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THE IMPROVEMENT OF PUBLIC HEALTH WORK THROUGH
THE STABILIZATION OF HEALTH BUDGETS, SOUND HEALTH , :
ee atten AND THE EVALUATION OF ACTIVITIES / :

During the past two or three years health appropriations, never adequate to
do a completely satisfactory job, have been cut severely.

Some departments of health lost most if not all their child welfare activi-
ties, others a majority of their public health nurses, and still others such im-
portant functions as tuberculosis and venereal disease eontrol. Suen eliminations
of essential health activities are bored if continued, to eventually adversely
affect the public health. Such reductions are clear cut examples of false economy
for which we are bound to pay many times over in the future.

There are three important functions which all those interested in the maine

tenance of public health protection shouid unite in fostering:

ay)

Gg The stabilization of public health appropriations. WA IG "os

 

(2) The stabilization of sound health organi gation and
administration.

(3) The evaluation of public health activities to the end
that funds expended for public health shall be used
in the most scientific and effective manner.

The first of these functions can be achieved only by a widespread educational
campaign aimed to acquaint the public, and most particularly those. officials who
are entrusted with the appropriation of funds, with the importance and necessity
of maintaining adequate health machinery and of the false economy in reducing es-
sential. public health appropriations.

The average individual, including legislators, knows something about highways,
he sees them and he uses them, he sees the parks and recreation centers and uses

them, he sees school buildings and uses them, he sees the policeman on the corner

and knows what he is there for. All these things he is interested in because
 

they affect him personally. He may have heard of the health department, probably
not much more than that. It is doubtful if he has ever actually seen any real
public health work going on. If hé has any impression at all as to what consti-
tutes public health work he is more than likely to picture it as embodying primar-
ily garbage collection and tacking up quarantine signs. He does not see that
public health work affects him personally in any way and he therefore quite
naturally lacks interest in it.

Even granting, as we must, that public health work is far more difficult to
dramatize than highways and public schools, nevertheless the average individual 's
complete lack of understanding of what public health means to himis a severe crit-
icism of our methods of general public health education.

The keynote of our general public health education programs must be to in-
dividualize public health if we are ever to attain the measure of success which
the importance of the work merits. This seems to be the crux of the entire prob-
lem. Public health protection must be made the problem of the average individual.
He must be made to see that public health does affect him personally, intimately,
definitely, and in an important way.

How can this be done?

Obviously all the various avenues of publicity may be made use of - radio,
talks, newspapers, pamphlets, and magazine articles, and the program should be
nationwide in scope.

These are, of course, merely the avenues of approach. How shall the message
or messages be prepared and presented? This presents a much more difficult prob-

lem but we may perhaps formulate certain principles which might prove helpful:
(1) The talks and articles, particularly radio talks, should be short.

(2) They should be simply worded and their keynote must be an in-
dividual personal appeal. We must minimize the general appeal
to civic mindedness and impress the average individual, to
whom our remarks are addressed, with the fact that our message
affects him personally.

 
(3) Particularly in radio talks, the dialogue is apt to be far
more effective than the individual talk.

(4) We should not attempt to cover more than a few pointe in any
Single talk or article.

(S) We should bear in ‘mind the fact that our usual audience is
already interested in and has some knowledge of our message.
In this program we must constantly endeavor to reach a dif~
ferent type of audience ~- one that has as yet no special
interest in and knowledge of our message.

(6) We should recognize the fact that with very few exceptions
public health workers are not properly trained to themselves
do the job which we wish done. We should, therefore, wherever
possible, avail ourselves of professionally trained people:

(a) Professional actors for radio dialogues,

(b} Persons trained in advertising and journalism
for the preparation of talks and articles.

With these general principles as a background, with the aid of professionally
trained people, and with a nationwide well planned program, we may look forward to |
at least come measure of re

The second function, that of stabilizing sound health organization, may be
approached through an educational campaign, perhaps a somewhat more direct campaign
than the one aimed to stabilize health appropriations, in which the American Public
Health Association sends directly to legislators and legislative bodies its pro-
nouncements on what constitutes sound health organization.

Such pronouncements would include at least the following definite statements:

(1) The health officer should be directly responsible only to his
board or to the chief executive of his community.

(2) All public health work should be coordinated under the leader-~
ship of the health officer and the health officer should have
no other responsibilities. Health and welfare activities
should not be combined in a single department.

(3) (a) The health officer should be employed on a full-time
basis and should be well trained for his position.

(b) There should be full-time well trained personnel for
all executive and administrative positions.

 
(4) The health officer should have supervision over the entire
community public health program (whether or not he actually
earries on all the integral parts of the program) and
should provide such personal health services as are essen-
tial and cannot be adequately provided through other channels.

(5) Preventive and curative medical activities are very closely
allied and should be inter-related as closely as possible
but:

(a) Curative medical activities such as the care of the
indigent sick should be carried on by medical insti-
tutions, hospitals, universities and the like. Al-
though welfare and charity organizations may well
finance such activities they should not themselves
carry on medical work.

(o) All preventive medical activities should be carried on
under the direct supervision of the health officer.
This does not mean that the health officer need neces-
sarily be in direct charge of all preventive services
but rather that he should have such supervisory juris-
diction as would protect the public health and ee
duplication of effort.

Now we come to the third function in which we should also all be interested;
the evaluation of public health activities to the end that funds expended for pub-
lic health should be used in the most scientific and effective manner.

It is unreasonable for us to expect appropriating bodies to provide adequate
public health budgets unless we can show that funds appropriated are being used in
as Wise and scientific a manner as knowledge permits. It is probably safe to say
that there is less public health money wasted than in perhaps any other govern-
mental department but on the other hand it is probably true that there are a
great many health departments which could make a more scientifically effective use
of some of their funds.

There are two main objectives in evaluating health activities and the rela-

tionship of health activities to each other:

(1) To show appropriating bodies that we are using funds in as
wise a manner as possible;

 
(2) In communities where, in spite of efforts, appropriations
remain decidedly inadequate to make the health dollar just
as effective as possible.

City and Rural Appraisal Forms have given us excellent measuring rods for
the general adequacy or inadequacy of health programs and the degree to which
these programs were well or poorly balanced. They also provide some actual evalu»
ation of services rendered but with the exception of the weighting factor which is
applied to each major activity there is nothing to evaluate the relative importance
of the various component parts of the public health program nor is there in these
Forms any means of evaluating the effectiveness of individual procedures.

Are we spending too mich or too little for a given health activity in rela-
tion to other essential activities of the program?

Are the procedures used in carrying on an admittedly essential activity so
designed as to give maximum results for effort and funds expended?

These are questions of great importance which every health department ought
to seek answers for.

Today our deh, and one of our principal jobs is to take out the "slack" in
our programs, to differentiate between essentials and non-essentials, to judge the
relative importance and effectiveness of the various factors in and phases of pub-
lic health work. Obviously this cannot be done by any rule of thumb method for
eee differ both in their problems and in the eelative importance of their
problems. Malaria control may be of paramount importance in one community and of
no significance at all in another, and so on. It does mean, if we are to do our
job well, that we must consciously or unconsciously appraise and evaluate the
component parts of our program and in many even the details of procedure within a
Single activity. We must first clearly define our major problems and then study

the relative effectiveness with which our activities are meeting these problems.

 
For example, we must determine first, whether or not all the activities of our pro-

gram are essential and secondly, having established the fact that a given activity

is essential we must examine the various procedures employed in carrying on that

activity to determine their relative importance and effectiveness.

While, as previously stated, it is obviously impossible to determine precise-

ly how any given community can make its health dollar more effective there are

perhaps certain fundamental principles and general considerations which any com-

munity can profitably make use of.

Three fundamental principles readily occur to one:

(1)

(2)

(3)

That we should exert our major efforts to those activities
which give the greatest promise of effectively protecting and
promoting child health, particularly of young children. This
would immediately classify communicable disease control, pre-
natal, obstetrical, and infant work, and milk control as es-
sential activities. Since water supply and sewage disposal
affect persons of all ages attention to those activities
would, if this principle is accepted, be essential parts of
our program.

That our major efforts should be confined, as far as prac-
ticable, to those activities the results of which are reason-
ably definitely known. Thus diphtheria immunization, smallpox
vaccination, typhoid fever control, the protection of the
water supply and the pasteurization of milk become integral
parts of our public health program.

To, insofar as it is feasible to do so, carry on those activi-
ties which are likely to produce maximum results at minimum
cost. While naturally this group of activities will in most
instances be synonymous with those activities the results of
which are definite this principle would tend to eliminate
(during this period of depression) elaborate epidemiological
communicable disease control methods which although effective
are very costly. For example, it would probably be foolhardy
for a department of health today to institute the elaborate
malaria control measures which were so effectively and neces-
sarily carried on during the construction of the Panama Canal.
As at present carried on, much of our school health work

falls within this category.

Bearing in mind these three fundamental principles, let us discuss certain

general considerations. Some of these are:

 
If we have been spending an unduly great amount of time and effort in inves-
tigating nuisances most of which have little or no public health significance,
this work can be eliminated without doing any great harm.

If we have any inefficient employees this is obviously the time to get rid
of then.

One of our major considerations should be to maintain, at almost any cost of
curtailing other activities, our maximum public health nursing staff for without

these important emissaries in the home our opportunity of accomplishing results

is tremendously reduced.

If after examining our program on the basis of the three fundamental prin-
ciples previously referred to and having eliminated all but essential ma jor
activities our budget reduction has been such that we are obliged to still further
reduce our work, what is our next stent

The next thing to do would seem to be to study carefully the procedures and
methods used in carrying on essential activities.

Such an examination and study might conceivably bring to light practices
which could be either eliminated or altered in such a way as to effect a saving
without impairing the general effectiveness of the service.

If, for example, our nurses are calling on prenatal cases eight or ten times |
during pregnancy, this number of calls may perhaps be reduced to three or four,
depending of course on the needs of the individual patient, without increasing
our maternal or infant mortality.

Infants may be coming to our well baby conferences routinely every two weeks.
We may well change this rule and have the clinic physician determine the fre-
quency of visit based on the condition and progress of the individual infant.

This will very likely reduce clinic visits to 5 or 6 visits a year except for

 
special cases. The tendency seems to have been to try to have an unnecessarily
large number of visits.

Preschool clinics or conferences often attempt to have their children come in
every month or every other month. Pediatricians usually do not succeed in having
their children of preschool age come in more than 2 or 3 times a year. This is as
much &$ W6 can expect and is probably as often as is necessary, except of course
in special individual cases. Preschool service in Bonerel. while potentially pro-
ductive of excellent results and worth while, particularly in the splendid educa-~
tional effect of such a project as the a Round-Up of the National Congress of
Parents and Teachers, is less well defined both with respect to procedure and re-
sults accomplished than some other forms of service. It would seem that because
of this fact both prenatal and infant service would take precedence over it.

Probably nowhere in the entire public health program, with the possible ex-
ception of nuisance investigation, is the public health dollar less effectively
spent than in school health service. There are, of course, notable exceptions to
this general statement but considering the country as a whole, in spite of the re-
markable potential benefits of a well conducted school health program, we have
spent more money on school health services with less to point to in the way of
tangible measurable results than in any other major phase of public health work.
We are not referring particularly to school nursing service, although that could
be greatly improved and is probably the poorest done of any public health nursing
service, but rather to the so-called medical examination of school children. The
story of the reasons for the ineffectiveness of school examinations, which might
more appropriately be termed "inspections" (and we are referring here to the
routine examination of elementary school children) is altogether too long to be

told in this brief article. Suffice it to say that while it is our claim that the

primary object of the school examination is to educate parents to the value of a

 
périodic health examination it has failed miserably in so doing. Although it is

true that we have succeeded in having large numbers of physical defects corrected
We still continue to find approximately the same percentage of physical defects in
school children of a given age as we did ten or fifteen years ago and moreover
comparatively few parents have accepted and put into practice the principle of

having periodic health examinations for their children of school age.

Let us examine our milk control progrem. This is unquestionably an essential

activity but one in which not infrequently there is a good deal of lost motion.
If milk control work of the past twenty years has been at all successful, and we
believe that it has been, it has convinced both farmer and distributor that it is
good business to produce good quality milk. We no longer have to employ police
methods to accomplish results. If in our program we are attempting to visit each
producing farm 2 or 3 or more times each year perhaps making a detailed score each
time, would it not be wise to reduce the number of farm inspectors and divert time
thus saved to a more productive field? If each farm has had one thorough es
tion to assure us that equipment and methods meet satisfactory standards it would
seem practical from this point on to devote, as far as the work in the country is
concerned, our major effort to checking the milk at the country loading or dis-
tributing stations, through temperature, sediment, and odor tests and bacterial
examination or reduction or methylene blue test, going back to the individual farm
from which the milk came whenever milk of unsatisfactory quality is found.

| These are, of course, only a few of the things which a study of procedures
and methods may reveal. In general, we may say that rules of routine procedure,
such as visiting the home of a patient regularly once a month, which may have been
valuable at the time they were instituted, if continued too long and followed too

religiously, often result in much wasted effort.

It is perfectly clear that in order to make the best use of our public health

dollar we must know our problems and our program thoroughly.

September 20, 1933