CITY ‘ile HEALTH 30 cents a copy November, 1925 $3.00 a year duty ILLIAD ( ea 3 Dy ISCONSING Eide lu NCALIFORNIZ iia MICHIGAN Pee = Be Book fie atte irs | Among the largest one-man shovels in the world is this tremendous one, used on the Mesabi Range in Minnesota. It picks up 16 tons of ore ai a bite, which it deposits in a car—all in less than a minute, ca ary day’s work at every gulp Surgeons use a tiny A hand shovelful of ore weighs 21 oe they examine pounds, and a man can handle 200 an ear. Miners use G-E. shovelfuls in an hour. But here is motored hoists tg re- . ° te move tons of ore from a giant that picks up, in one gulp, a mine. Wherever there ; is dificult work to be more than a man can shovel ina day! done you will find that the General Electric Company makes some- _And the G-E motors that animate thing electrical that will . . help. the giant never get tired. ~ GENERAL EL CTRIC No. 2) 30 cts:, $3 00 a year; foreign postage, 50 cts. extra; Canadian 30 cts. Changes of address should be mailed us two weeks in advance. 5 ill ‘be sent only upon request. Entered as second-class matter, November ‘ 25 1 Yi Apeabtanon for mailing re special rate. of postage “providedfor in~Seetion 1103, ‘Act of October 3, 1917, authorized December 21, 1921. ‘Sec’y, Ann Reed Brenner. ‘Treas., Arthur Kellogg. SURVEY GRAPHIC, published nionthly: and copyright 1925 by SURVEY ASSOCIATES, Inc., 112 East 19th Street, New York. Price: this copy (November, 1925; Vol. VIII, When payment is by check 1921, at the post office, New York, N. Y., under the Act of March 3, 1879. Pres., Robert W. de Forest. ere i emcee rs etna Typical Interior of Block at Sunnyside, Long Island City. Fifteen Minutes from 4and Street, Manhattan, by subway: 5c fare. Garden Homes for 1000 Families. Sold—not Rented—at about $10 per room per mosth. Only 30% of the land is built on—70% left for playgrounds and gardens. All houses are only two rooms deep, giving a maximum of sunlight, fresh air and cross ventilation. Here is a unique BOARD OF DIRECTORS Alexander M. Bing President Dr. Felix Adler John G. Agar Leo S. Bing William Sloane Coffin Thomas C. Desmond Douglas L. Elliman Prof. Richard T. Ely Frank Lord V. Everit Macy John Martin rs. J. M. Proskauer Mrs. F. D. Roosevelt Robert E. Simon ARCHITECTS Clarence S. Stein Henry Wright Fred. K. Ackerman investment opportunity Buy stock in City Housing Corporation and secure a safe investment and a steady 6% in- come, at the same time helping build healthy homes fir people of moderate means ITY HOUSING CORPORATION is a limited divi- dend corporation, with ideals of better homes and communities. Large scale building operations and pur- chase of land, together with better planning and group- ing of houses, enable it to sell well built homes for less than current rentals; at the same time much needed playgrounds and gardens are provided, insuring the healthiest environment. Dividends, which are limited to 6% per annum, have been earned since the company was organized and a substantial surplus accumulated to assure the safety of the investment. CiTy HOUSING CORPORATION A Limited Dividend Company— Organized to Build Better Homes and Communities 587 Fifth Avenue, New York City Authorized Capital, $2,000,000 in shares of $100 each CITY HOUSING CORPORATION, 587 Fifth Avenue, New York City, N. Y. Please send me full information: 6.2 Name eee eee eee ere sere eee reese eee seer revere eee eeenee (12 answering advertisements please mention THE SuRVEY. It helps us, it identifies you.) 109 No Such Free Homes As St. Rose’s Home on the Lower East Side of New York, or Rosary Hill Home on the Westchester Hills, an hour away from the city, exist from North to South in the United States. They are for cancer-cases that are destitute and pronunced incurable; and absolutely no pay is received from relatives or the State. The reasons are beneficial to the patients, and the public mercy is the softest mercy for them, as many letters of harsh indif- ference prove. Please help to complete our Fund for a fire- proof Country Home for our present mem- bers of 60 or more such men and women of all Creeds and Nationalities. MOTHER M. ALPHONSA LATHROP, O. S. D., ‘Treasurer, The Servants of Reliet Rosary Hill Home, Hawthorne, N. Y. STATEMENT OF THE OWNERSHIP, MANAGEMENT’, CIRCUU,A- TION, ETC., REQUIRED BY THE ACT OF CONGRESS OF AUGUST 24, 1912, of SURVEY GRAPHIC, published monthly at New York, N. Y., for October 1, 1925. State of New York, ; ; County of New York, SS. Before me, a Commissioner of Deeds, in and for the State and county aforesaid, personally appeared Arthur Kellogg, who, having been duly sworn, according to law, deposes and says that he is the business manager of the Survey GrapHic, and that the following is, to the best of his knowledge and belief, a true statement of the ownership, management (and if a daily paper, the circulation), etc., of the aforesaid publication, for the date shown in the above caption, required by the Act of August 24, 1912, embodied in section 411, Postal Laws and Regulations, printed on the reverse side of this form, to wit: 1, That the names and addresses of the publisher, editor, managing editor, and business managers are: Publisher, Survey Associates, Inc., 112 Fast 19 Street, New York City; Editor, Paul U. Kellogg, 112 East 19 Street, New York City; Managing Editor, Geddes Smith, 112 East 19 Street, New York City; Business Managers, Arthur Kellogg, John D. Kenderdine, 112 East 19 Street, New York City. 2. That the owner is: (If owned by a corporation, its name and address must be stated and also immediately thereunder the names and addresses of stockholders owning or holding one per cent or more of total amount of stock. If not owned by a corporation, the names and addresses of the individual owners must be given. If owned by a firm, company, or other unincorporated concern, its name and address, as well as those of each individual member, must be given.) Survey Associates, Inc., 112 East 19 Stas New York City, a non-commercial corporation under the laws of the State of New York with over 1,700 members. It has no stocks or bonds. President, Robert W. deForest, 30 Broad Street, New York, N. Y.; Vice-Presidents, Julian W. Mack, 1224 Woolworth Building, New York, N. Y.; V. Everit Macy ‘“Chilmark,” Scarborough-on-Hudson, N, Y.; Secretary, Ann R. Brenner, 112 East 19 Street, New York, N. Y.; Treasurer, Arthur Kellogg, 112 East 19 Street, New York, N. Y. 3. That the known bondholders, mortgagees, and other security holders owning or holding 1 per cent or more of total amount of bends, mortgages, or other securities are: (If there are none, so state.) None. 4. That the two paragraphs next above, giving the names of the owners, stockhelders, and. security holders, if any, contain not only the list of stock- holders and security holders as they appear upon the books of the company but also, in cases where the stockholder or security holder appears upon the books of the company as trustee or in any other fiduciary relation, the name of the person or corporation for whom such trustee is acting, is given; also that the said two paragraphs contain statements embracing affiant’s full knowledge and belief as to the circumstances and conditions under which stockholders and security holders who do not appear upon the books of the company as trustees, hold stock and securities in a capacity other than that of a bona fide owner; and this affiant has no reason to believe that any other person, association, or corporation has any interest direct or indirect in the said stock. bonds. or other securities than as so stated by him. [Signed] ARTHUR KELLOGG, Business Manager Sworn to and subscribed before me this 25th day of September, 1925. [Seal] MARTHA HOHMANN, Commissioner of Deeds, City of New York. New York Co. Clerk’s No. 148. New York Co. Register’s No. 26032. My Commission Expires May 20, 1926. 4 $1.00—New Edition $1.00 Mind in the Making The Relation of Intelligence to Social Reform By James Harvey Robinson James Harvey Robinson, author of “The Mind in the Making,” and Joseph K. Hart, associate editor of Survey Graphic at Frederic C. Howe’s School of Opinion at Siasconset, Mass. Mr. Howe and the Atlantic Ocean are be- hind the School and do not show in the picture. They were snapped red-handed in a plot to make people use their minds as well as their fingers and feelings. | James Harvey Robinson: “As an old stoic proverb has it, men are tormented by the opinions they have of things, rather than by the things themselves. This is eminently true of many of our worst problems today. We have available knowledge and ingenuity and material re- sources to make a far fairer world than that in which we find ourselves, but various obstacles prevent our in- telligently availing ourselves of them... . In short, how are we to rid ourselves of our fond prejudices and open our minds?” Joseph K. Hart: “Few people ever knowingly begin a book that is likely to challenge their prejudices and make them uncomfortable. . . . Reviews help in this. by giving readers advance notice of books to be avoided on pain of being stirred into thought. A single book might start a new age if it were widely read. Such a book is Prof. James Harvey Robinson’s ‘The Mind in the Making’.” H. G. Wells: “When I come to reckon up this American visit, I think I may well feel that the encounter of most importance and likely to have the greatest lasting effect upon me is meeting and talking to Prof. James Harvey Robinson and reading his fascinating book.” The new Survey Associates Edition of “The Mind in the Making” at $1.00 is printed from the plates of the original edition, of which 100,000 copies were sold at $2.50 each. Cloth bound. 238 pages including the final chapter, “‘Some Suggestions in Regard to Reading.’’ SURVEY ASSOCTATES 112 Fast 19 Street, New York I enclose check (or money order) for $........ r which fo please send me ........ copies of The Mind in the Making at $1 each. Name 0000099000980000090C95000009000000000000000000000000000 11-1-25- (In answering advertisements please mention THe SURVEY. It helps us, it identifies you.) 110 ‘A-62 — The Bradford. A prize - win- ning ~ design. A-75 — Dinner i bell. Solid A - 145 — B-160 — Lady long and brass. A min- Christmas Elizabeth. 2%” wide. iature mor - candlesticks. A-94—Cake tray in brass. Not hammered. A-21 — Colonial peas English din- It was never tar and pestle. 38” high. 942” long and 7” wide. Special...... . .$3.00 roomstick. Solid ner bell. BS priced so 2” high. Price, the B-94—Sandwich tray. Same as A-94, “except brass. 4” high. 8%" hig low .. $2.75 sellesces: Ga.ee pair .. $1.10 flat, without.base. Price. vos stee ss Peed Special, each. ‘SI. 95 Special. o$t. 0 A-63 — Bud vase. Ham- A-142—The pro- A-29 — Brass mered brass. A-78—Card-tray. In brass or A -{62 — The verbial Cheshire wall - sconce. About 6” tall. copper. A very fine piece for Renfrew. Solid Cat. Solid brass. Back is 9%” A good prize the reception-table. It is brass. 3%” long 344” long. Its long. Arm suggestion for A-165 — Can- 34%” high and 6%” in di- and 2” wide. pedigree dates extends out your whist dleholder in ameter. It could also be Carries the sem- back to ‘“‘mer- B-21 — Dolphin candlestick. 3 5”. Specially party. Speci- brass or cop- used as a candy tray. Not lance to a coat rie old Eng- Brass. 4” high by 4” in di- . price d, ally priced per. 4” high. hammered. Specially priced ofarms. Special- land.’’ Special- ameter. Price, each....$2.25 . each .. $2.95 95c. Special .. 95e ......... eee «see. $2.00 Jy priced...$1.25 ly priced...$1.10 : A-161 — Jacobean winding candle- sticks. 1144” high. Strikingly artis- A-37—Prize -win- tic and tastefully A-134—Bud-vase candle- sticks. 744” high. Can- dlesticks are popular A-4—Russian tea-set. Hammered brsas or copper. The kettle is 6” high and ning candlesticks. different in de- with men, Price, holds 10 large cups. The tray, hand-made, is 18” long and 12” wide. The 6” high. Price, the sign. Price, the DAT ........ sees $4.95 creamer and sugar-bowl are good mates. Featured, the set................ $18.00 pair ....... $3.50 pair ....... $7.50 A-9— Tulip candle- sticks. 11” high. A tulip cup, a slender body, and a flat a.149—Dutch coffee - -pot. Hammered brass or ECC eas copper. Made| Zor a party of ae: 64" high, * Y i y . ecial.....$4. : pair ......... $5.95 eo eas SrRO" CUDS gees: vs A-24 — Lion candelabra. os 11%” high. A very inter- A-!— Foxboro can- A-159—Eagle candelabra. Solid brass. h ip d b d esting object for the living dlesticks. A simple Height, 14%”. Width, Oaes di It W room. It will add a mellow colonial creation. would make an appropriate wedding roug t f rom sou rass an copp er tone, where one is needed. They are 914” high gift, and is something attractively A wonderful value for very and more massive different from what the bride cus- Created by the little money. Specially than they look. tomarily receives. Specially priced, priced, each ......... $3.95 Price, the pair..$5.25 each ........ eerie -50 a reneccegrenpranereren ART COLONY INDUSTRIES pepesepasnpancnaneitte Americas leading metal craftsmen, 34 Union Square, N.Y.City (In answering advertisements please mention Tue Survey. It helps us, it identifies you.) 111 Some of the agreeable things people are saying — “Altogether a remarkable issue, per- haps one of the finest numbers, not merely of Harpers, but of any magazine that has ever been published in the United States.” TIME. “The neu: Harpers has just come in. My sincere congratulations. The format is superb, and I like the new cover im- mensely.” . H. L. MENCKEN. “I am delighted with your new maga- zine in every way.” T. W. LAMONT. “T can’t resist making myself heard in the cheering gallery for the new Harpers. ...I don’t know when I have seen so much literature spread on a single table of contents.” ANNE O’HARE McCORMICK. “You are off to a fine start with the new Harpers. The September issue is about as good a magazine number as I ever saw. Congratulations!” VILHJALMUR STEFANSSON. “I read Dr. Fosdick’s article yester- day. It is as good as can be, and ex- tremely well written—as well written as it is logical—inseeing and far-seeing. Fle is a man of great ability and you - have done well to get him.’ SIR GILBERT PARKER. “I want to send you my congratula- tions on the September number of Har- pers. It is a great magazine, and I should think that any author of creative literature would take especial pride in seeing his material in such good company and in such good form.” FREDERIC MELCHER. We are continuing our Special Anniver- sary Offer to new subscribers. For only $3.00 you may have Harpers for one year (The usual price is $4.00). Simply sign this form ‘and we will bill you later. (Or, if you prefer, enclose your check.) Mail -it-'toy, Harper & Bros., 49 E. 33rd St.. New York. Pa aR aR Lae aR a AR ARRON IRC INU aU a Pea ae aR RU aN EN y Phenomenal Success of the New HARPERS MAGAZINE The indispensable periodical for alert minded and sophisticated America 5 HE new Harpers Magazine has achieved an unqualified suc- cess. The September issue—its first appearance—was com- pletely sold out in ten days. And from all over the country enthusiastic and wholly spontaneous letters continue to pour in, in gratifying appreciation of the vigorous, youthful, provocative per- sonality of the new magazine. Moreover, the editorial forecast promises for the coming months. even richer material. ‘The best in fiction from America and England ; fearless and vivid discussions of significant phases of American life; important points of view from and about Europe; brilliant criticism and absorbing problems involving the human equation. — In short, the new Harpers will triumphantly fulfill the promise of its first numbers just as it has already established itself as the periodical most sympathetic to the modern educated mind—a periodi- cal of rapid wit, clarity of judgment, independence of thought, and high literary flavor. In the November Number LAW MAKING AND LAW ENFORECENT, by Arthur T. Hadley ° I BELIEVE IN MAN, by Dr. Harry E. Fosdick THE HOME-TOWN MIND, by Duncan Aikman THUNDER ON THE LEFT, Part III, by Christopher Morley WHERE THE NEXT EUROPEAN WAR WILL START, by Frederick Palmer THESE AMERICAN WOMEN, by Rebecca West THE FETISH OF THE JOB, Anonymous AMERICA’S POLITICAL DECLINE, by Frank R. Kent THE PROMISED LAND, by Hendrik Willem Van Loon THE WAYS OF THE WEEVIL, by Henshaw Ward THE ONCE OPEN ROAD, by Charles Merz STORIES; . by Walter De La Mare, Roy Dickinson, Philip Curtiss ‘Harpers PPP PPPOE POPP RPP PPP PG Add coos coceeeeesseesseeeeteeenee MAGAZINE BRR TINS ne SORE REE: (In answering advertisements please mention THE Survey. It helps us, it identifies you.) 112 First—Last—Always MEN have been known to go for months without shelter, for weeks without food and for days without water, but no one can live for more than a few minutes without air. Breathing is the first necessity of life—yet few of us know how to breathe to develop our bodies and to improve our health. If we could be always in fresh air taking plenty of exercise, our usual undirected, instinctive breathing would naturally develop to give us better health. Nature would take care of us. But the condi- tions in which we live, the stress of present-day life, cause us to accumulate an excess of poisonous waste products in our bodies. To help dispose of these we should go beyond instinctive breathing and at frequent times during the day mentally direct the breaths we take. Count Your Breaths— How many breaths a minute do you take? Stop now with your watch in hand and for 60 seconds count them. Fifteen to twenty short, top-of-your-lungs breaths? You are not breathing deeply. Occasionally you should take six or eight long, leisurely breaths a minute—so deep that the dia- phragm is expanded and the ribs are barreled out. Several timesa day stop what you are doing, stand straight with head up, shoulders back and breathe—al- ways through the nose, of course. Try it this way—inhale, one, two, ) Baby’s first cry! However it may sound to grand- mother’s ears, it is music to the baby’s mother. Under the spell of her eager imagination that thin little cry is a call for her. But what he really is cry- ing for is air. Inthe Land of Unborn Babies he had no need to use his lungs. But here, in the great wide world, his first need is air and through every moment of his life he will demand air. three, four; hold, five; exhale, six, seven, eight, nine; relax, ten. This will give you six breaths a minute—dquiet, unhurried breath- ing. After a time your uncon- scious breathing may become deeper and you will begin to feel a new and delightful sense of buoyant power. Good Posture First— When you stand or sit with shoulders rounded and chest con- tracted you squeeze your lungs and make deep breathing impossi- ble. Lift your head, raise your chest, straighten your spine, ele- vate your ribs and you cannot help “breathing for health”’. Deep breathing exercises should be taken night and morning. Empty the lungs as fully as pos- sible with each breath. This is important. because fresh air re- moves harmful waste matter in the blood. That ‘‘Stitch in the side’ — Have you ever felt a stitch in the side when running? This is a warning—not always that your heart is weak, or that you have indigestion, as many persons sup- pose, but sometimes that your lungs are unaccustomed to being filled to their full capacity. Most of us rarely breathe to the bottom of our lungs. One-third of the lung cells of the average person is unused. These cells tend to col- lapse and stick together. When the air is forced into them, it sometimes causes pain. Your health demands that you should breathe properly. The blood circulates all through the body distributing material to build and repair the tissues, picking up waste products and fighting disease | germs. The turning-point of its journey is in the lungs where it deposits the waste and takesa fresh supply of oxygen from the air. Without deep breath- te ing of fresh air there ‘SS cannot beamplesupply of oxygen. Without sufficient oxygen there cannot be adequate growth or repair of any part of the body, nor vigorous warfare against disease. Begin today to breathe deeply —hbreathe for health. 1 “CC oo ng ya? 4 Bierce About one out of six of the total number of deaths in the United States each year is caused by diseases which affect the lungs. Pulmonary tuberculosis and pneumonia claim more than 210,000 victims annually. Ten years ago the: death-rate from tu- berculosis was sixty per cent higher than itis today. Only a short time ago it was thought that fresh air must be kept away from patients suffering from lung troubles. Today it is known that fresh air is one of the main aids in getting well—and . this knowledge has helped to produce the 6 marked decrease in tuberculosisdeath-rate. Deep breathing must be studied. There is more to it than the taking of a full breath. The diaphragm and abdominal muscles must be strengthened by exercise and the . posture. Defects in the air passages should be cor- rected if one is to breathe most effectively. Wise parents should keep careful watch over their children’s noses and throats to see that they are not afflicted with adenoids or diseased tonsils. body must be trained to maintain correct The Metropolitan Life Insurance Company “has prepared a booklet giving simple and interesting health rules, including scientific advice about fresh air and proper breath- ing. These rules, withthe simple breathing exercise given above, can be followed by anybody who wishes better health. Send for a copy of “How’'to Live Long”. It will be mailed free. HALEY FISKE, President. Published by , et € METROPOLITAN LIFE INSURANCE COMPANY~NEW YO Biggest in the World, More Assets, More Policyholders, More Insurance in force, More new Insurance each year (In answering advertisements please mention Tur Survey. It helps us, it identifies you.) 113 THREE INCOMPARABLE CRUISES WITH CONGENIAL VOYAGERS Around the World Cruise A World trip of 30,000 miles on the magnificent S. S. Laconia, visiting a score of Far East countries, each like a different world, is a supreme experience and becomes travel glorified. ! The Clark management (Mr. and Mrs. Clark accompany the Cruise) makes this an ideal opportunity for world travel. | Cruise sails Jan. 20, 1926. $1250 to $3000. With private bath $4000. Another Mediterranean- Norway Cruise The Mediterranean-Norway Cruise of 1925 has proved such a success that we are already announcing a similar trip sailing June 30, 1926—same ship, the new S. S. Lancastria, same itinerary, same rates. The prices, $550 to $1300 ($1700 with bath) are phenomenally low and we will have, as this past year, an immediate rush of ap- plications, especially at the lower rates. It only costs $10 to make a reservation. © It is certainly the banner Summer Cruise. The Mediterranean Winter Cruise Twenty-one successful Mediterranean Cruises give an assured guarantee that the 22nd on the beautiful new S. S. Transyl- vania will be just as conspicuous a success. This Cruise of 62 days of princely travel furnishes the acme of enjoyment and in- tellectual inspiration. This Cruise includes a superb ship, the famous Cunard service and cuisine, con- genial fellow-passengers, inspiring lectures and services, elaborate shore sight-seeing. This cruise represents the climax of travel, Sailing date, Jan. 30, 1926. $600 to $1700. ‘With private bath $2000. \ Illustrated book and ship diagram sent free on request. Address: CLARK’S CRUISES, 112 East 19 Street, New York City (In answering advertisements please mention Tur SuRVEY. It helps us, it identifies you.) 114 ADVENTURES on the BORDERLAND Richard C. Cabot ARMERS who have burned old zigzag Be fences have discovered their most productive land in the strips which have lain fallow between fields. So with the professions. Adventures aplenty and abundant human harvest may be reaped on their frontiers. There is needed only the adventuring mind and the seeing eye to discover what those harvests may be. Dr. Cabot writes a series of exploring arti- cles. As a physician, he is an authority on the human heart; as a social worker, he pioneered hospital social service; as a teacher, he holds the chair of social ethics at Harvard. In the first article, which he calls ‘“‘A Plea for a ‘Clinical Year’ in the Course of Theo- logical Study,” he proposes a definite plan for training theological students “‘in the difficult wrestle of personal relations.” He believes that both teachers and pupils would find re- freshment and invigoration if, in addition to their regular theological studies they had been ‘on the firing line together” in the face of ‘‘the hopeless discouragement written on the face of a chronic sufferer or the profusion of sophis- tries fired at one by the hard-pressed sinner.” The minister, like the doctor, must “look after the minds, the emotions, the wills, the souls” Medicine The Min istry of ETHICS By RICHARD C. CABOT, M.D. A series ot articles in Survey Graphic in which the author of “What Men Live By’ discusses the Penetration of Ethics into the Professions of Business Social Work Education of humankind. Ministers trained for such ser- vice would, he believes, “become far better preachers and for this reason, as well as for their greater experience and helpfulness in the great common problems of human personality and human association, they would be more prized, sought after and rewarded by their congregations and by the public at large.” Equally vigorous and exploratory articles, freely illustrated from Dr. Cabot’s experience, will traverse the fence-lines of the other pro- fessions. Here is a series to send to your thinking friends, particularly those among them who are Doctors, Ministers, Teachers, Business Men, Social Workers. p—---------- CUT OFF HERE——-——~—__.______]| i SURVEY GRAPHIC, if ew] 112 East 19 Street, New York. | I enclose $........ for which please enter 6 months’ trial subscriptions at following new subscribers: Name .. Address Name Address Name Te ew ee eC we ne We Se 8 8 9 00 0 0 8 0 we ce ee 6 oa cs ne crriCA NCCI CCI MON Mo Deo cor olerie legit eel sl ale eae are SO ee ee wee we oe oe woe eee te Poof? 22°999090000000000000000000K CIPOO9T"9ZF992999 900000000000 0000 ee Address 115 $1 each (yearly $3) for the cc cee ww ww ee ee mere rrr err reer eccece TT ee em meme mee eee ese er ccc cove cee THE SURVEY’S DIRECTORY OF SOCIAL AGENCIES AMERICAN BIRTH CONTROL LEAGUE—President, Margaret Sanger, 104 Fifth Avenue, New York City. Objects: To educate American people in the various aspects of the dangers of un- controlled procreation; to establish centers where married persons may receive contraceptive advice from duly licensed physicians. Life membership $1.00; Birth Control Review (monthly magazine) $2.00 per year. AMERICAN CHILD HEALTH ASSOCIATION—3270 Seventh Ave., New York. Herbert Hoover, President; Philip Van Ingen, M.D., Secretary; S. J. Crumbine, M.D., General Executive. Objects: Sound promotion of child health, especially in cooperation with the official health and education agencies. AMERICAN COUNTRY LIFE ASSOCIATION—K. L. Butterfield, president; Henry Israel, executive secretary. Room 1849, Grand Central Terminal Bldg., New York City. Emphasizes the human aspect of country life. Annual membership $5.00 includes ‘‘Rural America’ (monthly bulletin) and Annual Conference Proceedings. AMERICAN FEDERATION OF ORGANIZATIONS FOR THE HARD OF HEARING—Promotes the cause of the hard of hearing; assists in forming organizations. Pres., Dr. Gordon Berry; Field Secretary, Miss Betty Wright, 1601 85th St. N.W., Washington, AMERICAN HOME .ECONOMICS ASSOCIATION—Lita Bane, executive secretary, 617 Mills Bldg., Washington, D. C. Organ- ized for betterment of conditions in home, school, institution and community. Publishes monthly Journal of Home Economics: office of editor, 617 Mills Bldg., Washington, D. C.; of business man- ager, 1211 Cathedral St., Baltimore, Md. AMERICAN PEACE SOCIETY—Founded 1828, labors for an inter- national peace of justice. Its official organ is the Advocate of Peace, $2.00 a year. Arthur Deerin Call, secretary and editor, 612-614 Colorado Building, Washington, D. C. AMERICAN SOCIETY FOR THE CONTROL OF CANCER—Dr. George A. Soper, managing director; 370 Seventh Ave., New York. To disseminate knowledge concerning symptoms, diagnosis, treat- ment and prevention. Publication free on request. Annual mem- bership dues, $5.00. AMERICAN SOCIAL HYGIENE ASSOCIATION—3870 Seventh Ave., “New York. To promote a better understanding of the social ?thygiene movement; to advance sound sex education; to combat }prostitution and sex delinquency; to aid public authorities in the «campaign against the venereal diseases; to advise in organization wf state and local social-hygiene programs. Annual membership dues $2.00 including monthly journal. CHILD WELFARE COMMITTEE OF AMERICA, Inc.—730 Fifth Avenue, New York. Telephone: Circle 9623. To secure Mothers Allowance laws in states now having no such provisions; to pro- mote desirable amendments to existing Mothers Allowance laws, to harmonize them with the maximum necessary protection of - @ependent children; to secure proper laws affecting adoption, boarding out and placing out of dependent children; ‘so far as possible to secure home life for normal children in preference to sending them to institutions; to aid in the enforcement of Mothers Pension and kindred laws. States Council of Child Welfare Com- mittee of America comprises representatives of practically every state. Committee publishes digest of laws and educational material on Mothers Pension and kindred topics. Invites requests from responsible public and private organizations for aid in Mothers Pension problems. Sophie Irene Loeb, President; Governor Alfred €. Smith, Honorary Chairman; Margaret Woodrow Wilson, First Vice-President; Edward F. Brown, Executive Secretary. COUNCIL OF WOMEN FOR HOME MISSIONS—156 Fifth Avenue, . New York. Composed of 20 Protestant national women’s mission : boards. Florence E. Quinlan, Executive Secretary. . Work among Farm and Cannery Migrants, Summer service for college students, Laura H. Parker, Executive Supervisor. . Bureau of Reference for Migrating People, follow-up of New ’ Americans, Raymond H. Cole, Executive. FEDERAL COUNCIL OF THE CHURCHES OF CHRIST IN AMERICA—Constituted by 28 Protestant communions: Rev. C. S. Macfarland and Rev. S. M. Cavert, Gen. Sec’s; 105 E. 22d St., N.Y.C. Dept. of Research and Education, Rev. F. E. Johnson, Sec’y. Commissions: Church and Social Service, Rev. W. M. Tippy, Sec’y; International Justice and Goodwill: Rev. S. L. Gulick, Sec’y; Church and Race Relations: Dr. G. E. Haynes, Sec’y. HAMPTON INSTITUTE—Trains Negro and Indian youth for com- munity service. Advanced courses: agriculture, builders, business, thome-economics, normal. Publishes ‘Southern Workman” and free material on Negro problems. J. E. Gregg, principal. INTERNATIONAL MIGRATION SERVICE—To assemble data en international social problems and through work with individual cases to develop methods of international social service. Head- quarters, London. Viscountess Gladstone, chairman; Professor Gilbert Murray, treasurer; Ruth Larned, executive. Address all inquiries to American bureau, 1 Madison Avenue, New York City. Director, Mary E. Hurlbutt. JOINT COMMITTEE ON METHODS OF PREVENTING DE- LINQUENCY—Graham Romeyn Taylor, executive director, 50 East 42nd Street, New York. To promote the adoption of sound methods in this field, with particular reference. to psychiatric clinics, visiting teacher work, and training for these and similar services; to conduct related studies, education and publication; and te interpret the work of the Commonwealth Fund Program for the Prevention of. Delinquency. NATIONAL BOARD OF THE YOUNG WOMEN’S CHRISTIAN ASSOCIATIONS—Mrs, Robert E. Speer, president; Miss Mabel Cratty, general secretary, 600 Lexington Avenue, New York City. This organization maintains a staff of executive and traveling secretaries to cover work in the United States in 1,034 local Y. W. C. A.’s on behalf of the industrial, business, student, foreign born, Indian, Colored and younger girls. It has 159 American secretaries at work in 49 centers in the Orient, Latin America and Europe. NATIONAL CHILD LABOR .COMMITTEE—Owen R. Lovejoy, general secretary, 215 Fourth Avenue, New York. Industrial, agricultural investigators. Works for improved laws and admin- istration, children’s codes. Studies child labor, health, schools, recreation, dependency, delinquency, etc. Annual membership, $2, es $25 and $100 includes monthly publication, “The American Child.”’ NATIONAL CHILD WELFARE ASSOCIATION, INC. (est. 1912, incorp. 1914), 70 Fifth Ave., N. Y. C. (tel. Chelsea 8774). Pro- motes as its chief object the building of character in the children of America through the harmonious development of their bodies, minds, and spirits. Its method is, in co-operation with other organizations, to originate and disseminate educational material in the form of posters, books, bulletins, charts, slides, and insignia. Through its ‘‘Knighthood of Youth” it provides homes, schools and church schools with a method of character training through actual practice. Officers: Dr. John H. Finley, Pres.; Amos L. Prescott, Treas.; Charles F. Powlison, Gen. Sec’y. THE NATIONAL COMMITTEE FOR MENTAL HYGIENE, INC.— Dr. William H. Welch, honorary president; Dr. Charles P. Emerson, president; Dr. Frankwood E. Williams, medical director; Dr. Clar- ence J. D’Alton, executive assistant; Clifford W. Beers, secretary; 370 Seventh Avenue, New York City. Pamphlets on mental hygiene, mental and nervous disorders, feeblemindedness, epilepsy, inebriety, delinquency, and other mental problems in human behavior, educa- tion, industry, psychiatric social service, etc. ‘Mental Hygiene,” quarterly, $3.00 a year; ‘‘Mental Hygiene Bulletin,’’ monthly, $ .50 a year. NATIONAL COMMITTEE FOR THE PREVENTION OF BLIND- NESS—Lewis H. Carris, managing director; Mrs. Winifred Hath- away, secretary; 180 East 22nd Street, New York. Objects: To fur- nish information, exhibits, lantern slides, lectures, personal service for local organizations and legislation, publish literature of move- ment—samples free, quantities at cost. Includes New York State Committee. NATIONAL CONFERENCE OF SOCIAL WORK—Gertrude Vaile, president, Denver, Coiorado; W. H. Parker, Secretary, 25 East Ninth Street, Cincinnati, Ohio. The Conference is an organization to discuss the principles of humanitarian effort and to increase the efficiency of social service agencies. Each year it holds an annual meeting, publishes in permanent form the Proceedings of the meet- ing, and issues a quarterly Bulletin. The fifty-third annual meet- ing of the Conference will be held in Cleveland, Ohio, in the Spring of 1926. Proceedings are sent free of charge to all members upon payment of a membership fee of five dollars. NATIONAL COUNCIL OF JEWISH WOMEN—2109 Broadway, New York. Miss Rose Brenner, pres.; Mrs. Estelle M. Sternberger, ex. sec’y. Promotes civic cooperation, education, religion and social welfare in the United States, Canada, Cuba, Europe. Department of Immigrant Aid—799 Broadway. Miss Florina Lasker, chairman. For the protection and education of im- migrant women and girls. . Department of Farm and Rural Work—Mrs. Leo H. Hertz, chair- man, 5 Columbus Circle, New York City. _ THE NATIONAL COUNCIL OF THE YOUNG MEN’S CHRISTIAN ASSOCIATIONS OF THE UNITED STATES OF AMERICA—347 Madison Avenue, New York City (Telephone, Vanderbilt 1200). Composed of 344 business and professional men, representing 1,540 Associations in 48 states, Hawaii, and the Canal Zone, and 388 Associations in $2 Foreign Lands. Officers: F. W. Ramsey, Cleve- land, O., President; Adrian Lyon, Chairman of the General Board; John R. Mott, New York, General Secretary. NATIONAL LEAGUE OF GIRLS’ CLUBS—Mrs. Fannie M. Pollak, president; Mary L. Ely, Educational Secretary. Non-sectarian and self-governing organization of working women’s clubs for recreation and promotion of program in Adult Education. Vacation Camps. 472 West 24th St., New York City. (In answering advertisements please mention Tur Survey. It helps us, it identifies you.) 116 THE SURVEY’S DIRECTORY NATIONAL ORGANIZATION FOR PUBLIC HEALTH NURSING— Member, National Health Council—Anne A. Stevens, R.N., direc- tor, 370 Seventh Avenue, New York. For development and stand- ardization of public health nursing. Maintains library and edu- cational service. Official Magazine, ‘‘Public Health Nurse.” NATIONAL URBAN LEAGUE—For social service among Negroes. L. Hollingsworth Wood, pres.; Eugene Kinckle Jones, exec. sec’y; 127 BH. 28rd St., New York. Establishes committees of white and colored people to work out community problems. Trains Negro social workers. Publishes ‘‘Opportunity’’—a “journal of Negro life.’”’ NATIONAL WOMAN'S CHRISTIAN TEMPERANCE UNION— Anna A. Gordon, president; Headquarters, 1730 Chicago Avenue, Evanston, Illinois. To secure effective enforcement of the Highteenth Amendment, to advance the welfare of the American people through the departments of Child Welfare, Women in In- dustry, Social Morality, Scientific Temperance Instruction, Ameri- canization and other allied fields of endeavor. Official publication “The Union Signal’ published at Headquarters. NATIONAL WOMEN’S TRADE UNION LEAGUE—Mrs. Raymond Robins, honorary president; Mrs. Maud Swartz, president; 311 South Ashland Blvd., Chicago, Ill. Stands for self-government in the work shop through organization and also for the enactment of protective legislation. Information given. PLAYGROUND AND RECREATION ASSOCIATION OF AMER- ICA—315 Fourth Avenue, New York City. Joseph Lee, president; - H. S. Braucher, secretary. Special attention given to organization of year-round municipal recreation systems. Information available on playground and community center activities and administration. PROPORTIONAL REPRESENTATION LEAGUE—To secure rep- resentation for all. C. G. Hoag, sec’y, 1417 Locust St., Philadel- phia. Membership, $2.00, entitles to quarterly P. R. Review. RUSSELL SAGE FOUNDATION—For the Improvement of Living Conditions—John M. Glenn, dir.; 130 E. 22d St., New York. Depart- ments: Charity Organization, Delinquency and Penology, Industrial Studies, Library, Recreation, Remedial Loans, Social Legislation, Statistics, Surveys and Exhibits. The publications of the Russell Sage Foundation offer to the public in practical and inexpensive form some of the most important results of its work. Catalogue sent upon request. TUSKEGEE INSTITUTE—An institution for the training of Negro Youth; an experiment in race adjustment in the Black Belt of the South; furnishes information on all phases of the race problem and of the Tuskegee idea and methods; Robert R. Moton, prin.; War- ren Logan, treas.; A. L. Holsey, acting sec’y, Tuskegee, Ala. WORKERS’ EDUCATION BUREAU OF AMERICA—Spencer Mil- ler, Jr., sec’y; 476 West 24th St. A clearing-house for Workers Education. . We assist in preparing special articles, papers, speeches, SPEAKERS: debates. Expert, scholarly service. AUTHOR’s RESEARCH e . Burau, 500 Fifth Avenue, New York. Best Sellers At the National Conference of Social Work in Denver The Child, The Clinic and The Court, by Jane Addams, Julia C. Lathrop, Judge Mack, Dr. Healy and many others, based on the 25th Anniversary Conference of the Chicago Juvenile Court. $1.00. Youth in Conflict, by Dr. Miriam Van Waters, referee of the Los ,;Angeles, Juvenile Court. $1.00. The Art of Helping People Out of Trouble, by Karl de- Schweinitz. $2.00. ; . How Foster Children Turn Out, by Sophie Van S. Theis. 1.00 The Problem Child in School, by Mary B. Sayles. $1.00. The Challenge of Childhood, by Ira S. Wile. 3.50. — Three Problem Children, by Committee for Prevention of Delinquency. $1.00. a The Unadjusted Girl, by William I. Thomas. $3.00. Foundations of Personality, by Abraham Myerson. $2.25. Sex and Common Sense, by Maude A. Royden. $2.50. Races, Nations and Classes, by Herbert A. Miller. $2.00. Any or all of these books, by return mail postpaid in the U. S. SURVEY ASSOCIATES 112 East 19 Street New York Analytic Index to This Number November 1, 1925 Child Welfare: Prevention of infant mortality, p. 126 Inoculation against measles, p. 134 A child hygiene program, p. 141-146 Child guidance clinics, p. 43 _ Establishing health habits, p. 153 Family Welfare: Health education for mothers, p. 135 A family health program, p. 152 The Law and Lawbreakers: Medical legislation in California, p. 161 The Klan in Colorado, p. 169 The Conquest of Disease: The conquest of epidemics in cities, p. 123 Conquest of typhoid, p. 126 Control of tuberculosis, p. 134 Treatment of venereal disease, p. 136 Communicable disease control, p. 141-145 ‘The science of health administration, p. 167 Elimination of diphtheria, p. 180 The Framingham tuberculosis demonstration, p. 182 The Promotion of Health: Municipal sanitation today, p, 121 Dividends from public health work, p. 126 English and American public health progress, p. 127 Importance of vital statistics, p. 141-144 The work of the public health nurse, p. 142-43, p. 146 The laboratory in public health, p. 143, p. 145 Food inspection, p. 143, p. 145 The nurse as a health teacher, p. 151 The beginnings of public health work, p. 154 ff. Fighting anti-science in California, p. 160 The full-time health officer, p. 167 Organizing Social Forces: Voluntary organization in health work, p. 127 Relation between public health authorities and voluntary health agencies, p. 137 Community health organization, p. 147 A central council of nurses, p. 151 Coordination between nurse and case worker, p. 152 Social education in Petersburg, Va., p. 173 Town Planning: The possibility of survival in cities, p. 121 The city of the future, p. 172 The City Community: City organization for health, p. 121 Community health centers, p. 136 Immigration and Race Relations : The study of Negro life and history, p. 170 School and Community: Mental hygiene in the schools, p. 136 School health supervision, p. 142 Health education in the schools, p. 153 Text book fight in California, p. 160 The American Federation of Teachers’ program, p. 171 Industrial Relations: The new president and policies of the A. F. of L., p. 168: Peace and International Relations: The Sixth Assembly of the League of Nations, p. 169 Results of the Locarno Conference, p. 169 The Chinese situation, p. 170 Motives and Ideals: The citizen and public health, p. 147 The health fight with ignorance, p. 159 (In answering these advertisements please mention THE SuRvEY. It helps us, it identifies you.) 117 ‘Getting Behind the Newspaper Headlines’ Have you ever thought how the historian twenty years from now will strike a new balance between some obscure item and the streamer at the top of your newspaper page? Why watt twenty years? Read Survey Graphic , The West—and U p Chester Rowell can’t get over his lifelong habit of daily editorials and the Scripps papers spread them before twenty million readers. But in his private life he is up to his elbows in the social and economic experiments and problems of the Pacific Coast, and these he will interpret in a series of six articles for Survey Graphic. Overseas — Francis Hackett, S. K. Ratcliffe, Cornelia Stratton Parker, John P. Gavit—social interpretérs all, with the gift of plumbing deep into the currents of life, will write from Europe in the coming year. When Boys and Girls Go to mash You discuss the oncoming generation with men and women your own age; and are a bit uneasy about it. A boy murderer, or a college girl run amuck, strikes you like a bruise to youth itself. What do people whose business it is to deal with discipline and youth- ful spirit in the ’teens have to offer in this day and age? Miriam Van Waters, referee of the Juve- nile Court of Los Angeles, is one of these. She works with children—not at them. . I. Q. 73 What Miss Van Waters does in group experience, . Eleanor Rowland Wembridge does in the individual life stories of boys and girls. Take Matilda, for ex- ample, a girl with an I. Q. of only 73 but a disposi- tion so winning that she had the spruce retired grocer. standing on his head—literally—and dancing in her mistress’ kitchen. The author is psychologist for the Women’s Protective Association of Cleveland. Gandhi Speaks to Americans We should have to go hack to the abolitionist move- ment to find anything in American histery to compare with Gandhi’s campaign in India in behalf of the Un- touchables. A message from the great Indian leader. SURVEY GRAPHIC, 112 East 19 Street, New York. I enclose $3 for a year’s subscription (trial trip for new subscribers, 6 months for $1). Name Address see eee erases secre eee cece esc eee sere se sce ccesesevecece eee eee eee eee rece cere reser ree esr ener reer evr ecosee The Indivisible Utility To Mary Austin’s mind a primal force is reshap- ing the community life of the Southwest. The whites are facing the same problem of the desert country, faced for a thousand years by its primitive people. Van Loon’s Cartoons ; Hendrik Willem Van Loon draws with a burnt match as often as with pen or brush. He cannot draw a horse but he can sum up a whole civilization in a broken pillar or a file of soldiers crossing a bridge. What he has done for ancient life and man- ners in “The Story of Mankind,” he does for con- temporary affairs for us. Harlem—and After . Last March, Survey Graphic brought out a special number on Harlem: Mecca of the New Negro. The demand was instant; we had to put it back on the press and run off a second edition. Throughout the year we shall follow the rich vein it opened up—not so much the Negro’s needs nor his grievances, but his contribution to life in the northern cities. The Pacific Rim For two years, some of the colleges of the Pacific Coast have been cooperating with Professor Robert I. Park in a survey of race relations for the Insti- tute of Social and Religious Research. We shall tap their findings in a special number on the Orient in America. SURVEY ASSOCIATES, INC. PUBLISHERS THE SURVEY—Twice-a-month—$s5.00 a year SURVEY GRAPHIC—Monthly—$3.00 a year RoperT W. DEForEsT, President Junian W. Mack, V. Everir Macy, Vice-Presidents ANN REED BRENNER, Secretary ARTHUR KELLOGG, Treasurer PAUL U. KELLOGG, Editor Associate Editors HAvEN Emerson, M.D. RoBperT W. BruiRE SARA MERRILL JosEPpH K. Harr GEDDES SMITH Mary Ross LEON WHIPPLE Contributing Editors Epwarp T. DeEvINE JANE ADDAMS GRAHAM TAYLOR FLORENCE KELLEY ARTHUR KELLOGG, Manager Joun D, KENDERDINE, Extension Manager Mary R. ANDERSON, Advertising ew ‘ SURVEY GRAPHIC Vol. VIII, No. 2 November 1925 CITY HEALTH _A special number edited by Haven Emerson, M.D. and Mary Ross, Associate Editors of The Survey CONTENTS THE ROBUST CITY . Haven Emerson, M.D. 121 HEALTH WORK PAYS Louis I. Dublin 125 THE FEVER CHART OF PROGRESS .... Sir Arthur Newsholme 127 GUARDIANS OF HEALTH . Lewis W. Hine 129 IN AND OUT OF THE HEALTH WORKSHOPS Mary Ross 134 . Homer Folks 137 2 oe ee 89 PUBLIC, PRIVATE—AND BOTH THE T P R OF PUBLIC HEALTH WHAT SHOULD A CITY DO? I. The Large City Ira V. Hiscock, C.P.H. 140 II. The Small City Philip S. Platt, C.P.H. 144 WHAT YOU CAN DO. George T. Palmer, Dr. P.H. 147 WHERE DOES YOUR CITY STAND? A Question- naire prepared by George T. Palmer, Dr. P.H. 148 THE NURSE... . Katharine Tucker, R.N. 151 THE SCHOOLROOM . .. .-. GC. E. Turner 153 FIGHTING HEALTH OFFICERS I HAVE MET W. A. Evans, M.D, 154 Chester H, Rowell 159 162 CANCER OF IGNORANCE . LETTERS AND LIFE eee CITY HEALTH ADMINISTRATION. A Reading List compiled by C.-E. A. Winslow, Dr. P.H. 166 EDITORIALS . 2 1. 1... aby Lhe Gist of It IXTY years ago the cities of the United States were facing a losing fight for survival. Now they are winning. It is the public health movement that has changed the balance—the most exactly and most extensively applied of the social sciences. This num- ber of Suryey Graphic is devoted to outlining and inter- preting the public health movement as a function of American city government. It is edited and published with the cooperation of the American Child Health Asso- ciation, the American Public Health Association, the American Social Hygiene Association, the Metropolitan Life Insurance Company, the Milbank Memorial Fund, the National Organization for Public Health Nursing, the National Health Council and the National Tuberculosis Association, besides a host of other organizations, offi- cials, and voluntary health workers. A general editor of this issue, as a teacher of public health administration, as a surveyor of health situa- tions, and a past health officer of the nation’s largest city, Dr. Haven Emerson of the Columbia University School of Medicine opens the issue with a trenchant picture of The Robust City (p. 121). TATISTICIAN of the Metropolitan Life Insurance Company, lecturer at Yale University, author of a thick sheaf of books and pamphlets in which the arithmetic of health is convincingly presented, and _secre- tary of the Committee on Municipal Health Department Practice, Louis I. Dublin underwrites Dr. Emerson’s thesis with a set of trial balances from the health ledger (p. 125). IR ARTHUR NEWSHOLME, K.C.B., M.D., F.R.C.P., writes on American public health from the vantage point of years of study of health practice in this and his own country. He has served in the United States as lecturer in public health administration at the School of Hygiene and Public Health of Johns Hopkins University ; at home, among many other offices, he has been principal medical officer of the Local Government Board, now merged in the Ministry of Health, examiner in public health and state medicine at the Universities of Cambridge, London, and Oxford, and Crown Nominee on the General Medical Council (p. 127). ARY ROSS, who writes of the distinctive and fresh bits of methods to be found In and Out of Health Workshops (p, 134) is the associate editor in executive charge of this health department number. F Homer Folks and his long and distinguished ser- QO vice as executive of the New York State Charities Aid Society what need now be said? On p. 137 he writes of his observation and experience in the relations between private and public health agencies. UT of the voluminous material gathered by the Com- mittee on Municipal Health Department Practice Ira V. Hiscock, C. P. H., assistant professor of public health in the Yale School of Medicine, sketches a normal program for the health department of a large city (p. 140). OR the small city a similar service is performed by Pea S. Platt, C.P.H. (p. 144), using the materials of the survey of eighty-six small cities made by the Ameri- can Child Health Association, of which Mr. Platt is associate director in research. MALL or large, the graphic scoring chart on pp. 148 and 149 gives every city a chance to find its own rough rating on the scale of public health practice. It was prepared by George T. Palmer, Dr. P.H., director of the division of research in the American Child Health Association, and formerly on the staff of the Detroit De- partment of Health. Mi: TUCKER, who writes on the new responsibili- ties of the public health nurse (p. 151) is herself a registered nurse and general director of the Visiting Nurse Society of Philadelphia. HE SCHOOLROOM, too, is part of the publie health picture. Mr. Turner (p. 153) is assistant professor in the department of biology and public health at Massachu- setts Institute of Technology. HERE were giants in those days; perhaps there still are giants. Certainly Dr. Evans himself, health com- missioner of Chicago from 1907 to 1911 and now, as editor of the health department in the Chicago Tribune, a health teacher of all the Middle West, is qualified by stature and experience to write of his fighting friends in city health service (p. 154). ACK of all health progress—indispensable, indeed, if we are to do no more than hold our own against dis- ease—is the willingness to accept scientific fact and act on it. Chester Rowell traces the course of the spirit of ait.-science which jeopardizes the hard-won gains of public health (p. 159). Editor and publisher for more than twenty years ot the Fresno (California) Republican, long aetive in politics, education and the civic affairs of his state, he is now writing daily for twenty million newspaper readers. Can we sutvive in crowds—in cities? The answer is in the hands of the health workers—this sanitary inspector and all his colleagues Photograph by Lewis W. Hine SURVEY GRAPHIC oS Sion NOVEMBER : ; 1925 Se 2 Volume VIII No. 2 The Robust City Our Sole Hope of Survival in Crowds By HAVEN EMERSON, M.D. IFTY-FIVE millions of us living in cities— think of it!—are trying out the utmost limits to which we can gather a crowd with- out committing municipal suicide. The earth is dotted with dead cities, paralyzed by some form of Nature’s ruin, flood, quake, submersion or the flame of molten lava, broken by the conflict of armies, atrophied by the loss of trade, resorbed into the jungle when parasites and winged plagues have emptied homes and temples; each a case history of failure in the aim of man to live with his fellows in a crowd for safety, profit, pleasure. More and more are the open spaces labored by fewer people, while more wheat is harvested, more trees are felled, more cattle tended, more coal and iron dug by smaller units of workers in proportion to the product. “Thus the cities grow in number and in size and the human swarms squirm physically, and strain their thoughts to escape the threat of extinction which hovers over mass gatherings of all living things. The very least of creatures—our relentless enemies the bacteria—give us, when they are colonized by man, the clearest lesson in the sanitary danger of crowding. ‘They begin to die out at the center of the mass. They disintegrate in the poison of their own body wastes. Watch the ants and bees for model scavenger and ventilation systems; learn orderliness, system, division of function; watch the sacrifice of individual rights for the good of the swarm and the unquestioned obedience to the law of cleanliness and in- dustry. . Sanitation has permitted the survival of cities, salvaged them from self-destruction in the but recent past, and promises protection and a permit for even mightier masses of men in safety, if it be that the drive toward herding cannot be broken by some way of tempting people to go out from cities into littler places and wider views of life. Before there can be beauty, contentment, convenience, effectiveness in a city there must be health. No city, any more than a nation, tribe, clan or family, can survive if the deaths come faster than the births, if the survivors of childhood have too few years.of productive labor to add anything beyond their own self-support to the possessions of the group. It was this unfavorable balance in the register of life which made Britons listen to Simon when he laid down the laws for London’s survival. When deaths came at the rate of thirty-seven and the births were only twenty- nine among each thousand of the population in New York the Council of Hygiene was needed and a dying community developed its own renascence by following the advice of its wise physicians. “Come what events there may to affect the physical, social, political or commercial interests of the city, let it be borne in mind that sanitary science and its preventive skill are of more value to our fellow beings and to this city than all the curative arts of medicine and surgery; that the evils which now bear so heavily on the poorer classes already seriously endanger the sanitary safety of all other classes and multiply the social perils and public burdens of the city; that a careful regard for human life and wel- fare is an unerring index of social advancement.” So thought, and wrote, and acted sixteen of the great physicians of New York when its population was but a million, while these young men were in the midst of their early practices among the poor, at the very height of the Civil War, and they gave out this ringing message of warn- ing and faith after carrying out the most thorough health survey ever made in an American city. “Twelve of these men became professors in medical schools and at least six grew to be nationally famous in the sciences of curative medicine; Willard Parker, Valentine Mott, Edward Dela- field, Alonzo Clark, Ogden Doremus, Elisha Harris. ROM the 1853 report of the A. I. C. P., whose “mis- sionaries” of the religion of cleanliness and self-support were then the best informed agents of practical sanitation, ‘comes the now familiar plea for “healthy homes for the poor, the provision of which would be the most interesting and useful efforts of benevolence” to remedy the conditions which “doubled the number of resident poor in one ward in six years.” “Cellars are the worst of habitations, which have to be baled out after every rain storm—so damp as 121 122 to destroy health—so dark as to, prevent industry—so low that ventilation is impossible. . . . Tenant houses averag- ing six persons per room of twelve by ten feet floor area, and rented at rates which ought to procure comfortable dwellings.” Again in the 1857 report of the New York Senate In- vestigating Committee, we learn that while the United States were credited with a general death rate lower than that of any of the leading eight European nations, the city of New York showed a higher rate than any of eight large cities of the world. United States 15 London 25 Denmark 23 Berlin 25 France 23.5 Turin 26 Holland 24 Paris 28 Sweden 24 Genoa 31 Prussia 28 Lyons 33 Austria 31 Hamburg 36 Russia 36 New York 38 And yet even in a city in the depths of sanitary degreda- tion, a “devouring sink of disease,” there were areas of excellence, several wards “where even the domestics occupy comfortable sleeping quarters above ground,” showing death rates of only 14.3 per 1,000 of the population while the poor wards ran rates up to 45.5 and while rentals by the room to families of eight or ten brought the owners from 15 to 30 per cent of the value of the property each year. N 1865 came the Magna Carta of municipal sanitation for the United States, the report of the Council of Hygiene and Public Health of the Citizens Association of New York upon the Sanitary Condition of the City. This is a masterpiece of public service, a model of reasonableness and of thorough and accurate observation leading to prog- ressive and courageous conclusions. No body of citizens now could follow a better example in studying the causes of an unfavorable health situation than this essay on the problems of society and the part science plays in making life and happiness possible in the midst of growing masses of ambitious but reckless people. How fairly the conclusions of 1865 still match with the decisions of today in many of our hundreds of cities! The causes of the serious conditions in New York City are: 1. Utter inefficiency and unsuitableness of the municipal health organizations, under which sanitary wants of the city have been increasing for years. 2. The almost universal prevalence of ignorance and apathy among the classes most endangered by their own sanitary wants. 3. Absence of an adequate public appreciation of the vital importance of sanitary improvements and competent officers of health. The legislature expressed its desire to see equal security of health for all and commented upon the enormous sums spent for the care of preventable sickness. How familiar is the list of causes of New York City’s ill health of seventy years ago: Crowding in tenements. Poor construction in tenements. Lack of light. Lack of ventilation. Impurities in domestic economy. Insufficiency of sewerage. Dirtiness of streets. Disregard of sanitary precautions. Imperfect execution of existing ordinances. THE ROBUST CITY How abundantly have we failed to meet the ideal of a spotless town, of social justice -among landlords, of civic efficiency, and yet how far- we have gone with the then unknown facts that personal relations, individual resistance, specific precautions by informed and well nourished persons would avail to prevent most of the epidemics of disease even now that crowding on acre and lot equals or exceeds that of The City That Was. . UNICIPAL sanitary activity had its start on this continent in 1678 with the effort of the selectmen of Boston to restrict the spread of smallpox through the first application of maritime quarantine on these shores to Sir Francis Wheeler’s fleet, bringing, as it was believed, the dreaded “Yellow Jack” to Boston harbor from Martinique. The selectmen did what city officers have done as far back as history goes. ‘They assumed absolute responsibility for protecting their closely packed crowd against invasion by disease. Of all the functions of government, health control is probably more universally a home rule job than any other. Health services fall under the general police powers of the state and although they may be provided by the state for any community in its area, they are usually specifically delegated to municipalities and even to the least of in- corporated villages. New Orleans until 1898 was the sole important exception to this local control of health admin- istration. ‘The state of Louisiana maintained by eminent domain entire direction of this great gateway city, which used to be the main channel for the distribution of yellow fever through a score of the southern states, and the Mis- sissippi River cities in particular. Many a state reserved and still uses its power of direction, however, in requiring observance or enforcement of health precautions when lag- gard intelligence, pinching parsimony, or organized opposi- — tion to science by public officials has made of their com- munity a menace to themselves and their neighbors. In most parts of the United States the provision of a health board or officer is obligatory whatever may be the attitude of the community toward police or fire protection. Does not that suggest a fairly deep-rooted conviction that with the machinery for liberty of belief, for protection of personal rights by courts of justice, for popular choice of legislators and excutives all assured, the obligation of health protection must take precedence even over the establishment of compulsory education? So firmly were the earlier efforts — at sanitation entrenched in legal precedent and power that until recently in Connecticut most of the health officers were appointed by the superior court and had to be selected from among attorneys-at-law, perhaps a necessary pre- caution during the pre-educational period of health work when science had to conform to statute rather than the contrary. . * How gradually and properly submissive have we become to the right of entry into our sick rooms by health officers, without court warrant, on suspicion alone, to search for possible cases of communicable disease! How we welcome the searching and protecting eye of the badged emissary of health law who warns us of a hazard in well, or privy, who stops our sales of food and confiscates our dairy products summarily lest disease spread! Where will you find any such breadth of power so universally supported by our high- THE ROBUST CITY a Pail i i te nA a t | i it ih am AnTTRTT i ; ny neti init . j LD rt From the report of 1865 of the Council of Hygiene and Public Health of the Citizens A ssociation of New York upon the Sanitary Condition of the City School and slaughter-house: a city health hazard of sixty years ago est courts as is shown in the records of boards of health? All that need be shown before the courts to give free scope for regulation in the interest of safety of life is that the board of health and the executive, the health officer, have not been tyrannical or arbitrary. Commerce waits, produc- tion and use may be limited, even personal liberty in one’s own house, its construction, occupancy and contents is restrained so that we, the 51 per cent and more who live in cities, shall live and thrive. And so the cities lead in the methods and results of sanitary science, in spite of, rather than because of, their handicaps of crowding. Keen as the competition is nowadays in well doing, it is with the city dweller that the advantage rests in the probability of his survival at birth, in the likeli- hood of his protection against infection in childhood, the security of his water and milk, in safety from the nuisance of his own wastes, in quick warning and service in the presence of threat of disease. OOK, you city dwellers, upon your present security and be thankful for it. Ask the reasons; see who bore and bears the burden and why; and learn what you may further expect in relief from the hazards to life, its quality and quantity, its depth and breadth, as well as its length. Your grandparents, if they were city dwellers, lost one child in four before it was a year old, while you and your friends maintain the silver ratio of sixteen living to one lost. Let us get on a gold basis of not less than twenty- five babies living for every one we lose before our children learn to mock us for our backwardness. My guess is that a city will reach the goal before a farmers’ region; a city of 100,000 or thereabouts before a metropolis; a city west of the Rockies before our industrial maelstroms of races and traditions on the east coast. And those of you who have time and money, lend a hand to cities in other lands eee en aa SEE Sane Fp NN A Rit A a rt nt nl A, Ce ee a ee ee sats tnt tt lt nee ep where caste, misplaced faith, fatalism in’ the shadow of famine, the immaturity of mothers and their utter ignorance of the rights and wrongs of babyhood kill half and more of those born alive. Clean water gave us back some of our threatened babies; more light and air in the homes may have helped a bit too, but the great saviors of infancy were and always will be the nursing mothers and Louis Pasteur, the patron saint of city milk. How little the sanitarian asks of you for the safety check he puts on the most indispensable of foods! The price of one glass of milk a year is all it costs the city dweller to have his officer of health guard him against milk-borne tuberculosis, typhoid, scarlet fever, diphtheria, epidemic sore throats, and a multitude of minor disorders including most of the summer diarrhea of babies. “Think of it, five cents a year from each of us suffices to provide a public service which has its thousands of lives to its credit. each year. It costs us ten cents apiece a year for other types of control of communicable diseases which as a group have been reduced by 75 per cent in the past fifty years. Those same grandparents of ours fifty years ago saw four hundred of their friends and neighbors carried off by tuberculosis where less than a hundred are lost today. Clinics for diagnosis, laboratories to aid and check the physician and prove the infection, separate wards or hospitals and sanatoria, quick and early efforts to arrest the beginning sickness and save the children from exposure, good food in the stomach and clean air in the lungs, and best of all a point of view well and widely taught that tuberculosis is communicable, preventable and curable, have worked the miracle. Not 50 per cent of the tenement children in our poorest city wards are today even infected with tuberculosis vhile but one generation ago scarcely a child of sixteen could be found who had not been at least attacked by the tubercle bacillus. ain nn ns it Pa ee ae petite inno armenanasantet tte SS ate 124 In our city dwellings today we have come up out of cellars, it is true, but perhaps to find ourselves no nearer a place in the sun than formerly; not so damp perhaps, but windier in our concrete canyons. abundant water, the best wash inside and out for persons and premises, and yet there are people among us who will go into debt or jail or move abroad to make and drink a pickling fluid to dull their senses and push them back into brutishness. . For the asking we have protection against: smallpox, typhoid, diphtheria, scarlet fever, but there are whole cults and clans of persons devoted to the creeds and clamors of ignorance who poison the minds of childhood and seek to wipe out the safeties which they share in spite of them- selves. The stakes of the average citizen in public health are as great as ever, but there cannot be held up before him such tempting progress in gross quantities of life-saving as faced our health councils half a century ago. Our principles of sanitary law are well accepted. The organization is now much as it must remain for many years. The direction and personnel still reeks of partisan politics but is gradually winning clear and approaching the desirable freedom of most school systems. ‘The main objectives of education in place of enforcement, of personal rather than official inter- est in health, have been gained. The result, most crudely expressed, is that within the experience of men and women still active and responsible for health services we have reduced our dedths in cities in this country to a third, A death rate of twelve per thousand is éommon in our cities instead of thirty-six. ° E have “made good” in our “will to survive” in hordes. How can we keep the mass interested in further progress? Hardly by doing more things for the individual. Perhaps by doing things to him with his own consent. Certainly by getting him to do them for himself. The picture has wholly changed from that of 1865, and it is time we started from our present fortunate level to build greater and more glorious mansions. It will not be by the edict of the health officer that rickets will cease to be the most prevalent nutritional disease of city children. No operation of sanitary codes will stop diabetes from forcing its way among the leading causes of death in our middle-aged men and women of American cities. Full-time health officers and the mechanism of administrative health services will not greatly affect the disorders of mind, conduct and emotion which fill more hospital beds with permanent derelicts than all other diseases put together. This conflict we have set for ourselves means much more than reducing a twelve per thousand death rate to a possible ten, or, under rarely ideal conditions, to nine, below which we can certainly never go. It is not merely the struggle to avoid disease or cure it, to reduce sickness and its cost as we know it now. What the city is facing is the eternal fight of adjustment, of adaptation. Human beings are the most accommodating creatures so far evolved; it seems to be a necessary corollary of that fact that we must search everywhere for the most difficult situations just to prove that neither sky nor sunken mine shaft, neither utter dark- ness nor ultra and invisible light, nor cold nor heat exist to which we cannot fit ourselves. The adventurer goes forth single-handed to explore the earth. The rest of us We have clean and > THE ROBUST CITY find that the fascination of staying at home has brought upon us in generous measure all the thrill of chance, all the uncertainty of unknown things. _ The city of today, as always, is the peak expression of human gregariousness. Made possible by using the facts which express the laws of health, growing beyond the bounds of human convenience, the city presents a challenge to something more fundamental than organization of public and private services for health. The health of a city demands more self-denial, more intelligence in personal con- duct, deeper understanding of the natural sciences and of the causes and effects of error in individual performance of life, than have been called for ever before. It is each individual who must be cautious, thoughtful, persistently considerate of others—not alone the visiting nurse, the school medical inspector, the baby health station doctor. . It is the housewife upon whom the task of sanitation falls today. It is by her care to ensure cleanness of spoons and tumblers, her watchfulness in buying and safekeeping of milk, fruit, bread and meat that she controls our bodily health. It is at the breakfast table, at the school lunch, in the games, during the discussions in the living-room that conduct, habit, feelings and thoughts are guided, and of such will the safety of cities be made. Even in the glorified living offered by garden homes, by the ideal health department, by the emancipation from the unnecessary filth and ugliness of industry, we are far from gaining under the leadership of science the mini- mum of clean air, sun light, play-space, quiet, reasonable separation in sleep and work and travel which we see is needed. City dwellers will win the crown of health sooner by giving thought and time to sweet reasonableness in their relations to each other than by any new device of science or authority. Let our faith be that we can make our city not only a place where physical health is easily possible but where happiness is seen as its inseparable corollary. When, or where, would any of us have rather lived than now and here? : Dr. Osler expressed best in his. Edinburgh address of 1910, Man’s Redemption of Man, the spirit that is the genius of today’s City Health: The outlook for the world as represented by Mary and John, and Jennie and Tom has never been so hopeful. ‘There is no place for despondency or despair. As for the dour dys- peptics in mind and morals who sit idly croaking like ravens-— let them come into the arena, let them wrestle for their flesh and blood against the principalities and powers represented by bad air and worse houses, by drink and disease, by need- less pain, and by the loss annually to the state of thousands of valuable lives—let them fight for the day when a man’s life shall be more precious than gold. Now, alas! the cheap- ness of life is every day’s tragedy! If in the memorable phrase of the Greek philosopher, Prodi- cus, “That which benefits human life is God,” we may see in this new gospel a link betwixt us and the crowning race of those who eye to eye shall look on knowledge, and in whose hand Nature shall be an open book, an approach to the glorious day of which Shelley sings so gloriously: Happiness And Science dawn though late upon the earth; Peace cheers the mind, health renovates the frame : Disease and pleasure cease to mingle here, Reason and passion cease to combat there, . Whilst mind unfettered o’er the earth extends Its all-subduing energies, and wields The sceptre of a vast dominion there. Health Work Pays | By LOUIS I. DUBLIN N 1921 the city of Salem, Ohio, suffered an epidemic of typhoid fever which in round numbers cost the community half a million dollars. The epidemic resulted from an at-, tempt of the city fathers to save $1,500 by substituting a tile pipe for an iron one in the construction of their sewer system. For the past fifteen years a business organization, the Metropolitan Life Insurance Company, with which I am associated, has spent an average of more than a million dollars a year in its public health campaign for industrial policy holders. This vast investment has reaped a return of 200 per cent; the money saving resulting from a lowered deathrate which the Company attributes to that campaign totals almost twice its cost. Two bits of concrete evidence these, in support of the peint I purpose to make: that the cost of sickness and pre- mature death is very great; that public health procedures are an effective means of preventing much sickness and death; and that an extension of public health facilities will pay large dividends to any community which will organize and administer them effectively. We can make only a very rough approximation of eco- nomic losses resulting from sickness and premature death. I shall take pains to make the estimates under rather than over-statements of the case. A few years ago, Dr. Frankel and I conducted a number of sickness surveys among some half million industrial policyholders of the Metropolitan Life Insurance Company, and found that, on the average, they lost about seven days each year from sickness involy- ing inability to work. ‘There were additional days of dis- comfort which interfered more or less with people’s duties, but these were not included. That 2 per cent of the population is sick at any moment of time, was the outstand- ing conclusion of our studies. Converted into economic terms, this means that there is a loss of 2 per cent of total current production, which in round numbers would amount to more than a billion dollars annually in the United States. To this huge figure should be added the cost of such items as medical care, hospital service, drugs and appliances, and the like. Investigating the cost of sickness in a limited eroup of people, we have found that the average annua! expenditure was nineteen dollars per capita for medical and nursing care, for drugs and other items necessary during illness. This figure is probably higher than the average in the general population because of the favorable economic status of the group studied. But, if even a half of the figure were used, say in round numbers ten dollars per capita, the total cost of medical care in the United States will amount to more than a billion dollars a year. The community’s loss by premature death is another problematical value, because we do not as yet know the money value of a human life at various ages. I have been in the habit of using the figure of one hundred dollars per year per capita as a rough measure of the economic loss re- sulting from death. That is the amount by which our national wealth has been apparently increasing per capita in recent years. It should be a fairly good, rough approxi- mation of the economic value of a year of life in the general run of the population. On this basis a year lost would mean one hundred dollars lost to the wealth of the nation. A year of potential life lost by each person in a nation of one hundred and thirteen million means a loss of eleven billions of dollars to the present generation; conversely, the gain of a year in the average length of life would mean ulti- mately a gain of that much wealth during the life span of the present generation, or an economic gain of about two hundred millions of dollars per annum. ‘These sets of figures, which are’broadly correct, suggest the immense values at stake in the effort to save and prolong human life. HERE is already abounding evidence that the work of public health authorities to prevent illness and con- serve life, considered from a purely economic viewpoint, pays large dividends. Many other social welfare activities appeal to our sense of justice or to our emotions as generous acts: they may be expected to move forward slowly be- cause our sentiments falter at heavy costs. But public health work is of a different character. Under the present con- ditions it can be looked upon as a financial investment, which, in many instances, gives immediate returns out of all proportion to the sums invested. It can be shown that much of the increase in our national wealth has resulted from the added years of life and vigor which are now available to us for productive work because of the better hygienic and sanitary conditions under which we live. Any community whose credit is good should, therefore, be en- couraged to obtain and expend the funds necessary to pro- ceed with its public health program, provided, of course, this program is well-considered and suited to the local situation. Let us examine some of the evidence upon which this assurance rests. “The outstanding fact is the great decline in the death rate which has occurred during the last fifty years, the era which has seen the development of the public health movement. The facts for New York city are fairly typical of what has happened in other large cities of the country. In 1875, the death rate was 28.3 per 1,000; in 1924, it was 11.8, or a ‘reduction of 58 per cent. A better measure of the improvement is, perhaps, the gain in average duration of life. In 1880, the average life span was about forty years in New York (and most likely in other large places) ; it is now fifty-five or fifty-six years, a gain of about fifteen years. ‘The greatest additions have been achieved recently. In 1901, a baby born in the United States Regi:- tration Area might expect to live 49.24 years; this expec tation of life has risen to 57.32 years. The present high figures are not accidental but are the result of a definite 125 126 Deathrates per 100000 for Diarrhea and Enteritis in Twenty-three American Cities ISN00 to 1924 TREND Fall per year im units of mean rate for eathrate perl00,000 specified penod t900 mI924 4.48 440 Period 1900 1905 {910 1915S i920 1924 Sa: Charts by courtesy of Statistical Bureau—Metropolitan Life Insurance Company trend which has been fairly continuous for a whole genera- tion, reflecting the workings of a new force in the life of the people. If we examine the facts of the death rate more closely, we find that the gains have been achieved in very definite ways. A great addition to the life span has resulted from the prevention of infant and child mortality. The diseases and conditions which have been materially reduced are tuberculosis, the communicable diseases of childhood, the general infections, such as typhoid fever and intestinal dis- orders, and the insect-borne diseases, such as yellow fever and malaria. ‘These have been the object of public health measures. “The machinery of the official and private agen- cies has been directed to controlling them with apparent success. "The reduction in the death rate in that group of conditions which have been the prime interest of the authorities has been much greater than that of other con- ditions which have not lent themselves to public health management. , In the last twenty years the infant mortality rate has been cut 60 per cent, largely by a national campaign of education, by the general safeguarding of milk supplies and other activities of the better organized health departments such as visiting nursing and baby welfare stations. Che CHILD OF PRE-SCHOOL AGE Deathrates per 1000 children at ages one to four years, United States Registration Area, 1900 to 1922. PERCENT DECLINE 53 IN 22 YEARS Lt tt td dd 200 ‘Ol 02 03 04 05 ‘06 07 08 09 10 Wl 2 13 4 15 16 17 16 19 20 2l. 1922 . YEARS The deathrate has declined more rapidly among children of pre-school , age than in any other age division under fifteen years THE REDUCTION OF INFANT MORTALITY HAS STIMULATED AND NOT HAMPERED THE REDUCTION OF CHILD MORTALITY. wee STATISTICAL BUREAU ~ METROPOLITAN LIFE INSURANCE COMPAH HEALTH WORK PAYS theless, there are cities in which infant mortality rates are still twice as high as the average for the country. In a survey recently made by the American Child Health Asso- ciation it was found that, although the average infant mor- tality rate in more than 600 cities of the country was 72 per 1,000 births, there were 82 cities which had rates of 100, and more, per 1,000, and 9 cities with rates of more than 140 per 1,000. Such communities need only choose to do those things which have been proven effective by the more progressive. It is impossible to give an accurate estimate of the cost of such work for the protection of babies. No attempt has been made by health departments to segregate the expense from such allied work as the protection of mothers and of older children which is usually carried on by the same nurses and clinics, and in many places much of the best work stil] is done by private agencies, which very rarely keep adequate records of cost. The figures obtained by the Committee on Municipal Health Department Practice of the Amer- ican Public Health Association show that the large cities of the country have been spending only three to four cents of public money a year per capita of population for this work. Obviously larger sums will be required if the work is to be conducted in an approved manner and if a marked impression is to be made on the infant mortality rate that still prevails. Never- Typhoid Fever Mortality in Axmerican States and Cities 1885 to 1923 o———— 24 CITIES ——— 6 STATES TREND LINE Not long ago typhoid fever was a common cause of sickness and death throughout the United States. Even as late as 1900, the death rate was 36 per 100,000 in the then Registration Area. Epidemics raged in the large cities of the country because of the polluted water supplies and because little was done to prevent the spread of the disease through secondary infection. With the installation of excellent water systems in the larger cities and the better supervision and chlorination of most other supplies, the typhoid fever rate dropped in an amazing manner. The experience of Philadelphia, Cincinnati and Pittsburgh, among other cities, offers most interesting proof of the big and immediate returns to communities which are wise enough to make the necessary investment to provide their people with an adequate supply of pure water. Frank F. Wing, for the Pittsburgh Survey, showed that for the 4,283 cases of typhoid fever (Continued on page 182) The Fever-Chart of Progress By SIR ARTHUR NEWSHOLME A distinguished sanitarian of the Old World appraises Ameri- can public health practice in the light of British experience ERHAPS the most outstanding early im- pression of American public health adminis- tration is its relatively small regard for historical continuity. With us the long existence of an institution, however illogical (on paper) it may appear, is a reason for continuing it, or, at the most, for contenting ourselves with modifying it to fit new circumstances. is little hesitation in varying fundamentally the principles _ of city administration; and the new sometimes is preferred, apart from its merits, because it is novel. This is evidenced in the light-hearted change for a period of years from nominally democratic municipal government to the autocracy of a mayor or city manager. I assume that the change has followed previously inefficient or even corrupt representative control; but the fact that the electors prefer a business manager to elected representatives, pledged to reform, im- plies a temporary abandonment of the democratic local government by means of which England has made public health an all-round success. One may remark, similarly, on the autocratic powers entrusted to health officers or commissioners, which would never be granted to an Eng- lish medical officer of health. Such powers, I do not doubt, are wisely and discreetly used; but the English medical ofhcer of health has the satisfaction—even though he may gaze somewhat enviously on the powers of his American confrére—of knowing that at the end of his three or five years of office he is not liable to ejection on the whim of the next elected mayor. He has learned the lesson, further- more, that autocratic powers—however beneficent—which do not carry with them the conviction of the majority of the population are liable sooner or later to be withdrawn. HE foregoing facts explain in some measure the differ- ing course of public health reform in Britain and in the States. Whether considered historically or geographical- ly American public health work forms a zigzag curve re- sembling that of an attack of intermittent fever; while the English curve has few oscillations, but has steadily advanced on the up-grade from year to year and from district to dis- trict. To pursue this somewhat crude illustration, Amer- ican public health can show peaks of advance not yet reached in England, as for instance in the protection of the milk supply of some cities and in the recent anti-diphtheria work in New York and other cities; but it will, I think, be gen- erally agreed that these peaks are relatively isolated, and that speaking broadly the general level is markedly higher in the old than in the new Engish-speaking world. That this is so is illustrated in many ways. It is shown in the fact that in many American cities voluntary public health work bulks larger than official public health work, especially as regards child welfare, tuberculosis, and the 127 In the States there — care of the destitute. This is an historical phase, through which England has passed. It is still passing through it as new developments appear; for new movements commonly emerge outside official shackles. But in England the greater part of what was just undertaken by voluntary associations has become official ‘activity, and thus voluntary initiative is always being released for new adventures. Such voluntary work, without the official machinery of government, must in most instances suffer from a yearly handicap. ‘Drives’ are needed to raise funds; and is it not true that in some voluntary associations half or three- fourths of the money raised, and at least an equal pro- portion of the possibilities of good work, may be exhausted in the effort to get money, leaving workers depleted both in finance and in vim for the actual work in hand? HE best form of voluntary public health work—which needs to be indefinitely continued—and increased—is the unpaid work of the members of public health author- ities (municipalities, state legislatures, etc.). And this leads me to emphasize what I regard as a fundamentally important point. Let me illustrate it by the English method of administration with which I am most familiar. The medical officer of health and his staff can only obtain financial support and are only permitted to carry out in- dividual items of public health work insofar as they convince. the voluntary workers who are the unpaid representatives of the public. First, a majority of the dozen men or women who form the health committee must be convinced of the necessity of the given item of work; and then these must convince a majority of the sixty or more men and Wwomen—unpaid representatives—who form the local town council, Thus all the time the medical officer of health is an educator; and no other educational work in any other quarter can rank in importance with his. It is by work thus subjected to the sifting of representative public opinion that good government is rendered steady and permanent. True, reforms greatly needed are often crabbed and mini- mized by the inherent stupidity, the negligence, or the in- terested motives of elected representatives. But it is by conflict with such motives, checked and more than counter- balanced by public opinion and by public spirited representa- tives on the governing body, that steady and persistent progress has been made. . After the first struggle on a given point has ended successfully, funds are voted year by year almost without comment; and the health officer’s educational efforts are then needed only for new measures having for their object further public health progress. I lay special stress on this official educational work because of its supreme importance; and because I am confident that it is through such work, rather than by the appointment 128 of business managers for communities, that the future of public health will be secured. True, progress is slow, but it is continuous; it is not intermittent and wasteful, nor are there the intervals of inertia and neglect which are asso- ciated with spasmodic waves of reform. Instances of both varieties of progress, spasmodic and uninterrupted, are to be found on both sides of the Atlantic; but until the public can be made to realize and to act on the belief that the greatest and most fruitful field for the work of voluntary social workers is in the municipalities and state legislatures, progress will continue to be unnecessarily slow and im- perfect. Public health work is becoming more and more women’s work. This should be so for work by elected representatives as well as for work by social workers in voluntary organiza- tions. To the extent to which women can influence public opinion and action to this end, will solid progress be made. Perhaps everywhere we need to talk less and to work more _ to secure the right representatives on our municipalities and legislatures. ‘That certainly is the case in the old country. But when they have been obtained, unless the electors— as interested onlookers—stimulate efforts for good, make persistent inquiries in respect of procrastination, avoid carp- ing criticism, and liberally commend all good work and workers, they have failed in their social duty and cannot wash their hands of the responsibility for imperfect. or evil government. UCH of what has been said applies both in Old ~and in New England. But the old country fulfills certain conditions of successful public health work which are lamentably lacking in the new. I have been deeply impressed by the valuable work oi many public health medical administrators in America. The pioneer work of Hermann Biggs is an outstanding example. If I depart in a single instance from the avoidance of liy- ing illustrations, I would mention Dr. Charles V. Chapin as one whose scientific insight and prevision of the essentials of public health work has had great influence in shaping the cause of public health work both in the Old and in the New World. But in present circumstances the people of the States cannot expect a reasonably efficient service of medical officers of health in the majority of communities unless policy is radically changed. The establishment of the Johns Hopkins School of Hygiene and Public Health and of other similar schools—through the beneficence of the Rockefeller Foundation—makes a further indispensable ad- vance possible without which these schools can never realize more than partially their potentialities for good. Public health work must be made practicable as a career; and to this end reasonable security of tenure of office must be given to competent officers, and their remuneration must compare not unfavorably with the earnings of physicians in private practice. Happily both these objects are now ap- proximately secured in England. So long as the health commissioner in office is liable to* removal when changes occur in a city council, as for instance on the election of a new mayor, this remains im- possible: and it is imperative that the civil service con- ditions of office which are now exceptional should become universal. As soon as public health becomes a fairly certain adminis- trative career for a section of physicians who have special- THE FEVER-CHART OF PROGRESS ized as hygienists, municipal and state authorities can rightly demand as a condition, sine qua non, of appointment that the officer appointed shall possess a diploma or degree in public health of a satisfactorily high standard. ‘This repre- sents the desirable and necessary complement of civil service conditions of tenure of office. In Great Britain this con- dition is already imposed : practically every medical officer of health now appointed is required to possess a diploma in public health, obtained by a physician after a year’s sub- sequent practical instruction and training in the science and art of public health. If state legislatures were to make it illegal—after a reasonable warning—to appoint medical officers of health without such a degree or diploma, there would follow a rapid levelling up of public health adminis- tration throughout the States to the standard already reached in some of its cities. Perhaps ere these lines appear in print, — some state legislature will already have led the way in securing what is more or less tentatively required adminis- tratively in a few instances? : While emphasizing the importance of public health ad- ministration as an indispensable means for advancing com- munal health, I do not desire to ignore the many collateral agencies which work to the same end. Of these may be mentioned in passing an efficient and incorrupt police, the enlightened education of every member of the community by trained and adequately remunerated teachers, and recre- ative agencies which—unlike many cinemas—do not appeal to false sentiment or excite in undesirable directions the imitative faculties of the young. In all English-speaking communities there is in these and other directions ample scope for improvement. N an earlier part of these desultory ‘remarks, I have mentioned the “troughs” and “peaks” of American pub- lic health administration. The injurious influence of the “troughs” on public health would have been immensely greater, had not another influence favoring the public health come into operation throughout the United States. In this, which in reality is a branch of public health administration, America is uniquely supreme. I refer, I need hardly say, to the enforcement of a national policy of prohibition of the sale of alcoholic drinks; by means of which, so- far as the mass of the people are concerned, the terrible working of alcohol in the production of destitution, disease, vice and crime has been eliminated. This is the greatest among the many advances in public health in America; and it places America facile princeps in the public health world. This reform could not have been secured on a national scale, had it not represented continuous and persistent press- ure on the part of.a large majority of the American people, steadily increasing decade by decade, and year by year. If in this spectacular instance such a result has been secured, we cannot doubt that the public conscience can be so aroused and awakened, and continuously preserved from sleep, as to ensure the concentration of all well-wishers for social reform on municipal and state government, which is thé main and the permanently valuable channel for the effective work of all voluntary workers. There will tre- main, even when this ideal has been realized, ample work for non-municipal voluntary workers; but it will in most instances then be the work of pioneers in new work and of activators of official work, and will not involve: the bearing of the main burden of social and health reform. Courtesy of the Henry Street Visiting Nurse Service A visiting nurse uardians of City Health PORTRAIT STUDIES BY LEWIS W. HINE EHIND the scenes where laboratory workers are busy with microscope and test-tube, “out front” in the clinics and hospitals where doctors. and nurses and social workers are dealing one by one and face to face with the citizen and his offspring, in the executive office which controls the whole complex apparatus, and in the tenement home of the sick baby where all the health resources of the city come to focus in the person of the visiting nurse, Mr. Hine has made studies of the men and. women who guard the city against disease and cherish the public health * ry technician Photographs by courtesy of the A laborato ty Health Department New York Ct interne An A director of a hospital A laboratory director A laboratory. technician A milk examiner A bacterio logist A member of the health squad A supervisor of public health nurses The commissioner’s office A social worker In and Out of the Health Workshops By MARY ROSS HERE is plenty of money and attention for anyone who will proclaim that he has found the elixir of life. But after a briet try, the crowd turns away, disappointed. It is not by magic, but by slowly built up, well directed method that this generation has won an added ten years of life for its children. The pro- cess is that of water dropping on a stone, wearing away by almost perceptible degrees a dead weight of ignorance, apathy and superstition. The health department (and with it the voluntary agencies working to achieve the same ends) is the conduit that carries that stream from the laboratories of the scientists and engineers to the people, which trans- forms knowledge into working power. You go into the offices of a health department and you see the charts that show its records of lives saved and lost in other years, the spot maps which register the cases of typhoid and tuberculosis, measles, smallpox, and so on, then in its midst. There are the filing cabinets with records of births and deaths, the rows of bound reports that witness continuous service. In other rooms statisticians are at work interpreting the trickle of fact that flows steadily in by letter and telephone; technicians are making their rou- tine examinations of water and milk,. and aiding the city’s physicians in diagnosis of disease by laboratory analyses. But all their skill and their equipment of micropscope and test tube, of book, paper and chart, is nothing until it reach- es the working point of protecting and enriching health— the health of people. Hence it is that the discoveries of a health department are largely of method, of popularization, education, enforce- ment. From the outside looking in, its practices look like a matter of ordinances, organization and techniques. From the inside looking out, they spell the lives of men, women and children, the common and the dearest possession of all of us. These scattered instances tell of some of the unique pieces of work—or of pieces of work so uniquely well done that they entitle their city to grateful and honorable mention. Mitigating Measles OR one of those inside pictures, for example, take a winter morning in an ordinary family. The six-year- old young hopeful has been home from school for two or three days with snuffles. Last evening, his mother thought he seemed feverish. By morning he had sprouted tell-tale red spots. It hardly needed the doctor to say measles. Now that family friend was sufficiently concerned with the measly child and the precautions of warmth, rest, and — the like, necessary to prevent an ordinary illness from be- coming a serious or even a deadly one. But his thought was even more for the little two-year-old sister, who had just weathered a touch of pneumonia. Ideally, of course, she would not have been exposed even to snuffles, but that ideal is hard of accomplishment under the conditions of ordinary family life. In almost any city in the United States, all that one could.do now would be to keep the children apart and hope for the best, knowing that measles is pretty nearly 100 per cent contagious. But not so in New York city. There a telephone call to the Department of Laboratories would bring the assur- ance of a waiting supply of measles convalescent serum, kept especially for such cases as this. And the injection of a little vial of that serum would mean that she would not have measles at all, or at the worst, very lightly. For more than thirty years it had been realized, and in- creasingly, that the blood taken from persons convalescent with measles contained antibodies which would protect other persons, inoculated with it, from the disease, The New York City Department of Health tried it successfully with children in the contagious hospitals who were exposed to cases which developed in the wards. Then it occurred to Dr. Louis I. Harris, director of the Bureau of Preventable Diseases, that this serum should be available for children in institutions, in which epidemics of measles run a peculiar- ly deadly course, and for all children under three who are in danger of a complicating pneumonia. The difficulty was. to find healthy adults, convalescent from measles, who could and would spare the blood; measles is so highly contagious. that most people have it in early childhood when they can- not afford such a loss of energy. But with the opportune occurrence of a measles epidemic at Berea College the initial supply was obtained. An agent of the Department went out to take blood, by peaceful and practically painless methods. Bought at ten dollars a pint, it costs about thirty-five cents in sufficient quantity to ward off an attack of measles in a baby who has been exposed to it. In one institution alone, in 1923, on the basis of prev- ious measles epidemics in the same building, this convales-- cent serum probably saved the lives of twenty babies. For such children and for very young patients of private phy- -sicians who are poor risks, the Department supplies the serum free. The Law vs. T. B. PHILE New York saves the youngest and weakest: of its children from measles by a serum, Chicago. invokes the law to keep them from tuberculosis, and several of the cities in central New York state have determined to save them from diphtheria by simply abolishing it. A gen- eration ago, as Dr. Emerson tells elsewhere in this issue- (p. 121) one could hardly find a city child of sixteen whose- body had not been at least scarred by the tubercle bacillus ; today among Chicago’s three million people there are not. more than twenty children in contact with a case of the: disease in its communicable or “open” stage. As is common. throughout the country, Chicago requires that physicians. report all cases or suspected cases of tuberculosis, which thus come under the control of the Municipal Tuberculosis. Sanitarium in cooperation with the Health Department. Records of new cases—reported by the clinics or the private- physicians—are filed at the Sanitarium and at the appro-- 134 IN AND OUT OF THE HEALTH WORKSHOPS priate dispensary district—and the dispensary doctor or the tuberculosis field nurse visits the patient at regular intervals to note home conditions, to see if.the patient and family are using conscientious. care, and to advise that he go to a hospital if he cannot be cared for properly and safely at home. In Chicago there are now 2,090 “open’’ cases of tuber- culosis out of a total of 22,318 diagnosed cases, and there are approximately 1,900 beds for tuberculous patients in public institutions. If there is a child under sixteen in the family, there is no choice. Either the child or the patient must leave the household. If this cannot be accomplished by persuasion, the law is called in: the patient is taken to the sanitarium in one of the Department’s ambulances. Even with an increasing population, the next generation should need fewer and fewer of those hospital beds! Abolishing Diphtheria HE value of the Schick test to determine whether or not a child is susceptible to diphtheria, and of the’series of toxin and anti-toxin injections which will make him im- mune, has been demonstrated many times over in small groups of children. But several cities in central New York state determined to show that it worked on a large scale. In Auburn, for example, the disease had cost the lives of ten children each year for eight years before concerted action was started in 1922. Practically 85 per cent of the school children and almost as many of the children under school age have been immunized; and since 1923 there has been only one death from diphtheria (that of a two-year-old, who had mot been immunized) and there have been fewer cases among children than among adults, an unheard-of situation in sanitary history. ‘The village of Homer, which immunized its children in 1922, has not been troubled with diphtheria since. It is on the basis of such evidence as this, watched with eagerness from both sides of the Atlantic (see p. 127) and the ease and convenience with which this record was made, as far as the children were concerned, that the campaign to wipe out diphtheria altogether in New York state by 1930 (see p. 182) has been built. The “Baby Letters”’ HEALTH — department can do much directly for the children of its city; it can do even more by educating the children’s parents to fulfill their responsibilities. To this end the notably successful cam- paign against infant mortality which Bridgeport, Connecticut, started in 1921 has centered a part of its varied program on the education of the mothers— and of all the mothers, regard- less of social station. In addi- tion to an effective battery of well baby stations, staffed with public health nurses who are re- sponsible also tor the school children in their respective dis- ‘tricts, the Bridgeport Depart- ment of Health adopted the plan Courtesy of the New York Tuberculosis Association A city nurse in the Health shop window, New York Tuberculosis and Health Association, East Harlem 135 of having each nurse deliver the birth certificates to the mother, and at the same time a little folder to contain monthly letters on the care of the baby with space for notes on his progress. At the appropriate time she returns with the next letter, and asks for the folder so that she may add this to the ones already delivered. Most important of all, the Department finds that the letters are read and kept and re-read. ‘There is hardly a baby in Bridgeport with whom the Department does not keep in touch in this way and through the well baby clinics. And the line that charts the baby deathrate has gone downward in sharp leaps. ‘The average during these four years of demon- stration has been the loss of about one baby in six-. teen; during the five years preceding it, the city lost about one in ten. When It’s “Catching” NCIDENTALLY New York has just decided to turn even its illnesses to educational account by utilizing the city hospitals for communicable diseases, recently reorganized by Dr. S. W. Wynne, director of the Bureau of Hospitals, to teach internes and nurses the care of those who are ill with such diseases—a technique which is indispensable in any field of public health work, yet too little stressed in the ordinary training schools and universities. Study of the records of one hundred children who died of diphtheria at Willard Parker Hospital showed that in half the cases the physician had been at fault—he had not recognized the disease in time. (In almost all of the other cases the parents had waited too long to call in medical aid.) The training school for nurses, which will be opened there in January, will affiliate with the other training schools for undergrad- uates for special training in this type of nursing, and will give a special postgraduate course for public health nurses, to teach them the methods which make it possible to care for different contagious diseases in glass-walled cubicles side to side, without ever a _ cross-infection ; methods as necessary in the home where is tuberculosis or pneumonia or even a common cold, as in the hospitals themselves. Bored or Bumptious HEALTHY body is of little account if the mind which should direct it is sick. So far public effort in the field of mental sickness has been directed almost entirely toward care and custody of the insane; there has been little work along the pre- ventive or mental hygiene side. Newark ran a mental hygiene bureau under its health depart- ment from June 1919 to Decem- ber 1921, and then had to dis- continue it because a special ap- propriation could not be ob- tained. “It is extremely difficult to convince money-appropriating bodies of the need for mental work in preference to those activities which are more easily recognized,” writes Dr. William 136 IN AND OUT OF THE H. Young, Acting Health Officer, looking back on that experiment. It is in just such a situation that the voluntary agency finds its ideal opening, and in this case the opportunity has been taken by the National Committee for Mental Hygiene, which, working with the Commonwealth Fund, have pro- vided and operated child guidance clinics in a number of cities to prove their right to public support. As a result Los Angeles, Dallas and Memphis now have permanent child guidance clinics supported out of the community chest ; St. Paul has one supported by the Amherst H. Wilder Charity, and in Minneapolis the city itself has stepped in to meet the need and give pioneer proof of the value of safeguarding and aiding the growth of its children in a clinic on the budget of the board of education, which, as Mr. Platt shows on p. 144, often bears a considerable share of a city’s health expense. As far as we know [writes Dr. Smiley Blanton, its director] this is the first time that any large school system has had con- nected with it a completely equipped mental hygiene clinic for the care and treatment of the children in the schools. The clinic, however, stands ready to serve not only the public schools, but also the juvenile court, various social agencies of the city, and the parents. The sensitive child, the anxious, moody, timid, egocentric, morbidly suggestible, seclusive, sullen, or “bumptious” child is suffering from a severe handicap; as severe as though he had a crooked foot, crossed eyes, or chronic appendicitis. We are beginning to see, too, that physical health depends a great deal upon mental health. The moody, unhappy, tired, un- interested child cannot be a physically well child. By Means of Good Will ARDLY anyone, unless it is an up-to-date health officer, regards an attack of typhoid as something to be ashamed of. Probably that is one reason why there are fewer and fewer cases to the country’s discredit. Yet there is one other problem with which most health depart- ‘ments have to deal whose natural complexity is further com- plicated by the haze of moral disapprobation, of secrecy and concealment, with which it customarily is surrounded. That is the problem of the venereal diseases. “How do you keep them coming?” is one of the common- est questions asked by students of health practices who visit the excellent venereal clinics of the Detroit Department of Health, well-known in professional circles for the signal success with which they carry on the more or less stand- ardized work in that branch. ‘The first of the series of answers made by Dr. R. S. Dixon, chief of the Venereal Division, is this: We attempt to treat a person with a venereal disease. with the same courtesy and consideration that we should use in treating a person with any other communicable disease. The treatment of the patient consists not only in the diagnosis and the medicine we prescribe, but also in our attitude toward him or her from the admission desk till discharge. It is easier and cheaper to develop good will and secure regular attendance through it, than it is to use the customary legal and social measures. If the doctor cannot sell himself or herself to the patient, then something is wrong with the attitude in the clinic. It sounds simple, but the results are almost unique. Of course, behind this attitude lies the skill of the specialists who staff the clinic, and with it a policy of explaining the treatment to the patient in definite terms which he can understand; a policy of conferences of the staff on a case, so that the treatment adopted is the best judgment of the group, and the patient as a result finds continuous agree- HEALTH WORKSHOPS ment even though he may not see the same doctor at suc- cessive visits; and again, of course, there is a systematic follow-up of cases. The diagnostic service is free, but treat- ment is given only to those who cannot pay; the rest are referred, with an appropriate letter, to private physicians. East Orange, New Jersey, also known for eminence in this kind of work, has worked out a particularly helpful amount of cooperation between the municipal venereal di- sease clinic, and other agencies in the Oranges, such as the hospitals, the Bureau of Associated Charities, Children’s Aid Society, the Visiting Nurses’ Association, the State Peni- tentiary, Parole Officer and so on, linked together by the tact and resourcefulness of a “truly cooperative social worker.” Health Stores HE bigger the city the deeper the chasm between that imposing central office of the department of health and those potential clients who most need its knowledge and skill. One day some unnamed person had the simple but useful. idea that from this point of view, as well as others, a city could be treated like a set of villages, and each vil- lage could have a local health center with some of the friendliness and individualism which is more easily obtained in smaller places. Health centers started in New York city, but transplanted to Boston they grew with a vitality which at present overshadows the original plant (p. 142). The Boston achievement is executed at present on a scale which makes it perhaps discouraging for beginners—and most cities still are beginners in the provision of health centers. The story of East Harlem in New York, which has been told in several instalments in The Survey (e. g., May 15, 1925) is perhaps a simpler instance that cooper- ation can work; that representatives of a city health depart- ment and of more than a score of health and welfare agen- cies can be housed under the same roof with the aid and comfort of the county chapter of the American Red Cross, to the pleasure and profit of all; and that through this center—a kind of a neighborhood department store of health —there can come a neighborhood interest and pride that makes for health. HE cities here mentioned are pioneers, or have won special distinction through these achievements of method and organization. But supposing you, reading over such paragraphs as these, say “We do all these things in our city—and more. What next?” It is easy enough to point to the waste land—mental hygiene, industrial health services, heart disease and so on— which invites cultivation. But before a city moves-on to new fields, it might pay to stop and take an inventory. The fact that now for the first time in sanitary history a way has been devised whereby a city can make such an inventory, and compare it with that of its neighbor in the next county, or its rival across the country, is the immediate reason which lies back of this issue of ‘The Survey. ‘This form of appraisal, which has been changed and will be changed as standard practices vary and improve, is based on surveys which cover all American cities of more than 40,000 population—186 of them in all. “Of course our children get a health examination,” one city said. ‘Then the surveyor found out that the examina- tion of a child took, on the average, forty seconds. Another health officer reported that he had examined 650 children in a day! (Continued on page 177) Hermann M. Biggs, M.D. Public And Private—And Both By HOMER FOLKS “Voluntary agencies can find their greatest usefulness only as supple- mentary to the public authorities and in close cooperation with them” T is easy to state the general principles which should govern the relationship’ be- tween public health authorities and volun- tary health agencies. It is not at all easy to apply them to any particular situation. Public health is primarily a function of gov- ernment. Voluntary agencies should supplement and strengthen public agencies. How simple! Very likely in the first city in which you try to apply these excellent principles, the health department does not wish to be supplemented or strengthened, but only to be let alone; in the next the board of aldermen is under the influence of the cults and refuses to amend an obsolete health measure or to give the health department any addi- tional funds. How difficult! In another city with which you deal there may be an economy era, and the health com- missioner does not dare even to ask for more money; in the next, the health department, and all other departments, may be riddled with cheap politics and not really care any- thing about health. How very difficult! Travelling on, vou come to a city in which the secretary of the voluntary association thinks that his organization must do something “different,” something “popular,” to secure a good seal sale next Christmas; in another the secretary does not like the commissioner, personally, and in the next, the commissioner does not like the secretary: in cities generally the boards of directors of volunteer associations are apt to think that all public officials are “politicians” and are afraid of hav- ing any dealings with them. And all those voluntary or- ganizations are quite independent (otherwise they are not voluntary) and can.do as they please. difficult ! Every state and every city has such difficulties as these from time to time, and the real problem is not to state the valid principles, but to adjust and continually re-adjust them to ever-changing sets of facts and circumtsances. The problem is not getting simpler. In fact it is getting hourly more difficult, because of the extraordinary expansion of the field of public health. When public health was largely a matter of quarantine, and depended largely on the police power, it was obviously, and almost exclusively, a public function. It would be intolerable that any private agency should have any such powers. But now health is, so to speak, permeating pretty much the whole of life. Its police aspects are becoming more or less obsolete. Many of them never were scientifically valid. Health is now pri- marily a matter of education in its broadest sense—of the development of better habits and sounder views of life, of a better attitude towards one’s doctor, and of a changed attitude on his part. It deals with the most intimate con- cerns of our daily lives—it touches the very center of our personalities. It has to do with everybody—and from the cradle, nay from conception, to the grave. But if public opinion will not .tolerate the exercise of How very, very 137 138 police powers by private agencies, it is equally intolerant of granting a monopoly of education to any branch of goy- ernment, or in fact to government as a whole. ‘The aver- age citizen is in fact very anxious to learn about health from any and all who seem to have any reason for setting them- selves up as teachers in this field, but he insists on choos- ing his teachers. He will listen to them all, but will judge for himself which of them seem to him sound and con- vincing. He may, and often does, judge wrongly, but to the prerogative of judging for himself in such intimate and personal matters, he will cling while life lasts. So the anomaly presents itself that while public health is primarily a function of government, and while public health agencies are growing apace, health is at the same time becoming more and more a personal matter, and volun- tary agencies are constantly getting more numerous and more effective. In many states there has been, for several decades, some public health authority for every square foot of territory; no farm or hamlet has been without the juris- diction of some public health officer charged by law with various functions in the protection of public health. And yet every one of those public health authorities is further from having a monopoly of the health field now than it was when it was created. T is a truism that in any particular locality at any given I time, the actual relations between public health author- ‘ities and voluntary health agencies will depend very largely on the individuals who happen to hold the governmental ofhces and those who hold the executive positions in the voluntary agencies. Perhaps more is to be learned from recalling how certain official authorities and voluntary agen- cies have worked together than from considering further how they ought to work together. I think always of the rather remarkable relationship which has existed between the New York State Health Department and the Committee on Tuberculosis and Public Health of the State Charities Aid Association, as developed under Dr. Hermann Biggs as commissioner from 1913 to 1923, and as fully continued by his successor, Dr. Nicoll, formerly Dr. Biggs’ deputy. It was the voluntary agency, in this case, which took the initial steps, and, in fact, most of the steps, which made it possible for Dr. Biggs to enter the state service and to find on the statute books a modern and vastly improved public health law. There had been a close and effective cooperation between the state health department and the Association’s tuberculosis committee since the organization of the latter in 1907, though the Association, to fall back on a boyhood phrase, had “had to do most of the lovering.” It had become evi- dent, however, that after certain promising. beginnings, the Department had reached a stage at which it did not desire to develop its activities further, but rather to be allowed to lead a quieter and simpler life, without continually crowding legislatures and governors and local authorities ‘to more aggressive action in the anti-tuberculosis fight. The advent of a new governor in January 1913, and the ex- piration on the same date of the term of office of the state commissioner of health, brought the question into the foreground, and the new governor on his own initiative stated that he desired to make a new appointment, and in fact to appoint the greatest health authority in the entire United States. PUBLIC AND PRIVATE—AND BOTH The existing statute carried several limitations as to those who were eligible. It was suggested to the governor that he ask a group of citizens to consider not only this particular provision of the public health law, but the public health law in general, and to recommend to him the changes which ought to be made. He appointed an unofficial group of citizens, giving them quasi-official status, and the volun- tary agency worked through that committee, providing it with a staff and furnishing its secretary. By such happy cooperation, and by the hardest of work, it proved to be possible to turn in a full report in February, to accompany the report with a draft of a bill, to have this transmitted to the legislature by the governor in a strong message with his full-approval, and to have this bill made a new public health law by the legislature then in power and in sympathy with the governor. A model vital statistics law was swept along with it, and a large increase in appropriations to carry the new laws into effect followed almost as a matter of course. Dr. Biggs had no thought of becoming state commissioner of health at that time. It was only in January, 1914, when he found that what he considered vital features of the new public health law were likely to be replaced or made of no effect unless he himself accepted the official position, that he could be persuaded to permit himself to be appointed. HE relations which continued to exist between the commissioner and the assisting voluntary agency, with- out interruptions or exception, until Dr. Biggs’ lamented death in midsummer of 1923, and which have continued unimpaired under Dr. Nicoll, afford, it seems to me, an almost perfect object lesson of what such relations should be. ‘There was complete independence on the part of the voluntary agency. It arrived at its own policies and spoke only for itself. “The commissioner spoke only for the Depart- ment. As a matter of fact, during the entire decade, there was never a single instance in which the recommendations received by the legislature from the official department and from the state-wide voluntary agency differed in any respect. They might have differed constantly. The complete harmony which existed without a single break was due to several factors—the remarkable ability and prestige of Dr. Biggs, and his extraordinary gift for administration, which made it equally a pleasure, a privilege and a duty to support him on all occasions; his punctilious observance of the complete independence of the voluntary agency, and the fact that he never undertook to control its action; and the strategic fact that he was a member of the executive committee of the voluntary association, was present at practically all its meetings, participated in all its discussions, assisted in thinking through all its problems, and could always state and explain the official policies of the Department. » When a new political party came into power in the sec- ond year of his administration, before his strength with the people was fully established, and its leader announced as part of his program the repeal of vital features of the new public health law and the reduction of the expenditures of the State Health Department by 50 per cent, it was the voluntary agency which took the brunt of the fight to up- hold the law and continue the appropriation. The acts and opinions of this voluntary agency had very great weight with the press and in (Continued on page 178) Courtesy of American Public Health Assn. . FALL RIVER . SYRACUSE DETROIT BUFFALO WASHINGTON WORCESTER CINCINATI The TPR of Public Health | HE carpenter has his foot-rule; the physician, his clinical thermome- ter; the laboratory worker, scales so delicate that they register the weight of a lead-pencil mark. Be- cause of the lack of such objective standards the social sciences have stood handi- capped, denied by many their claim to science cies at all. Yet this year 1925 sees the emergence of one of them—-public health administration— from the old rule of thumb to the attainment of a way of evaluating the health of a community, just as the TPR (temperature, pulse, respiration) on a hospital chart tells the patient’s story in a moment to a qualified observer. In 1920 the American Public Health Association ap- pointed a Committee on Municipal Health Department Practice to find out what the large American cities were doing for their people’s health. Out of the work of this Committee, supported by a grant from the Metropolitan Life Insurance Company, came Public Health Bulletin No. 136, a highly technical government document of some five hundred pages, which told the experts’ story of eighty- three cities which had a population of 100,000 or more, and with it a section which outlined an ideal health depart- ment for a city of 100,000. Later this list was expanded to include all cities of more than 70,000 population, a hundred in all, and the record of these for 1923 will be in print before the year is out. In 1923 the American Child Health Association began a similar study of health work in the eighty-six cities which had from 40,000 to 70,- 000 population — the re- sults of which reached publication two weeks ago. With the gathering of these data there became available for the first time in the history of cities the story of how one public duty was fulfilled, or left undone, in the large mu- nicipalities of a nation. To put these facts to work was the next mon- umental task of both groups of health experts. With the aid and: coun- 86 Cities: Arrangement 66 Cities Total ‘Score ° 400 600 600 000 Total Score Courtesy of American Child Health Assn. Courtesy of Kansas City Council of Social Agen- The dollar ‘in Kansas City sel of other national health agencies, the Ameri- can Social Hygiene Association, the National Organization for Public Health Nursing, and the National Tuberculosis Association, and the Na- tional Health Council, they worked out a tenta- tive appraisal form for city health work. ‘This in turn was submitted to a group of practising city health officers whose opinions carried the de- ciding weight, and vote. And so came into being the City Rating plan—a social tool as exact as the conditions of public service permit. That Appraisal Form lists and defines the functions ordinarily exercised by city health departments and tells what set-up and results may be demanded under each. ‘The graphs which head this page and border the cover (used with the health officers’ permission) chart the tides of health work in their respective cities at the time the surveys were made. Each column registers the credit then due under the rating plan for each of the eleven major activities: vital statistics ; control of communicable disease, venereal disease, and tuber- culosis; prenatal health work; protection of the baby, the pre-school child and the school child; sanitation, laboratory service, and popular health education. At a glance health officer or citizen can see which, according to this standard, are well done; which need further emphasis. Sanitation, oldest of the civic health duties, has the highest average score in the summary of the eighty-six smaller cities (and the larger cities show much the same tendencies ). Popular health education, a comparatively new responsibility, stands at the bottom of the list. Is your city health program well balanced or would you find that much is_ spent for care and garbage and little for prevention, as Kansas City did in an independent self-survey ? Among the smaller cities, total scores ranged from 235 to 792. Where does your city stand? Ask your health officer. The experts have decid- ed what should be done; he can tell you what has been done; to do the rest will take them Sanitation 67 Laboratory: 60 Infant Hygiene 58 Vital Statistics 57 Venereal Disease 34 Tuberculosis “45 School Hygiene “44 Communicable Disease 43 i Pre-natal Hygiene 38 Pre-school Hygiene 32 Pop. Health instruction ; 21 Average Scores of the 86 Cities in 11 Major Health Activities : Expressed as the Per cent of the Maximum Score and him and you. Courtesy of American Child Health Assn, ~ 139 aster patserehaeee ea The requisite health machinery What Should a City Do? I. The Large City By IRA V. HISCOCK Scissor pictures by Martha Bensley Bruere Responsibility and Scope of Work. The authorized force created by a municipality for the preserva- tion of public health is the health department. rs Its scope of activity has broadened in recent years, to include not alone environmental sani- tation and the control of acute infections but also edu- cation in principles of personal. hygiene, child hygiene, and the development of medical and nursing service for the early diagnosis and preventive treatment of disease, in health centers and sometimes even in the home. As cities have recognized their responsibility in regard to these affairs they have instituted the requisite health machinery, supple- mented in many cases by excellent service rendered by volun- tary agencies whose achievements in pioneer fields are well known. For the purpose of the present discussion of modern health practice, however, it has been assumed that all activ- ities are performed by the health department unless other- wise indicated. ‘The cities to which reference is made below are cited merely as outstanding examples; many others might well have been included by reason of the excellence of special or, general pieces of work. An advisory council to approve the budget 2 Organization and Budget. Four essentials for success- * ful health administration are expert officials, adequate funds, proper health regulations, and a favorable public opinion. The general administration of the department should be conducted on a full-time basis, by an able medical health officer, well trained, well paid and secure in tenure. A board of health or advisory council of about five members, serving for overlapping terms, is customarily provided to advise the health officer in regard to general policies, to approve the budget, and to promulgate the sanitary code. It is obviously desirable that the members of this board shall be interested in public affairs and shall meet regularly, as once a month. One member should be a physician, while one might be a woman, one a business man, one a lawyer and one an engineer. It is somewhat surprising to find in one city that an undertaker heads the board of health, while plumbers are still not uncommonly represented. _ Attractive and spacious quarters are needed for the departmental bureaus representing the principal functions, with full-time directors in charge of each bureau. The majority of health departments are located in the municipal building, near other city departments, such as education, engineering and public works, with whom the health depart- ment necessarily maintains close contact. A central health building, adequate for the different bureaus and special clinic rooms, has proven of practical and educational advantage in Bridgeport, Connecticut; and in Flint, Michigan. Clinic and consultation service in many cities is provided through health centers in various parts of the city which serve as district offices of the department of health. Two health center units in Boston provide district headquarters for all the health and social agencies working in the district, and this has resulted in the closest correlation and cooperation between the workers of the various agencies. According to reliable estimates, based largely on the findings of the Committee on Municipal Health Depart- ment Practice of the American Public Health Association [Public Health Bulletin 136, U.S.P.H.S. 1923], a health department organization, competent to deal adequately with the fundamental problems of municipal health administra- tion, needs a budget of $2 to $2.50 per capita of population, including the cost of hospitalizing cases of communicable diseases. This figure includes provision for many types of service, such as infant welfare, tuberculosis clinic, and public health nursing, which are now frequently performed by private agencies. Even including these items, however, the amount suggested as desirable is actually provided in only a few cities, while the total appropriations of health depart- 140 WHAT SHOULD A CITY DO? ments vary from a few cents per capita to about three dollars, when garbage disposal and hospital service are also included. While there is a tendency for official agencies to undertake more and more activities, it has been well said by Sir Arthur Newsholme that the best official worker is he who manages to bring as much voluntary aid as possible into his work. 2. marriages and deaths should be localized in the health department, as sound conduct of health work is governed by the careful analysis of information obtained from these sources. Legislation, substantially identical with the model laws for birth and death registration endorsed by the United States Census Bureau, should lead to the reporting of practically all deaths and of at least 95 per cent of all births. The International Classification of Causes of Death should be followed. Records and certificates should be preserved in fireproof vaults, and not allowed to accumulate on. the office table or in the registrar’s home or drug store. For many years the weekly, monthly and annual reports of the New York city bureau, for example, have proved exceed- ingly valuable: Completeriess of‘ reports is maintained by occasional checks, and by education among doctors and mid- wives. Recording of births, deaths and sickness by permanent sanitary area units has been instituted in some cities. Health bulletins in Detroit warn against danger 4 Control of Communicable Diseases. Effective control of * communicable disease depends on prompt reporting of cases to health authorities, investigation of sources and means of spread, and elimination of avenues of infection. Consulting diagnostic service for use by physicians is most desirable. The Detroit health department, for example, has maintained for years a diagnostic service consisting of well trained clinicians who have specialized in contagious disease work. The department has twelve part-time physicians in this service who give approximately three hours daily to such work, and the practicing physicians of the city are accustomed to call freely upon them for consultation. It is the practice in Milwaukee, Wisconsin, among other cities, to vaccinate contacts of smallpox cases, to culture the con- tacts of diphtheria cases, and to examine the contacts of tuberculosis cases. Release from isolation of cases of typhoid and diphtheria is based upon negative cultures. Hospitaliza- tion of important communicable diseases is successfully en- couraged. The value of the Schick test in detecting suscepti- bility to diphtheria and of toxin-antitoxin in producing immunity has been clearly demonstrated as in New Haven, Vital Statistics. The function of registration of births, | 141 where 70 per cent of the school children and a large pro- portion of pre-school children are protected. A health department should aim to obtain full reporting of cases of tuberculosis and to maintain a systematic register of all such cases, not only that each case may be so cared for as not to be a menace to others, but that it may receive the necessary medical and nursing care, either at home or in an institution. Adequate dispensary facilities are necessary ‘for the diagnosis of tuberculosis and the treatment of ambulant cases. Both day and evening clinics are desirable. Present standards indicate that under an effective system, four hundred patients a year per one hundred thousand population may be expected to come to these clinics, making an average of ten visits a year. On the same population basis, good nursing follow-up will require about eight thousand nursing visits a year paid to tuberculosis cases annually. Advanced cases may often be cared for in general hospitals or isolation hospitals, but sanatorium and hospital facilities should be provided to the number of one hundred beds per one hundred thousand population. An adequate program for the control of venereal diseases includés educational, recreational, social and medical meas- ures, as well as law enforcement. Day and evening clinic facilities for the early detection of these diseases, followed by efficient intensive treatment, is vitally ‘important. Hospital facilities for a limited number of bed cases are likewise essential, but these again may be provided in general hospitals. In. Newark, New Jersey, municipal clinic service, with paid clinic physicians, nurses and social workers, provides early diagnosis, treatment and follow-up of cases of tubercu- losis and veneral disease. The educational campaign includes the use of lantern slides and motion picture films in lectures. Provision is made in the city hospital for bed cases of venereal diseases and for emergency cases of tuberculosis, in addition to more extensive facilities offered for tuberculosis cases in county and state institutions (amounting to approxi- mately one bed for each annual death). It is also noteworthy that in this city, 48 per cent of the cases of typhoid, 25 per cent each of the cases of diphtheria and scarlet fever, and 100 per cent of the cases of smallpox are hospitalized. Child Hygiene. "The modern conception of an adequate * child hygiene program includes provision for pre-natal and obstetrical care, infant welfare, pre-school and school hygiene. New York City was the first to create a bureau of child hygiene and to establish a sound policy of health protection of maternity, infancy and childhood, reaching through school life. A system of pre-natal clinics and baby health stations covers the city and is supplemented by an excellent visiting nurse service. In her study of conditions in Cleveland, Dr. S. Josephine Baker concluded that one nurse, to obtain the best results, should have not more than one hundred infants under observation. Midwives should be licensed and effectively supervised. In Minneapolis, Milk inspection from the source to the point of delivery 142 Minnesota, where the Infant Welfare Society conducts pre- natal, infant and pre-school work, 93 per cent of the babies born in 1923 were delivered by physicians, while 65 per cent of all the births occurred in hospitals. Twenty per cent of the expectant mothers received pre-natal care in clinics. poo In Boston, special attention is given to the care of the pre-school child by both official and non-official agencies. Well child conferences for children of pre-school age are held at the various health centers. An average of seven thousand services per month with emphasis on prophylaxis is being rendered at each unit, where the program includes pre-natal service, baby conferences, prophylactic dentistry, serum therapy, posture, nutrition, mental hygiene, periodic health examinations and general health education. The health department has developed a plan which has received universal commendation wherby the three grade A med- ical schools, Harvard, Tufts and Boston University, furnish the medical personnel which functions at the baby and pre- school age weekly conferences. The medical personnel in each instance is supervised by the professor of pediatrics of the respective schools and the city of Boston pays each med- ical school for the services rendered. This assures the babies of Boston a high type of pediatric service free from any inference of political preference or placement. The medical schools in turn are availing themselves of the facili- ties presented by these conferences as a training opportunity for medical students. The department is now conducting thirty-one baby and pre-school age weekly conferences with an average attendance of thirty-seven babies and an aver- age of eleven pre-school age children. A total of 114,657 home visits were made to babies and pre-school age chil- dren during the eleven months since the reorganization of the work under the health department. The nursing di- vision is linked up with the Simmons College department of public health nursing, whereby the students at this in- stitution receive an opportunity for doing field work in child hygiene. The chief aims of school health supervision are to edu- cate the child in the principles of healthful living, so that he may himself have sound health and thus safeguard the community in the future; to find and correct physical, “mental and medical defects in the child before they affect his ability to learn and interfere with his school career; to provide a healthful environment for the child; and to protect the community from the spread of communicable diseases, Sufficient personnel should be provided to allow one doctor to every three thousand children and one nurse to about two thousand children, in addition to an adequate staff of dentists and specialists. nations including heart and lungs, should be made of each child at least three times during school life and continuous records should be maintained. Unfortunately, such a pro- gram is still an ideal not yet realized in many cities, where funds and personnel are not adequate to allow sufficient time for thorough examination, or records are not maintained of defects found and defects corrected. In Providence, Rhode Island, an excellent program has been developed in the division of child hygiene, directed ~ by a woman physician. The children of the public and parochial schools are examined three times in their school career, in the first, fifth and seventh grades, and 55 per cent of the school children examined in 1924 were found to have defects. The results of follow-up are so good that Thorough physical exami- WHAT SHOULD A CITY DO? treatment was secured in 77 per cent of the cases in which it was advised. There are nutrition classes and open-air classes for undernourished or pre-tuberculous children. In several cities, parents are urged to be present at the time their children are examined; the health officer of Toronto, Ontario, Dr. Charles J. Hastings, reports that a large proportion of the parents take advantage of this excellent opportunity of obtaining first-hand information of the con- dition of their children. In Cleveland, Ohio, the school health organization of the public schools has been developed within the board of education. "The work of the physicians and nurses is closely correlated with other .school activities among which are open-air-rooms, school for crippled children, classes for the blind, school for the deaf, classes for educationally ex- exceptional children, classes for speech defects, the exami- nation of children seeking working permits, and nutrition classes, Outside the school system, their work is correlated with all those agencies having to do with child welfare, such as the department of public health, various hospital dispensaries, tuberculosis clinics, fresh-air camps, visiting nurses association, federated charities, juvenile court and the Humane Society. School health supervision of children of the parochial and private schools, comprising 20 per cent of the total enrollment of grade school children, has prop- erly been developed within the division of health. Through a close working relationship with the public school activities for special cases, children who are crippled, blind or deaf, or exceptional in other ways, are referred to public school facilities not provided within the parochial school system. 114,657 visits to the babies of Boston 6 Public Health Nursing. The importance of the nurses’ * work in the whole public health campaign is real- ized more fully each year, especially in its relation to edu- cation in matters of personal hygiene. Nursing personnel equivalent to one nurse to every two thousand people is considered necessary for the execution of a complete pro-- gram, as indicated in the 1923 report of the Committee on Municipal Health Department Practice, previously men- tioned. The following fundamental functions of a nursing examination were outlined at that time: (a) The home visitation of cases of acute communicable disease for the instruction of attendants in the technique of isolation and concurrent disinfection, for the taking of cul- tures and preliminary examination. of contacts, and for the dissemination of knowledge in regard to the value of vaccine and serum therapy. (b) The assistance of physicians at tuberculosis clinics; and home visitation for bringing contacts and suspicious cases to the clinics, for instruction of patients in home care, and for the following up of arrested cases. . (c) The assistance of physicians at venereal disease clinics ; and home visitation in special cases where such visitation may be advisable. (d) The assistance of physicians at infant welfare clinics and pre-natal clinics; and home visitation for the instruction of mothers and expectant mothers in the hygiene of maternity and infancy. WHAT SHOULD A CITY DO? (e) The assistance of school physicians in the examination of school children; and home visitation to secure needed treat- ments and to instruct mothers and children in the hygiene of childhood. For economy of the nurses’ time and for the benefit of closer personal contact with families, the organization of nurses on a generalized basis has proven most satisfactory in some of the large cities, as Columbus and Dayton, Ohio; and Los Angeles, California. In Columbus a coordinated plan has been developed by the health commissioner and the superintendent of the Instructive District Nursing Asso- ciation. A division of nursing is organized in the depart- ment of health with the associate superintendent of the district nursing association as chief of the division; her salary is paid jointly by the nursing association and the department of health and she in turn is responsible to the superintendent of the nursing association and also to the health commissioner. ‘The department of health has as- sumed a part of the salaries of the staff nurses of the nurs- ing association, which has taken on its payroll the nurses _ employed directly by the department of health, thus making a joint staff of the two organizations. The superintendent ef. the Instructive District Nursing Association is not on the payroll of the department of health but is responsible only to her board. In Dayton, the control is centralized ; the same director supervises the nurses of the health de- partment and Visiting Nurse Association, and offices are furnished by the health department. The public health nursing service of many of the large cities is on the specialized basis, but, as in Chicago, with centralized direction in the department of health, and with close cooperation between the public and private agencies. A creditable plan of securing coordination of nursing activi- ties of the official and voluntary agencies has been evolved in Providence. ‘The city makes an annual appropriation to the nursing association and the superintendent of health is an ex-officio member of its board of managers. Every year the superintendent of health and the director of the nursing association meet and plan their work so as to se- cure the best possible cooperation and the greatest efficiency. The two departments are in almost daily conference. Keeping a check on the swimming pools of the city 7. Laboratory. A well organized laboratory should be * maintained to provide free diagnostic service, to aid in the sanitary control of milk and water supplies, and to carry on research problems of a public health character. Health officials now recognize the laboratory as one of the foundations of effective health work and as an inval- uable means for coordinating their activities. In only one of a large number of cities recently surveyed had laboratory work once undertaken been discontinued, and this was a city in which the dangers of political interests had apparently been demonstrated, as judged by the striking lack of con- structive health work and the frequent changes in personnel. Laboratory service in the large cities is generally well de- veloped and specimens are annually examined at a rate which corresponds to about one to every twelve people. 143 A very few city laboratories manufacture biological prod- ucts for diagnosis, prevention and treatment of disease. The New York laboratory which is a pioneer in this kind of work manufactures smallpox vaccine and bacterial vac- cines, diphtheria toxin for Schick tests, and toxin-antitoxin for immunizations, diphtheria and tetanus antitoxin, and anti-pneumococcic and anti-meningococcic sera. ‘The clin- ical division of this bureau advises physicians in the use of these products and when requested aids with such prod- ucts in diagnosis and treatment of patients. The splendidly equipped Bridgeport laboratory performs a wide range of examinations for the physicians of the city, for the city clinics. and for city hospitals. ‘These include examinations of specimens for diphtheria diagnosis, release and virulence; tuberculosis; gonorrhea; syphilis; typhoid fever; paratyphoid; cerebrospinal meningitis; pneumonia; malaria; Vincent’s angina; ringworm; and dysentery. Blood counts are made, and examinations of gastric con- tents, while urinalyses are carried on as routine. In co- operation with the police department, analyses are made of liquors, while for the public works department analyses are made of the products of the garbage reduction plant. A constant check is kept on all public and private water. supplies and swimming pools of the city, while a con- siderable part of the time of the division is devoted to the bacteriological and chemical examination of milk samples. Behavior problems 8 Mental Hygiene. ‘There should be in every city a com- ¢ prehensive program of mental hygiene for children and adults, including psychiatric hospital facilities, psychiatric clinic facilities and psychiatric social service. This work, however, is at present considered to be largely a function of voluntary agencies. ~The Commonwealth Fund through the National Committee for Mental Hygiene has rendered particularly valuable service in Cleveland, Dallas, Los Angeles, Minneapolis and Philadephia in bringing about the estabishment of child guidance clinics. "These clinics deal with any type of mental disease or defect involving definite behavior problems, referred by schools, physiciaris, family welfare workers and parents. Provision is made for complete physical, psychological and psychiatric exami- nation as needed, with clinic treatment and necessary fol- low-up work in the homes. 9 Inspection. An inspection service should be main- * tained for the control of milk supplies from the source to the point of delivery, for the systematic inspection of food- handling establishments, and for general nuisance inspection and the supervision of housing conditions in occupied build- ings. ‘The extent and character of inspection service needed in a given case can only be determined by a knowledge of local conditions. ‘There is still a tendency, particularly in many of the smaller cities, to feature sanitary inspection out of all proportion to other health activities which may have a more direct effect on the prevention of sickness and 144 deaths. In a few cities, unfortunately, almost all efforts are directed toward environmental sanitation. An effective inspection service, well balanced with other activities, is maintained in Richmond, Virginia. Restau- rants, hotels and food stores are inspected and permits are required for their operation. Special regulations exist for sterilization of utensils at soda fountains. Particular effort WHAT SHOULD A CITY DO? has been directed to the safeguarding of the milk supply since 1907 when local officials took the view that the “dairy was a factory where the most delicate of foods, as well as the most valuable and most easily contaminated, is produced.” Uniform plans of dairy barn construction were provided to dairymen by the health department. At the present time dairy barns (Continued on page 180) Il. The Small City By PHILIP S. PLATT N order to arrive at a better conception of what constitutes reasonable public health work and the cost of such a service, the Research Division of the American Child Health Association has prepared a plan of organization of community health work for a city of 50,000, published in full in its Health Survey of the 86 Cities,* on which the present discussion is based. This plan is in no sense to be taken as an ideal or a rigid and unmodifiable proposal. It was based: originally upon the recommendation of five investigators after each had sur- veyed from fifteen to nineteen cities. Every effort has been made to base its assumptions of work to be performed, the time and personnel required and the cost of each ser- vice, on conservative, average practice in the better cities. The plan has received the continuous study of its sponsors for more than a year; it has been under repeated revision in whole or in part, by members of the staff of the National Health Council, the National Organization for Public Health Nursing and the National Tuberculosis Association, and embodies the suggestions of several health officers, state and local. Substantial contribution to the plan has also been made by Professor Ira V. Hiscock of Yale University. The estimated cost of this moderate, well-rounded public health program, for a city of 50,000 population, is $79,490 or $1.59 per capita, if the entire nursing service of the city on a generalized basis were to be included. Of this budget, 72 cents per capita, or 45 per cent, represents the cost of the community nursing service. ‘These figures may seem, at first thought, to be out of all proportion to the present practice and financial resources of our smaller city. How- ever, a number of cities spend an even larger sum, if the cost of all of the health activities of the community is in- cluded. The figures cannot be fairly compared with any existing health department budget for there is no one of the 86 cities in which the health department attempts to carry on all the branches of health work which are outlined in the plan. In 61 of the 86 cities the school nursing work is carried on by the deparment of education. In 75 cities, private organizations provide nursing services, supplement- ing in most cases the meager nursing service of the health department. Hospitalization of communicable diseases and tuberculosis appears to entail no expense to the health de- partment in 57 of the 86 cities, while in the remaining cities it varies from I cent to 85 cents per capita. In other words, in not a few cities the total amount spent on health by the department of health, the department of education, the state department of health, the local nursing associations, the societies interested in tuberculosis and venereal diseases, the *The Health Survey of 86 Cities (Section IV, pp. 540-590, by the Research Division of the A. C. H. A.). American Child Health Association. Price postpaid of The Survey, $3. special clinics or dispensaries, the office of registrar of vital statistics and the parochial schools, would be equal to or exceed the total required by the rounded plan put for- ward, namely $1.59. The following table summarizes the budget of the pro- posed plan for the health for a city of 50,000: THE Crrizens’ Britt: A HEatty DEPARTMENT ‘BUDGET FOR A CITY OF 50,000 Cents Service Salaries Maintenance Total per capita Administration, education and records (including vital statistics) ....... $8,200 $2,500 $10,700 21.4 Inspection (including sani- tary inspection, food and milk) ................ 5,600 500 6,100 12.2 Laboratory ............. 2,800 1,000 3,800 7.6 Communicable disease control (including tu- berculosis and venereal diseases) ............. 2,750 3,000 5,750 11.5 Child hygiene (including pre-natal infant, pre- school and school).... 10,700 1,600 12,300 24.6 Total (without nursing or hospitalization) ...... $30,050 $8,600 $38,650 77.3 Hospitalization of com- municable disease — 5,000 5,000 10.6 Total (without nursing). $30,050 $13,600 $43,650 87.3 Generalized nursing. .... 36,900 1,500 38,400 76.3 Grand total ........... $66,950 $15,100 $82,050 164.1 Less income from nursing S€rVice ...05.6....0...- 2,560 5.1 Net total ............... $79,490 159.0 In considering this budget for commumnity health work it must be borne in mind that the health department is con- sidered the general executive organization. ‘This does not - mean that the private agencies have no place or that they should be exterminated or curtailed by such a plan. Pro- gressive private agencies are essential to effective health work, but the release of much of their energies from the work they are now doing would permit them to continue to make im- portant contributions along lines of activity which are exclu- sively those of the private agency. 1 Administration, including Vital Statistics and Health * Education—twenty-one cents per capita: the price of a package of cigarettes. The administration of the department, under which term is included the specific health education work and the regis- tration and analysis of vital statistics, is in a very real sense the brain center of the department. The objectives, the quality of work and the results that are accomplished are THE SMALL CITY decided here, depending on the leadership and the ability of the health officer. For this service the following staff could be assembled: (1) A capable health officer, with special education and experience in public health, and with those personal and professional qualities that will make him acceptable to the medical as well as to the lay group. In addition to his duties as director of the department, the health officer would act as registrar of vital statistics. A salary of $5,000 might be considered a fair remuneration. . (2) A secretary-stenographer whose duties would be the: conduct of daily routine of the office, with special responsi- bility for the registration and tabulation of the vital sta- tistics. (3) A clerk-typist for the office routine, including the copying of birth and death certificates. The salaries and maintenance of this division would amount to $10,700. 2 Inspection Service—twelve cents per capita: the cost * of a special delivery letter. The inspection service of the smaller city which has no malarial problem can, as a rule, be adequately maintained by three inspectors, one for milk, one for other foods and one for sanitary inspections. It must be assumed that these inspectors are imbued with a modern health attitude and with real enthusiasm for their jobs. Such inspectors become effective health educators instead of merely unimaginative enforcers of a sanitary code. The close working relation- ship between the laboratory and the milk and food inspectors, and between the nursing service and the sanitary inspector xem a Health Dept. alone-or with Other Agencies Other Official Agencies alone or with Private Agencies Yin, Private Agencies alone C_) No Agencies 86 o J © o Number of Cities gi © 10 123 4 $5 6 7 8 9 10 Activities . 1. Vital Statistics 6. Infant 2. Communicable Disease 7. Pre-school 3. Venereal Disease 8. School 4.Tuberculosis 9. Sanitation 5. Pre-natal 10. Laboratory Types ofagencies conducting health work in the eighty-six cities 145 will do much to increase the efficiency of all concerned. The salaries of the three inspectors and the cost of main- tenance of automobile transportation would be about $6,000 a year. The Laboratory Service—eight cents per capita: the cost of a morning paper and a carfare. If the health work of the modern city is to function eficiently, if the control of the water and milk supply and communicable disease is to be based upon facts rather than personal opinion, and if the clinical service is to put into practice for its patients all of our present-day knowledge of disease prevention, there must be available a public health laboratory doing work of such high character and broad scope that all workers in this field will instinctively seek its technical knowledge and advice. ‘This has been recognized for some time by the larger cities and not a few valuable contributions to public health are the results of the painstaking and patient effort of the laboratory worker. The laboratory should be satisfactorily administered by a bacteriologist of good training, assisted by a part-time helper to clean glass-ware and prepare media. Some six thousand examinations, including all types, would probably be made yearly and the cost of the service including main- tenance would not exceed $4,000. Communicable Disease Control—11.§ cents per capita (exclusive of hospitalization and nursing): the price of a loaf of bread. . Under this heading are included epidemic diseases as well as tuberculosis and venereal diseases. “The control of epidemic diseases will fall upon the health officer, who, however, would be assisted in the consultant diagnostic work of the department by a physician. who has had special train- Ing in recognition of the communicable diseases. As this service is called upon infrequently, it is considered that the full-time school physician can fulfil its demands without detriment to his regular work. It is estimated that some twelve hundred cases of com- municable disease, exclusive of tuberculosis and venereal diseases, would be reported annually to the health depart- ment of a city of this size, and that these cases will be visited, on an average, three times. This would require the full time of two nurses who would have a small amount of time left over to be spent in the immunizing clinic, for which provisiom should be made. Provision should also be made for the cost of hospitalization of individuals who can- not afford such care. An additional $5,000, or ten cents per capita, has been allowed for this expense. The tuberculosis service might take the form of two two- hour clinics, conducted by a part-time physician assisted by a nurse, home visits by the nurses, hospitalization facilities, legislative measures and special activities conducted largely by private organizations, such as nutrition classes, mid-session lunches, open-air schoolrooms, playground facilities and day camps or preventoria. On the basis of the average tuber- culosis problem, two nurses would be required. The control of venereal disease should embrace medical, educational and recreational measures, law enforcement and protective social expedients. “Iwo clinics should be held weekly, in charge of a part-time physician with one nurse and one male attendant. Nursing visits to patients require ° 146 a part of the time of a nurse. The physician should, of course, be remunerated. Child Hygiene—24.6 cents per capita: the price of a movie. Under child hygiene are included maternity care and the hygiene of infant, pre-school and the school child. Pre-natal Hygiene. ‘The deliberate limitation of this health program does not permit of anything like a com- plete service. Indeed it is assumed that pre-natal service should limit its activities to approximately 25 per cent of the pregnancies. A weekly two-hour clinic should be sufficient to meet the demands for clinical services, of which about one-half of the number registered would avail them- selves. An obstetrician, assisted by a nurse, should conduct this clinic. The nursing service to the patients in their homes would require the full time of a nurse who should see that their special medical, dental and nutritional needs are met. Likewise the nursing care at the delivery (which if available would be utilized by about one-fourth of the mothers) would require the time of a second nurse, while the post-natal care of these cases would require the ser- vices of a third. Infant Hygiene. A sound program of infant care em- braces a system of infant welfare clinics with the regular medical examinations and supervision, a nursing service in the homes, educational work among girls in the higher school grades, and group conferences with mothers and expectant mothers, for discussion of problems of nutrition, dental hygiene and infant care. The clinic service which is provided restricts its activities to 30 per cent of the children under two years of age, a number which would amount to about 675 infants in a city of fifty thousand. It would require four clinic sessions a week, provided the visits were made every four to six weeks, This would require about eight hours of medical service a week and about one-fourth of the time of a nurse. The nursing visits to the homes of these children would require three nurses, on the understanding that every new-born child receives one visit, one-half of the infants under one year of age receive seven visits a year, and one-half of the children between one and two years of age receive four visits a year. This is less than the number reported in numerous cities of this size. Pre-school Child Hygiene. In the four-year interim be- tween the end. of babyhood and his entrance into school, the pre-school child is likely to find himself no longer in the limelight. During this period he is growing normally in wisdom and stature or he is acquiring a multitude of de- fects which unless detected and corrected will handicap his school career and future development. Clinics should give: special attention to these children, remedying defici- encies and guiding the mother through the problems of nutrition and behavior habits. Home supervision by nurs- ing and special workers should be provided for those who cannot avail themselves of the advice of the private physician. If only one child in ten comes to the clinic five times during the year (diphtheria immunization followed by Schick test- ing requires five visits), still two two-hour clinics a week would be required, with a doctor and a well-trained nurse. in attendance. If only 25 per cent of the pre-school children were seen three times a year in their homes, the number of nursing visits would require the time of two nurses. THE SMALL CITY School Hygiene. The five-fold purposes of a school health supervision program are: (1) to protect the community from the spread of com- municable diseases. (2) to insure sanitary conditions in the school plants. (3) to discover early and correct physical and mental de- fects. (4) to provide systematic physical education. (5) to educate the child in the principles of healthy living. Broadly speaking, for economy of service and simplicity of organization, supervision should be exercised through one administrative department. Whether this be the health department or the department of education is of less im- portance than the assurance that the work is done effectively. The minimum requirements in personnel to carry out this program even moderately well for eight thousand school children would be a full-time school physician and four nurses, aided, of course, by the cooperation of the teachers and the school principals and special workers. Nursing Service—generalized service 71.7 cents per capita; specialized service 90.9 cents per capita: the price of a box of candy. Community nursing has come to be recognized not as an expense but as an investment which pays large dividends in the saving of human lives and the prevention of suffer- ing. No community can afford not to spend the money for this home missionary of health. While it is obvious that other development of the public health nursing service should be gradual, it is equally im- portant that our eyes should be open to the considerable number of nurses that are necessary in a city of this size if even the restricted program outlined above is to be carried out. “The method which has been followed in the plan for estimating the nurses needed was based on the assumption of an average of 2,000 nursing hours per nurse a year, or expressed another way, 2,000 nursing visits per nurse a year. Having determined approximately, first, the number of persons to be reached, and second, the average number of times each patient is to be visited, the number of nurses necessary for a given service is easily calculated. The virtue of such a method of computation is that by modifying the number of individuals to be served, or the number of services to each individual, according to the prac- tice observed in any city, the number of nursing hours re- quired may be determined, and the degree to which the existing number of nurses can meet the needs is clearly indicated. The use of such methods reveals that the number of nurses required to meet the restricted public health pro- gram, if the nurses are to specialize in the various fields of nursing, is as shown in the table below. However, if the generalized plan of nursing were adopted in which each nurse confines her work to a definite district and meets the whole nursing needs in each family, it is believed that the saving of time usually consumed by specialized nurses in travelling between visits would result in a considerable saving in the number of nurses required. "This number would be equivalent to about one field nurse for every twenty-five hundred of the population. The number of nurses required under the (Continued on page 181) What You Can Do By GEORGE TRUMAN PALMER, Dr. P.H. HAT is this public health business and where does the citizen fit in? . Public health means less sickness of the kinds which can be avoided if one knows how, fewer babies dying, less money spent for doctor’s bills, less unemployment because of less disability, more efficient work, a more comfortable life, a more livable life, a richer life, and the possibility of a longer life. Its aim is to lessen the waste in health. This is practicable. It is being achieved. It will be increasingly effective as each individual person becomes conscious of the possibilities of health preservation. The administration of public health calls for the services of professionally and technically trained people. There is the physician, the dentist, the dental hygienist, the nurse, the sanitarian broadly trained in health administration, the bacteriologist, the chemist, the sanitary engineer, the statistician, the publicity specialist, the health-trained school teacher, the nutrition specialist, the veterinarian, the dairy and milk expert, as well as the administrative staff. What is left for the citizen to do? 'N the first place, inasmuch as the average citizen is the I recipient of all this attention, he can harken to the way of life these specialists map out for him and act on it. Should he do just that he would become so healthy that the bodyguard of scientists could probably be considerably reduced in number without detriment to the progress of the race. At least they would be free to devote more time to studying new ways of becoming even more healthy. ‘This is not mere joking. One cannot expect every citizen to respond imme- diately to the advice that he have his children immunized against diphtheria, for example. ‘They are his children and it is only natural that he should want to make sure that any unusual step he may take is safe and is worth while. Granted. He can be alert, however, for new ideas of health ; he can take a reasonable and interested attitude toward those scientifically trained people who are making the recom- mendations. Secondly, the citizen can aid the public health by disci- plining himself to do those things which he knows to be best for his personal health, and that of his neighbors, and by ceasing or at least curbing those actions which judgment informs him are inimical to health. Chauncey Depew is reported to have said, “Longevity is largely a matter of curbing appetites until temperance and moderation be- come habits.” This is one of the first principles of personal health. Finally, with a receptive public and a self-disciplined individual, there is needed from the great mass of citizens encouragement and support of public health enterprises. This active support can be most effective when it is ex- pressed in the creation of actual working public health ‘committees which will stand intelligently behind the progressive health officer. “There should be a health com- mittee in the social clubs, business organizations, chambers of commerce, churches, women’s clubs, fraternal bodies, ‘ health organization called in for the purpose. parent-teachers associations and the like. "These committees do not need to become so active as to interfere with each | other. ‘They can function best by constituting themselves the health intelligence service of their respective organiza- tions, first receiving stations, and then transmitters of health news and information to their parent groups. Represent- atives of these committees should be ready to serve as an advisory committee to the health officer. alts first step in health progress is for a community to “know itself.” It can best “know itself” by taking an annual inventory of its health assets and liabilities. The facts must be revealed if a city is to build intelligently. The conduct of this inventory is a most appropriate task for the advisory committee on health, looking to the health officer for technical advice as to methods and for interpretation of findings. A practical form of Community Health Inventory suitable for cities with populations between 10,000 and 100,000 is presented on the following pages. The diagram shows a large letter H, which stands for Health. When the necessary information is gathered the twenty-five separate blocks can be filled in, the result in- dicating in a simple graphic manner the extent of health activity or health security in the community. By multiplying the number of items receiving credit by four, the result may be expressed as a percentage of the total possible credit. Counsel should be taken of the health officer and the superintendent of schools before such a Community Health Inventory is launched, as they will be the source of much valuable, practicable advice in the undertaking. The in- ventory committee should be organized with a chairman and the gathering of the separate pieces of information should be assigned to different members of the committee. The answers turned in by the committee members should be discussed by the committee prior to entry on the chart. ‘The twenty-five items selected are not meant to: be ex- haustive. In fact they are simple questions capable of an- swer. ‘They are meant to serve merely as indices of health work. ‘The city that can fill in most of these items is at least on the road to success'in its public health program. The smaller cities, it is true, will find it more difficult to register favorably than the larger city, but the working out of the plan will bring up most interesting subjects for discussion, and after all the greatest possibilities for ad- vancement in public health have their beginnings in live and widespread interest in the subject. This inventory of health is simply a beginning, a pre- liminary test. It should not be looked upon as a substitute for the more detailed and technical appraisal of health activi- ties to be made by the health officer or by an outside public For a more technical evaluation there has been prepared an Appraisal Form published by the American Public Health Associa- tion. ‘This association as well as the American Child Health Association stands ready to assist communities in the appli- cation of this technical Appraisal Form. (Either may be addressed at 370 Seventh Avenue, New York.) 147 1. Have you a full time health of- ficer ? If a community has but a small amount of money available for public health, the best initial investment is to secure, at an adequate salary, the service of a full-time health officer, a person trained and experienced in the field of public health. Interest, attention, and wise leadership will accomplish results even with limited assistance. Assistance without seasoned leadership frequently results in waste motion and produces a false sense of security. It is better for the smaller community to combine with other communities in supporting a trained health officer or to become part of a county health unit than to attempt half-way measures independently. 2. Have you consulted your health officer before making this in- ventory ? The first essential in a community health program is that the different organizations should pull together. Betterment enterprises should not be undertaken without first obtaining the counsel of the official head of health work in the city. If leadership and vision is expected from the health officer he must be kept informed of the wishes of his constituents. 3. Have you a staff of public health nurses either within or without the health department? The public health nurse is the great messenger of health. She reaches the home and knows how to translate the seemingly complicated rules of safe living into a simple language that the mother and the father and the children can understand. 4. Have you a safe public water supply? It is a crime to have anything else. Typhoid fever is only one-fourth as prevalent as it was twenty years ago and this is due largely to the better safe-guarding of public water supplies. Your health officer, city engineer and state health department can answer this question. 5. Is there a public sewerage system which serves the major portion of the city? This is most important as it does away with the necessity of cesspools and outhouses. The open privy is always a danger spot when it is accessible to flies. Of course, to derive full benefit from the sewerage system, all houses should be connected to it. Credit should be al- lowed if 90 per cent or more of the dwellings and business blocks have sewer connections. One thing more: provision should be made in the disposal of the sewage that it does not pollute the water supply of some other city. It should be treated in such manner as not to cause a nuisance or constitute a danger to others. The Golden Rule holds good even for public sewerage systems. 6. Is there a public health labora- tory ? The laboratory determines whether throat cul- tures contain diphtheria ge-ms, whether the sputum from a suspiciously s’ck person has the tubercle bacteria, and whether the milkmen are supplying clean milk. The laboratory is the right hand of the piysician when a diagnosis of certain communicable diseases is to be made. A city without a laboratory is almost as handicapped as a scout without eyes. 7. Is there an established service for the inspection of dairy farms supplying milk to the city? This is one of the steps to insure clean milk. Many dairymen who are producing dirty milk will produce clean milk when they appreciate the necessity for it and understand what things are important in clean milk production. 8. Is pasteurized milk so universally used that no raw milk is sold in the city other than a small amount of. certified milk ? The only safe milk is pasteurized milk. The dairyman can produce clean milk but the only sure protection against the transmission of certain communicable diseases from the sick milker or bottler to the consumer is pasteuriza- tion. This means real pasteurization—140 to 145 degrees Fahrenheit for twenty minutes. The pasteurization plants should have record- ing thermometers and they should be inspected at intervals. Samples of milk should be taken to the laboratory for analysis. All these checks are necessary to insure continuously safe milk. .9. Are there one or more sanitary inspectors in the health depart- ment? If attention is to be given to the innumerable calls for inspection relating to fly and mosquito breeding, rodents, buildings, quarantine enforce- ment and other miscellaneous matters this service must be provided. 10. Is there a communicable disease code? There must be rules and regulations adopted by the board of health governing the actions of householders and others when cases of com- municable disease arise. These should be reasonable, comprehensive and_ specific and there should be means for transmitting this information to the householder. 11. Is communicable disease reason- ably well reported? This may be judged from the records of re- ported cases and deaths. Obtain from the health department the number of reported cases and deaths of each of the following diseases for the last five years. If three out of four equal the standard given, credit should be taken. Diphtheria— 15 cases for each death Scarlet Fever— 'o eet ee ‘Fuberculosis— Cee eer aye = Typhoid Fever— Fk Meek ks coe . These standards do not necessarily imply com- plete reporting but they will serve as a useful guide. 12. Is there a venereal disease clinic? In order to protect the family there should be a clinic where people may go for examination and where treatment may be obtained for a nominal fee. The clinic serves as an educa- tional force in teaching infected persons how to safeguard other members of the family. 13. Is the population well protected against smallpox by vaccination? As a test of this arrange with the superintendent of schools to secure from say all fifth grade children written answers to the question as to whether or not they have ever been vaccinated. This will give you a dependable cross section of a portion of the population. Credit should be allowed if 90 per cent or more of these children have been vaccinated. . \ i 4 x ‘ (A Nays Where Does Your | City Stand? Here are the questions for your health inventory. Handle it like a ballot. If you can answyr “Yes” to a question, put 2 cross in the white square i/\ the picture block that bears the same number. The crosses in your big ““H” will give you a rough score for the city you live in. ; ) Questionnaire prepared by GEORGE T. PALMER, Dr. P.H. Drawing by MARGARET SCHLOEMANN bon eee Reoeee Se 8 oe neks o of® ee vo per ege 0 o 8 > oe RT) os ht 0 0000s ote Menem? & faans DISEASE NTINE 4 ¢ ( NATAL UNIC 13 U 14. Are there hospital provisions within your county for the seg- regation and care of cases of communicable disease? There is less likelihood of spreading certain communicable diseases to others when cases are promptly hospitalized. This plan also permits the other members of the household to havetheir freedom sooner thanotherwise would be possible. 15. Is there a tuberculosis clinic? The curbing of tuberculosis demands that there be provision for early detection of cases. The clinic serves this purpose and also teaches the patient and others of the family how to live to the mutual advantage of all concerned. 16. Are births well reported? If the health department is to engage in useful infant welfare work it must have available accurate records of births. Complete registra- tion is one of the prime essentials in a child health program. This may be tested in several ways. It is unnecessary in this test to check every birth. A fair index can be obtained by making inquiry of all households in the city where the family name begins with E or M or S. This will safeguard the inquiry from being confined to a special section of the city. Send out about 300 return post cards stating clearly the purpose of the inquiry and ask people to indicate on the return card whether a birth has occurred in the family during the preceding 12 months, and if so to write the name of the baby and parents, the address of birthplace, whether hospital or home, the city and date. With this information visit the office of the registrar of births to find out how many of these records are on file. Credit isgiven if goper cent or more of the births have been reported. 17. Is there a pre-natal clinic? Many babies are either sickly or die because of lack of intelligent care or because of pre- natal influences. The care of the baby should begin long before its birth. The city which is concerned in advancing the health of all its people will provide a pre-natal clinic where a pregnant mother may go for examination and for early advice in self-care and care of the baby. This is an educational force of vital im- portance and is a direct means of attack against death and illness among mothers’ and babies. 18. Is there an infant welfare clinic? The care of the baby may be taught to mothers through the medium of an infant welfare clinic. Here babies are examined and weighed and instruction is given the mother in such matters as diet, clothing and bathing. The precepts unfolded here are passed on to other mothers and mischievous superstitions and harmful prac- tices in baby care are combatted, to the eventual profit of the general health of the city. 19. Is there a pre-school clinic? The toddler or pre-school child is not to be neglected. The city will find its efforts well repaid by teaching mothers facts about the care and training of young children at the age when habits once acquired are destined to persist for long years. The pre-school clinic is a good place to conduct the Schick test to determine immunity to diphtheria, and to give toxin-antitoxin to those children who do not possess a natural immunity. It should be re- membered that diphtheria claims its greatest number of victims at this age. 20. Do all kindergarten or first grade children receive a physical ex- amination at school? The examination is essential that the child may proceed with his school work unhampered by correctable physical defects. The informa- tion acquired serves to acquaint parents with the conditions found and directs them to their family physician for necessary remedial atten- tion. It also indicates to the school authorities how they may best proceed with the education of the child. If special senses are materially impaired, the child may be taught to better advantage in special classes. The physical examination is one of the best guides to the maintenance of health. 21. Are there special classes for the child whose health is handi- capped? The near-blind and the near-deaf, the crippled, and those with weakly constitutions require special consideration if they are to acquire an education. They are often unable to compete on equal terms with the normal child and yet they, too, are entitled to an education. Credit should be allowed only if there is one [or more] such class in the school: system. 22. Is there an organized course of study for the education of the school child in health? Advancement in the health of the nation is dependent upon the extent to which the coming generation appreciates the value and meaning of health. Health is more important than an understanding of geography. The teachers should be trained to teach health and the schools should adopt a definite plan for the imparting of health knowledge to pupils and for the encouragement in them of health -at- titudes and practices. Ask the superintendent of schools for a printed or typewritten copy of the health education course. 23. Are the daily newspapers a medium for carrying the message of health into the home? The daily newspaper may be one of the most fruitful teachers of health. Check over the issues for the. last two months. If local health articles are found at least once a week, credit is allowed. Credit should not be taken for the syndicated health columns, which, while valu- able, do not indicate local initiative in health publicity. 24. Are graphic charts of the various indices of the community’shealth to be found in the heaith dept.? The presence of graphic charts is an indica- tion of use of the records. Credit should be taken if there are charts showing the death rates and the infant mortality rates of the city for the last ten years. 25. Is there an advisory committee on health? The health of a city depends largely upon the degree of active interest manifested in the sub- ject by the public. There should be an advisory committee of health made up of influential citizens interested in health. A community owes this organized interest to its health officials. By reason of its closer intimacy with health problems this body should stand ready to back the capable health officer in his en- deavors. Furthermore, this committee should stand for high ideals and progress. Its judg- ment should be of such weight as to be sought by the mayor and city council in decisions af- fecting the health activities of the city. The live committee will not stand by in silence when the shortsighted mayor seeks to place un- qualified men in places of responsibility in the health department. The advisory health com- mittee should be the unofficial guardian of the city’s health. ing October 1925, by Mary Herr ’ Photograph WALD . LILLIAN D fei oe 4 a, t ° oY nono ne B oe PP Rega OG "2 3 Of ee ~ qv aco ES > ae 85 o Vv ES nm .g & wu a'e Te ‘os uO eG yy Se Vv ze uo aie of d to the far corners ie craftsmanship and spirit of home care of the sick ses have carti , Dur y Street g at Henr in the world the in tra The Nurse: A New Social Force By KATHARINE TUCKER, R.N. Scissor pictures by Martha Bensley Bruére N struggling to its professional feet nursing seemed at times in imminent danger of falling between many stools. On one side it has been conceived as what every woman knows by instinct from birth; on another, as the useful but modest handmaiden of another profession, always keeping respectfully in her place; on still another as a very much over-institutionalized, over- formalized professional service; and finally as only a highly developed form of personal service—a kind of super-maid- service. Such a motley array of points of view, which still may easily be encountered in a day’s march, tempts those within the profession to cry out, “Lor’ a’massy, is this really I?” With the dawn of the new public health movement, still other possibilities have arisen above the horizon—and far enough to be recognized generally. However, these new developments and their special emphases are not so new as they might appear at first; they have been working below the surface since the very inception of nursing as a pro- fession. In the notes of Florence Nightingale, there is con- stant reference to the nurse’s opportunity as a preventive agent and effective health teacher. The nurse was. brought into the modern public health movement because there was need of someone with medical background and the ability to get in touch with folks— plain folks, ignorant folks, folks prejudiced in favor of their own traditions, which sometimes made health difficult or impossible for themselves and others. In other words, a home-to-home interpreter was needed to “get over” in plain, simple, acceptable terms the astounding facts that such a scientist as Pasteur was revealing. The printed word, the platform voice had been tried with little effect. ‘There was need of someone to talk with the mother over her own kitchen stove about the children’s food; to help the husband ~ arrange for. the care of his children while his wife went to the tuberculosis sanitarium; to translate scientific facts into workable human terms. The nurse already had much of the necessary equipment for this new extension of her work, but by no means all. Heretofore her duty had been to care for the sick, This technique still was very much needed. ‘The diseased person is the original source from which disease spreads. His proper care is the first step in prevention. Furthermore, help to people in their time of need is the introduction most likely to pave the way for the more subtle and difficult _task of teaching them new points of view and different ways of living. Too often, however, the facts of health and methods of teaching it were not in- cluded in the equipment of 151 nurses. It took a weighty body of knowledge and tech- niques to make the nurse a health nurse as well as a sick- ness nurse. The nurse has acquired this new equipment in various ways, too often at first through trial and error and appli- cation of individual intelligence as well as through daily contact with the two closely allied fields of public health and social work. Within the last decade, three definite educational processes have been developed to meet the need —post-graduate courses in public health nursing; educa- tional programs within public health nursing agencies; and the inclusion in the curricula of many schools of nursing of theoretical and practical instruction in public health. HAT is the soundest form of organization so that this nurse with her new emphasis and extended scope may fit into the general scheme for city health work? A few outstanding trends may be noted. If the public health nurse is to play the part assigned to her, certain fundamental principles, so well known as to need only enumeration, must be recognized: the professional require- ment for trained, graduate, registered nurses; in addition, a post-graduate course in public health nursing or work under trained supervision; a staff educational program; an organization non-political as to appointments or’ re- strictions on service; a non-sectarian organization; a com- munity service for all rather than a charity service for the poor; adherence to accepted standards of professional ethics; cooperation with all other social and health agen- cies; community participation in responsibility and support. It would be highly desirable if all the agencies—sometimes numerous—which offer public health nursing service in any given community would get together as they have done in at least one large city and form a central council repre- senting the public, the medical profession and the agencies, to make uniform requirements for staff appointments and perhaps develop other uniform standards of organization. Where there are many different special types of public health nurses in a community there is a crying need for some understanding -and definition of function. Equally necessary, too, is greater exactness in the division of re- sponsibility between agencies, careful consideration of which might lead to a much more constructive and comprehensive alignment. If it still seemed necessary after such a study to have the same type of work included in the programs of two separate nursing or- ganizations, there would be great advantage in uni- formity of procedure and standards. There is need of a closer relationship between official 152 Protecting the community trom communicable diseases and non-official public health nursing agencies, with decided emphasis on the ultimate responsibility of the former and the experimental opportunities of the latter. An interesting experiment arises in a combination of the two. In such an amalgamation certain con- tributions of each must be kept, particularly the partici- pation of the lay public as board members of public health nursing agencies. This principle has been more readily incorporated into non-official organizations than official, and such board members often have played a leading part in the development of the public health nursing movement. In helping to shape the policies of their own organization, by coming in contact with the health conditions in their own community, through their interest in a high standard of performance and their desire for results, they in turn have been interpreters of the new public health to a wider public. Again in the private agencies, particularly the visiting nurse association, there has developed a policy of payment on a cost basis by those patients who are able. This is wholly sound and the logical extension of the principle that health and trained service for the sick should be available for all, irrespective of their economic status. The direct participation of the lay public through committees in such a pay service is not as incompatible with public adminis- tration or public appropriation as it might seem. In cer- tain cities there are advisory committees of representatives from the general public whose functions in relation to the public health nursing division of the department of health extend beyond representing and influencing public opinion, to the standards of the service itself. “This insures an under- standing, intelligent group of people working with those who have direct professional responsibility to make the serv- ice more nearly meet the health needs of the community. In other cities the department of health turns over a defi- nite lump appropriation and a definite health job to the private public health nursing agency, while elsewhere the private agency is simply paid out of public funds on a cost basis for service rendered within the province of the city department of health. There are still other ways of reaching these same ends— payment out of taxes for that which is the city’s responsi- bility, payment by individuals-able to pay for individual . service, payment either out of taxes or voluntary contribu- tions for those individual services for people who cannot THE NURSE: A NEW SOCIAL FORCE pay; and all these with the active interest, participation and support of citizens representing the general public. Still in the experimental stage is a plan whereby the city depart- ment of health assumes all the public health nursing service, including care of the sick in their own homes, allowing for payment on a cost and part-cost basis for those who are able, where the service is not necessarily payable out of taxes. Already the patients in many city hospitals are ex- pected to pay the cost or towards it if they are able. The principle is exactly the same if the patients remain in their own homes. A CLOSELY allied trend is that which puts emphasis on family health work, and therefore on a general-- ized rather than a specialized program of public health nursing. This adjustment is not so simple. A general family health program with its three-fold purpose of getting the sick well, preventing sickness, and promoting health, implies within the worker a very sound general basis with much specialized knowledge, with the ever present danger of her becoming a jack-of-all-trades and master of none. ‘There is no easy solution. It calls for a more inclusive education for nurses, especially in obstetrics, pediatrics and all communicable diseases. In addition the ideal would be to have a post-graduate course for all who are going into public health nursing. This is a practical impossibility, but it is not im- possible to require that all supervisors responsible for the work of others have a post-graduate course so that a public health nursing agency with a staff of nurses may have worked out a progressive and continuing program for staff education with supervisors who are primarily teachers and secondarily executives. There should be only enough nurses assigned to each supervisor to make possible individual teach- ing in the field and office, as well as group teaching. And if such a family health program is really to give due weight to protecting the health of the mother, infant, pre-school and school child; to protecting the family, the neighbors and the community from communicable diseases; to teach- ing the possibilities of health through proper nutrition; to ‘giving attention to mental health as well as physical health, a group of supervisors who ate specialists will also be needed. Some public health nursing agencies are consider- ing also a family case-work supervisor to insure sounder case-work methods and a better balance between the de- mands and needs of the social and the health situation. That is a formidable array, but no whit more formidabls than what is expected of each public health nurse today if her agency sees its opportunity and is trying to meet it through family health work. So we see the nurse emerging, very much a part of the social and health program for any city. Those in the public health nursing movement are alternately stimulated by the task and aghast at its magnitude, realizing fully the dangers of such rapid development, yet tremendously inspired by the opportunities. Every public health nurse needs the attitude of mind of a student—there is so much to learn, so much progress to be made, so much that is in process of change. Possibly the essential soundness in the progress of the public health nurse is that she is part of a goodly and helpful com- pany of social workers, doctors and laymen, all working together with an increasing sense of the unity of their pur- pose—a socially, mentally and physically healthy community. The Schoolroom-A Health Force By C. E. HE city does much for the health of the in- dividual. It leaves much for him to do for himself. Habits and conditions of food, clothing, and work, daily rest and degree of nervous stimulation have all changed with the increasing complexities of modern life. Social evolution has changed the environment of man, but. it has not changed his body. The decrease of the death rate and the increase of the happiness rate during the next few decades will come chiefly through more intelligent in- dividual health control. The physical examinations of soldiers and school children as well as studies of the causes of nervous, organic and degenerative diseases as they con- . tiually appear in medical and hospital practice. show in- numerable examples of wrong living as the cause of loss of health. Yet consciously or unconsciously people are still acting upon the assumption that health and disease are matters of Providence over which we have no control. Sponsored by the organizations which cooperate in the preparation of this issue of Survey Graphic and by other agencies, a new movement for the health education of our people is making its way into the educational system. The object of this movement is to develop and organize such a systematic training program through the entire school life of the child as will assist him in developing the habits, atti- tudes and knowledge which will be most productive of the best attainable mental and physical health. School health administration is not a new procedure. It has long been an important phase of official health activities. As formulated by the Committee on School Health Program, it includes: the protection of health by sanitation of the school plant, physical and psychological examinations, and control of communicable disease; the correction of defects by special classes, clinics, and follow-up; the promotion of health by the hygienic arrangement of the daily program, physical activities and health instruction, motivation and training. The outstanding development of the last decade has been the growth of the program for the promotion of positive health which aims to provide the most hygienic conditions for all school children and to assist every child to develop the best possible program of healthful living. All over the country the old program of hygiene teaching—merely in- formational, negative, and usually impractical—is being supplanted by a modern program of health training. All of the school health specialists—doctor, nurse, physical educator, nutrition worker and home economics teacher— contribute in the development of the new program. Each has furnished leadership. ‘But the new and important de- - velopment is the addition of the great army of classroom teachers to the health workers of the country. No one else except the parent can contribute so much to the habit forma- tion of the child. Through her intimate contact with the child, -her knowledge of the psychology of habit formation, her leadership and her example, she creates a new attitude TURNER toward health. Cleanliness becomes a manly procedure ex- pected of all members of the class. It is as important to go to bed on time as to go to school on time. More children take time to eat a good breakfast. The child is stimulated to play more out of doors, eat less candy between meals, drink less tea and coffee and take more pride in his personal appearance. The schoolroom has more fresh air and is kept cooler. There is a conscious effort to maintain cheerfulness, courtesy and wholesome thinking. No one doubts that healthful living improves health; witness college athletics, the military training camp, the tuberculosis preventorium and our individual experiences. Studies by Holt, Collis and others show that habits affect growth as well. Clearly these fundamental: habits and atti- tudes toward health should be formed in childhood—the period of habit formation. What can the schools‘do to help the home in this important task ? Not only does the child spend many of his waking hours in school but the school possesses a powerful advantage which the home lacks. This is the force of group judgment. Call it “style” or ‘“‘the force of public opinion” if you prefer. At home the child has been in the society of grown-ups whose thoughts and interests are different from his. At school for the first time he finds a social group of his own, one made up of boys and girls who think and feel as he does. Like all human beings he is sensitive to the approval and disapproval of his friends and associates. ‘Their judgment is a more vital factor in his life than the suggestion of parent, nurse or physician. Moreover, the school is the only piece of machinery which will reach the whole population during the period of habit formation. HE health education program has the delightful ele- ments of play. It is a program of do’s and not of don’ts. It is a program developed by the children and not at them. It includes projects and activities fitted to the age and in- terests of the child. The acquisition of habits is first. Knowledge is supplied to form the basis of action. Habit formation demands repetition of emphasis but the health program of a child can be so adapted to his changing in- terests that each year’s program is new, fresh and delightful. Classroom discussion, the correlation of health ideas with the other subjects of the curriculum, morning health in- spection, health records, competition, posters, scrapbooks, health plays and songs all have their appropriate uses. Health as an abstract term carries little interest but health as represented by growth and attractiveness is something to be desired. The child’s interest in his growth is perhaps the most useful basis of teaching. From the teacher’s viewpoint health education has proved to be an opportunity rather than a burdensome responsibility. It came at a time when the educational forces were turning their attention from the teaching of subject matter to the teaching of children. The modern teacher visualizes her task as not merely the implantation (Continued on page 179) — 153 Fighting Health Officers I Have Met By W. A. EVANS, M. D. OMEHOW the United States got through ‘the Revolution, the War of 1812 and the Mexican War without learning many public health lessons. The men who wrote the Federal Constitution knew nothing about public health or its need. In consequence, that Constitution is almost silent on the subject and so are most of the state constitutions founded upon it. But out of the Civil War there came several army surgeons who had gained a new point of view. Some of these became health officers and, finding the returned soldiers ripe for a change in the care of community health, these men led— or forced—the beginning of American public health work. Among these was Dr. John H. Rauch, who became health officer of Chicago under first one title and then another and later inaugurated the Illinois Health Department. Among other achievements, Dr. Rauch was responsible for Lincoln Park and, through that, for the beginning of the Chicago park and playground system. . This was not accomplished by a frontal attack. The site of Lincoln Park was a large cemetery. It lay on the lake front within two miles of the center of the city. In 1866, Dr. Rauch read a paper in Chicago on Intra-mural Interments and Their Influence on Health and Epidemics. He was creating public sentiment to force the closure of the city cemetery. At the same time, he was working hard for the unrivaled park system which now has arisen from his initia- tive. The theory that burials within a city spread disease had been held by Dr. Rauch for several years | before he began the Chicago crusade. In 1850, when Dr. Rauch lived in Burl- ington, Iowa, he called at- tention to the prevalence of cholera among people who lived near a cemetery following the burial of several people who had died of cholera. This agitation resulted in the vacation of the cemetery, which was turned over to Burlington University for educational purposes. Dr. Rauch was forceful, if occasionally a misguided administrator. If he overemphasized the dan- ger of cemeteries within cities, out of his error good camé, for he caused the E. M. Snow, M. D., Providence 154 beginning of a great park system. Incidentally, in the great cholera epidemic of 1866, Dr. Rauch taught the public to boil the water. After serving for five years as a member of the Chicago Board of Health, and its executive officer, Dr. Rauch re- tired by resignation in 1873. So far as the records show _this resignation was voluntary. In 1877 he became a member of the first Illinois Board of Health. At first he served as president, later as secretary and administrative officer. By 1888 Dr. Rauch had ac- cumulated enough enmities to oust any ordinary official. But he was both an extraordinary official and a civil war veteran. Ousting him was no easy job. A powerful business magnate, able to do about as he wanted with the legis- lature, was in the opposition. A bill to abolish the state Board of Health was introduced into the legislature. Dr. Rauch resigned but the Board refused to accept his resig- nation, and the bill died. When his term expired, Dr. Rauch was not reappointed a member of the Board. Under a ruling that the secretary and executive officer need not be, or should not be, a member of the Board, Dr, Rauch, after retiring from the Board, was elected its secretary. Another bill abolishing the Board of Health was introduced into the next legislature. The committee reported back that this bill should not pass. But the same legislature passed an appropriation for the state Board of Health with the. proviso that the secretary “shall be chosen from and be a member of said Board - of Health.” Since Dr. Rauch was not a member of the Board, and the gov- ernor would not appoint him to membership, he was forced to resign. Thus ended the public health work of Dr. J. H. Rauch —a denouement more or less typical of the political buffets suffered by ener- getic and independent health officers. Another of the men who found their urge for public health work in the experi- ences of the Civil War was Dr. F. W. Reilly, for many years assistant com- missioner of health of Chicago. In 1872, Dr. Reilly conceived the idea of publishing a monthly FIGHTING HEALTH OFFICERS I HAVE MET | 155 F. N. McCormack, M.D., Kentucky magazine devoted to public health, and convinced the larger insurance companies that such a journal circulated among their policy holders would be a means of protecting the lives of the insured and decreasing the risk of the insurance companies. [he name of this magazine was Hygiene. Dr. Reilly served as a physician and sanitary ofhcer during epidemics of cholera and yellow fever. He -was essentially a publicist. “The bulletin of the Chicago depart- ment began to be a propaganda document for many years before health department bulletins acquired this quality. Dr. Reilly was largely responsible for this bulletin for more than twenty years. In 1885 he wrote on flies and disease saying: ‘There is a strong probability that flies are carriers of disease.” In the same year he wrote: “Some very learned doctors tell us that the mosquito is a disseminator of disease; that he eats the germs of disease in the marshes and carries them withersoever he flies. “Then, too, he takes diseased blood from one person and plants it in another.” One of Dr. Reilly’s successors, Dr. A. R. Reynolds, commenced being health commissioner of Chicago in 1893 and did not get ovet the habit until 1905. He laid the foundation of the department as it is. While many men contributed to the solution of Chicago’s difficult drainage problem, no one had more to do with it than he. Dr. {Reynolds conceived the notion of a health department bulletin designed to educate and interest the people in health. He selected Dr. Reilly to edit this bulletin. He and Reilly made a great team, each supplementing the other. I did not have many contacts with Dr. S. H. Durgan, for thirty years health officer of Boston, but I well re- member the first time I ever saw him in his office. It was on a Saturday afternoon in June, 1907. I sat in the room during a meeting of the Board of Health, called to receive a communication from the mayor. The Board consisted of three members—two who were not professional public health workers, and Dr. Durgan. The mayor recommended the appointment of two unneeded gentlemen as sanitary inspectors or something of the kind. “The question. was put. ‘The two lay people voted for the appointments. Dr. Durgan, the administrative head, voted against them, Dr. Durgan said these appointees were not expected to do. any work; they would render no service; they would draw more pay than hard-working, efficient men. The meeting adjourned. That. was my first contact with the board of health plan for administering a health department. My friend, Dr. S. H. Durgan, caught yellow fever while sleeping in a carbolic acid warehouse and he always thereafter pro- claimed: “I haven’t had a darn bit of faith in carbolic acid since.” I have had no faith in the board of health plan of administering a health department since, _. I never lost my faith in Dr. S: H. Durgan. One of the great outstanding health officers of twenty- five years ago was Dr. Justus O’Hage, of St. Paul. On one occasion, Dr. O’Hage tried to persuade St. Paul to buy an island in the Mississippi River and to establish a bath house and swimming beach on it. The great, unthinking majority thought the notion foolish. They said the old German at the City Hall was “hipped.” They could see no relation between bathing and health. Besides, if a fellow wanted to go.in swimming, couldn’t he strip and go in? “They were like the old time mayor of St. Louis who objected to electric lights, saying: “Ain’t you got the moon, yet?” Arthur R. Reynolds, M.D., Chicago 156 Charles V. Chapin, M.D., Providence Dr. O’Hage could see a relation to health, and even if they could not, he would not be balked. He bought the island, started the bathing establishments, equipped them, made rules which amounted to laws, and presented the whole thing, as a going concern, to the city of St. Paul two years later, in 1901. Dr. O’Hage’s report for 1903 says: “There was but little enthusiasm shown by the public at the beginning and not until the baths were firmly established and their benefits and usefulness demonstrated, did I receive any assistance in liquidating the accrued in- debtednéss.” In the end the school childrén: and other interested citizens helped to meet the cost of the enterprise. This 1903 report has much to say about picnic grounds, swimming, baths and other activities which contribute to public health by promoting personal hygiene. HEN Stephen Smith, 95 years old, stood up to speak at a birthday party given him by Dr. J. H. Kellogg at Battle Creek, he radiated strength and force. One who saw his pointed chin and heard his direct speech could wel] understand a circumstance which he relates in his classic story of the early days of the public health work in New York City, The City That Was. In the middle fifties Dr. Smith was a member of the staff . at Blackwell’s Island. An epidemic of typhus fever was raging in the city and Dr. Smith’s wards were filled with cases of this disease. ‘The history sheets showed that a large number of cases were coming from one address on East Twenty-second Street. of medicine was the humane and scientific care of the end At that time, about all there was FIGHTING HEALTH OFFICERS I HAVE MET product—the sick person. But Stephen Smith was not that kind of a doctor. He decided to find out what was the matter with this house on East Twenty-second Street. He had no trouble finding the house, nor in seeing how abominably unsanitary it was, but he had much trouble ,in finding who the owner was, and still more trouble in getting anything done about it. He could not find the health department. There was none to be found. He found the police depart- ment, but they could not discover any law covering disease- breeding houses*and the people who were crowded into them. A less determined doctor would have turned back at this point, to give all his thought to caring for his patients. Not so Stephen Smith. He had an N. S. Davis mind. He had started. and he proposed to see the thing through. He consulted his friend, William Cullen Bryant, editor of the Evening Post. ‘They decided that since there was no iaw and no health department, the case called for a little high grade blackmail. It was arranged to have the very pious, highly vulnerable owner of the house on East ‘Twenty- second Street arrested on some charge. A reporter, with all the paraphernalia of his calling, was to he very much in evidence in the Jefferson. Market* Court. Mr. Bryant in- formed the owner that the price he would have to pay to have the story killed was to put his property in first-class condition, to maintain it so, and to stop all the practices which had made the house he owned a breeding place for typhus. The end justified the means. This high-handed act was far-reaching in its consequences. The house on East Twenty-second Street became a model tenement and never again did it feed typhus into the community. The owner was converted to the theory that it pays to offer clean, sanitary homes for rent. He filled what had been an old shack, profitless as well as an eyesore, with first class tenants who paid him high rents and finally, and far more im- portant than all, out of this experience grew the agitation which never stopped until New York had a health board, on which Stephen Smith served from 1868 to 1875. Un- iortunately for most health officers, they have no William Cullen Bryants to arouse the people and so to convert direct action into a due process of law, or something which gets there just the same. - We sometimes think of health. slogans as the invention of health officers in recent years. I am not certain but that I thought I was the inventor about 1907. I find the following health slogans in Stephen Smith’s report to the legislative committee of the Citizens Association, made in 1865: “Transactions in human life’; “Tenant house packing”; “Cesspool abominations”; “Cellar population” ; “Dens of death”; “Cave dwellers’; “Tenant house rot”; “Tenant house cachexy”; “Fever nests”; “Fever breeding, stagnant water”; polluted drinking water he called “liquid poison.” The Metropolitan Health Board adopted in New York as the result of this agitation served as a model for other cities. The Chronological Annals of Health and Sanitation in Chicago prepared by Dr. G. Koehler, Assistant Health Commissioner of Chicago, record a strong movement at that time in Chicago for a health board similar to the Metro- politan Health Board. The men connected with every health department in those early days had a collection of stories of brave, courageous men like Stephen Smith who, confronted by an FIGHTING HEALTH OFFICERS I HAVE MET urgent need, sometimes were enough beyond the law to devise extra-legal means of protecting their fellow men. I once heard a good example of this kind from Saginaw, Michigan. An epidemic of malignant smallpox had been brought into that city from Bay City. It raged principally in the red light district, and among people who did not care much for their neighbors or their city. Saginaw had no vaccina- tion ordinance. ‘There were many deaths and the disease was not coming under control. ‘The people in the sur- rounding country were afraid to go to Saginaw on business. The Board of Trade held a meeting to discuss the loss of trade due to smallpox. They decided the people of Saginaw must be vaccinated. The mayor told them he had no law and no money for vaccination. He was told the Board of Trade was willing to issue an order which could be regarded as a law and also to pay for the expense of its enforcement. The mayor agreed. A strong, religious cult consulted their attorney. “Can a board of trade legally pass an ordinance requiring vaccination?” they asked. ‘They cannot,” was the reply. “Then prepare a petition for an injunction stopping this thing,” they told him. “No,” he replied. ‘Public sentiment is aroused. “Take my advice and do nothing.” His opinion ran straight to the heart of all such questions. In the last analysis, legislatures and councils only exercise delegated authority. “The people have the right of direct action, when that kind of action is necessary for public protection. O set of recollections of municipal health officers. would be complete without mention of those of Providence, R. I. Providence may have had more than two health officers, but if se, I do not know of them. But two have figured large in our health history. Dr. E, M. Snow was of the small group, about five in. number, who formed the American Public Health Asso- ciation. They were men of far-seeing vision and of great learning as well, but they must have been mighty poor parliamentarians. No Boss Reed among that lot. The first constitution of the society called for a rather large number as a quorum—nine, I think. After a few years they found it difficult to get so many to attend a meeting, whereupon they deliberately killed the baby and “borned” another one. The constitution or by-laws of the new society set five as a quorum. Dr. Snow’s successor, so far as the annals of fame of the Providence Health Department show, is the present courteous, careful, learned health officer—Dr. Charles V. Chapin. How long he has served, I do not know. I have heard forty years—it is certainly more than thirty years. He is easily the Nestor among American municipal health officers. It was said that Dr. J. N. McCormack served as a health officer for fifty years. But he was a state health officer, and the fatality rate among state health officers is lower than it is among those who serve municipalities. J] Know of no municipal health officer who, in length of service, approaches Dr. Chapin except Dr. G. W. Goler, of Roch- ester, New York, and Dr. Goler is Dr. Chapin’s junior by several years. Dr. J. J. Kinyoun deserves a place on this list. Dr. Kinyoun was bacteriologist to the Washington, D. C., health department, and he may have served as a municipal 157 L. M. Powers, M.D., Los Angeles health officer in North Carolina at one time. At the time of this story, acting as an official of the United States Public Health Service, he made a diagnosis of plague for the San Francisco health department, and thereby started trouble for himself and everyone else. In 1900 a Chinaman died in San Francisco from plague. The case was diagnosed largely through the skill of Dr. Kinyoun. Measures for control were inaugurated by the local and state health departments. Everything was pro- ceeding smoothly when the long arm of influence began to reach out. Before the health department’s activities had been suppressed, this long arm had reached into the city and state health departments and on to Washington itself. Policies were overrruled and plague was allowed to gain a foothold. When the “policy of political and business in- terests’” had accomplished its purpose there was no plague, that is, officially there was none. But that did not alter the facts. Kinyoun was right, he knew he was right and he had the courage of his convictions. He was forced out of the service. For one reason and another, he never got in again. Years later, he was proven to have been right by scientific com- missions and in every other way. Had he been supported in 1900, San Francisco, California and the nation would have been saved many million dollars and plague would never have gotten a foothold among the ground squirrels in the West. As an act of atonement, Cafifornia should build a monument to Joe_Kinyoun—a man of courage. Nor - 158 should we forget the courage of Dr. J. H. Kellogg, who stood with Kinyoun in this time of trial. When speaking of California health officers I like to think of the best of the lot—Dr. L. M. Powers of Los Angeles. Dr. Powers was a “tar heel.’? He looked like a farmer. He was a very able and learned man and a fine executive. He served his city for more than thirty years. Dr. Powers taught me never to shoot a ground squirrel im the face. If you did, he always fell back into his hole. Reaching into the hole exposed. one to fleas and plague— not to mention rattlesnakes. ‘This is the gentle art of killing a ground squirrel, according to health officers’ requirements. As you approach the colony, the ground squirrels sit on their hind parts, watching you. ‘They are planted on your side of the hole at its edge. If you shoot one then and there, he falls back into the hole. ‘Therefore, restrain yourself. Yell or clap your hands together. At once every ground squirrel dives into his hole. Now quietly circle the colony and quietly take a stand on the other side. Presently, the squirrels will come out. They will emerge on the other side where you were when you made the noise and they will face in the old direction, looking for you. Shoot them in the back and they will fall in the clear. But why should a health officer kill ground squirrels? Because they spread plague. Dr. Powers’ alertness in finding human plague and in combatting plague in rodents is one of the reasons for the relative freedom of southern California from this infection. Almost simultaneously with the death of Dr. Powers, Los Angeles had its first experience with a serious manifestation of plague. F a health officer makes a mistake, he should not lose heart. He may even make mistakes of major importance and still win out. . When the United States took over the health work in Cuba they did some quiet boasting as to how they would put an end to yellow fever on that island.- In fact, the country had been promised that the Cuban yellow fever menace, always at our door, would be removed. General Gorgas, then Major Gorgas, was designated to have charge of the work. As chief sanitary officer of Havana, he went to work to make it a spotless town. But the cleaner Havana got, the worse the yellow fever. Many Cuban physicians were chuckling with delight. These superior Yankees were showing us Cubans how to control yellow fever. It was to laugh—or words to that effect. After a while, Gorgas saw he was on the wrong track. Something had to be done. He knew of Finlay and the mosquito theory. He had no false pride. Dr. Walter Reed and he gave the mosquito theory a trial. It worked. Without hesitation, Gorgas scrapped everything he had been doing, switched to the new line and went at it baldheaded. history. The result is medical In Panama also Dr.-Gorgas’ career was far from being all roses. During his first year and a half the death rate mounted constantly. It seemed probable that the Ameri- cans were headed for the same kind of defeat that fell to the lot of the French; if so, the Canal could not be built. In Havana General Wood, himself a physician, had stood behind all Gorgas’ policies, but in Panama there was no General Wood. It seemed certain that Gorgas was headed for inglorious defeat; the plans were all drawn to remove FIGHTING HEALTH OFFICERS I HAVE MET him and stop his policies. When the case was laid before Roosevelt, however, as Mrs. Gorgas tells in her book on her husband, the President sent for Dr, Alexander Lambert, who stated the case so clearly and forcibly that Roosevelt exclaimed, “By George, I will back up Gorgas and we will see it through.” He did, and the Canal was saved. N that same biography Mrs. Gorgas comments on the part yellow fever played in directing her husband’s destiny. ‘The physician who presided when the future health ofhcer was born was Dr. J. C. Nott, an ardent advocate of the theory that mosquitoes spread yellow fever and malaria. When Miss Doughty, later Mrs. Gorgas, was supposedly dying from yellow fever, Dr. Gorgas picked out a choice grave for her. He changed his mind, decided to save her and to marry her instead. Miss Doughty decided to change her mind, to get well and to marry the handsome army officer. She says: “It would be untrue to say that Yellow Jack was the best man at our wedding, but it would be perfectly true to say that in a sense he was an usher. It was yellow fever in Cuba and Panama that gave him n opportunity to gain world fame. His last act of national importance was laying plans for the eradication of yellow fever from Ecuador. He was on his way to Africa to fight yellow fever there when he was taken sick and died in London.” Dr. Gorgas was no quarter horse. He was a four miler. He started slowly, got up speed slowly, and then finished strong. Had we plunged into the World War in 1914, with Dr. Gorgas at the age he was when he went to Ha- vana, it is a safe bet that 1918 would have found him with a war record for the health of troops at which the world would have marveled. He was a living example not only of the fact a mistake is not fatal to a good man, but also that in the long run you can’t keep a good man down. I once attended a health court day in Panama City. The judge was the municipal health officer, Dr. Henry Gold- thwaite. Dr. Goldthwaite made the health ordinances of the city, (legislative action) ; administered them, (admin- istrative action) ; sat as a health court passing judicially upon them, (judicial action). The good health of the people of Panama is the best proof of the advisability of this three-in-one policy for a health officer. Upon inquiry, I find that the plan was used by Dr. Gorgas in Havana probably, and in Panama possibly, and that since then it has been used by the municipal health officers of, both Colon and Panama. When one contemplates the very great difh- culty of the American municipal health officer in having offenders promptly tried for their offenses, he longs for the three-in-one method. These recollections have rambled as recollections always do when they are untrammelled and organized. In the main they relate to men who were active in the last quarter of the last century. When health officers of the present are referred to almost all the incidents recalled happened prior to 1910 and some of them prior to 1900, From 1875 to 1910 was a period of profound change in public health methods. “The men who guided municipal departments of health in those years were pioneers. ‘They had but few precedents and almost no science to guide them. There was little public health intelligence and no public health conscience. It was their privilege to create. ‘The municipal health officer of the present day is a wiser, better official. He stands on foundations which they laid. The Cancer of Ignorance The Spread of Anti-science in an American Commonwealth By CHESTER H. ROWELL NTI-SCIENCE is something more than mere unscientific thinking, or lack of scientific in- formation. It is an active emotional hostility to science ; to its conclusions, and especially to its process of reaching them. It is a repudia- t.o.. of the authority of science, of the in- tegrity of scientists, and of the validity of the scientific method, and an active, practical effort, moved by intense feeling, to combat and suppress them. Scientists, in defending their cause, commonly overlook this. “They assume that if they prove a thing is true, it will therefore be accepted as true. “This does not begin far enough back. ‘They must first persuade people to accept proof itself as a criterion of truth. ‘People who have never _in their lives known anything in conclusive evidence, and whose most cherished beliefs are based on no evidence what- ever, are not going to surrender fixed convictions on mere demonstration that they are mistaken, or accept anything unfamiliar on mere proof that it is true. In fact, they have not been even trained to ask whether anything is true or false. To them the only question is whether it is virtuous or wicked, or whether it conforms or does not conform to certain accepted taboos. , Mere unscientific thinking is a fairly universal human process. None of us can keep up with all the discoveries of science; few of us think always scientifically even within the range of our information. Probably the vast majority of the population has not yet emerged into the scientific age at all. The world lived too long under the anthropomorphic, the symbolic and the magical conceptions of the universe to pass all at once to the scientific one. Most of us still think with our imaginations, accepting whatever is easiest to pic- ture, or with our memories, taking for granted whatever is familiar. The mystery of sleep we do not question, but the more easily explicable part-sleep of hypnosis we explain as magic, performed by the hypnotist. We let our quacks per- suade us by superficial analogies, and applaud when our demagogues attribute impersonal economic ills to the personal witches of “Wall Street” and “the Interests.” It is more popular to impugn the motives than to examine the facts or refute the arguments ‘of the critic of our prejudices. After the analogy of religion we.conceive of medicine as divided into sects; after the analogy of politics we suppose science to be divided into parties. In loyalty to the equalitarianism which we mistake for dem- ocracy, we mistrust the expert. Even the readiness with which we accept the only scientific thing to which all our minds are open—the daily miracles of the mechanical applications of physical science—is scarcely an exception. We accept these wonders, not because they are reasonable, but precisely because they are magical. Credo quia impos- sibile. ‘There have always been miracles; these are merely a new sort. And if we are less receptive to the biological sciences, it is perhaps because they perform few miracles themselves and tend to cast doubt on some traditional ones. Indeed, ‘even in the biological sciences it is the miracle- worker who is most readily accepted. Witness the gland rejuvenators, the Abrams electronic apparatus and the quack cure-alls. It is easier to sell an impossible than a possible thing, in medicine, and the chief objection to evolution is that it offers a rational explanation of a process which we prefer to regard as irrational. | Anti-science consists of all this non-science, plus a de- fense reaction which gives it emotional content and inspires it to a practical crusade. We defend our prejudices by making them faith; our ignorance by associating it with moral rectitude; our provincialism by calling it patriotism, and our intolerance by dubbing it reform. Behind this moral barricade we are safe against any merely intellectual ‘weapons of scientific evidence. We avoid the trouble of proving our critics wrong by proceeding against them as wicked. It is only one step more to enjoining them as illegal, or, finally, prosecuting them as criminal. ‘Then we get militant anti-science. T may seem paradoxical that California, statistically the highest-educated state in the Union, should have had in recent years so many outbreaks of anti-scientific medi- evalism. [Evidently it takes more than one generation of overflowing high schools and universities to complete the modernization of a people. At any rate, some of Califor- nia’s experiences, which happen to be the ones with which the writer is most familiar, may be illustrative of states of mind and of politics not unknown elsewhere. California has not been the chief center of the two mest advertised of anti-scientific crusades—anti-history and anti- evolution—but it has not escaped them. California many years ago adopted the system of free text books for the common schools, printed at the state printing office. Later, it extended the system to the high schools. ‘Thus the state is responsible, not by indorsement merely, but by actual physical production and gift to the student, for every text-book used in the schools. Plates of established books may be obtained from the publishers, but the actual press work and binding are done by the state. Naturally, the superpatriots of the American Legion, the Daughters of the Revolution, and the politically reaction- ary Better America Federation, have sought to ‘exclude all text books of American history based on modern re- search. Only the edifying hero-tales of our tradition must be permitted to impinge on the tender minds of high school youth. . ‘Two years ago protests to this end were presented to the state Board of Education, which finally referred them to a committee to be, selected by the state Commissioner of Secondary Education, A. C. Olney. Mr. Olney appointed the professors of American history in the two universities, together with leading high school teachers and others, who 159 ¢ 160 examined the offending books and found nothing to con- demn in them. The board accepted the report, but similar protests were renewed this year, witout, however, suc- ceeding in putting any books on the Index. For the past year protests against permitting evolution to be taught or to be printed in text books have been before the state board, with at least one member for a time posi- tively favorable to their suppression, and some others doubt- ‘ful. Tactful handling of the situation by the professional staff of the board finally secured a compromise resolution that evolution might be taught “as a theory, but not as a fact,” and the endorsement of the disputed text books. The fundamentalists now threaten to carry the issue to the legislature, and, failing there, to the people by initiative or referendum. If that is done there will be a real crusade, with fears already in the minds of some educators that the large fundamentalist vote of Southern California might make some risk of the passage of the laws. Northern and central California, being traditionally heathen, are not teared. Doubtless there is no serious danger in southern California, either. Its people reflect the mentality of rural lowa and Illinois, rather than of the hills of East Ten- nessee and West Virginia, which is probably liberal enough. 'HE majority of anti-scientific movements everywhere are anti-medical. The traditional confusion of medi- cine with religion and of religion with sectarianism make the claims of scientific medicine appear to many people like the claims of an established church to suppress dissenters and heretics. Hence the cults, and the pro-cult and anti- medical agitations. The most continuous of these in California has been the anti-vivisection crusade. An anti-vivisection law was slipped almost unnoticed through the legislature of 1913, but was pocket-vetoed by Governor Hiram W. Johnson when it came to his attention after adjournment. Since then there have been at least two attempts, in 1920 and 1922, to pass anti-vivisection bills by popular initiative. As often happens with initiative measures, these bills, submitted by petition to the direct vote of the people, were more extreme than any that would be proposed for debate and criticism in a legislature. One of them defined vivisection as any experimentation, surgical or physiological, on man or any living creature lower than man, and forbade it absolutely, with or without anesthetic, and whether painful or not, if the purpose was scientific investigation. On the other hand, the farm operations of dehorning, gelding, spaying, caponizing, branding, etc. were expressly permitted, with pain and without anesthetic. The expressed purpose was to prohibit scientific experimentation even without pain, and to interfere with no torture unless it was for scientific purposes. The usual lurid tales of alleged brutalities in medical laboratories were distributed, but the central argu- ment was that these experiments are of no value, anyway, and: have never contributed to the knowledge or cure of disease. To do this it was necessary to deny most of the findings of modern medical science and the efficacy of most of its treatments, including vaccination and antitoxin, and to accuse the medical profession of being actuated wholly by selfish mercenary considerations. It was an hysterical crusade, primarily against medical and physiological science, and only incidentally against the alleged torture of the THE CANCER OF IGNORANCE laboratories. Both initiatives were defeated, but received very substantia! votes. If they had passed, they would have literally forbidden even feeding and breeding experiments, and would have made impossible in California the produc- tion, testing or use of vaccines and serums, for man or beast, and the Wasserman, Vidal and other diagnostic tests. At the same legislature of 1913 which passed the anti- vivisection bill an impure milk bill was lobbied through by a political creamery organiaztion formed for the purpose, which was also vetoed by Governor Johnson. The next year the women’s clubs, with equal ease, lobbied through a pure milk bill, which is still the law. It was apparently as easy, even in these politically reformed legislatures, to pass one sort of a bill as another. The impure milk bill of 1913 was, of course, not anti-science, but pure sordid commercialism. ‘The anti-science appeared in the arguments used in the agitation against the .governor’s veto. The veto had been advised by the state veterinarian, the: state Veterinary Society, the state Board ot Health, the state Medical Society, the agricultural department of the uni- versity, and by the writer, who was charged with being tainted with scientific knowledge. This list was paraded in triumph before the people as evidence that the governor was wrong, because he had preferred the advice of these highbrows and professional experts instead of trusting to the common people! It was obviously assumed that this appeal against the experts would strike a responsive cord. About the same time a tuberculin test ordinance for cat- tle of dairies supplying milk to the city was passed by the city government of Los Angeles, but was defeated, on refer- endum petition circulated under Christian Science auspices, by direct vote of the people of Los Angeles. California had a law requiring vaccination as a condition of entrance to the public schools. This was later amended to exempt children of parents who signed certificates of “conscientious objection.” This meant, in prac- tice, exempting all children whose parents were not ready to have them vaccinated, whether the objection was “con- scientious” or not. Finally, the state law was further changed, making no routine requirement in ordinary times, but permitting the state Board of Health to take charge and enforce such regulations as it thought appropriate, in case of actual epidemic. Since then, smallpox has greatly increased in California, and last year there were several out- breaks which took strenuous measures to prevent from reaching dangerous proportions. ‘The one exception is the University of California. Under the constitution the regents and not the legislature are the law-making body of the university. Their terms are six- teen years and they are usually reappointed, thus serving practically for life in a position of peculiar independence. They have persisted in requiring vaccination of all students of the university, even when the state law relaxed it for the schools. There has never been a case of smallpox among the students of the university, though there have been among unvaccinated employes, and the numerical share of the student body, measured by the proportion of the general population, would be a number much too large to make this showing possible by the mere doctrine of chances. An initiative measure was placed on the state ballot in 1922, depriving the regents of the power to make such regulations, but it was defeated by the people. There was THE CANCER OF IGNORANCE 161 also an initiative forbidding the requirement of vaccination, scientific medicine. The medical practice act of California inoculation or other medical treatment as a condition of ‘employment in the public schools, or the holding of any public office. As originally formulated by its sponsors, it would also have forbidden medical tests or treatment as a condition of any employment, or of the exercise of any right or privilege, thus preventing the elimination of typhoid carriers from hundling food or of syphilitics as barbers, and making impossible quarantine regulations, but thes latter requirements were eliminated from the final version. Petitions have since twice been presented to the regents to relax the vaccination rule, and, on their refusal, they have been menaced with an initiative amendment to the state constitution making their office elective, or appointive for short terms. N 1912 the platform of the National Progressive Party contained a plank (written in part, it may as well now be said, by the editor of The Survey), advocating a pro- gram of social insurance. There were progressive movements in many states, but California was the only state in which the third party, Bull Moose Progressive party, as such, was in possession of the state government—-the governor, most of the state officers, and the large majority of both houses of the legislature. The legislature of 1915 authorized a social insurance commission, (of which the writer was sub- sequently chairman) to investigate the question and present a proposal to the legislature of 1917. “The commission recommended to the legislature of 1917 the submission of an enabling amendment to the people at the election of 1918 which would give future legislatures constitutional authority to enact a health insurance law. This at once aroused the anti-science of the doctors. ‘The physicians are receptive enough to scientific advance in the knowledge and treatment of disease, but on the social and economic aspects of their own profession, many of them are fundamentalists — of the most obstinate sort. “They are as anti-scientific against social science as any cultist is against medical science. Be- cause medical practice, in. its business and. distributive as- pects, was individualistic in the individualistic age, they insist that it shall remain so even in this new age when everything else has become socialized. So they organized themselves politically, to fight this measure, and joined themselves with the insurance companies, and even with their pet enemies, the Christian Scientists. The combina- tion was successful, and the measure was defeated. The political organization, the League for the Conserva- tion of Public Health, formed by the physicians ’at this time to fight a single measure, then expanded its purposes to the general defense of scientific medicine against political at- tacks, and has rendered such valuable and generally con- structive services in this line that the writer, to fight whom it was originally formed, and Dr. Ray Lyman Wilbur, president of Stanford University and president last year of the American Medical Association, one of the many far- seeing medical leaders who advocate socialized advance in the administration of medicine, have both joined cordially with this organization whose chief bugaboos they once were, and have assisted it in its generally successful crusades in behalf of public health and against anti-medical legislation. The most directly anti-medical legislation is of course the attempt to break down educational requirements, and the setting up of cults and sects on an equality with conditions. of medical hoaxes than of convinced anti-science movements. has several times been amended in this direction. Not satis- fied with the law which permitted the licensing of “drug- less healers” on a showing of educational qualifications only halt as g-eat as tiiose requi.ed of regular medical practi- tioners, the osteopaths and chiropractors have continuously pressed for separate boards, to enable them to license them- selves. “I'wice defeated in this by successive legislatures, they twice resorted to initiatives before the people; and the second time, in 1922, were successful. Both sectarian boards are now functioning, but there was a long delay in estab- lishing the chiropractic board, successive appointees being disqualified by the court on showings that they had been practising illegally, under the former laws. ‘There are at least a score of other sects advertising in California and practising illegally—spondylotherapists, naturopaths, napra- paths and a whole jargon of others. No move has yet been made to give them separate boards, but if medicine is sec- tarian, they should have them. Christian Science anti-science in California has centered its principal activities in the Public School Protective League, an organization with a very able attorney whose purpose is to interpose legal obstruction to what they re- gard as baleful health measures, and at times even to physi- ological and hygienic instruction in the public schools. They regard bacteriology as a sectarian doctrine, and have a de- cision of some court, on which they rely, that the physical examination of the throat of a child, during a diphtheria epidemic, unless by express consent of the parent, is assault and battery. They have also joined with the other anti- scientists in their variéus anti-scientific crusades, and’ have’ gone into active politics, especially in southern California, against health measures, except those which confine them- selves strictly to the promotion of cleanliness. ‘That, it seems, is a spiritual virtue, and therefore permissible. ‘They also urged in the last legislature—but were defeated by the counter-politics of the League for the Conservation of Public Health—a measure which would have authorized Christian Science treatment, and the compulsory payment therefore by the employer, in the case of industrial accidents under the Workmen’s Compensation Act. Since these cases are all surgical, and no Christian Science practitioner is licensed to operate surgically, the illogic of the measure, even conceding sectarianism, was obvious. A measure was also submitted to the people in 1920, at the instance of the practitioners of the drugless cults, per- mitting the prescribing of narcotics by those not licensed to administer other drugs, but this was defeated. It remains only to add that California is also the seat of the most preposterous of recent medical impositions—the Abrams “electronic” diagnosis machine [see The Survey, Jan. 15, 1923] which diagnosed red ink as suffering from syphilis and two drops taken from the same patient at the same time as suffering from irreconcilably different This, however, belongs in the history rather California is an intelligent, progressive and highly-edu- cated state, peopled generally by the enterprising, the suc- cessful and the adventurous of other states, who, in reach- ing out for new fields, are the ones who have gone farthest. If the things here recounted can have happened in Cali- fornia, they can happen—most of them have happened-— anywhere. Is this the scientific age? Letters & Life In which books, plays and people are discussed Edited by LEON WHIPPLE Prophylaxis in Print NK is apparently the best serum there is. Spread on wood-pulp and applied extern- ally to the eyes it heads the pharmacopeia of preventive medicine. “The printed word is not a cure-all, but it has one blessed quality that doctors must be thankful for: it sometimes helps to keep the human being from making a fool of himself. It may persuade us to eat sensibly, rest quietly, get sunshine and fresh air, secure the doctors’ help when we need it, and prepare our children against the ravages of disease. Of course it needs behind it all the wisdom and character we can muster and accompanying it all the technique and services that science affords. But printed and spoken words are certainly one of the bases of social medicine, and the wise man will use them for all they can so easily and so cheaply do. Someday instruc- tion in writing and public speaking may be required courses in our schools of medicine. For to tell people what we do and do not know on the cause and cure of disease; to persuade them into right ways of living that will lessen disease; to urge upon them health examinations; and to warn them in emergencies of epidemic character, surely these are ways of making good health catching. Physicians have rightly been fearful of the printed word. It can be very misleading, even destructive. It is easily seized by the quack and charlatan to exploit the simple or the desperate. It generally needs the complement of sound personal advice «and the best of treatment. It may easily get the right message into the wrong hands. It seems to the scientist a blundering and unprecise instrument—not susceptible of laboratory standardization. But these dangers are to be found in many remedies, and are chal- lenges to proper control, not reasons for discarding printed words. The fact is, print serves now and will serve us more in the future. I wonder whether we realize how much of our work for health is now based on words—not the Latin formulae needed to keep the layman from tampering with himselt ' and the medicine he takes, but plain simple English. For example, I have just fallen in with a book on Colds— sensible advice needed annually by about 99 per cent of the population of our latitude. Two books on cancer appeared .a month or so ago—books of rigid scientific honesty, yet telling what we may hope for, and what we must not yet hope for in the prevention or cure of this dread disease. The National Health Council Series of little leatherette volumes could alone probably cut the death-rate in half— if everybody read and obeyed their suggestions. “The revolu- tionary achievements of the Metropolitan Life Insurance Company in cutting its death-rate have been in an impor- tant part due to its rock-wearing distribution of health pamphlets. Dr. Emmett Holt’s baby books are almost a national institution—better known and more generally obeyed than the Constitution! The list would fill a volume. The tale of this use of words runs back into pre-history. Who knows whether medicines or incantations came first ? We presume instinct made the ape-men lick their wounds and maybe eat herbs to begin with, but among the very first uses they made of words when they got them was the mumbo-jumbo of priest or medicine man to ward off, or take away disease. He was placating the angry God who caused the sickness, not curing the sickness itself. And if we substitute Subconscious for God we will find the same chants rising to the stars to-day. The mud-rolls of Mesopotamia, the papyri of Egypt, the manuscripts of Greece and Rome and the scrolls of the medieval monk— all hold their codes for health. They had some idea of tell- ing people how to keep well—even if the prescription was to let a wax image melt in the sun. HEN finally print was achieved, what a flood let loose! Herbalists, and books of alchemy, the cures that depended on astrology, on interpretation of dreams, on the rigamaroles of folk-Jore, generally quite mad, but sometimes with that residual truth that has become the bed- rock of science. The people as they learned to read wanted to read almost first of all one message—how to get well. The other idea—how to keep well—had not yet been born, except perhaps among the heathen Chinese. So by degrees began to crystallize the popular forms of “health in print.” First and longest enduring were the almanacs. An al- manac with a Bible made up a library, and as one ministered to the stricken soul so the other to the broken body. Here where the disembowelled gentleman surrounded with the signs of the zodiac stood for astrology, and the weather predictions stood for meteorology, and the jokes stood for literature, the recipes, imbrocations, stews, and concoctions stood for medicine. Here flourished the jimson-weed plaster, and the gunpowder-and-sour-cream lotion, and the spider web plug for hemorrhage, (how the tetanus God must have roared!) and the shot of alcohol for most everything. They bled and they leeched and they steamed and they stewed and they produced a hardy race. Only the hardy could stand the cures. But then our ancestors really began to master the uses and misuses of print, and the family almanac proliferated into two forms. ‘The single prescription that had won fame crept into the advertising columns of the newspapers; and secondly all the medical and surgical lore of all the almanacs got itself dignified and codified into a special volume. We had what we have not yet escaped from the Compendium 162 ‘LETTERS & LIFE. of Heath, One Thousand and One Prescriptions for the Sick, The Guide to Family Health, the Home Doctor and the like. Much they contained was dangerous and evil stuff, and much more was just futile nonsense, but prob- ably here too was a sediment of wisdom that may have helped rear families and alleviate pain. Along with them came the host of books on sex and marriage—quack ad- vice gotten out to suck money from the millions who found that they could not keep themselves healthy in their sex life. There can be no human estimate of the amount of physical and moral damage the majority of these vile things caused. Even yet they flourish under a thousand disguises, battening like vultures on the agony of the race in its search for wisdom in love. Medical advertising demands a history in itself. It be- gan in this country almost with the birth of the weekly newspaper in the Colonies. ‘The editor himself often adver- tised some water or pill that was a universal panacea and his office was a resort for the sick. He would advertise your slave for sale or your liniment for sale with equal fervor. With the rise of the daily and the cheap popular newspaper the evil boomed and prospered. No paper seemed to be too respectable to print the claims of the “specialist in private diseases’ or the testimonials of sooth- ing-syrups full of laudanum, head-ache powders full of dangerous heart depressants, tonics made of bad alcohol and strychnine, or catarrh powders concocted of cocaine. The manufacturers became millionaires and newspaper publishers fattened off this diabolical pandering to the health hunger of the race. It is not too much to say that so long as this quack doctoring through print kept up, we could never have a real science of public health: But it did not. keep up—at least in the old luxuriant form. ‘The crusade of the physicians themselves, backed by the so-called muck-rakers, drove the newspapers to reform from within or to be reformed by state and federal acts from without. It is not without its lesson that the evils of print were reformed largely by the good offices of print —the development of an anti-body in the social structure itself. We still have patent medicine and quack advertis- ing but the new attitude is found in the best grade of proprietary advertising which no longer claims to cure or to supplant the doctor or dentist, but urges the reader to consult experts, and recommends its own product only for purposes that may be approved by sound advice and good sense. The lesson of the Health Compendium and the fake health advertisement took a long while to sink into the medical consciousness. “The doctor was too prone to damn the whole thing, get-rich-quick pander and silly sheep reader. He wanted to blot it out and forget while he personally ministered to the sick of his own neighborhood. But in this evil mess were two inescapable facts: first, the health hunger of the race made them turn to printed advice as one way out of sickness; second, these books and_ publicity -messages furnished a wonderful instrument to help heal the sick, and even better, prevent sickness—if the instrument was seized by reputable agencies and made the vehicle of honest and helpful modern knowledge. It needed not be abolished, for it was too useful; it needed only to be trans- formed so that the new compendium should be sound, factual, ably edited, and confined to the tieid in which printed advice can serve. 163 The use of print for health to-day has not complete- ly escaped the taints of its ancestors—the follies of the almanac and the boom promises of the alchemist are still to be found. But the modern book on a special disease, the modern pamphlet on public health, and the modern health column in the newspaper are all well intentioned, generally honestly and ably done, and if they suffer from rashness, credulity, superficiality, and sometimes unsoundness, these are but the failings we find in any social tool, and they can be found among physicians and scientists as well as amon editors and publicists. Striking a balance, we feel that it can be said that there is only a small percentage of positive harm done by printed words in the health fight; that the amount of silly though well-meaning exploitation of false hopes has been reduced within human limits, and that much valuable information in the fields of personal hygiene and sensible living has been widely spread among all classes of people. The moral is that science and medicine must use print or it will be used by the quack and the exploiter of fears to the destruction of honesty and faith in science. It must be directed to its legitimate ends and engineered by ex- perts both in medical knowledge and publicity methods. The curse must be taken off it and the highest talents en- listed. Its achievements have already proven its usefulness, and as social diseases breed through ignorance social knowl- edge is the essence of their cure. LEON WHIPPLE. A Humanist In Health ao NIVERSAL history, the history of what man has accomplished in this world is at bottom the history of the great men who have worked here,” wrote Carlyle, and, “Great men, taken up in any way, are profitable com- pany.” The life of Osler is certainly profitable company and a record of remarkable accomplishment. Dr. Cushing has let the story of Osler’s life tell itself, and left to the future any nice appraisment of Osler’s place in the history of medical thought and philosophy. This story is delight- fully told, full of that humor and whimsicality for which his hero was famous, and yet implicit with a sympathetic veneration for a great personality. No easy task to do well, for the life is not only the record of a personality but it so happened that these years span a period of most astounding growth of knowledge of disease. It has been said that this knowledge has advanced further in the last century than in the whole Christian era preceding it. But it is not for a glimpse of this drama that the general reader will peruse two fat volumes but rather for acquaintance with a man who was famous, not only as a teacher of medicine, and as an authority in medical affairs, but also as a scholar who could not be ignored by Oxford dons in their own fields of literature and classic lore. Anyone to whom the Osler tradition is but a phrase and a mystery will not read far without some intimation of the spirit which engendered this intangible influence. No aloof dignity is this hospital chief, surrounded though he be by satellites, but one who links his student by the arm and cracks a joke; is as sympathetic as a woman with the sorely afflicted ; leaves the staff breathless by an acute observation ; and romps with children heedless of time. What sort of man is this who is addressed as “Willie” by doting children 164 of an hour’s acquaintance, who can give a man a rough buffet and leave no bruise, who shakes his threatened fist under the mayor’s nose and is seen an hour later arm in arm with him who has been won over to the radical forces for civic redemption? Held in awe by physicians who knew him only as a name, no man in his time was more respected or so much beloved. Yet in almost every field Osler’s aims were at first accounted radical; men were won to those views by reason; he was not the mere head of an established tradition. ‘The rare peculiarity in his temperament enabled him to distinguish between a man and that man’s baggage of ideas. Unless mean or dis- honorable, there seemed always something in the man worth while and Osler could detect this as he might as a physician, detect a latent disease; working on this deeper man the result was sometimes near to a miracle. In this he was often most aided by his own reputation for prodigal generosity. His money he gave away when he had little, to friends, to relatives, to strangers in dis- tress; he would “sanctify a fee’ by turning it over to a library; his notes made on the study of some disease were at the disposal of any sincere student; all done in a way that left his identity concealed if possible. But as they were oft repeated, a tradition could not be prevented. Char- acteristic of his attitude in all relations was his refusal to delegate his little charities. The procedure of charity organization societies was not his way. No one asking aid should be turned away without money, were his instructions to the Negro butler. ‘There was no dis- crimination,” he once said, “in the charity of the Good Samaritan, who stopped not to ask the stripped’and wounded man by the wayside whether it was by his own fault the ill had come, nor of his religion, nor had he the where- withal to pay his board.” In these modes of thought and in many others he was - classic Greek, not as an adopted philosophy, but naturally. Someone has said in commenting on Osler’s biography that he was a Puritan, but as a man whose rule for conduct is Aequaminitas, who controls emotion to imperturbability ; who holds the feelings of others in sacred respect and is withal blithe and gay, he is a pure Stoic. A complex, elusive, and delightful personality is disclosed in this masterly biography. Now what did Osler accom- plish? His earlier reputation was first as a great teacher. And it was not what he taught that was remarkable but the way he did it. He imparted enthusiasm, the only thing worth while that any teacher can impart. Osler surrounded by his crowd of students, streaming from ward to ward, eager, excited—they appear bent on a swimming excursion (his special delight), so happy do they seem. At the Johns Hopkins Hospital he introduced the Scot- tish method of bed-side teaching, an innovation in America, and it is amusing that this school at first was said not to be sufficiently practical. The Alpha and Omega of Osler’s method of teaching he took from Latham—“TIt is by your own eyes, and your ears, and your minds, and your heart that you must observe and learn and profit, I can only point to the objects and say little else than see here and see there.” And it was repeated in bed-side aphorism and elaborated in essay that the physician must practice with his heart as well as with his head—oft forgotten in this day of ignoring the man in search of his disease. He was ever appreciative of the overcharged state of the student LETTERS & LIFE mind, and advised him always to read some good book, not medical, every night before going to sleep—and he would recommend the books. ‘Then there was the radical cus- tom of having the students at his house an evening each week when they gathered about him drinking beer while he chatted of great men in medical history-—the idea always that inspiration is more than knowledge, character stronger than science. Then the text-book of medicine, translated into many tongues, even Chinese, and a standard work the world over. It was this text read by a layman which inspired the founda- tion of the Rockefeller Institute. It is hard to realize that the effective sanitary methods of to-day are a growth during one generation. The con- cern of health officers a few years ago was epidemics— chiefly small-pox; their concern to-day extends from chil- dren’s teeth to iodine in potable water. No one man brought this about, but it came by the perseverance of relatively a few. In Montreal Osler was physician to the small-pox hospital during an epidemic. He saw the need cf popular education to prevent repetition of the catas- trophe and persistently hammered this idea into indolent heads. In the South, in Baltimore, typhoid was an annual scourge, Osler with a lone health officer and a selected group made the plague a political issue and by public meetings awakened the complacement populace. By papers in medi- cal journals, by addresses to medical societies, by showers of letters to physicians, he constantly insisted that typhoid could be eradicated. And to-day the Delian tribute is not to typhoid but to the motor car. Both in this campaign and in that against tuberculosis it is worth note that the’ efforts to awaken a public “which supinely acquiesces in conditions shameful beyond expression” were with Osler tempered by a “larger sympathy of man with man.” His motto was “Let us meanwhile neither scold nor despair.” It is difficult to realize that Osler’s paper on the Home ‘Treatment of Consumption, in which he advocated fresh air and food, was a novel idea twenty-five years ago, and that the campaign against the “white plague” was restricted to a very few members of the medical profession. And it required speeches, exhibits, congresses, to arouse physicians and public alike. In the beginning of this large task much effort was lost due to divergent views of scattered societies, but with Trudeau, Hermann Biggs, Flick, Welch, Sternberg, and Osler, the national society was finally born, rather puny at first, with no promise of its sturdy growth to a size when its financial strength exceeds its imagination in expenditures. Osler was also active in the British congresses for tuber- culosis and years later at Oxford he started a local move- ment there. Interested as he was in scientific discoveries relating to medicine, he was ever eager to mint the gold of discovery for the benefit of humanity. In precept and prac- tice he was first a humanist. And his interest in public health never flagged; one of the first things he did after he became Regius professor at Oxford was to advise the Eng- lish about their teeth, so that they might masticate rather than bolt their food. As a thread of god woven through the close-knit texture of a busy life was the love of classic literature. When a mere boy, Johnson, one of his teachers, introduced him to the Religio Medici, and this book became to Osler. a sacred text. The thread gradually becomes a pattern and in his LETTERS & LIFE _ mature years Osler’s taste and interest extended to include the best writings of all time. It was not only the history of medicine which absorbed him, though in this field he was an authority and a veritable bibliomaniac known. to every book mart from Amsterdam to New York, buying rare editions, not for himself alone, but to present to medical libraries everywhere; but the record of noble thought in noble language was to him an inspiration. Even this source of fuller life he shared with others; his addresses and essays are often built on those texts. And how deeply he studied and absorbed the spirit of the ancient, especially of Greek thought, is evidenced by conservative Oxford electing him, a radical Canadian, president of the classical society. This is the record of a delightful life told with all the charm and vigor that characterized the great “chief.” Neus B. Foster, M.D. - THE LIFE OF SIR WILLIAM OSLER, by Harvey Cushing. Oxford Univ. Press. 2 vol. 685, 728 pp. Price "$12. 50 postpaid of The Survey. The Smaller City HE analysis of the complex but careful study of the health activities of the eighty-six cities is admirably handled by Dr. Palmer and his associates. “The authors are especially to be congratulated upon the concise, definite and clearly worded summaries and recommendations. “The book is a most important contribution to public health ad- ministration. Every health officer should have a copy. The survey, undertaken primarily of course to determine the status of child health in the eighty-six cities of the United States whose populations fell between 40,000 and 70,000, was wisely designed so as to include all health activities both official and non-official. ‘Through the careful survey- ing of the cities by five well trained health men of the Research Division of the American Child Health Asso- ciation and the scientific and painstaking tabulation, analysis, and interpretation of results the authors have been able to present a clear and accurate picture fo health activities as they actually exist in cities of this size. ~The report has four sections: The Conduct of the Investigation. Administrative Practices in Public Health. Sketches of the Health Work in Each City. A Proposed Plan of Organization of Community Health Work for a City of 50,000 Population. The section on Administrative Practices in Public Health deals with the subject under the headings, “The Character- istics of the Cities, the Organization and Personnel of the Health Department, Vital Statistics, Communicable Dis- ease Control, Venereal Disease Control, Tuberculosis Con- trol, Maternity Hygiene, the Hygiene of the Infant, the Pre-school and the School Child, Sanitation, Laboratory Facilities, Popular Health Instruction, Pubic Health Nurs- ing, Recreation and the Private Agency in the Field of Public Health. The presentation of each subject is well illustrated with charts and tables. The Appraisal Form for City Health Work has been used as a basis of rating each city on the various items included in Administrative Practices in Public Health. While comparisons of individual! cities are not made by name each subject as Vital Statistics. Infant Hygiene, etc. is treated, as far as ratings are concerned, as a separate entity. Under each health practice the average scores have 165 been expressed for the third of cities having the highest scores in that particular activity, the third having the next highest, and the third having the lowest scores. The average score for all cities and the maximum and minimum for each group are given without the mention of names. The fore part of the report is given over to an especially well worked out series of summaries and recommendations covering each of the phases of Administrative Practice in Public Health. Some of the more striking revelations of these summaries are: That while every city is doing some work toward bettering the health of the child the average amount is not over half of what is to be expected i in a eee health program. Only 45 of the 86 cities had full-time health officers. Sanitation and laboratory work were the health activities having the highest ratings. Popular health instruction and pre-school hygiene were the most neglected activities. The average salary of the full-time health officer is only about $1,000 more than that of the part-time health officer. The layman’s conception of the present day job of the health department is that of nuisance inspection and garbage collection. The plan of surveying, the survey itself and its tabula- tion, analysis and interpretation, as a whole, form a unique and particularly valuable piece of work in that, as far as we know, it is the first time in the history of this country that a small group of well trained health men has devised a plan, actually carried out the field work, and assisted in the tabulation, analysis, and interpretation of the records which it has gathered. In addition to this the same group has reviewed its work and in the light of its experience been chiefly responsible for the formulation of a carefully devised plan of organization of community health work for a city of 50,000 population. Henry F. Vaucuan, D.P.H. A HEALTH SURVEY OF 86 CITIES, by George T. Palmer, Philip S. Platt, W. Frank Walker, Annetta J. Nicoll, Anna Jablonower. Americaw Child Health Association, 370 Seventh Avenue, New York. 614 pp. Price $3.00 postpaid of The Survey. A Study of Louisville UBLIC health and hospital officials will be Pena interested in a recent survey report of the health and hospital agencies of Louisville, Kentucky. This survey was made for the Community Chest of Louisville, during the early part of the year, by Dr. Haven Emerson of the College cf Physicians and Surgeons of Columbia University and Anna C. Phillips, now executive secretary of the health council of the community chest. It is interesting in this connection to note that one of the local newspapers is carrying approximately two-thirds of the report in serial publication, accompanied by comments from those prominent in the local health and social fields. | This survey includes a statement of the present facilities of the hospitals and health agencies of Louisville, together with a description of their work and relations to each other and to the community, followed by recommendations as to the development of a future community health program. “The infancy, childhood, rate of growth and physical or material proportions of a community are as essential for a description of a city as are similar elements in picturing an individual.” Chartered in 1828 as a city with about 10,000 inhabitants, the estimated (Continued on page 174) S U R V E Y RE A DIN G LIS. T: N-U M B ER TEN City Health Administration By C.-E, A. WINSLOW, Dr. P.H. P to the beginning of the present century public health administration (with the ex- ception of a few pioneer departments like that of New York city) was concerned al- -most wholly with environmental sanitation and with a generally ineffectual attempt to control acute epidemic disease by crude methods of quaran- tine. During the- past twenty-five years the health officer has been developing his activities along new and untried lines, infant welfare, school hygiene, anti-tuberculosis work, venereal clinics, immunization—opening up constant vistas of service, but ofttimes confused by conflicting demands and guided by local sentiment into a one-sided and top-heavy development of one or the other activity. Nineteen twenty-five marks what I believe to be truly an epochal event in the history of the public health move- ment—a formulation on behalf of the public health pro- fession of definite standards of city health service which gives us a norm for developing a balanced and effective pro- gram and a means of crystallizing public support and securing needed financial aid such as we have never had before. This is a very new movement and the literature bearing directly upon it is therefore tion. Hiscock has presented an outline of ideal organiza- tion for a city of 20,000 population. Finally the Committee on Municipal Health Department Practice will this fall make public with its formal sanction a revised appraisal form for the scoring of city health departments which is recommended for standard use during the next three years. This practically completes the list of existing references on the detailed comparative study of public health practice. ‘The student of this subject will of course find it exceed- ingly helpful to examine in detail the published reports of intensive surveys of the health problems of individual cities, such as New Haven, Louisville, and above all the monu- mental study made by Emerson and his associates at Cleve- land. Horwood’s book on the technique of health surveys will also prove valuable particularly on the engineering side. Of textbooks on the general subject J Moore’s study per- haps deals most fully with actual administrative problems. The texts of Luckett and Gray and Overton and Denno will also, however, prove very helpful in this connec- tion. Some idea of the historical backgrounds of the public health movement may be gained from recent Gamma Alpha and Sedgwick lec- very scanty. The attempt to measure public health work on a direct and quan- titative basis began with Dr. C. V. Chapin’s Report on State Public Work in 1916 (out of print but to be obtained in many libraries). The first sys- tematic comparative survey of city health work by the Committee on Municipal Health Department Prac- tice was published by the U.S. Public Health Service in 1923 with data as to the. eighty-three large cities of the country as of 1920, and with a plan for an ideal health department for a city of 100,000 population. The American Child Health Association has just issued a comparative survey of eighty-six cities between 40,000 and 70,000 popula- tion in 1924; and the Pub- lic Health Service during - the coming winter will give us a similar report for the cities of over 70,000 popula- Health’ Dr. Winslow Recommends: A REPORT ON STATE PUBLIC HEALTH WORK, by C. FV. Chapin, American Medical Association, Chicago, 1916. Out of print. REPORT OF THE COMMITTEE ON MUNICIPAL HEALTH DEPARTMENT PRACTICE OF THE AMERICAN PUBLIC HEALTH ASSOCIATION, Public Health Bulletin No. 136, United States Public Health Service, Washington, 1923. 50 cents. HEALTH SURVEY OF 86 CITIES, American Child Health Asso- ciation, New York, 1925. $3.00. THE ORGANIZATION AND BUDGET OF A HEALTH DE- PARTMENT IN A CITY OF 20,000 POPULATION, by JI. P. Hiscock, American Journal of Public Health, March 1924, Vol. 14, p. 203. Free reprint. COMMITTEE ON MUNICIPAL HEALTH DEPARTMENT PRACTICE, Fifth Report (Containing revised Appraisal Form). HL appear in forthcoming issue, American Journal of Public ealt A AL TH SURVEY OF NEW HAVEN, CONN., by C.-E.A. Winslow, J. C. Greenway, and D. Greenberg. Yale University Press, New Haz ten, 1917. $1.00. HOSPITALS AND HEALTH AGENCIES OF LOUISVILLE 1924, by H. Emerson and A. C. Phillips. Health and Hospital Survey Committee, 1925. CLEVELAND HOSPITAL AND HEALTH SURVEY, Cleveland Hospital Council, 1920. 11 Vols. 50 cents each. PUBLIC HEALTH SURVEYS, by M. P. Horwood. John Wiley and Sons, New York, 1921. $4.50. PUBLIC HEALTH IN THE Cee STATES, by H. H. Moore. Harper and Brothers, 1923. $4. ELEMENTS OF PUBLIC HEALTH ADMINISTRATION, by G. S. Luckett and H. F. Gray. P. Blakiston’s Sons Co., Phila- delphia, 1923. $3.00. THE HEALTH OFFICER, by F. Guerin and W. J. Denno. W. B. Saunders Company, 1919. $5. EVOLUTION AND SIGNIFICANCE OF THE MODERN PUB- LIC HEALTH CAMPAIGN, by C.-E.A. Winslow. Vale Uni- versity Press, New Haven, 1923. $1.50. PUBLIC HEALTH IN THEORY AND PRACTICE, by W. H. Welch. Yale University Press, New Haven, 1925. $1 00 NATIONAL HEALTH SERIES, National Health Council, New “ York, 1924:.. 20 Vols., 30 ceuts each. THE COMMUNITY HEALTH eee by A. C. Burnham, Macmillan Co., New York, 1920. 1.50 AN OUTLINE OF THE PRACTICE OF PREVENTIVE MEDI. CINE, by Sir George Newman. Ministry of Health, London, 1919. ee MINISTRY OF HEALTH, by Sir Arthur Newsholme. G. . Putnam’s Sons, London and New York, 1925 $2.00. bone for which the price is given in the accompanying list may be ordered from The Survey and will be sent postpaid. 166 tures. Its more important present objectives are out- lined in the admirable series of monographs issued by the National Health Council. The broader social aspects of the public health move- ment and its relations to general medical practice have been analyzed by Burnham and Newman; while News- holme gives a valuable picture of what has been accomplished in the field of public health administration in Great Britain. No attempt is here made, of course, to refer to the many admirable texts on the hasic subject of public health but only to those dealing primarily with health ad- ministration. See also Survey Reading Lists No. 1 (Psych- iatry and Mental Hygiene, Nov. 1, 1923; Nos. 3 and 4, Social Hygiene, Feb. 15, 1924; No. 5, Nutrition, April 15, 1924. APPY legends to the contrary, there seems no reason to believe that the world ever has known a golden age of health. Geologists find diseased bones which are thought to show that even great pre-historic lizards and after them the early mammals, suffered from tumors and infections, and even knew the fate which, accord- ing to the advertisers, will claim the teeth of four out of five of us. Man probably falls heir to troubles which other flesh suffered before him. By herding in crowds, by giving up his dower rights of sunlight and space, he even has added to many of those ' troubles, has created wholly new ways of wracking body and mind. For a time the balance of life and death prom- ised doom to cities; they survived only because life was pro- duced abundantly and cheaply without their walls, and the best and most adventurous were fed into them. The slow process of observation and control which has made it safer now to live in a big city than in a village, (and often safer to live in a city than in the open country itself) is the science of public health. T is amusing enough now to hear how early students of public health investigated the theory that tomatoes were the cause of cancer, that diphtheria bred in house drains, that the ozone in the air produced pneumonia. ‘The serious point was that they were accepting the theory that disease was caused, and caused by something which could be studied, not a mysterious stroke from blind providence. Their pro- cess of noting and investigating single instances, and of formulating their outcome in the hope of finding a common quality or law, is that of science itself. This issue of The Survey shows the application of that process not to the individual but to the whole group of people who make up a city. The science of health administration (as opposed to that of the cure of disease) is built on a study of the case histories of cities, as medical practice is determined by the physicians’ study of experience in other cases of the same disease. Its body of laws show reactions and interactions of human health as other sciences show them in terms of atoms or acids and alkalis. The product—health—needs little selling. Everyone wants it for himself and his family. But the process which is back of the health of a community and of individual health in a community, is too little known. Dr. Hermann Biggs expressed its negative objectives when he wrote on the bulletin of the New York State Department of Health “Public health is purchasable. Within certain limits a com- EDITORIALS. munity may determine its death-rate.” Even more impor- tant, perhaps, is the possibility which this new science holds out to those who will take it, to determine the quantity and quality of its life-rate, HE citizen must realize fundamentally that he needs a city health department and the protection it gives him. That realization is coming to be nearly universal. But he must also realize that he needs in it a man who can give his whole time and attention to the practice of public health. ‘That is an issue where fighting is still to be done. What city would rely today on a part-time fire de- partment, even if the volunteers were good enough for our grandfathers? What city today would allow a Herbert Quick to divide his time between practicing law and super- intending its schools? The civic pride which insists on a full-time and highly paid corps of experts to represent a city on the league baseball diamond will hardly be satisfied— once the stakes are clearly seen—to compel its health officer to eke out his existence by splitting his time between public and private service. Yet as Mr. Kingsbury pointed out in Survey Midmonthly for October 15 (p. 91) only three of the ten cities of more than 50,000 population in New York state have full-time health officers, and though some other states make a better showing the need for greater concen- tration of health effort is a general one. City managers save cities money: Louis Brownlow in Knoxville was even able to make a ten per cent refund on taxes paid: and city man- agers are now recognized as experts to be hired where they can be found (regardless of local residence) and paid ade- quate salaries. Full-time health officers save cities lives: once that fact is common knowledge their status as public servants must be recognized and improved, until the worst of the troughs in American health practice to which Sir Arthur Newsholme calls attention so pointedly are leveled up and form the basis for new achievement. N October 15, the forty-fifth annual convention of the American Federation of Labor elected William Green president of the federation, thus reaffirming the action of the federation’s executive council in designating him to fill out the unexpired term of Samuel Gompers who died on December 13, 1924. The election of the former secre- 167 168 tary-treasurer of the United Mine Workers of America to the highest office in the gift of the organized labor move- ment was uncontested, unanimous, and enthusiastic. Mr. Green has neither the vibrant magnetism nor the colorful personality of his predecessor. One of Mr. Gom- pers’ ardent admirers characterized him at the time of his death as an actor—a man who had conceived for himself a definite role and who always carried himself in conscious conformity with his conception. It was this histrionic quality in him that often conveyed the impression that hé was fearful lest the world might not accord him the importance to which his leadership of the American labor movement entitled him. It was this quality that seemed to explain a certain strut and bellicosity in his manner, a certain touch of Falstaffian bravado in his use of long, black cigars and other more potent stimulants. It accounted for his habit of hurling defiance at the “enemies of labor” and then sitting down with not a few of them at the banquets of the National Civic Federa- tion. Mr. Green lacks this picturesque quality. He is more like a Methodist bishop than a star of the footlights. He neither smokes nor uses liquor. He is barred by the rules of his union from membership in the National Civic Federation. He is not given to hurling defiance, except on all convenient occasions at the communists and other shades of “red.”’ The men who cheered him at Atlantic City acclaimed him as “Green the Peace Maker.” ‘This sobriquet referred more immediately to his remarkable success in settling jurisdic- tional disputes which had threatened to disrupt a number of the most powerful unions affiliated with the federation; but it referred also to the conciliatory attitude he has taken, during the months of his presidency, toward the American public in general. He has apparently determined to win for the trade unions such sympathy and solid regard that their right to participate in the government of American industry shall in due course be generally taken for granted. HIS attitude was manifest in the report of the Federa- tion’s Executive Council to the convention and in the resolutions which he supported. ‘The principal items in the report dealt with subjects that had been sponsored by Mr. Gompers, but those that were marked for special con- sideration conveyed an impression not only of a new emphasis but also of an almost fundamental change in policy. The first topic under New Economic Developments was the federa- tion’s affiliation with the Personnel Research Federation, an association of employers, trade unionists and technicians, devoted to the “scientific study of man in relation to his occupation,” and to the development of facts, both in the field of economics and that of psychology, “by which policies and methods may be evaluated.” ‘The second item dealt with company unions. Instead of brushing these rivals of the trade unions aside as beneath contempt, as dishonest snares of “industrial autocrats” for luring wage-workers away from their proper allegiance, it declared that “‘it is useless to con- tinue to use tactics and methods adapted to organization of industry and methods of opposition based upon conditions that existed in previous decades. “The unions that make progress against existing difficulties must be able to match brains against brains. . . . We should first collect data on -ments and technicians to this end. EDITORIALS company unions and then on the basis of this information plan further investigation and how best to secure the cooperation of research agencies.” Under Union-Management Co- operation, after stressing collective bargaining as the first function of. the trade union, “participation in finding better methods of production and greater production economies” was characterized as “the still more important service that the union can render.” ‘The prerequisites of effective co- operation are “‘well developed trade unions, and dependable, competent, expert advisors.” As supplementing this new emphasis upon labor’s interest in increased eficiency of production, the convention adopted a wage policy which President Green acclaimed as the “enunciation of a new era... a position far in advance of any we have taken before,” one demanded by the advent of giant electrical power. Instead of a “fair day’s pay for a fair day’s work,” instead of a “living wage,” organized labor will in the future base its wage demands on the increased productivity of industry resulting from its own more active cooperation in improving production and the heightened efficiency of machinery, especially electrical machinery. “We oppose all wage reductions,” runs the resolution as adopted after considerable discussion: We urge upon management the elimination of waste in pro- duction in order that selling prices may be lower and wages higher. To this end we recommend cooperation in study of waste in production. We hold that the best interests of wage- earners, as well as of the whole social group, are served by increasing production in quality as well as quantity, by high wage standards, which assure’ sustained purchasing power to the workers and therefore higher national standards for the environment in which they live and the means to enjoy cultural opportunities. . Social inequality, industrial instability and injustice must increase unless the workers’ real wages—the purchasing power of their wages—coupled with continuing reduction of hours making up the working day, are progressed in proportion to man’s increasing power of production. The Federation, under Mr. Green’s leadership, is making a point of stressing organized labor’s interest in more efficient and increased production, and in cooperation with manage- In formulating its new wage policy, it serves notice that a condition of cordial co- operation and sustained productive efficiency on the part of the workers is a reciprocal interest on the part of manage- ments and the technicians in labor’s desire to share in the results of increased efficiency. It would be a happy omen for the future of American industry if the groups of manage- ment engineers, such as the professional members of the Taylor Society who have made a gospel of efficiency in pro- duction, should take the initiative in meeting labor’s fresh interest in production by giving constructive consideration to the Federation’s new wage policy in its relation to their programs for the development of science in management. EADERS of the June Graphic will remember Judge Lindsey’s story of the fight against him by the Ku Klux Klan, which first tried’ to legislate the Denver juvenile court out of existence, then ran a candidate against him in the elections, and finally endeavored to have the count thrown out in the courts. He defeated the Klan in the contest in the District Court. Recently the Klan EDITORIALS candidate against Judge Lindsey was found dead in his kitchen, with all gas jets turned on. It was pronounced a case of suicide by the coroner—no inquest being held. Pro- ceedings for disbarment upon charges of unethical conduct, made by his former clients were, at the time, pending be- fore the Grievance Committee of the State Bar Association. They were to have been finally heard the night of the day he was found dead. | Notwithstanding these circumstances, the Klan influence backing the contest is continuing the case in the Supreme Court, in an effort to have the judgeship of the Juvenile Court declared vacant. In that event they hope that the Klan Mayor will appoint someone of their choice to take _ over the Juvenile Court of Denver, as was originally planned. The case is now in the Supreme Court and a decision is expected within the next two or three months. SHE Sixth Assembly of the League of Nations was both disappointing and encouraging. achievements were minor or negative. Steps were taken looking towards the technical preparation for three inter- national conferences, one on disarmament, a second on the private manufacture of arms, and the third on economic problems. ‘There is no assurance, however, that any one ~ of these conferences will be called within the next two or three years—although the subsequent developments at Locarno enhances that possibility. The assembly’s action in reference to them was rather an expression of hope than the laying down of a concrete programme. The failure to accomplish more was attributable in con- siderable part to the attitude of Great Britain. As the Foreign Policy Association Bulletin of October 16 puts it: _, .. despite the presence of Lord Cecil as the head of the delegation after Austen Chamberlain left, the British repre- sentatives on almost every occasion found reasons for not favor- ing affirmative action. It was thus with the proposal to ask the Council to make preliminary plans immediately for a technical survey looking towards an eventual disarmament con- ference. They opposed plans for an international economic conference under the auspices of the League. They sought to minimize the importance of arbitration and to exalt the pro- cedure of political or diplomatic settlement. In short, they seized nearly every opportunity to explain why the League for this reason or that should remain quiescent. It is encouraging that this policy of negation found little support. Led by France, most of the states fought it. Before the end of the Assembly this opposition became so evident that the British were isolated and put on the defensive to a humili- ating degree. The League again, somewhat as in the case of Corfu and Italy, became a great international forum at which the moral sense of the world made itself unmistakably felt. To a degree unthinkable under the old diplomatic pro- cedure the small states were able to express with impunity and complete frankness their opinion of Britain’s policy. ‘They reaffirmed with every evidence of sincerity their faith in the principles of the Geneva Protocol: security, arbitration, dis- armament. It was a wholesome and refreshing spectacle. Equally encouraging was the cumulative evidence at the Assembly that the League has become institutionalized. It has grown to be a fixed habit for the responsible governmental authorities of more than fifty states. More and more foreign ministers, heading their respective delegations, utilize the Superficially its 169 Assembly as the most convenient means of doing in informal conferences within a few weeks what would require many months to do less well with the more usual diplomatic pro- cedure, either the exchange of notes or communications through ambassadors or ministers. Similarly the vast improvement in the mere mechanics of this Assembly over that which met five years ago is a con- vincing evidence of healthy growth. Both in the general meetings of the Assembly and in the Council, commissions and committees, there is constantly offered even to the casual visitor unmistakable signs that all of these organs of the League are functioning with a smoothness and pre- cision not always equalled by our national parliamentary or administrative bodies. And this, despite the heterogeneity of race, religion, legal and social background and language. Despite, therefore, the lack of brilliant achievements at this Assembly, it is indisputable that the League is more firmly entrenched in the confidence of the great majority of the states than ever before. It has decisively demonstrated that it has become an essential and. integral part of the world’s international machinery. ONCILIATION, not dictation, was the dominant note of the Locarno conference, which came on the heels of the Geneva meetings and which may even be said to have reacted to their psychology. It gave another chance for a more affirmative front, and this time the British did not hang back. Fundamentally the spirit in which it was entered upon was symptomatic of the weakening of the hitherto prevailing war psychology. Western Europe is determined to have peace. ‘The brilliant achievements of those two weeks at Locarno are the measure of this desire. Unlike the Protocol at the League of Nations Assembly last vear, the treaties signed at Locarno are likely to be ratified and to become an integral part of the published law of Europe, because they are the concrete embodiment of the dominant public opinion on both sides of the Rhine. The following are the outstanding points of agreement: First: France and Belgium on the one side and Germany on the other mutually pledge to maintain the inviolability of the demilitarized Rhineland zone. Britain and Italy pledge themselves to guarantee this treaty. Second: Germany agrees to enter the League of Na- tions without formal reservations in a special session of the Assembly to be called within the next few months. She is to be assured a permanent seat on the Council. There is a gentlemen’s agreement to support an interpretation or amendment of Article XVI of the Covenant (which pro- vides for sanctions) so as to take cognizance of Germany’s contention that her disarmament under the terms of the Treaty of Versailles left her in an exceptional position. It is also generally believed that the Allies have given a verbal promise that the evacuation of Cologne will take place soon; that the withdrawal of the allied troops from the rest of the Rhineland will be expedited; that the final determina- tion of the fate of the Saar may be made before the period provided for in the Treaty of Versailles; and possibly that 170 Germany may have returned to her under a mandate one of her former African colonies. . Third: General arbitration treaties have been signed between Germany and four cf her neighbors, Belgium, France, Poland and Czechoslovakia. These in effect outlaw war because under their terms all questions arising between the countries concerned must be referred to arbitration or to commissions of conciliation. If the latter fails to reach an agreement, the question at issue then goes automatically to the Permanent Court of International Justice.’ Even this brief summary gives some sense of the enormous gains embodied in these seven treaties. They mark drama- tically the close of one period and the beginning of another. If ratified, they can only mean that Europe has at last declared peace—and begun its prosecution. And peace on the west front means an infinite variety of human consequences—social, economic, psychological, in all that great workshop of steel and iron and coal and fabricat- ing centers which has been Europe’s battleground for cen- turies but which is, regardless of political boundaries, a great production region; the homeland of countless wage earners, German, French and Belgian. N that reawakening of race consciousness and pride in its own substantial achievements which several contri- butors to the Harlem number of The Survey marked as a factor of vital importance in Negro progress, the Association for the Study of Negro Life and History has played a distinctive part. It has just celebrated at its headquarters in Washington the tenth anniversary of its foundation. A two-day convention, with a program of scientific papers, such as it has offered annually, and with a special anniversary exhibit of historical documents, marked the occasion. The association is the outgrowth of the research and executive effort of Carter G. Woodson, who edits its offi- cial organ, the Journal of Negro History. This scholarly quarterly has now gathered, in its ten volumes of articles, monographs and reprinted rare documents, a body of in- formation upon the Negro of encyclopedic range and au- thority. In addition to this major effort, the association has given great impetus to the scientific historical training of Negro students, by supporting graduate scholarships for the training of expert historical investigators, and has also maintained through the affiliated Associated Publishers Inc. a two-fold series of book publications in furtherance of its aims. One of these is a series of more or less popularized but painstakingly accurate manuals such as Dr. Woodson’s The Negro in Our History and Mr. Kerlin’s Negro Poets and their Poems, designed for popularizing for the general reader, and especially for Negro schools, the au- thentic facts of race history and race progress. ‘The other isa series of monographs in Negro history, largely the work of Dr. Woodson or of investigators trained under him. In this way Dr. Woodson’s own The Education of the Negro Prior to 1861, History of the Negro Church, Fifty Years of Negro Citizenship as Qualified by the United States Supreme Court, and A Century of Negro Migration have appeared along with other notable studies like A. A. EDITORIALS Taylor’s The Negro in South Carolina During the Recon- struction, a similar study of the Negro in Virginia, a Docu- mentary History of the Negro Colonization Movement, and a Census Analysis of the Free Negro Population in 1830. Although the extension work of the society has been made possible by the general contributions of contributing and sustaining members, a large number of whom are Negroes, the research work, or at least its publication, has been made possible largely through the grants, over a five-year period, of $25,000 each from the Carnegie Corporation and the Laura Spelman Rockefeller Memorial. The association has creditably succeeded in putting the important question of history as it relates to the Negro upon a sound scientific basis, and rescued it, one may say, from the all too prevalent controversial bias and amateurish incompetency that formerly were tolerated in this field in which the work even of reputable historians has reflected in many cases almost total neglect of Negro sources and ex parte judgment. It has thus performed a general ser- vice to American historical scholarship. In addition, of course, it has been a helpful service to stimulate pride and knowledge of race among educated Negroes and to promote Negro scholarship. The immedi- ate projects of the association are a continuation of the pub- lication of monographs, especially relating to the difficult and misunderstood period of the Reconstruction, studies in the economic and social aspects of the Slave Regime, the printing of documents bearing on early Negro life in Ameri- ca collected from letters and manuscript sources, and the undertaking, if possible, of two new avenues of investigation ~—Negro folk-lore and studies in African history and culture. EPORTS trom China reflect a growing pessimism on the part of foreigners and Chinese over the possibility of a successful conclusion of the Customs Conference and the meeting of the commission on extra-territoriality about to begin in Peking. The international judicial inquiry into the Shanghai shooting, begun by the Powers in the face of strenuous Chinese opposition, has created a difficult setting fer the more important diplomatic negotiations. The in- quiry, delayed by months of bickering, is being boycotted by the Chinese on the ground that it cannot disclose any facts not already brought out by the earlier commission of inquiry, whose recommendations have been buried in the archives of the foreign embassies in Peking. It is serving, apparently, further to inflame Chinese opinion and to re- vive the indignation aroused by the violent outbreaks of last May and June. In such an atmosphere formal diplo- macy, seldom capable of constructive action at best, is severely handicapped. Meanwhile, meeting at Baltimore in September in the informal setting of the Johns Hopkins campus, the Con- ference on American Relations with China revealed the potentialities of unofficial public opinion. ‘The two hun- dred men and women who went to Baltimore represented virtually all of the interests concerned in American rela- tions with China: business, education, the church and missions, the press. ‘They reflected all shades of opinion, and while they failed to agree on the program to be fol- EDITORIALS lowed in carrying out the reforms which all felt must come, they met and exchanged ideas with a frankness which led to full and sympathetic understanding. A SENSE of the urgency of immediate action prevailed throughout the conference. The discussion inevitably centered about the dominant aspirations of China, ably presented by a little group of Chinese students, a Chinese educator representing the best of Eastern and Western cultures, and the Chinese Minister to the United States. Should American citizens press their government to go further in meeting Chinese demands for customs autonomy and revision of unequal treaties than other powers are ready to go? Should China pledge herself to maintain an administration of justice adequate to safeguard foreign interests? What is meant by “immediate autonomy”? On these and other questions the Conference was frank to ad- mit its divergence of opinion. On the fundamental issues, however, the’ Conference ‘was in accord. By HARVEY CUSHING awe publication of the Life of Osler by his friend and disciple, Harvey Cushing, is an event. Osler’s profound influence pervaded the whole of the English-speaking world. His name was a talisman wherever medicine was taught, studied, or practiced. The vari- ety of his interests, and his we ve cae 8 poe enormous powers of work, made Siargeeaen eeontisniecest his life a kaleidoscope of public thirty-three halftone plates, and six collotypes. The bind- ing is blue cloth with gilt lettering. Price in a box $12.50 net At booksellers or from the publisher activity. It is impossible to read fifty pages of this book without realizing that Osler was indeed a very great man. It is not technical, and the layman will perhaps be even more struck than the professional by the pic- ture which the “Life” gives of the profession as a whole. The secret of a wonderful life is unfolded in these pages. OxFORD UNIVERSITY PRESS 35 West 32nd Street American Branch New York }. Womans The Womans Press 600 Lexington Ave., New York, N. Y. Haier Are you interested in religious education? Are Have You need SAINTS AND LADIES By CrarissA H. SPENCER 1.50 She writes of the response of women to Christ’s challenge: ‘“‘Behold I have set before thee a door opened that none shall shut.” you responsible for physical educa- tion? You should own WOMAN’S PHYSICAL FREEDOM By Cretia D. MosHer, M.D. 1.00 Dr. Fishbein says it is the most sensible brief book of advise to women ever written. you a budget to raise? You must have FUNDS AND FRIENDS By Toitman LEE 1.50 “Tt will be of great help to those who raise benevolent funds, college presidents, denomi- national secretaries, social agencies, pastors of large churches.” Warren H. DENISON I. THE LARGE CITY (Continued from page 144) are inspected and scored monthly, while the milk plants, where 98 per cent of the supply is pasteurized, are super- vised by more frequent inspections and by laboratory methods. All the milk sold in the city whether pasteurized or raw is obtained from tuberculin-tested herds, approxi- mately 25 per cent being of Grade A quality, including the 2 per cent of the total supply sold raw. In New Orleans, Louisiana, a systematic sanitary inspec- tion for the abatement of nuisances and control of breeding of flies and mosquitoes and the destruction of rats is carried on vigorously by the department on its own initiative and in response to complaints. An interesting step in coordination of activity in Chicago has been the organization of a bureau of inspection service, the personnel of which comprises former quarantine officers, sanitary inspectors and food inspectors other than those as- signed to technical meat and milk inspection, The city is divided into one hundred districts, two to each ward, and each inspector handles the quarantine work and gen- eral inspection in his district. Sanitary inspection includes not only the abatement of nuisances discovered as a result of citizens’ complaints, but a systematic house-to-house in- spection for the remedy of violations of the sanitary law and overcrowding; control of the sanitary condition of stables is maintained and suitable action is taken to control the fly nuisance. Particular emphasis is put upon the abate- ment of excessive smoke discharge from power and heating plants and factories. A comprehensive study of ventilation has been made and reasonable regulations instituted for the ventilation of places of public assemblies and public con- veyances. 10 Public Health Education. Education of the public in * principles of healthy living is a mostimportant activity. The health department depends for its support upon the public and must keep the people informed of its activities and of the developments in the public health field. In most cities, however, public health education as a service of the municipal health department is still an ideal rather than an accomplished reality. In Detroit, a publicity di- rector has charge of the educational work of the depart- ment. Weekly and monthly bulletins are issued, press stories and news items are prepared for the papers, a portable exhibit is utilized, and lectures are’ frequently given by members of the department staff to various civic clubs and local organizations. Finally, it may be appropriate to refer to that form of public health education which is carried on by voluntary agencies devoted to experimentation with the newer forms of public health activity, to the criticism and helpful sup- port of public authorities and private organizations exer- cising recognized and established health functions, to the mobilization of popular support for the community health program and to the general dissemination of information in regard to it throughout the community. However per- fect the work of public health authorities may become there will always be need for a voluntary organization of this type in every progressive community. (In answering advertisements please mention Tur Survey. It helps us, it identifies you.) 180 Il. THE SMALL CITY (Continued from page 146) two plans, with an estimate of comparative cost, is given below: Type Specialized Generalized of Nurses Nurses (1:2,500 pop) Service Number Number Administration ........... Director Director Administration* ......,.... 2supervisors Asst. Director Communicable Disease .... 2 Venereal Disease ......... 1 Tuberculosis .............. 1 20 Maternity (Pre-natal, de- field livery, post-natal) ....... 8 Nurses; Infant ................05, 4 4 acting Pre-school ................ 2 as School ................... 4 super- Care of sick .............. 9 visors Total vo. cece eee 29 22 Budget (plus clerk and maintenance)** ......... $48,700 $38,400 Less estimated income from bedside nursing ...... Dad 3,250 2.560 Net cost ..............000, $45,450 $35,840 Per capita ........ cee eene 90.9 71.7 The inclusion of nine nurses for bedside care of the sick has been based on conservative sickness surveys and the actual practice in a city with a well-established nursing service, and: represents daily nursing service to fifty-nine individuals, exclusive of maternity patients. Since the success of any nursing plan depends upon wise supervision, provision has been made for this in both plans. In the plan of generalized nursing four of the nurses which have had special training are unassigned to a district. ‘These _ four nurses would assign and supervise the daily work of the remaining sixteen nurses, be principally responsible for: the clinic work and act as vacation substitutes. While it may appear too visionary to conceive of the entire public health nursing service of a city unified under one organization, the consequence of dividing the work among several organizations is chiefly the effect of dupli- cating the work, multiplying the administrative labor and increasing the cost to the community. In several cities as many as six organizations were found each employing only one or two nurses. It was usual to find three or four organizations each employing a small number of nurses. HIS plan outlined is only a brief analysis of the amount of health protective service that a community of fifty thousand population can buy for approximately one dollar and a half per capita—the price that the “average” citizen pays without a thought many times over during the course of a year when he buys a theater ticket or a restaurant dinner. It makes no pretense of being ideal or of being a model to accept or reject as it stands. It js rather a plan which may serve as a useful basis of comparison with the small city’s health activity and health expenditures, pub- lic and private. The specialist should see that his specialty is but a part of the whole, and the health officer, concerned in the development of a complete health service for his community, should find it a more concrete guide than he has possessed heretofore. The taxpayer will find it presents ‘a reasonable bill. *1 clerk is also included. **Exclusive of rent and transportation. “Books from Beacon Hill’? of Interest to Survey Readers ‘THE PRESCHOOL AGE: A Mother’s Guide to a Child’s Occupation By Minnie Watson Kamm Practical suggestions for the training of the small child’s senses. The author of this valuable book be- lieves that the energies of a child should not be left until the kindergarten time, but should be directed from the very beginning. She by no means limits herself to - the expensive Montessori apparatus but suggests a large variety of commonplace household articles, by — which the child’s senses are trained and his baby mind led forward by logical steps to ever greater develop- ment, while his curiosity and energy are given plenty of opportunity for exercise. Mrs, Kamm is by no means merely a theorist; she has put her ideas into practice and has developed them with her own family of children. A sensible mother with this book will be able to keep her not-yet-ready-for-school child properly employed to their mutual benefit. $1.50 MENTAL DISORDER AND THE CRIM- INAL LAW: A Study in Medico-Sociological Jurisprudence By S. Sheldon Glueck Professor, Department of Social Ethics, Harvard University The purpose of this volume is to interpret the law of insanity for psychiatrists and social workers, and the psychology and symptomatology of mental disorder for lawyers and judges, so that the two groups may. be in accord in their attitude on the problem of the mentally- disordered offender. Doctor William Healy, Director of the Judge Baker Foundation, Boston, considers the book “a splendid piece of work which might well become the standard reference book on this subject.” $7.00 FROM INFANCY TO CHILDHOOD By Richard M. Smith, M.D. The author’s first book, The Baby’s First Two Years, is a standard on the subject, and a host of parents will wel- come this new book which continues the care of the child from two to six years old. $1.25 WHEN LIFE LOSES ITS ZEST By Abraham Myerson, M.D. Professor of Neurology, Tufts College Medical School, Boston In this volume Dr. Myerson, an expert neurologist, ex- plains for the layman the causes of boredom—emotional, physical or social—of this morbidity of mind, this strange weariness that takes the zest out of life—and the cure for it. $1.75 HEALTH AND DISEASE: Their Determin- ing Factors . By Roger I. Lee, M.D. Contains the principles which should guide an individ- ual in living an effective life; and the principles which should govern a community in facing its many health problems. $2.50 THE UNADJUSTED GIRL. With Cases and Standpoint for Behavior Analysis By William I. Thomas The trend of this volume is toward solving, by modern humanitarian methods, the problems of the girl whose conduct does not conform with our social laws. This book has the backing of the most advanced thinkers and workers along sociological lines and should prove of great value. $3.00 Order these books from the Survey Associates, or from your bookseller, or from the publishers: Boston LITTLE, BROWN & CO. Publishers (In answering advertisements please mention THE Survey. It helps us, it identifies you.) 181 which occurred in Greater Pittsburgh in 1907, the di- rect cost was approximately $540,000, and that the 409 HEALTH WORK PAYS (Continued from page 126) teachers and physicians, the supplying of facilities. for the segregation of danger- ous cases, the inspection . deaths from the diesase in- volved a life-waste of nearly $2,500,000. The life-waste from typhoid fever in Pittsburgh for the years 1904-1907 was estimated at $9,000,000 in community capital, or enough to have built the $5,720,000 plant of the city and the 41 additional filter beds for serving Allegheny City and the entire Pittsburgh urban district. . Even in a city like New York which has spent hundreds of millions of dollars to insure a safe water supply, the immediate returns are so large as to make it one of the best investments which the city has ever made. For it must be remembered that a supply of pure water not only re- duces the mortality very appreciably but, what is perhaps even more important, cuts down a much larger amount of sickness. For every death from typhoid there are usually ten cases of serious, prolonged and very expensive illness. Among those who recover from typhoid fever there is double the expected mortality during the next three years. Further- more, water supplies polluted with typhoid fever germs often carry other sources of illness which, if not as fatal, are conducive to widespread sickness and disability. The health officer’s ideal of no typhoid fever is still far from attainment even in the large cities of the country which, on the whole, have the best facilities for typhoid fever control. There were only two cities of 100,000 pop- ulation or over in which there were no deaths from this disease during 1924. On the other hand, there were six cities which reported typhoid fever death rates above 10 per 100,000; one of them had a rate of more than 40. In certain states, especially in the South where there is a heavy rural and Negro population, the figures are still very high, indicating that there is much to be done along the lines of rural sanitation. But wherever a serious effort has been made to control the spread of typhoid fever, it has been effective, and at relatively small cost. Disease prevention is usually inexpensive; the salaries of health officers, sanitary inspectors and of nursing personnel are relatively small items, while the costs of sickness and of death are usually large and a crippling burden to any community. THIRD instance of the value of the public health compaign is the story of the reduction of diphtheria since the discovery of antitoxin by von Behring in 1894. At the end of the last century, diphtheria was one of the important causes of death, especially among children. In 1900, when the first registration figures became available, this disease had a death rate of 43.3 per 100,000. In 1923 the figure was 12.1. The rate has been reduced to hardly more than a quarter of that of twenty-five years ago. To- day we are considering seriously the possibility of the com- plete elimination of diphtheria by 1930 in such large areas as the state of New York. Nor is this an idle dream; it is the ambition of responsible health agencies which are very conservative in their aims and plans. The almost precipitate drop in this disease is the reflex of the widespread use of antitoxin by physicians and health departments and more recently of the prevention of infection through the im- munization of children. The health officers have been the responsible agents in this achievement in the preparation and distribution of antitoxin, the -education of mothers, of school children, and more recently, of wholesale Schick testing and of im- munizing those who are susceptible. The expenditures for such service again are relatively small as compared with the value of the results obtained. ‘The returns of the Com- mittee on Municipal Health Department Practice show that child welfare work, including the control not only of diph- theria but of all other contagious diseases, cost only betweer seven and eight cents per capita a year in seventy-two of the larger cities of the country where information is avail- able. In most communities an expenditure of about fifty cents per capita would provide adequately for the control of all communicable diseases including nursing service, hospitalization and other measures usually administered by health departments. 23 YEARS OF PROGRESS IN TUBERCULOSIS CONTROL Deathrates per 100,000 - Tuberculosis - all forms Original Registration States and District of Columbia, 1900 to 1922, DATA | Year Rete Year 1900 195.2 i911 1§9.0 1901 189.6 1912 49.6 1902 1141 ° 1913 148.7 1903 WH i9/4 146.6 1904 188.5 915 46.7 1905 1809 1916 143.6 1906 177.8 i9!7 147.1 ISO7 175.6 1918 151.0 1908 1694 1919 1249 1909 633 © 1920—s 112.0 1910 1647 = 92). aes 1922 92.3 Throughout 23 years, 8 tote! fall of 85 deaths per 100000 of population, or 43 percent. A much more rapid rate of decline between 1918 and 1922 (10.2 percent per year) than in preceding !7 years (1.6 percent per yesr). THE .TUBERCULOSIS DEATHRATE 1S STILL DECLINING RAPIDLY One might proceed in this manner and show that tuber- culosis and other preventable diseases upon which public health efforts have concentrated have responded favorably to the work done, and that the results have more than justified the expenditures. The amounts available to health officers have been so meager and the improvement in health conditions have been often so striking that rarely has any criticism been directed at their work except by persons asso- ciated with cults and groups who either deny the existence of disease altogether or who question the validity of mod- dern medical practice as a whole. | We do not claim that the reductions in the death rate and in the sickness rate have resulted only from the activi- ties which health officers have instituted. Allied to official nublic health work there has been the constant effort to raise standards of medical practice, to promote hygiene in- struction in the schools, the movement for physical educa- tion and recreation, the activities of women’s clubs and of journals devoted to home interests, the work of the life insurance companies, the rise of public health nursing, etc., ctc. The health program of the last half century has had many irons in the fire; it has made use of a multitude of measures, some sanitary in character, others educa- tional, and still others social and industrial. In addi- tion to controlling the specific causes of disease, the aim has been to help break the chain of infection, to 182 improve the general wellbeing of the population, to in- crease the resistance of children and, above all, to teach people to live more intelligently and happily. The sum total of such efforts has been responsible for the gains. But, in all of this, the health authorities and their associates in the private welfare agencies have been the center of in- fluence. But for them, the other efforts would either not have arisen or would not have been carried oftt. They have often been influential in stimulating others to do what they have not done themselves. N the record of the last fifty years it is clear, first, that health, work pays large returns; and, second, that we have not by any means exhausted the possibilities of our investment. When in a group of the larger cities of the country, the average amount spent for public health work is only fifty-two cents per capita, it must be obvious that we have barely scratched the surface. When the losses from ill-health and premature death are so great and so readily preventable, is it not an indictment not only of our better feeling, but also of our good judgment as a business people that we have been so slow to extend our efforts along ap- proved lines? If a city can reduce its infant mortality a half by expending for a few years fifty cents per capita (and this has been demonstrated too many times to need repetition here), then it is bad judgment on the part of the city fathers if they delay their resolution and activity a day more than is necessary to organize the work for a successful conclusion. And the same may be said to a greater or less degree of those other agencies which a mod- ern and well-conceived health department ordinarily would organize. But, in periods of heavy municipal expenditure and of burdensome taxation by all branches of government, fed- eral, state and municipal, those who are responsible for budgets may be especially skeptical. For them, it is possible to point to very specific demonstrations in the last ten. or fifteen years which have shown, perhaps even more dramati- cally than the routine achievement of health departments, how profitable well-directed expenditures for health work may be. Again let me draw in the experience of the Metropolitan Life Insurance Company as a striking ex- ample of the economic soundness of a preventive and edu- cational program. ‘This business organization in the last fifteen years has expended a total of $18,709,000 in the conduct of its public health campaign for industrial policy- holders. It has increased its annual budget for welfare work in response to an increasing demand for service and also to the increasingly favorable results of the work done. For in the interval, the mortality rate has declined more than 30 per cent, and the accumulated saving in mortality between 1911 and 1923 which can be ascribed only to the work of the Company has totaled the amazing sum of $35,000,000, nearly twice the total expended. . ~The Framingham Tuberculosis Demonstration, financed by the Metropolitan and conducted by the National Tuber- culosis Association, cost $200,000 during the seven years of its existence. But during this interval the death rate from tuberculosis in Framingham declined from 121 per 100,000 for the decade preceding 1917 to 38 per 100,000 in 1923. During the same period the death rate from tuberculosis in a group of control communities ‘declined 32 per cent, less than one half the Framingham (Continued on page 188) @ée WORLD IN REVIEW Europe urns the Corner By STANLEY HIGH Introduction by COLONEL EDWARD M. HOUSE “The book is one of the most illuminating that have been written on the situation in Europe and will give the reader an entirely new point of view. No student of contemporary history can afford to ignore it.’’— New York Evening Post Literary Review. Net, $2.00, postpaid. The Recent Foreign Policy of the United States Problems in American Cooperation with Other Powers By GEORGE H. BLAKESLEE “Throughout the work the author makes himself neither the advocate nor adversary of any controverted policy. He is eminently fair in starting both sides, adhering to facts which he has gathered with painstaking effort. The book can be profitably read by American citizens who are anxious to gain a far wider knowledge of the foreign policy of the United States.’—The Oakland (Cal.) Tribune. Net, $2.00, postpaid. The Political Awakening of the East Studies of Political Progress in Egypt, India, China, Japan, and the Philippines By GEORGE MATTHEW DUTCHER “Moderation and common sense. fairness and impartial- ity are among the qualities radiated from these pages. The originality of thought and treatment, shown time and time again, lighten the pages and add to the en- lightenment of the reader. One is impressed also by the amount of valuable and needed material that the author has been’ able to bring together.’’—A merican Political Science Review. Net, $2.00, postpaid. Economic Liberalism | By JACOB R. HOLLANDER “Tt is Professor Hollander’s opinion that the spread of economic liberalism is broadly modifying that old domi- nant spirit of Americans which prevailed during Colonial days, and that the traditional individualism is being slewly changed.’’—Journal of Commerce. Net, $1.50, postpaid. © At the Better Bookshops THE ABINGDON PRESS NEW YORK CINCINNATI CHICAGO BOSTON DETROIT PITTSBURGH KANSAS CITY SAN FRANCISCO PORTLAND, ORE. The Negro Year Book 1925-1926 edition on sale. The standard work of reference on all matters relating to the Negro. Gen- eral and special bibliographies. Presents a_ succinct, comprehensive and impartial review of the events of each year as they affect the interests and indicate the progress of the Negro race. In addition to its interest to the general reader, the book is especially adapted | for use in schools where historical and_ sociological courses.on the Negro are given. Price, paper cover, $1.00; board cover, $1.50. NEGRO YEAR BOOK COMPANY Tuskegee Institute, Alabama (In answering advertisements please mention Tus SurveY. It helps us, it identifies you.) 183 WESTERN RESERVE UNIVERSITY School of Applied Social Sciences CLEVELAND Offers exceptional opportunities for graduate professional study and training in social administration. Public Health Nursing Family Case Work Child Welfare Group Service Work Write now for Information. Application foe admission must be made in advance. JAMES ELBERT CUTLER, Ph.D:, Dean, 2117 Adelbert Road, Cleveland, Ohio LECTURES WILLIAM PEPERELL MONTAGUE, Ph.D. Professor of Philosophy in Columbia University Will deliver a course of Six Lectures in The Community Church Auditorium Park Avenue and 34th Street, New York City. On Thursday Evenings at 8:15 On RADICAL SOCIAL THEORIES Dec. 3—Socialism and Justice Dec. 10—Socialism and Liberty Jan. 7—Democracy and Dictatorship Jan. 14—Democracy and Anarchism Jan. 21—Internationalism and the Pacifist Ideal Jan. 28—Internationalism and the Patriotic Sentiment Course tickets $3.50, can be secured in advance at the Office of Community Church, 12 Park Avenue. Single Admission 75 cents. School of Social Work Simmons Calleye Courses in MEDICAL SOCIAL WORK Miss Kate McManon’ In charge Seminars in problems of medical social case work and administration, with coordinated field experience. PSYCHIATRIC SOCIAL WORK | Dr. Kart M. Bowman’ In charge Miss Suziz Lyons In charge of field work For specialists in psychiatric social work.—Also courses in the psychiatric approach to other fields of social work. Address The Director, 18 Somerset Street, Boston, 14, Massachusetts. ai Summer Institutes July 7 to August 18 The Bureau of Educational Experiment 144 West {3th Street New York City HEALTH EDUCATION AND THE NUTRITION -CLASS—A Report of the Experiment at P.S. 64, Manhattan. Descriptive and Educational Sections by Jean Lee Hunt. Studies of Height and Weight and Mental Measurements by Buford J. Johnson, Ph.D. Report on Physical Examinations, 1919-1920 by Edith M. Lincoln, M.D. 1921. Pp. 281. With numerous graphs and _ statistical tables. Price $3.50; Postpaid $3.60. Publication List sent on eee In addition to its present available material, the Bureau expects to issue during the coming year further studies on the growth of children and. on the Nursery School. TRAINING IN RECREATION Professional training for group leadership and recreation: play production for amateurs; stage and costume design; folk dancing; games; story telling; handcraft; gymnastics and athletics. Catalog. Recreation Training School of Chicago 800 S. Halsted Street (Hull-House) CORRESPONDENCE SCHOOLS 10,000 MEN AND WOMEN from all walks of life now studying the Bible under competent guidance. COURSES available. New course, JESUS’ WAY OF LIVING.’’ Modern Bible study broadens vision—deepens wisdom. Begin now. _Descri rele literature free. ALL COURSES, 75c each. 5 or moretoone Spa 60c each. The American Institute of Sacred Literature The Aniversity of Chicago Dept. 350 , Chicago, fll. SOT vi Become More Efficient Courses in Mathematics, Chemistry, Psy- chology, Education, Business and 40 other subjects command either High School or Ho O a ‘y College credit. Start any time. The Anibersity of Chicago é 19 Ellis Hall GHICAGO, ILL. (In answering advertisements please mention Tur Survey. It helps us, it identifies you.) “PLEASE RECOMMEND A TRAINED PUBLIC HEALTH NURSE” Are you ready for this call? The demand far exceeds the supply. Training Courses Begin February 1 and September 7, 1926 (1) Nine Months’ course in theory and practice equips graduate nurses to accept responsible positions as visiting nurses, community nurses, school nurses, industrial nurses, child health workers. (2) Four Months’ course of supervised and inter- preted field experience, for benefit of employed nurses who must postpone full training, earns partial credit upon full course. Field work includes observation and practice of social case work and community social work, as well as general and specialized public health nursing in urban and non-urban communities. Apply for special bulletin of Department of Public Health Nursing, THE PENNSYLVANIA SCHOOL OF SOCIAL AND HEALTH WORK 311 South Juniper Street, Philadelphia, Pa. The National Training School of the YOUNG WoMEN’s CHRISTIAN ASSOCIATIONS Graduate courses of interest to persons pre- paring for work with women and girls in social or religious organizations. Graduate | students in other institutions in New York City may register for single courses. Special arrangements for unclassified students with adequate experience in social or religious work. Spring Session opens February 3, 1926. For bulletins and information address NATIONAL TRAINING SCHOOL Young Women’s Christian Associations 135 East 52nd Street New York, N. Y. Smith College School for Social Work The Smith College School for Social Work operates in two successive sum- mers separated by a period of nine months of intensive field work during which each student gives her full time to some social agency. In 1925-26, students are attached to the Massachusetts General Hospital; Child Habit Clinics, Boston; Boston Psychopathic Hospital; Boston State Hospital; Foxboro State Hospital; Worcester State Hospital; Wrentham School for the Feebleminded; Manhat- tan State Hospital, New York; Essex County Juvenile Clinic, Newark, N. J.; Institute for Juvenile Research, Michael Reese Dispensary, Chicago; Philadel- phia, Minneapolis and St. Paul Child Guidance Clinics. The School emphasizes the applica- tion of modern social psychiatry and the psychiatric point of view in prepa- ration for case work in psychopathic hospitals, medical hospitals, child guid- -ance and child habit clinics, schools, Juvenile Courts, and other fields of social work. A summer course of eight weeks is open to experienced social workers. This course is designed for workers who wish to increase their theoretical knowledge, to study recent develop- ments in the field of social work, and — to obtain a fresh point of view in re- gard to problems of personality and the possibility of individual adjustments through a knowledge of psychiatry and the new psychology. A six weeks’ course is open to teach- ers and school deans. The course con- sists of a special seminar conducted by an experienced dean, together with lectures, discussions, and seminars lead- ing to an understanding of problems of personality and behavior. For information and catalogue address THE DIRECTOR College Hall 8, Northampton, Massachusetts (In answering advertisements please mention Tue SURVEY. It helps us, it identifies you.) 185 Sy CLASSIFIED ADVERTISEMENTS RATES: Display advertisements, 25 cents per agate lime, 14 lines to the inch. Want advertisements, 8 cents per word or initial, including the address or box mumber, for each insertion, minimum charge, $1.50. Cash with erders. THE SURVEY consecutive insertions. Address Advertising Department Discounts on three or more 112 East 19th Street New York City —_. WORKERS WANTED SITUATIONS WANTED GRADUATE NURSES, dietitians, labor- atory technicians for excellent hospital positions everywhere. Write for free book now. Aznoe’s Central Registry for Nurses, 3o N. Michigan Ave., Chicago, Illinois. FAMILY CASE WORKER, Jewish, who has sufficient training to do construc- tive work without close supervision and likes a pioneer job. Knowledge of Yiddish essential, Jewish Welfare Society, 156 E. sth Street, Erie, Pa. WANTED: Superintendent for Shelter for mothers and babies in New York City. Apply, Miss Drucker, 228 East 19th Street. HEAD OF BOYS’ DEPARTMENT in small Jewish Southern Orphanage. Un- married. Able to teach Hebrew and take care of athletics and musical activities. Apply Box 5306 with credentials. CASE WORK AGENCY in eastern city wants Nutrition worker with knowledge of Case Work. 5304 Survey. COLLEGE WOMAN, experienced re- search worker, graduate student Bryn Mawr, London School of Economics, de- sires position in statistical research, either social or industrial. Has special skill in chart making. 5326 SURVEY. .. MATRON, graduate nurse, dietitian, good manager, desires charge of cottage for children under school age; or will con- sider directing small home for crippled children with possibilities for individual touch. Middle aged, well bred, courteous, Protestant. Excellent credentials. 5319 SURVEY. YOUNG MAN, Jewish, 28 years old, experienced in handling boys for past two years in Orphanage, desires position with an Institution. Excellent references. 5331 SURVEY. POSITION as matron or Housekeeper in a small institution desired by experi- enced trained woman. 5328 SURVEY. WANTED: Organization interested in improving practice of case work desires women between 25-40 who may be holding supervisory or executive positions in case work, who are sufficiently skilled and in- terested in personal practice to return to it if compensation warrants. Reply stating fully, age, education, training, positions held and salary. Must speak Yiddish. 5322 SURVEY, . COOPERATIVE PLACEMENT SERYV- ICE. Social workers, secretaries, super- intendents, matrons, housekeepers, dieti- tians, cafeteria managers. The Richards Bureau, 68 Barnes Street, Providence, R. |. WANTED: a Dramatic Instructor and Coach for a large Jewish Community Cen- ter. Only those with best training and experience need apply. Good salary to the right person. 5329 SurRvEY. EXPERIENCED | stenographer wishes position two evenings a week and all day Saturday. 5327 SURVEY. A PUBLIC HEALTH NURSE with Social Service training, Tuberculosis, Hos- pital- Social Service, Industrial and organ- izing experience, desires position. 5330 SURVEY. EXPERIENCED Child Welfare Worker desires executive position in child-caring institution or Settlement, as organizer and club director or matron and housekeeper. 5317 SURVEY. EXPERIENCED PROBATION OFFI- CER, and executive wants position in Middle West or East. Several years in institutional work. Must have adequate salary. 5305 SURVEY. TEACHERS WANTED TEACHERS Wanted for colleges and universities. American College Bureau, Chicago Temple, Chicago; 1254 Amster- dam Ave., New York, — FOR THE HOME Alice Bradley, famous expert, “Shows just howtomake home cook- hg, cake-making, candy- making ive big profits. How to eater, run e TEA ROOMS, Motor Inns, Cafeter- own Bastions or oa ee tense Money, in your illus. booklet, “‘Cooking fo" ft. sa rE oe ; aa REE, Amer. School of Home Economic 849 .58th St.,Chicage HOSPITAL Social Service, Institutional, Settlement and Family Case Workers; Club Leaders and Trained Nurses, available for first class positions. Executive Service Corporation, Pershing Square Building, New York City. FOR RENT UNFURNISHED, NON-HOUSEKEEP- ING APARTMENT, 184 Sullivan Street, New York City, $65 per month. 1 large room, x small room, bath, 2 large closets. Up 3 flights on front of house. With use of garden, consisting of backyards ef 22 houses thrown into one, with trees, shrubs, grass, flagged walks, benches, etc. 2 blocks south of Washington Square. Near bus, 7th Ave. Subway, 6th Ave. “L”. Address K, care of THE SuRVEY, 112 East roth Street. LITERARY SERVICE We prepare essays, articles, club papers, speeches, etc. Let us do your research work. Satisfaction guaranteed. FAUL- CONER & STILL, Harrogate, Tenn. TRAVEL OPPORTUNITIES Earn Trip Europe or Palestine Lowest cost tours $390 up. Organizers, conductors, chaperons wanted. Allen Tours, Back Bay, Boston. WANTED: Copies of the Survey and Survey Graphic for 1924—Oct. 15; 1925— Feb. 15, March 1, 15. Unexpected demand has wiped out our stock. The Survey, 112 East 19 Street, New York, N. Y. Do You Need Institution Executives Superintendents Housekeepers Matrons Domestic Help Nurses Physicians Teachers Tutors Personnel Managers Industrial Welfare Workers Recreation Workers Boys’ Club Workers Girls’ Club Workers Social Case Workers Office Executives An ad in the Survey's classified de- partment will bring results. Rates: 8c a word, minimum charge $1.50 an insertion. THE SURVEY 112 E. 19 St. New York GRADUATE NURSE, age _ twenty- eight, six years secretarial, stenographic experience, ‘desires any executive position, possesses initiative, good education. Speaks Jewish, highest references. 5332 SURVEY. Advertise Your Wants in The Survey Bind Your Issues Our binder makes a book of The Survey. Put in each issue as it comes. ‘Take out any issue at any time without disturbing the others, Index free at the end of the volume, running six months. By return mail anywhere in the U. S. A. $2.20. The Survey, 112 East 19 St., N. Y. City. (In answering advertisements please mention Tue Survey. It helps us, it identifies you.) 186 CURRENT PAMPHLETS fifty cents a line for four insertions, copy to remain unchanged. CHICAGO STANDARD BUDGET FOR DEPENDENT FamiIuiges (Revised). Chicago Council of Social Agencies, 308 North Michigan Avenue, Chicago. 25c per ccpy. COOKING FoR Prorir, by Alice Bradley, describes home-study course, which in- cludes catering, tea room, cafeteria and lunch room management. “51 Ways to Make Money” free. Am. School of Home Economics, 5772 Drexel Ave., Chicago. ‘AGED CLIENTS OF BosTon SociaL AGENCIES, by a Group of Investigators and Social Workers, Lucile Eaves, Director. Ex- perienced Social workers comment on studies based on over a thousand case histories of care given the aged. Order from the Women’s Educational and Industrial Union, 264 Boylston Street, Boston, Mass., Cloth, 152 pp., $1.25. ‘THE SoctaL Workers APPROACH TO THE PROBLEM OF VENEREAL DISEASE is a pam- phlet containing information which every social worker, teacher, minister, and lay- man should have. It has been carefully compiled by the Venereal Disease Com- mittee of the Charity Organization Soci- ety and published by them in July 1925. Copies can be secured from the Commit- tee at 105 East 22nd Street at a cost of -25 per copy. { New Survey Book List—Write for it. Survey Book Department 112 E. 19 Se. New York BOARD New Jersey ‘ 7 Private fam- Ridgewood, New Jersey Frvate fam commodate one or two guests. Commuting Erie, Central. Ridgewood 125 M. 85 Woodside Ave. WEEK END GUESTS Week end guests accommodated. Home cooking. Duck and Chicken dinners a specialty. Trains met at Poughkeepsie. Phone 12. B. W. MOORE, R.N. Penmore Farm Pleasant Valley New York FOR THE HOME “Home-Making as a Profession” Is a 80-pp. ill. handbook—it’s FREE. Home-study Domestic Science courses. for teaching, institution management, etc. and for home-making efficiency. Am. School of Home Economics, 849 E.58th St., Chicage PERIODICALS Fifty cents a line for four insertions, copy to remain unchanged. THE AMERICAN JOURNAL OF NuRSING shows the part which trained nurses are taking in the betterment of the world. Put it in your library. $3.00 a year. 19 W. Main St., Rochester, N. Y. MENTAL HycizNne: quarterly: $3.00 a year: published by the National Committee for Mental Hygiene, 370 Seventh Avenue, New York. To Teachers of Sociology, Social Problems = ivics and Current Events OST teachers are experts in dealing with materials organized into textbooks or laboratory manuals. But there are areas of interest and information which are incapable of being so organized. They - must be taken as they come, or not at all. Such an area is that commonly called “current events.’ Although intensely interesting and im- portant, most teachers find themselves very much at a loss to know just how to deal with this area. It is easy to say to a class: “Find something interesting and tell about it in class tomorrow,” or “Read The Survey for December 15 and tell what you found there that was interesting.” But in both cases, your teacherly soul rebels against the smattering quality of the results. You feel you are wasting time and the students often achieve a fine degree of boredom. You want some- thing better. Well, here it is. We have published a handy little pamphlet which gives an analysis of social problems, a program for applying that analysis to class- room work and ways in which The Survey fits into such a program. It shows how The Survey can be used as a dependable current textbook of the world’s happenings in the fields of social progress and general welfare. A copy of the pamphlet will be sent gladly to any teacher who will take the trouble to send us a post card giving his or her name and address, name of the school and the subject taught. The Survey 112 East 19 Street, New York City ‘Printing Multigraphing Typewriting Mailing | Better, Cheaper, Quicker | We have complete equipment aud an expert staff to do your Mimeographing Multigraphing Addressing Mailing , If you will investigate you will find that we can do it better, quicker and cheaper tan you can in your own office. Let ws estimate on your next job ‘Webster Letter Addressing & Mailing Company 34th Street at 8th Avenue Longacre 2447 cree TE aT Fifth Avenue Letter Shop, Inc. 40 East 22nd Street nevent| Gedo BOCES O | Mais Ask The Survey about Us! _ Christmas Seals Stamp Out Tuberculosis The National, State and Local Tuberculosis Associations of the United States _ (in answering advertisements please mention THE SuRVEY. It helps us, it identifies you.) 187 Tune in on WPG and Chalfonte- Haddon Hall ~~ ROVE CHALFONTE-ADDON [ALL ATLANTIC CITY On the Beach and the Boardwalk. In the very center of things No message that you WRITE home from Chalfonte-Haddon Hall can be as gloriously convincing of the beneficial and delightful time you are having, as the message which you later TAKE home yourself, in good looks and. rénewed energy. A number of persons have grown so enthusiastic that they have made Chalfonte-Haddon Hall their permanent or semi-permanent home. American plan only; always open. Illustrated folder and rates on request LEEDS and LIPPINCOTT COMPANY. reduction (68 percent). The three years’ experiment by the company to reduce the infant death rate of Thetford HEALTH WORK PAYS (Continued from page 183) there was only apathy before. In connection with the re- duction of malaria there is fairly definite data of cost. Mines, in the Province of Quebec, succeeded beyond all measure. The expenditure of less than $30,000 carried with it a decline in the infant mortality rate from 300 per 1,000 births to 96 in the three year period. The Provincial Government is so convinced’ of the importance of this work that it has appropriated a half million dollars to be used along similar lines in other places in the province. These experiences may well give courage and resolution to public authorities who still hesi- tate to spend public funds. . The very extensive work ‘of the International Health Board of the Rockefeller Foundation is another example of a well-conceived and profitable investment in public health work. This organization concentrated its attention in the United States primarily on the eradication of hookworm and of malaria in the southern states. Both of these condi- tions result in the wastage of human life and energy to a degree quite immeasurable. For years whole areas of the South had suffered from this burden. Land values were reduced and industrial life was stagnant generally. In the face of this situation, the outlay of relatively small sums by the International Health Board and by the local authorities has changed the whole picture in many instances. Commu- nities have been relieved of the insidious infections of hook- worm and malaria; children have taken on a new lease of life and industry and agriculture are now possible where These show that in typical heavily infected communities, the disease has been virtually eliminated at a per capita cost of forty-five cents to one dollar a year, provided careful preliminary surveys are made in advance of the launching of the local campaign. When adequate central control has once been established, the work can be maintained from year to year at much lower cost. The chief lesson which we of the Committee on Muni- cipal Health Department Practice of the American Public Health Association wish to drive home is that good public health work pays and that the investment is one which should be made by all communities. In our judgment, it would be a relatively easy matter to prepare a balance sheet which would show the enormous disparity between the value of the results achieved by public health work and the cost of the service in the past. We need only to consider how valuable are human life and health to see how meager in- deed the financial items needed to remove the dangers which have been the special object of municipal and state interest. The experts of the Committee have reported that an ex- penditure of less than $2.50 per capita a year would permit the officials of the larger cities to do effectively all that they are now capable of doing. Certainly only the poorest and the most backward communities can now claim that they are incapable of making this moderate and assured invest- ment. (In answering advertisements please mention THE SurveY. It helps us, it identifies you.) 188 . _ Service cannot stop The telephone, like the human heart, must repair itself while it works. ‘The telephone system never rests, yet the ramifications of its wires, the reach of its cables and the terminals on its switch- boards must ever increase. Like an airplane that has started on a journey across the sea, the telephone must repair and extend itself while work is going on. To cut communication for a single moment -would interrupt the endless stream of calls and jeopardize the well-being and safety of the community. The doctor or police must be called. - Fire may break out. Numberless important business and social arrangements must be made. . Even when a new exchange is built and put into use, service is not interrupted. Conversations started through the old are cut over and finished through the new, the talkers unconscious that growth has taken place while the service continues. Since 1880 the Bell System has grown from 31 thousand to 16 million stations, while talking was going on. In the last five years, additions costing a billion dollars have been made to the system, without interrupting the service. , AMERICAN TELEPHONE AND TELEGRAPH COMPANY = AND ASSOCIATED COMPANIES | ly BELL SYSTEM TED LI One Policy, One System, Universal Service (Qe SERGALIRY QS G QL LD LOI PINION I VLALDOOD: 2 Teaching Staff of the New Core School of Social Work-—W inter Quarter 1926 (2 PORTER R. LEE ORDWAY TEAD EVAR? G. ROUTZAHN VALERIA H. PARKER M.D. KATE HOLLADAY CLAGHORN MARY ANTOINE TTR CANNON MARY SWAIN ROU TZAHN E. C. LINDEMAN HENRY W. THURSTON ee M. DAVIS, JR. JANE CULBERT HELEN PAYSON KEMPTON WALTER W. PETTIT LEROY # \. RAMSDELL, GORDON HAMILTON ’ ELEANOR NEUSTAEDT§£.& MARGARET LEAL MARION E, KENWORTHY SARAH IVINS S. STANLEY KING Ce Cee reste ; SHELBY M. HARRISON ELIZABETH DEXTER JEANNETTE REGENSBURG JOHN A. FITCH SAMUEL, BRADBURY LUCY CHAMBERLAIN RYAN LINDA WHARTON GEORGE W, KIRCHWEY ALBERT M. STEVENS — LEAH FEDER STELLA MINER STEPHEN P. JEWETT HTHEI, T. ALLISON O any student considering preparation for a position of responsibility and lead- ership in social work, the Announce- ment of Courses will be sent free upon request. The Bulletin will be found useful in map- ping out a program of study and training for success in the varied fields of social endeavor. ¢ # The diploma of The New York School: of Social Work is given upon the satisfactory completion of S1X- -quarters of such study. Matriculating at the be-. ginning of any quarter, the student may, if he wish- es, continue his studies without interruption until Praduacont The Winter Quarter begins January fourth. The New York School of Social Work, 107 East Twenty-Second Street, New York. A8eseesesesesaseseseseses S44464642646666446666444466466466664 Courses to be Presented at The New York School of Social W ork—W inter Quarter, 1926 METHOD of SOCIAL, CASE WORK HEALTH and NUTRITION _ LABOR PROBLEMS CONTENT of FAMILY CASE WORK PROBLEMS of DISEASE CURRENT EVENTS in INDUSTRY SOCIAL WORK and SOCTAT, CASE DISCUSSION CONFERENCE: LABOR LEGISLATION PROGRESS CHILDREN’S GUIDANCE BUREAU METHODS of SOCIAL RESEARCH SOCIAL CASE WORK - SOCIAL, IMPLICATIONS of MENTAL, SOCIAL SURVEYS and COMMUNITY LIONS IPN SD ID IOI ION ION scseeimiiowenttol IMMIGRANT PROBLEMS . 7 TESTING STUDIES CHTEpREN with SPECIAT, HANDI- DESCRIPTIVE PENOLOGY COMMUNITY PROBLEMS and ORGAN. . CRIMINAL LAW and PROCEDURE IZATION PECIAL PROBLEM: I RK » ECTAL PROBES. ig the WORK ef rie CAUSES of DELINQUENCY ADMINISTRATION of SOCIAL CHIED oy SPARS in DIFFERENT PROBATION cnd PAROLE AGENCIES 2 STA PRISON DISCIPLINE x) OC OOOO ONE NGO DVS DV DS DN DSS a hi