made only upon request of the physician, family, or teacher. The records indicate that 512 communicable disease visits were made by the nurses of the health department. The accepted standard of nursing visits in the control of communicable diseases is equal to three times the total number of cases re- ported, It will be noted that the number of nursing visits made in behalf of communicable disease control in Montgomery County is less than 25 percent of the accepted standard. Twenty cases of diphtheria occurred in the county in 1939 with two deaths. The five-year average of diphtheria cases reported is 4-5* The unusual prevalence of diphtheria in the county indicates the need for an intensive immunization program. The health department has not carried on an active immunization service. The Health Officer does a limited amount of immunization. The public health nurses do not participate in the actual administration of toxoid. The health department has encouraged the local physicians to assume the responsibility for the immunization of the infants and preschool children. The records indicate that only 335 children, out of approximately 1,4-00, were immunized during 1939. The health department has been carrying on an energetic campaign in respect to the Schick testing of school children. The school physicians administer toxoid to all Schick-positive children in the elementary schools. It is unfortunate that more emphasis has not been placed on the immunization of infants and preschool children. In order to lessen the incidence of diphtheria in Montgomery County, it will be necessary for the health department to assume definite responsibility for diphtheria immunization activities and to bring about the immunization of all infants during the first year of life. Complete immunization records should be kept by the health department, A system for checking births with respect to immunization should be instituted for follow-up purposes. Smallpox has not occurred in this area since 1924-. All children entering school for the first time are required by law to be vaccinated. This vaccination law is well enforced. At the beginning of each school year the nurses visit the schools to check on the vaccination of the children. The records indicate that there are very few children who present themselves to the schools without having previously been vaccinated against smallpox. The provisions of the State lan for the prevention of blindness in the newborn are being carried out, as is evidenced by the fact that no cases of ophthalmia neonatorum were reported during 1939* Under the provisions of a State law silver nitrate preparations used for the prevention of blindness in the newborn are supplied by the Maternal and Child Hygiene Division of the Maryland State Department of Health for the use of practising midwives. The county health department purchases from the State Health Department additional silver nitrate packets for distribution to county physicians. No graphs or spot maps on the prevalence or location of diphtheria, typhoid fever, or the other important communicable diseases are kept by the health department. The absence of this information and data makes it very difficult to determine the incidence of communicable diseases in various areas. The program with reference to communicable disease control should be extended to include teaching and demonstration of isolation procedures for all types of communicable diseases. Venereal Disease Control The health department conducts five weekly venereal disease clinics, and sponsors one cooperative clinician type of clinic. Local physicians serve as clinicians on a fee basis at each of these clinics* Three of the clinics are devoted exclusively to the treatment of venereal dises.se in the Negro population. Public health nurses are on duty at two clinics5 a Negro graduate nurse serves at three clinics. Clinic hours at three clinics are from J+ to 6 P, M, and at two clinics from B to 10 P. M, The number of patients registered at these clinics varies from ten to fifty. The Negro group makes up a large part of the registration. The services of the public health nurses are used in the venereal disease clinics for the performance of duties other than nursing activities, sue! as clerical, maid, and attendant services. In order to bring about an efficient clinic service and utilize the services of the professional staff in matters pertaining to treatment and clinic service activities, the professional staff should be relieved of the non-professional duties and there should bo made available for each clinic, clerical, attendant, and janitor services. It is believed that paid attendants such as rT, P, A,, workers should be placed on duty at each clinic. The district public health nurses are made responsible for the in- vestigation of venereal disease contacts and the visiting of delinquent vo;.orcad disease cases for the purpose of encouraging treatment. Owing to the limited nursing personnel in the districts it is not possible for the existing nursing staff to perform these duties satisfactorily. In the three clinics without public health nurses, an attempt is made, but without much success, to maintain adequate treatment records and follow—up service. The records indicate that only twenty cases of gonorrhea were treated in the health department venereal disease clinics in 1939. Little or no emphasis has been placed by the health department on control measures with respect to gonorrhea* The records indicate that only 3S percent of the cases of syphilis received the minimum amount of medication recommended by the Cooperative Clin- ical Group, The health department should take the necessary steps to follow up delinquent cases with a view to requiring these patients to continue treatment| measures should be instituted for the investigation of contacts and for epidemiological studies in order to determine the prevalence and geographical distribution of the venereal disease cases in the county. This information is helpful in locating clinics so as to serve the diseased group. The clinic attendance at two of the five clinics is less than twenty patients. Consideration should be given to the discontinuance of small clinics and provision should be made to include such patients in the well-staffed and well-operated clinics. None of the clinics is equipped for making darkfield examinations. The clinic equipment should meet the minimum clinic standards prescribed by the Maryland State Health Department. A total of 271 clinic sessions was held during 1939 with an average attendance of 20 patients at each clinic. The activities carried on by the health department in connection with venereal disease control during 1939 show that 4.4.O cases of syphilis were admitted for diagnosis or treatment, and 20 ;cre admitted for diagnosis and treatment of gonorrhea. The venereal dis- ease patients made 5,4/3- visits to the clinic centers. There were only 234- nursing visits made in connection with the venereal disease control program, which is less than 50 percent of the accepted standard for venereal disease nursing. It is the policy of the health department to make available free treatment to all persons infected with venereal diseases. The local physicians refer to the health department their venereal disease cases when the patients are no longer able to pay for private medical care. In instances in which clinic patients are found to be able to pay for private medical services they are referred to their family physicians. Tuberculosis Control A clinic was established in 1922 by the county and State tuberculosis association for the diagnosis of tuberculosis. The Montgomery County Health Department operates one clinic for the diagnosis of tuberculosis with clinic sessions every other week, A physician from the city of Washington, specializ- ing in diseases of the chest, is employed by the health department on a fee basis to conduct the tuberculosis clinic. Persons arc admitted to the clinic only by appointment and referrals from local physicians. Provision is made for making X-ray examinations at the health department on one morning of each week. One nurse is regularly on duty at each clinic session and is assisted by one of the district nurses. The clerical and attendant services arc per- formed by voluntary workers of the local tuberculosis association. The clinical findings and other pertinent data on the clinical records are transcribed to the district nurses’ case records. Tuberculosis patients are hospitalized in State tuberculosis sanatoria White adult patients are cared for in the Maryland State Sanatorium at Sabillas- ville, White babies with tuberculosis are admitted to the Eudowood Tuberculosis Sanatorium at Towson, Md, Negro patients are sent to the Maryland State Tuber- culosis Sanatorium for Negroes at Kenryton. There are no county quotas as to the acceptance of patients for admission to the State sanatoria. All patients in need of hospitalization are usually admitted two Y/eeks following application. Tuberculosis patients unable to pay for medical care are accepted at the State institutions without cost to the county. Tuberculosis patients are also ad- mitted to the State sanatoria as pay or part pay, according to the individual’s financial status. A project was instituted in the fall of 193S to tuberculin test all high school students. All pupils with positive tuberculin reactions receive X-ray examinations in the schools through the use of the portable X-ray equip- ment, The project should be completed by the end of 1910 and the health department does not contemplate continuing it. This is thought to be wise, because it is believed that there are other more important and productive tuberculosis control activities, such as the home visiting of known cases of tuberculosis, the search for contacts, and the investigation of contacts in homes in which deaths from tuberculosis have occurred during the last decade. Maternal Hygiene The Montgomery County Health Department’s program in respect to maternal hygiene is designed so as to provide facilities to safeguard the pregnant woman from the hazards and difficulties of childbearing and to assure the mother of the best opportunity for normal delivery. Medical conferences, maternity clinics, and home nursing supervision are the means used to attain these objactives. Five maternal and child health conferences are held monthly at various centers in the county in order to provide for periodic examination and medical nursing supervision of antepartum patients and examination after delivery. Local physicians serve as clinicians assisted by the public health nurse of the district in which the clinic is held. The Maryland State Health Department makes available the services of an obstetrical consultant who visits the county every other month. The consultant confers with the maternal hygiene clinicians for the purpose of advising them concerning the professional conduct of the clinic activities and of consulting with them on abnormal cases. Upon request this obstetrician consults with practicing physicians in matters pertaining to their private obstetrical cases. At only one of the maternal clinics are the services of a dentist available for making dental corrections for expectant mothers. A dentist from Sandy Springs spends a half day each month at the Olney maternal and child hygiene clinic. This dentist is paid by the Maryland State Health Department at the rate of $1.00 for each corrective treatment. The regular public health nurse on duty in the district assumes responsibility for the general management of the clinic in her area. This nurse is occasionally assisted by a nurse from some other district. No formal classes or group conferences are held5 however, the public health nurse instructs the mother in personal hygiene and in the care of the newborn during the home visits. Blood pressure readings and routine urinalyses are made on antepartum cases at the maternity clinics. The nurses also take blood pressure readings and examine the urine of expectant mothers for albumin during the course of the home visit. The test for albumin is made with the Robert’s solution. If the presence of albumin is doubtful, specimens of urine are brought to the laboratory for re-testing. Maternity patients in need of postpartum bedside care are referred to the Red Cross Nursing Service, No provision is made either by the Health Department or the other nursing services in the county for nursing service at the time of delivery. Nursing visits in behalf of antepartum cases also are made to expectant mothers under the supervision of local physicians. The antepartum care of the pregnant woman is essential to safeguard- ing the health of the expectant mother and every effort should be made to bring the maternity case under medical nursing supervision. It is believed that the health department should carry on an intensive educational program with a view to increasing the scope and content of the maternal nursing service. There are an ample number of hospital beds available for maternity- cases accessible to the residents of Montgomery County. Provision is made by the county welfare authorities for the payment of hospital care of indigent maternity cases in complicated cases only. Provision should be made to hospi- talize cases in which the home conditions are very unsatisfactory. The records indicate that 66 percent of all births in Montgomery County in the year 1938 occurred in hospitals. Only a relatively small pro- portion of indigent cases are hospitalized. Only four maternal deaths occurred in Montgomery County in 1938. Three of these were attributable to accidents and hemorrhage and one to septicemia. It is believed that the number of hospital deliveries accounts in a large part for the low maternal death rate in Montgomery County as compared with that of the State as a whole. In accordance with the provisions of the State law, the Maryland State Health Department licenses midwives on the recommendation of the Division of Vital Statistics and after investigation by the Maternal and Child Hygiene Division, The midwives are licensed as a result of written tests pre- pared by the Maryland State Health Department, The midwifery examinations are held in the county by two physicians appointed by the Maryland State Department of Health, who examine the candidates, grade their papers, prepare a report and recommendations for the information of the Maryland State Health Department, Very few midwives have been licensed by the Maryland State Health Department in the county during the past eight years. The State Health Depart- ment register indicates that there are fifty-four midwives licensed in Montgomery County, The Maternal and Child Hygiene Division has charge of the instruction of midwives. The course of instruction comprises a minimum of six lectures. The midwifery bags and equipment are supplied by the State Health Department to the practicing midwives. Nine white and thirty-six Negro births were reported by fourteen midwives in 1938; fifteen midwives reported births in 1939* The neonatal death rate in Montgomery County for the years 1936-1938 was lower than that of the State, These rates were as follows; Year Montgomery County State 1936 25.5 32.1 1937 20.9 31.2 1938 2S.5 29.0 Health Department Medical and Nursing Services - 1939 Antepartum cases admitted to medical service - 73 Antepartum cases admitted to nursing service - 157 Nursing visits to antepartum cases — 281 Postpartum cases admitted to nursing service - 198 Nursing visits to postpartum cases - 218 The number of nursing visits made to antepartum cases in 1939 averaged slightly less than two visits per case while the recommended standard requires four. The Montgomery County Chapter of the American Red Cross Nursing Service admitted twenty-four antepartum cases to the nursing service and made fifty-seven antepartum nursing visits. This nursing service, calculated on the basis of nursing visits, is slightly more than two visits per case. Infant and Child Hygiene Seven child hygiene clinics are held each month for the purpose of giving medical and nursing supervision to infants and preschool children. Five of the child hygiene clinics are held in conjunction with the maternity clinic, The service includes physical examinations, diphtheria immunizations, and smallpox vaccinations. The clinician's findings and recommendations are discussed with each mother by the nurse, who also outlines an infant care program. Special clinics are arranged during the spring and early summer months to serve the more rural sections of the county. The nurse in whose district the clinic is held assumes responsibility for the clinic management and is assisted by one of the other nurses and voluntary lay workers. Local 5 physicians serve as clinicians at these clinics and a dentist serves at one of the clinic centers where dental examinations and treatments are included in the service. The records indicate that 820 infants and preschool children were admitted to the medical service. This group made 1,083 visits to the clinic. It would appear that only a small percentage of the children are re-examined during the year, The frequency of a patient’s attendance at the clinic is determined on the patient’s individual needs. The infant and preschool hygiene medical nursing services during 1939 are as follows; Individuals admitted to medical service - Infants 153 Preschool children 667 Individuals admitted to nursing service - Infants 369 Preschool children 592 Visits to medical conference - Infants 2/+J+ Preschool children 839 Field nursing visits - Infants 632 Preschool children 960 The attendance of Infants and preschool children at these medical conferences is below the accepted standard. However, according to statements from local physicians, apparently an adequate number of those not attending the conferences are under medical care. In 1933 there were fifty-three infant deaths, an infant mortality rate of 37.7, Of these deaths, forty occurred during the first month, a neonatal death rate of 28,5. It will be noted that the infant mortality rate for the State of Maryland for 1938 was 54.4- and that only Baltimore County had a lov/er infant mortality rate than Montgomery County in 1938, For 1939 the rate was 34.3, Of the 1,405 births which occurred in Montgomery County during 1938, only 357 infants were registered with the health department for nursing service. In localities where the infant mortality rate is between thirty and fifty per thousand live births, one-half of the infants under one year of age should be brought under nursing supervision. The nurses make home visits and give instructions to the mother concerning infant feeding and care. One of the deficiencies in the infant hygiene program in Montgomery County is the failure of the health department to contact the infant group. It is believed that the Montgomery County Health Department should make a case analysis and study of the infant deaths with a view to determining when, where, and in what population groups the peak of the deaths occur, with particular reference to color, economic status, and age at time of death. It will be noted that 667 preschool children were admitted to the medical service and 592 preschool children were admitted to the nursing service. Of the number admitted to the nursing service, 960 field nursing visits were made to this group, which is approximately two visits per child registered. It is estimated that there are 6,500 preschool children in Montgomery County; in order to carry out an acceptable preschool hygiene program, approximately 1,950 of the preschool children should be brought under medical supervision and 1,625 under nursing supervision. School Hygiene Health examinations are made on all children in the kindergarten, the fourth, seventh, and tenth grades. Only new pupils are examined in the first grade and selected pupils of the other grades. The health department encourages parents to be present at the tine of the health examinations. Vision tests are made by nurses on pupils in the first and fourth grades. Dental inspections are made on all children in the kind.erga.rten, first, second, and third grades by a member of the staff of the Division of Oral Hygiene of the Maryland State Health Department, The dentist sees only children in the other grades who require emergency attention. Corrective dental service is rendered to children examined who are eligible for dental care in the school dental clinics. Dental clinics are held at the Rockville, Silver Spring, and Poolesville schools. School children in need of dental care are brought from other schools to these clinics for correction. The dental service in Negro schools is rendered by a Negro dentist during the spring and fall school months. The dentist devotes approximately two days each week to inspections and corrective dental work in the Negro school children. The Negro part-time dentist receives approximately $4-00 during the school year for his services. Of this amount $150 is provided by the Montgomery County Health Department, The county Board of Education contributes a like amount, and the remainder, approximately $100, is obtained from the colored parent-teachers association. A local physician performs Schick tests on all children in the elementary schools not known to be "Schick negative," The public health nurses visit the schools regularly for the purpose of conferring with the principal and teachers on health problems. Inspections of pupils for evidence of communicable diseases are made to only a limited extent. The nurse inter- vie¥/s pupils and the parents who may call at the school for the purpose of conferring with the nurse on the health problems of their children. The district public health nurses also make home visits in connection with the school hygiene program. The registration of school children for medical and nursing services of the health department for 1939 is as follows; Individuals examined by physicians 5 >250 Individuals admitted to nursing service 4-70 Field nursing visits 1,441 Inspections by dentist 5>093 It will be noted that 4-70 pupils were admitted to the nursing service and that 1,4-40- nursing visits were made to this group in connection with the school nursing program. This represents an average of more than three visits per pupil registered. The standard number of nursing visits in behalf of elementary school children should be 150 nursing visits to each 1,000 elementary pupils 3 there- fore, 2,-400 nursing visits should be made in connection with the school hygiene program. The Montgomery County School Board employs a nurse in the capacity of in-school public health nurse. This nurse devotes the major portion of her time to liaison activities between the school board and the health depart- ment in respect to the school hygiene programs. Her activities also include welfare functions and advisory service in connection with the cafeteria, menus, and noon-day lunches for needy school children. Crippled Children The Montgomery County Health Department in cooperation with the Maryland State Health Department holds three clinics annually at Montgomery County General Hospital for the diagnosis of crippling defects and deformities in children. These clinics are conducted by an orthopedic surgeon employed by the Maryland State Health Department on a fee basis, 025 per day, plus traveling expenses. Nurses, a stenographer, and a part-time physiotherapist are employed by the State Department of Health to assist the physician. Operations and post-operative care incident to the correction of defects in crippled children are performed at the Kernans Hospital for Children, or the Children's Hospital, both located in Baltimore City, The nursing staff of the county health department contacts patients prior to the clinic in order to get them to attend. After the clinic, these same nurses visit the patients to assist them in every practical my to carry out the recommendations of the clinic orthopedist. Transportation for patients to and from the clinics and orthopedic applicances upon request, are furnished by the local American Legion Post, The I.iaryland State Department of 24 Health defrays the cost of hospitalization and furnishes braces and other orthopedic appliances. In Montgomery County there are 93 crippled children registered with the Division of Services for Crippled Children, Maryland State Department of Health, Laboratory The laboratory service for Montgomery County is rendered by a branch laboratory of the State Health Department, This laboratory is located in the new court house building on the second floor adjacent to the office of the Health Officer, The location and service rendered by this laboratory relieves the Montgomery County Health Department of the responsibility for the maintenance of a public health laboratory. The laboratory personnel consists of a bacteri- ologist and two laboratory assistants, ’ The branch laboratory performs the usual public health laboratory services and serves as a repository and distrib- uting center for antitoxins, vaccines, serums, and biological products, not only to Montgomery County but also for the adjacent counties. Over 90 percent of milk and water samples from Montgomery County are examined in the local branch laboratory. This laboratory also takes care of about 25 percent of milk samples and about 75 percent of water samples from Prince George’s County, The branch laboratory does not make serological examinations for syphilis. Whole blood specimens for syphilis are sent to the State laboratory at Baltimore, The branch laboratory does the typing work in connection with pneumonia control and has available a few types of pneumonia serum for distribution to physicians in Montgomery County, Antirabic virus is not kept on hand at the branch laboratory. The needed supply is obtained by special delivery from Baltimore. The work of the laboratory is periodically checked by the State laboratory. Environmental Sanitation Environmental sanitation projects carried on as regular activities include inspection and/or supervision of public, sernipublic, and private water supplies 5 public and suburban sewer systems and rural sanitation5 milk sanitationi food sanitation! garbage disposal facilities and hog farms! and children’s boarding homes. These activities are carried out by three sanitarians. (a) Public, Semipublic, and Private hater Supplies The activity in connection with public water supplies consists primarily of collection of samples for bacteriological examination in coopera- tion with the State Health Department. In the field of semipublic water supplies, the activities consist of an annual inspection, at least, of institutional and camp supplies; in private water supplies, the work is limited to rendering assistance only at the request of home owners. There are no records available as to the number of private supplies improved. However, it is estimated that only about 30 percent of the rural population is served by protected supplies. (b) Urban and Suburban Sewer Systems and Rural Sanitation The supervision of public sewage disposal systems and treatment plants is under the direction of the State Board of Health and is not con- sidered as a function of the county health department, except in case of emergency* Excreta disposal is and probably will continue to be a real problem in the county, particularly in outlying suburban and rural areas, A large portion of these areas is not served by sewerage systems and must, of neces- sity, depend on individual excreta disposal facilities. The State Health Department supervises the operation of all municipal sewerage systems in the county, but the county health department is responsible for the supervision of construction and maintenance of all other sewage disposal systems. A special law applying to Montgomery County passed by the State Legislature in 1933? pertaining to sewage and drainage in the county, directs the county health department to review plans and inspect locations of proposed septic tank installations. The County Clerk issues permits for such installations based on recommendations contained in reports of inspectors. In addition to the initial inspection for the location, an average of two additional inspections at the time of construction are necessary before final approval of the installation is made. Records show that during the period 1937 to 1939 inclusive, 1,037 septic tank installations were inspected. This means that more than 3 >000 inspections were necessary, or an average of 1,000 per year. One of the difficulties in connection with the disposal of excreta at unsewered houses through the use of septic tanks is the lack of adequate space to provide sufficient underground disposal systems on many building sites. Recent observations made in response to complaints reveal that numerous underground disposal systems have become overloaded and have ceased to function properly. Due to the limited area of many plots, no additional space is available for new underground disposal systems. Conse- quently, many serious nuisances now exist. This problem could have been pre- vented had there existed regulations specifying minimum building plots at the time of these installations. Since this problem is likely to increase, additional personnel, well trained in public health work, should be provided to supervise this work. The sanitation of recreational areas and various types of camps is not now a problem. The school sanitation program is practically complete, but will require routine annual or semi-annual supervision. There is no organized program in the field of rural sanitation. It is estimated that at least 2,000 homes in the county, or about 65 percent of the rural population, are without safe methods of excreta disposal. During 1933 and 1939, only thirty-three sanitary privies were built. An additional sanitary inspector was employed late in 1939, who was assigned to this work. In the first half of 194-0, forty-one sanitary privies were constructed as a result of this inspector’s efforts. If this important problem is to be solved within a reasonable time, additional well-trained personnel will be required and some other method of approach will have to be adopted. There are no laws or regu- lations requiring individuals to provide sanitary excreta disposal facilities, and until such laws or regulations are adopted, the program will resolve itself into a matter of promotion and education. (c) bilk Sanitation The supervision of 167 milk producing plants is a function of the county health department. This work is carried on jointly under State and county milk regulations. County regulations are based on the 1935 Milk Ordinance and Code recommended by the U,. S,. Public Health Service, In May 194-0 a milk sanitation rating was made in Montgomery County, This rating did not include the dairy services of the city of Washington. The U, S, Public Health Service Code of 1935 was followed. The ratings were as follows? Public Health Service rating for retail raw milk B3.30 " " " n " raw milk sold to plants 80,83 n n ” n " pasteurization plants 86,23 " " n n M pasteurized milk 83.52 It is noted that no places in the county are included in the Public Health Service’s list of communities attaining 90 percent compliance with the Standard Milk Code, The minimum number of inspections as required by the regulations are made under the present program. All herds are tuberculin tested. The herds supplying Grade A raw milk are also tested for contagious abortion. Approximately 90 percent of the milk distributed in the county is pasteurized and is produced by six dairies. The remaining 10 percent is Grade A raw milk, produced and retailed by forty-five small dairies, A part of the raw and pasteurized milk for Montgomery County is supplied by the Chestnut- Farms-Chevy Chase Dairy and the Thompson Dairy, The pasteurized milk supplied by the above dairies is pasteurized in the Washington plants and distributed to residents in Montgomery County living in the metropolitan area adjacent to the District of Columbia, One or more sanitarians well trained in milk sani- tation Y/ould be very valuable in further stimulating pasteurization and improving the sanitary quality of the milk. (d) Food Sanitation A food sanitation program is now in the process of development. Prior to the present year practically no work was done in this field and little information is at present available as to the sanitary conditions of food- handling establishments. There are approximately 300 establishments dispensing food and to date only 266 have had an initial inspection. There is a definite need for additional personnel for this program. (e) Children’s Boarding Homes There are approximately 250 children’s boarding homes in the county. Owners of these homes are required by a State law to secure permits to operate. These permits are based in part on recommendations made by the county health department following a complete sanitary inspection of the premises. This activity was assigned to the health department during 1939. Since assuming this responsibility only eighty of these homes have been inspected. (f) Garbage Disposal and Hog Farms The collection and disposal of household garbage and rubbish is by- contract as provided in regulations adopted by the County Commissioners in 194-0, These regulations impose on the county health department the responsi- bility for the inspection and supervision of collection methods, transportation facilities, and private dumps. Regulations pertaining to private dumps pro- hibit the feeding of garbage to hogs at dump sites without special permission. Regulations which require permits for all hog farms of more than two animals also direct the county health department to make inspections for the purpose of issuing permits. Recent observations indicate that the super- vision of these farmers and garbage disposal methods is not adequate. (g) Other Activities In addition to the regular sanitation activities, the health depart- ment is called upon to inspect all projects of the Federal Housing Adminis- tration for water supply and sewage disposal methods prior to construction. An average of three Inspections is required before completion of construction. It is reported that housing improvements are needed in certain sections of the county, and it is highly desirable that the county health department accept this activity as a regular function. The supervision of swimming pools, the investigation of stream pollution by industrial wastes or sewage, and necessary remedial measures are functions of the State Health Department, MEDICAL CARE The responsibility of administering medical care to the general population of Montgomery County rests with approximately fifty local practising physicians. The County Commissioners employed local physicians to attend patients in the county home and jail at a cost of $328.00 for 1939* In addition the sura of $18,413 was expended for hospital and physicians1 fees incident to the medical care of the indigent. The responsibility for providing for the general needs of the county!s indigent is delegated to the County Aid Board, A person who is being aided financially by the board is expected to pay his attending physician from his regular allotment for any sickness in his home. With respect to maternity cases, however, the attending physicians, by a new agreement, may be paid $15.00 per case by the County Aid Board for each authorized home deliv- ery, The school dentist is also employed two days each month by the office of the County Aid Board to treat indigent adults in need of dental care. The com- pensation for this service is at the rate of $15.00 per diem, including supplies. There are available in the county two general hospitals for those patients needing hospitalization. The Montgomery County General Hospital located at Olney has forty beds and eight bassinets. The Washington Sanitarium and Hospital located at Takoma Park has 200 beds. The hospital facilities of the city of Washington are also available. There is no agency in Montgomery County or in the State of Maryland which is responsible for the care and treatment of the medically indigent. The Maryland State Health Department in cooperation with the State Department of Public Welfare is engaged in a study of the problem, the facilities, and the needs with a view to presenting this subject with recommendations to the next General Assembly, Mental Hygiene The Montgomery County Mental Hygiene Association is carrying on a psychiatric service in the county in cooperation with the health department, education department, welfare board, social service league and juvenile court. This service includes examinations, treatment, and advice to the patient. PERSONNEL REQUIREMENTS FOR THE HEALTH DEPARTMENT In order to carry out effectively the duties and functions of the Montgomery County Health Department, the following additional personnel is required? 1, Assistant Health Officer Provision should be made for the employment of a trained public health officer for duty with the department in the capacity of Assistant Health Officer and Epidemiologist. The Assistant Health Officer’s duties should include administrative responsibilities delegated by the Health Officer, epidemiological studies, medical duties in connection with the public health clinics, the making of annual physical and other examinations for the police department, and examinations for health certificates and work permits# 2, Public health dentist A full-time dentist should be employed on the staff of the Montgomery County Health Department to perform the oral hygiene activities in connection with the white and Negro schools, the clinics, and for rendering dental service to the beneficiaries of the County Aid Board. The present ex- penditures by the health department and the cooperating agencies aggregate the sum of $3>400* It would only require a supplement of $200 in order to procure the services of a full-time dentist at a salary of $3,200 and a travel allowance of $4-00 per annum. 3. One public health engineer, one sanitarian, one sanitary officer The work of environmental sanitation should be under the immediate direction of a sanitary engineer who would meet the professional qualifications recommended for public health engineers by the Conference of State and Territorial Health Officers, The sanitarian should be selected on the basis of his qualifications with special reference to his administrative ability and his technical knowledge of milk sanitation. 4# Assistant supervising public health nurse and six staff nurses The supervising nurse should assume the responsibility for the staff education and assist with the supervision of the public health nursing field activities. On the basis of population and the actual health needs in Montgomery County and in order to perform satisfactorily the generalized public health nursing services, a minimum of one nurse for each 5>000 population, or a total of 16, is essential. In the event the health department is expected to assume responsibility for the generalized nursing program, including bedside nursing care, a minimum of one nurse for each 2,000 population or a total of 10 public health nurses, will be required to conduct such services. 5. Part-time clinicians Two or three physicians with aptitude for and interest in the venereal diseases, tuberculosis, and/or maternal hygiene should be added to the clinical staff to assist at the respective health clinics. 6, Statistician (statistical clerk) The health department should employ a statistician (statistical clerk) having knowledge of biostatistics and training in the methods of col- lecting, recording, coding and analyzing of vital statistics data and the interpretation of such analyses. 7. Non-professional personnel. Provision should be rno.de for employing additional clerical, attendant, and janitorial personnel. RECOMMENDATIONS The organization of the health department and the health services and functions were described in some detail in the respective'sections under the public health program and included suggestions for improving the respective services. While the Montgomery County Health Department with its present limited resources and personnel is rendering good service, there is a deficiency in the intensity and scope of some of the services it is perform- ing* In addition to inadequate resources, insufficient personnel, and lack of authority, there is need for systematizing and coordinating the activities, and the health department is urgently in need of additional suitable space in order to discharge its functions satisfactorily. In order to emphasize the requirements for strengthening the existing services and for making provision for needed health services, the following recommendations are submitted. Recommendations 1 to 9 inclusive pertain to organization and facilities, and the responsibility for putting them into effect rests primarily with the County Commissioners, Recommendations 10 to 22 inclusive are of an administra- tive and functional character for improving the activities of the health department for which the Health Officer is primarily responsible. Organization and facility recommendations: 1, That the following additional personnel be added to the staff of the Montgomery County Health Department: (a) An Assistant Health Officer (b) One full-time dentist (c) An assistant supervising public health nurse (d) Six staff public health nurses (e) A public health engineer (f) One sanitarian and one sanitary officer (g) A statistical clerk (h) Three clerks (i) Part-time attendants for duty at each clinic It is further recommended that all personnel selected for the staff of the Montgomery County Health Department be appointed with the approval of the Maryland State Health Department, 2, Montgomery County should look forward to increasing expenditures for its health department in order to take full advantage of methods which are being constantly developed for the benefit of public health. Therefore, it is recommended that from county and other tax sources the sum of $100,020,00, or $1,25 per capita, be made available to the health department to be apportioned as follows: BUDGET Salaries Health Officer (? 5,600 Assistant Health Officer 4,200 Public health dentist 3,200 Supervising nurse 3>000 Assistant supervising nurse 2,400 Staff nurses (14.) 25 >200 Public health engineer 2,600 Sanitarians (3) 5 >4-00 Sanitary officers (2) 3>300 Laboratory assistant 1,320 Laboratory assistant (l/2 salary) 960 Statistical clerk 1,500 Clerk stenographer 1,44-0 Chief filing clerk 1,320 Clerks (4-) 4,080 Clinic physicians (5-8) 2,100 Travel Health Officer 500 Assistant Health Officer 600 Public health dentist 4-00 Supervising nurse AOO Assistant supervising nurse & 500 Staff nurses (L+) ® (>500 each 7,000 Public health engineer 500 Sanitarians (3) 1,500 Sanitary officers (2) 1,000 Equipment; non-expendable supplies; Services other than personal Health examinations 1,000 Registration of vital statistics BOO Furniture & equipment (office and clinic) 2,500 Clinic and laboratory; scientific equipment and supplies 3>100 Drugs and biologicals 4,000 Dental equipment and supplies 2,600 Operation and maintenance Expenses, including printing, stationery, telephone, heat, light, janitorial and attendant service 6,000 Total $100,020 3. That in the county’s building program consideration be given to the health department’s space needs both for its central office and district offices and that adequate spaco be made available immediately in a county owned building for the offices of the Montgomery County Health Department, including laboratories, clinics, library, and conference rooms. The offices should be centrally located and so arranged as to bring about a unifica- tion and coordination of the various activities and services of the health department. 4. That an ordinance be adopted by Montgomery County providing for the sanitary disposal of human excreta at unsewered homes and that the Fork Projects Administration Community Sanitation project be reinstated in the county. 5. That the county revise the building regulations so as to provide for the location and erection of houses on building lots in con- formance with the health and sanitation requirements. 6. That the regulation pertaining to waste disposal be amended so as to require sanitary methods for storage, collection, and dis- posal of garbage and the maintenance of garbage dumps in a sanitary condition, 7. That the county milk ordinance be amended so as to require pasteurization of the entire milk supply, 8. That the health department accept financial responsibility for the entire salary and traveling expenses of a full-time dentist and that the parent-teachers associations and other civic organ- izations be relieved of their financial responsibility towards the oral hygiene program. 9. That the several types of professional, scientific, and techni- cal personnel employed by the Montgomery County Health Department conform to the minimum standard qualifications for public health personnel recommended by the Conference of State and Territorial Health Officers, Administrative and functional recommendations; 10. That the Census Bureau be requested to appoint the county Health Officer as a special agent of the Vital Statistics Division of the Bureau of the Census, and that birth and death certificates be forwarded by the local registrars to the Health Officer within forty-eight hours after their receipt. 11, That an analysis be made of infant deaths with a view to deter- mining when, where and in what population group the peak of deaths occur, with particular reference to color, economic status, and age at time of death. 12* That epidemiological investigations be made on all communicable diseases and that spot maps and graphs of the incidence of these diseases be kept for educational purposes as well as for the general use of the personnel of the health department. 13. That the diphtheria immunization activities be extended so as to include a larger number of the infant and preschool group. 14. That the program for venereal disease control be expanded particularly with reference to epidemiological studies and the investigation of contacts for the purpose t-f bringing a greater number of venereal disease cases under treatment* The small venereal disease clinics should be consolidated or the clinic attendance increased so as to justify operation. Provision should be made for follow-up service to require the delinquent and recalcitrant patients to continue treatment. 15. That more time be given to home visiting of Jmovm cases of tuberculosis, to the search for contacts, an$ to the investiga- tion of contacts in homes in which deaths fn?m tuberculosis have occurred during the last decade. 16, That the health department carry on an intensive educational program with a view to increasing the scope content of the maternity nursing service. 17, That the program for infants and preschool children be augmented in order that a larger number of infants and preschool children may receive nursing service by the health department. 18, That a concerted effort be made in behalf of school and pre- school children to bring about the correction, of their remediable defects. 19. That every effort be put forth to bring about the pasteurization of the entire milk supply. 20, That the health department establish a sanitary rating system for eating and food-handling establishments, including the posting of sanitary scores for each food dispensing place. 21. In order to perform the field health activities effectively and to carry out an intensive sanitation program, a generalized public health nursing service, and the clinic activities, it is recommended that the county be divided into five health districts with headquarters, clinic, and conference rooms suitably located so as to serve the population of each area. 22, That present employees whose professional qualifications are below the minimum standard educational and training require- ments of their respective classifications and grades be given trainee scholarships or opportunities for additional instruction in order to qualify themselves for their respective positions.