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Full text of "The community health problem"

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THE 
COMMUNITY HEALTH PROBLEM 






THE MACMILLAN COMPANY 

WBW VOMC • BOSTON • CHICAGO • DALLAS 
ATLANTA • SAN FHANCISCO 

MACMILLAN & CO., Limited 

LONDON • BOMBAY • CALCUTTA 
UELBOURNK 

THE MACMILLAN CO. OF CANADA, Ltd. 

TOSONTO 



The Community Health 
Problem 



By 
ATHEL CAMPBELL BURNHAM, M.D. 

HEALTH SERVICE, ATLANTIC DIVISION, AMERICAN RED CROSS; 

ATTENDING SURGEON, VOLUNTEER HOSPITAL, NEW YORK 

city; LIEUTENANT COLONEL, MEDICAL RESERVE 

CORPS, U. S. army; fellow new YORK 

ACADEMY OF MEDICINE 



Nrto fork 

THE MACMILLAN COMPANY 
1920 

AU Rights Reserved 



Copyright, 1920 

By the MACMILLAN COMPANY 

6et up and electrotyped. Published October, 1920 



c:) 






PREFACE 

The various requests the writer has received for references 
to health literature dealing with what has come to be known 
as the community health movement, have indicated the desir- 
ability of a brief treatise upon the community health problem 
in its relation to the modern conception of social medicine. 

The welfare worker who is called upon to meet, from a 
practical standpoint, health conditions as she finds them either 
in the crowded tenement districts of the larger cities or 
scattered over a large territory in a rural community, often 
fails to accomplish maximum results because of a hazy and 
fragmentary understanding of the health problem and very 
^ indefinite ideas as to its solution. Public health nurses and 
practising physicians, who because of routine duties have been 
unable to follow the recent health literature, are sometimes 
handicapped in their work because of a lack of understand- 
ing of the modern movement toward the socialization of medi- 
cine. For such, and for all others interested in the improve- 
ment of health conditions as part of a community welfare 
movement, this work is intended. 

The attempt has been made briefly to outline the health 
problem as it exists, and to indicate the most important of 
the measures which are being suggested for its solution, in 
order to permit the reader to secure in one small volume a 
fairly comprehensive understanding of social medicine in its 
relation to community health. 
New York City. 



25iG*i^ 



TABLE OF CONTENTS 

Preface 

CHAPTER I 
The Health of the Community 



CHAPTER II 
Sickness as a Cause of Poverty 15 

CHAPTER III 
The Private Physician and Community Health ... 23 

CHAPTER IV 
Health Departments and Community Health. ... 30 

CHAPTER V 
The Public Health Nurse 38 

CHAPTER VI 
The Campaign for Better Health 54 

CHAPTER VII 
Workmen's Compensation Insurance 67 

CHAPTER VIII 
Compulsory Health Insurance 75 

CHAPTER IX 
Industrial Medicine 84 

CHAPTER X 
State Medicine 92 

CHAPTER XI 
Health Centers 99 

CHAPTER XII 
The Social Unit Experiment 108 



CHArTER XIII 
TUBEBCULOSIS 115 

CHAPTER XIV 
Social Hygiene in its Relation to Community 
Health 123 

CHAPTER XT 
Rehabilitation of the Disabled 128 

CHAPTER XVI 
Endowed Health Demonstrations 139 

References to Recent Publications 150 



THE COMMUNITY HEALTH PROBLEM 

CHAPTER I 

THE HEALTH OF THE COMMUNITY 

The public health problem of today is a community prob- 
lem. It is no longer possible to separate the health of the 
individual from the health of the community at large. Con- 
ditions of work, play, education, food supplies and trans- 
portation, which were at one time largely the personal con- 
cern of the individual have today become community prob- 
lems and must be solved as such. The health of the individual, 
influenced largely by man's environment, presents a similar 
problem. 

THE RESPONSIBILITY FOR SICKNESS 

Responsibility for accident and disease is no longer con- 
sidered merely as a personal problem, it is a community 
problem as well. Just as we insist that every American shall 
have the benefits of public education so should we insist upon 
the inherent right of every American to the possession of a 
body free from the handicap of preventable disease. 

The causes of disease are found in individual, industrial 
and community conditions, many of which are under public 
supervision. These conditions must be studied and corrected 
by the community before any appreciable decrease in pre- 
ventable disease can be attained. For example, in order to 
protect the growing child from infection with bovine tuber- 
culosis the state health authorities may inspect and condemn 
infected cattle hundreds of miles away — cows which neither 
the child, nor hk parents, nor even his physician have ever 
seen. The community recognizes its responsibility in the case 

3 



4 THE COMMUNITY HEALTH PROBLEM 

of bovine tuberculosis but in the case of human tuberculosis 
the responsibility is less clearly defined. Some communities 
make fairly adequate provision for the care of the tuber- 
culous, others undertake the care of charity cases only and 
some make little or no provision for the treatment of patients 
suffering from this disease. 

Until comparatively recently the problem of public health 
has been almost entirely one of prevention in the case of 
acute infectious disease. Small-pox, typhus and plague have 
been all but completely wiped out. Scarlet fever and diph- 
theria have been greatly diminished. During the last few 
)'ears there has been a praiseworthy stimulation of interest in 
the prevention of disease, with a consequent steady progres- 
sion toward better health. The movement at present is, not- 
withstanding the rapid progress already made or, possibly 
because of the very rapid growth of the movement, somewhat 
inco-ordinate and characterized by a certain amount of dup- 
lication of effort and waste of energy which is, from the 
nature of things, unavoidable during the early stage of a 
movement of this sort. 

DISABILITY DISCOVERED BY THE DRAFT 

Examination of the records of nearly five million drafted 
men has focused attention upon the fact that there is in 
the United States a health problem which has been gen- 
erally disregarded. Not entirely so, because during recent 
years many exliaustive health surveys have brought to light 
a tremendous amount of untreated illness, but such statistics 
have been read by comparatively few and have not made the 
same impression upon the popular imagination as have the 
more striking figures which resulted from the draft board 
examinations. 

There is in every community, if we accept the figures of 
the Surgeon-General, a comparatively large amount of pre- 
ventable disease among young men between the ages of 18 
and 31. The figures vary somewhat in different parts of the 



THE HEALTH OF THE COMMUNITY 5 

country and there is a variation between the urban and rural 
population, but the figures taken as a whole represent an 
approximately accurate cross section of the country. 

The following figures furnished by the Surgeon-General* 
of the U. S, Army, indicate the percentage of disability 
found in the examination of approximately 5,000,000 drafted 
men: 

SOME IMPOETANT DEFECTS REVEALED BY THE DRAFT 

Per Cent. 

1. Defects of feet (flat-foot 11 per cent.) 13. 

2. Venereal disease — 

During first period of draft 2.9 

In later period of draft 5.7 

3. Hernia and enlarged inguinal rings 4. 

4. Defective vision (largely errors of refraction) . . 3.5 

5. Defective physical development, including under- 

weight and under-height 3.5 

6. Organic diseases of the heart 3. 

7. Deformities or loss of extremities 3. 

8. Tuberculosis 2.5 

9. Hypertrophy of tonsils 3.33 

10. Defective and deficient teeth 1.33 

11. Mental deficiency 1.25 

12. Otitis media (purulent) 1. 

13. Hemorrhoids, varicocele, varicose veins 1. 

14. Goitre (simple and exophthalmic) 0.75 

15. Deformities of the hand 0.75 

16. Cardiac arrythmias and tachycardia 0.50 

17. Asthma 0.25 

According to figures obtained from various sources the 
number of men disqualified for military service was found 
to vary between 21 and 34 per cent., depending upon the 

•Ireland. Merritte W. ; Physical & Hygienic Benefits of Military Train- 
ing as Demonstrated by the War. Journal A. M. A., Vol. 74; No. 18, 
Feb. 21, 1920. 



6 THE COMMUNITY HEALTH PROBLEM 

statistics quoted. The records of tlie Surgeon-General show 
that 29 per cent, had some form of disability. Other records 
show a slightly higher figure. Suffice it to say that approxi- 
mately one-third of the young men of the country were phy- 
sically unable to perform full military duty. In the later 
examinations 14.5 per cent, were rejected by local boards as 
unfit for service and about 7 per cent, were rejected by military 
boards after having been sent to camp. Only fifty-three per 
cent, were accepted as fully meeting the military standard 
with no defects recorded. 

If preventable illness (and physical disability which results 
from preventable illness) is found to such a great extent 
among young men during a period when the highest degree 
of physical development is expected, is it not natural to sup- 
pose that preventable illness exists in a proportionate amount 
in other members of the community ? 

This number errs on the side of conservatism for in the 
haste of mobilization many minor disabilities were overlooked 
and many men were taken into the Army as "physically fit" 
only to be found disqualified at a later date. It is safe to say 
that over one-half of the young men of military age show 
some form of physical defect.* 



SICKNESS SURVEYS 

So much for the military. Without attempting to determine 
whether adequate treatment had been available for the aver- 
age drafted man and whether such treatment might have 
modified the findings, let us examine the status of the civilian 
population. In general, no such complete figures are avail- 
able for civilians, but in recent years a number of health 
surveys have been carried out in various parts of the country 
with most striking results, which indicated that general condi- 
tions were at least as bad as those discovered in the draft. 

•A report pnbHshed In the Journal of the American Medical Association 
(April 10. 1920), states that acporrtinn to recent figures only 25 per cent. 
of the drafted men were qualified according to pre-war standards. 



THE HEALTH OF THE COMMUNITY 7 

Just what is a health survey and how is it carried out? 
As ordinarily understood a health survey is the examination of 
the health conditions in a given community especially with 
reference to disability due to injury and disease. In some 
cases only meagre details are furnished and include only a 
report of those seriously ill and unable to work. In other sur- 
veys every member of the community is carefully examined 
and a notation made of non-disabling conditions such as 
defective teeth, adenoids, varicose veins, and other similar 
conditions. As a consequence of the varying conditions under 
which health surveys are carried out, it is very difficult to 
compare figures given in different surveys without clearly 
understanding the methods adopted by the examiners. 

Surveys are made difficult because of the fact that most 
adults object to a physical examination by a physician unless 
they are seriously ill. There are those who resent what they 
consider to be an intrusion into their private affairs and 
others who, while not actively antagonistic, show little incli- 
nation to supply information required to complete the survey. 

For this reason, and others which are self evident, it has 
been much easier to make a health sun^ey among children of 
school age than among either infants or adults. Consequently 
we are much better informed as regards the health conditions 
of children of school age than of other members of society. 
Aftea* making due allowance for those children who are crip- 
pled or too ill to attend school, the results of so-called "school 
examinations" offer reasonably accurate figures upon which 
to base an estimate of the general health of the community. 



EXAMINATIONS OF SCHOOL CHILDREN 



c 



For some years New York State has had a fairly compre- 
hensive law requiring the examination of school children. 
During the year 1918 over 700,000 school children were 
examined and over 500,000 were found to have physical de- 
fects. In New York City defects were found in 77 per cent, 
of the children examined. In rural districts and villages 



8 



THE COMMUNITY HEALTH PEOBLEM 



the percentages were somewhat lower. The New York State 
Reconstruction Commission, in discussing these findings, sug- 
gests that the smaller percentages in rural communities are 
due to "the varying degree of thoroughness in examinations." 

PHYSICAL CONDITION OF SCHOOL CHILDEEN 1918 

720,176 Children Examined in N. Y. State 



Defects 



New York 

City 
Number 



Cities and 
Villages 
Number 



Rural 
Schools 
Number 



Vision 

Hearing 

Teeth 

Enlarged or Diseased Tonsils 

Breathing 

Nutrition 

Lungs 

Total Number of Defective 
Children 



23,362 

1,214 

161,686 

33,475 

25,168 

35,225 

742 



15,692 

2,511 

63,925 

29,756 

10,203 

4,578 

642 



18,591 

4,699 

70,561 

42,202 

17,455 

3,859 

834 



190,898 
(77%) 



138,093 
(57%) 



177,063 
(63%) 



During recent years the Bureau of Child -Hygiene of New 
York City has made a careful study of the subject of mal- 
nutrition in school children.* Ignorance of the nutritive value 
of foods, the high cost of food, carelessness in its preparation, 
and the use of food substitutes all play a part in the causation 
of mal-nutrition. Many cases were found to be secondary to 
physical defects such as enlarged tonsils, defective teeth, etc. 
In a nutritive survey of school children an arbitrary stand- 
ard, known as the Dumferline Scale, has been adopted for 
convenience of classification. This consists of four classes 
as follows : 

Excellent — the child is well nourished. 

Good — nutrition falls short of excellent. 

The child requires supervision — borderline. 

Nutrition seriously impaired — requires medical 



Class 1. 
Class 2. 
Class 3. 
Class 4. 
treatment. 

•Report of the Public Health Committee on Reconetractlon. 
Zorfc State, Oct. 24, 1919. 



New 



THE HEALTH OF THE COMMUNITY 9 

During 1918 nearly 200,000 school children were examined 
and graded for nutrition with the following result: 

EXAMINATION OF SCHOOL CHILDREN, 1918 
City of New York 

Public Parochial 

Schools Schools Total 

Class 1 35,606 5,372 40,978 

Class 2 92,588 15,702 108,290 

Class 3 25,346 3,908 29,254 

Class 4 5,205 647 5,852 

Totals 158,745 25,629 184,374 

It is estimated that the number of children in Class 4 has 
increased during 1919, since the cost of milk and butter has 
risen so high that many families have economized by cut- 
ting down on the daily supply, substituting other less nutri- 
tious foods. 

Of the children requiring medical treatment probably only 
a comparatively small number actually are receiving medical 
attention. Some are under the care of private physicians and 
others are being treated by welfare associations and dispen- 
saries, but a large number are neglected and will continue to 
be neglected unless treatment is insisted upon by school 
authorities or by welfare organizations. 

COMMUNITY HEALTH SURVEYS 

^mong adults there are few surveys which indicate 
physical disability wdth the same amount of detail as is 
found in the draft board and school reports. As has been 
noted, adults are apt to object to physical examination and 
consequently most of the surveys include only personal state- 
ments as to actual disability. 

In six surveys made by the Metropolitan Life Insurance 
Company covering a total of 637,000 persons holding policies, 



10 THE COMMUNITY HEALTH PKOBLEM 

it was found that there were 12,114, or 1.9 per cent., who were 
suffering from an illness severe enough to prevent them from 
going to work. In addition to this number about 1200 were 
sick but were still able to work. No attempt was made to 
discuver tlio^^e suffering from light illness and non-incapaci- 
tating disability. In the Chelsea survey the figures were 1.5 
per cent, sick, and 1.4 per cent, disabled. In North Carolina 
the figures were 2.85 per cent, sick, and 2.3 per cent, disabled. 

Information as to adult sick rates may be secured in another 
way, that is, by considering the number of days sick per year 
for each member as shown by the records of sickness and 
death benefit societies. Such records compiled by the Bureau 
of Labor Statistics show that, for all ages, there was a disa- 
bility rate (per insured person) of 6.6 days per year. This 
figure is approximately 5 days per year for insured persona 
under 35 years of age and gradually increases to 15 days per 
year for members 70 and over. 

In time of epidemic the amount of sickness may be greatly 
increased. During the epidemic of influenza in 1918 it was 
shown that in a total of 148,245 persons canvassed* in various 
parts of the United States, 43,580 suffered from an attack of 
influenza. This is a case rate of 29.4 per cent. 

FEAMINGHAM HEALTH DEMONSTBATION 

In the Framingham Community Health and Tuberculosis 
Demonstration a careful health survey was made of the entire 
community.** Every individual who would permit examina- 
tion was systematically examined by a physician trained in 
this work. In all, 4,473 persons were examined during a 
period of several days. 

^Minor ailments such as colds and defective teeth were 
included with the result that 3,456 or 77 per cent, were found 
to show physical disability of some sort. This is an enormous 

•Annual Report U. S. Public Health Service, "WaBhlngton, 1919. 
•• Armstrnnpr, Donnkl B. : Frnmingham Monoprnph No. 4; Community 
Bealth Station, Framingham, Mass., November, 191& 



THE HEALTH OF THE COMMUNITY 11 

figure, and, as might be expected, represents largely "minor 
ills." These may be classified as follows: 

MINOR ILLS IN EXAMINATION OF 4,473 PERSONS 

Defective teeth 1,006 

Enlarged tonsils 5G3 

Colds, coryza, etc 132 

Bronchial pulmonary affection (undiagnosed) 265 

. Glandular system 277 

Miscellaneous '. 100 



2,443 



Of the major ills there was a total number of 1,113 of 
whicli 96 were pulmonary tuberculosis. The number seriously 
ill represented 25 per cent, of the total examined. 

The result of these examinations shows the large amount of 
illness usually disregarded. In this same group a census taken 
before the examinations showed only 6.2 per cent, who reported 
any illness. Compare this number with 77 per cent, as found 
by the medical examinations or even with 25 per cent, which 
represented those having "major ills." 

Of the total number of affections found, both minor and 
eerious, Doctor Armstrong estimates that 61 per cent, are 
either "theoretically preventable or easily remediable," while 
about 15 per cent, are non-preventable. The balance are 
classed as "doubtfully preventable." 

HEALTH IN THE ARMY 

If we turn now to the report of the Surgeon-General, TT, S. 
Army, for 1918, we find that among picked men (remember 
a large number were not accepted for the Army because of 
physical disabilities) there is always a fairly constant sick 
rate. This is called the non-effective rate, meaning thereby 
that among a given number of men a certain number per hun- 
dred are "non-effective" or unfit for duty. The non-effective 



1-i THE COMMUNITY HEALTH PROBLEM 

rate for 1917 among enlisted men "was 22.21 per 1,000 in the 
United States. In Europe it was slightly less and in the 
Philippines considerably more. Over a series of years the 
Army non-effective rate runs pretty regularly between 2 and 
3 per cent. There are several factors which tend to make the 
rate lower in the Army than in civilian life, chief of which is 
the fact that soldiers are carefully picked young men pre- 
sumably able to do full duty when enlisted. In addition, when 
soldiers develop chronic diseases they are discharged so that 
such diseases as tuberculosis and chronic nephritis play a com- 
paratively smaU part in the non-effective rates. 

THE SICK IN" THE COMMUNITY 

If the figures already given are carefully considered it will 
be seen that while there is abundant evidence of illness in a 
given community, it is rather difficult to state exactly any 
figure Avhich would fairly represent the total number requiring 
treatment at any one time, but by a consideration of the facts 
we may judge rather closely the number seriously ill. 

If we .start, for example, with a consideration of those who ^ 
are too ill to work we will find that, excluding the number, 
who have a permanent disability unsuitable for treatment — 
such as an amputated leg or deformed hand — there is a fairly 
definitely fixed percentage which represents those incapaci- 
tated. This figure is as a rule between 3 and 3 per cent. 
At times it may drop below this figure and during epidemics 
it may rise as high as eight or ten per cent, or even higher. 

Of this 2 per cent, probably at least one-half should be 
under hospital treatment so that in any given community 
there should be at least one hospital bed for every hundred 
persons. As a matter of fact this number is very conservative, 
it being claimed by many that two hospital beds for every 
hundred persons is the least number consistent with adequate 
treatment. In military camps where there are no accommo- 
dations for *Tiome treatment" this number should be increased 
to at least 5 per cent, in time of peace and considerably more 
during war. 



THE HEALTH OF THE COMMUNITY 13 

In addition to those unablo to work because of illness there 
is a certain percentage who feel the effects of illness but con- 
tinue to work (among these are cases of chronic heart disease, 
tuberculosis, kidney disease, chronic bronchitis and many 
minor ailments). This is usually estimated as about 2 to 
4 per cent., so that the figure for the total acknowledged 
illness will usually average pretty close to 6 per cent.* That 
is to say, that if one physician should, undertake the care 
of a typical community of a thousand persons ho would have 
about 60 patients at all times. This does not mean that such 
a physician would see 60 patients a day. Many would be at 
work, reporting for treatment weekly or monthly, or possibly 
even less frequently. 

If we accept the figure of 6 per cent, as representing the 
number in a community who admit illness and acknowledge 
the necessity for treatment, we still have a considerable dis- 
crepancy between this figure and the figures obtained from the 
draft boards, school surveys and the Framingham survey 
quoted above. Part of the discrepancy is due to those who 
suffer from a permanent disability such as a deformed hand or 
amputated finger and do not consider that they are ill; part 
is due to the ignorance of the symptoms of disease ; and a large 
part is due to minor ills which for economic reasons have been 
untreated and are consequently disregarded. 

However the exact percentage of sickness in a given locality 
is of less importance than is the fact that, in each and every 
community, there are constantly found some persons seriously 
sick, some ill but not incapacitated, and a large number of 
others suffering from minor ills of more or less consequence. 
The efficiency of the methods adopted in dealing with these 
conditions has a direct, influence on the social and economic 
life of the community. 

Every community should examine closely into the prepara- 
tion it makes for care of its citizens' health. Do the sick 
receive adequate treatment ? Are there sufiScient hospital beds ? 

•In Dr. Armstrong's health census the number who said they were 
Bick represented 6.6 per cent, of the total surveyed. 



n THE COMMUNITY HEALTH PROBLEM 

Are proper measures being taken to educate the mother in 
the care of her child and is every effort being made to decrease 
preventable disease and to diminish remediable ills? 

It is not enough to increase wages and to expect the indi- 
vidual to secure medical treatment. Every patient suffering 
from an infectious disease is a menace to his neighbors, and 
every case of disability is an economic drain on the community 
as a whole. Education of the medical profession has decreased 
illness but not sufficiently to wipe out certain easily pre- 
ventable diseases; public education has not, up to the present, 
sufficiently influenced physical health 

Neither increased wealth nor advances in medical science 
will develop the full resources of the youth of the nation 
unless directed by a well-planned concerted effort to apply 
the lessons taught by medical science to the every-day prob- 
lems of public health. 



CHAPTER II 
SICKNESS AS A CAUSE OF POVERTY 

In the struggle between capital and labor the pecuniary 
rewards of the workman have steadily increased, and this was 
true even before the World War upset all pre-war standards. 
The recent rapid increase of wages combined with a diminished 
supply of labor has tended to decrease the ordinary evidences 
of poverty. Bread-lines are strikingly short; municipal lodg- 
ing houses have few guests; and unemployment is at the 
minimum rate for many years. 

Tliere is, however, still considerable poverty due to disease. 
The increased income has not, as might be expected, been 
hoarded against the proverbial rainy day but has been 
expended for luxuries of a temporary character. The workman 
receiving an unprecedented high wage is living better than 
ever before. More automobiles, more phonographs, and more 
fine clothes have been purchased by wage earners than ever 
before. Moving picture theatres are flourishing, candy and 
soda-water is sold in enormous quantities, and silk has become 
the daily raiment of the skilled worker. This is perhaps as it 
should be. Certainly labor has waited a long time for the 
coming of the day of high wages and is entitled to a few of 
the luxuries of life, but it is certain that the average wage 
earner is not saving any considerable portion of his wage as 
an insurance against loss due to illness. There is today, in 
every large city, an enormous number of persons entirely 
dependent upon charity as a direct result of sickness and there 
will be more when the present boom begins to diminish, and 
still more when really hard times arrive. 

Prosperity during and after the war tended in one way 
to decrease poverty due to physical disability. In every com- 

15 



16 THE COMMUNITY HEALTH PKOBLEM 

munity there is always a certain number of crippled and 
eubnormal individuals who are unable to secure any sort of 
remunerative employment during periods when supply of 
labor exceeds the demand. In the prosperity which followed 
the "World War most of these individuals secured emplo}Tnent 
at a living wage. Others, however, who are actually too ill to 
work are less fortunate. The increased cost of living and the 
diminished purchasing power of the dollar makes their plight 
doubly difficult and throws an increased burden upon the 
resources of charity. When sickness occurs it is found that 
the cost of medicine has increased, medical attention is con- 
siderably more expensive than during the pre-war period and 
rents and household expenses have more than doubled. 

So that we find that, even with high wages, illness of the 
bread-winner of the family, for an extended period, often 
results in economic distress. This is true in the case of the 
wage earner so frequently as to be considered the rule. Those 
who are especially wasteful are almost immediately plunged 
into poverty; those who have greater means do not feel the 
pinch of want until later; while a few of the more provident 
may pass through a fairly long illness without actual distress. 

Edward T. Devine of the Charity Organization Society of 
New York City says in his book "Misery and its Causes": 
"111 health is perhaps the most constant of the attendants of 
poverty. It has been customary to say that 25 per cent, of 
the distress known to charitable societies is due to sickness. 
An inquiry into the physical condition of the members of the 
families that ask for aid, without taking any other complica- 
tion into account, clearly indicates that whether it be the first 
cause or merely a complication from the effect of other causes, 
physical disability is at any rate a very serious disabling con- 
dition at the time of application of three-fourths — not one- 
fourth — of all the families that come under the care of the 
Charity Organization Society." 

Sickness acts as a double cause of poverty. There is, first 
the direct loss due to the cessation of regular income and, 



SICKKESS AS A CAUSE OF POVERTY 17 

second, the loss of savings due to expenses for doctors' and 
nurses' fees and for medical supplies. 

The loss due to idleness has been estimated to be equal to 
an average of nine days' wages per year. The Pennsylvania 
Health Insurance Commission estimated that in that state 
alone employees are losing more than $39,000,000 annually 
because of sickness. In the Kensington Survey the wage loss 
was reported in 367 cases and averaged $78.53 per case. In 
only a small percentage of employees are wages continued 
during sickness, probably not more than five or six per cent. 
Illness may act further to increase poverty through its results. 
Frequently after an attack of rheumatism or typhoid or other 
disease, the body is left so shattered from the effects of the 
illness, that the former occupation is beyond the strength of 
the individual. Consequently a new and lighter occupation 
must be chosen which results in diminished earning power. 

The expenditure for sickness varies considerably in different 
families and in various localities. Many of the poorer families 
spend as much, or more, for patent medicines (self-medica- 
tion) as they do for medicines prescribed by physicians. In 
a number of families studied in Philadelphia, the average 
expenditure for this purpose was over $5.00 a year. In a 
survey by the United States Bureau of Labor Statistics the 
expenditures for medical relief of families with varying 

income was studied with the following findings ; 



18 THE rO^IMUXITY HEALTH PROBLEM 

YEABLY EXPEN'DITUEES FOE SICKNESS 

TTasMngton, D. C, 1916 



Income 




Number 

of 
Families 


Yearly 
Expenditures 


Under $600 


Total 

Whites. . . . 
Colored . . . 

Total 

Whites 

Colored . . . 

Total 

Whites. . . . 
Colored . . . 

Total 

Whites 

Colored . . . 

Total 

Whites. . . . 
Colored . . . 

Total 

Whites. . . . 
Colored . . . 


65 
45 
19 

235 
115 

118 

215 

167 

48 

209 

19S 

11 

198 
191 

7 

922 
692 
230 


$12.01 


$500-5900 


12.83 
10.03 

20.84 


$90a-$l,200 


25.52 
16.20 

40 19 


$1,20(>-$1,500 


42.31 
32.84 

42.42 


Over $1,500 


43.16 
28.95 

58.71 


Average, all incomes. . . . 


59.57 
35.21 

37.75 
43.59 
20.19 



This of course does not include the free treatment at chari- 
table institutions, such as hospitals and dispensaries, which 
would amount to considerably more. Therefore it is safe to 
say that medical attention and medical supplies cost each 
family at least $40 per year under conditions such as exist 
in large cities. In rural districts it is possible that the expen- 
diture is a little less. 

Though this expenditure is not large, it should, if it were 
expended scientifically and efficiently, purchase a fairly satis- 
factory medical service. However, under our present system 



SICKNESS AS A CAUSE OF POVERTY 19 

the money is to a large extent not well spent. In the first 
place it is spent almost entirely after illness has occurred. 
Only a small amount is devoted to the prevention of disease. 
Compared with the amount spent for the cure of illness the 
community spends only a comparatively insignificant amount 
for prevention, possibly from one to three dollars,* per capita, 
yearly in cities and very much less in most rural communities. 
in the next place the care of illness is left largely to the 
patient himself. Wlieu he decides he needs medicine he pro- 
ceeds to buy patent medicine; when he thinks he needs a 
doctor he secures the services of one, if he can afford the 
expense, only when he is convinced that there is no other 
alternative. In many cases this is too late to secure the best 
results. The physician, being paid to cure disease and not to 
prevent it, devotes most of his energies to curative medicine 
and very little to prevention. 

The experience of the Eockefeller Foundation in certain 
southern communities has thrown considerable light upon 
this point. In certain cases they have found that by expendi- 
tures directed toward the prevention of malaria they were 
able to reduce malaria almost to the vanishing point and this 
at a cost of less than had previously been spent for treatment 
of the disease. 

In an experiment carried on by the Foundation in Arkansas 
an attempt was made to rid four towns in the state of malarial 
infections by means of well recognized measures for the exter- 
mination of the mosquito. Pools were drained or filled, slug- 
gish streams were ditched and oil was applied to surface water 
which could not be otherwise dealt with. In other words the 
attempt was made to make these towns unhealthy places for 
the disease-carrying mosquito. 

The results were measured by the number of visits made by 

physicians to patients suffering from malaria. In 1916, before 

the erperiment, the number of calLs made in the town of Ham- 

•The expenditnreB of the New York City Department of Health is about 
65 cents per capita. This amount is increased by State and Federal 
expenditures and by voluntary donations. 



20 THE COMilUXITY HEALTH PROBLEM 

burg, Arkansas, was 2,312; in 1917, the year of the experi- 
ment, the calls dropped to 259, and in 1918 to 59.* 

In this town of only a few over a thousand inhabitants the 
per capita cost of the conquest of malaria was $1.45 in 1917 
and 44 cents in 1918. 

Similar results could not be secured in every community, 
but there are many towns and villages in the United States 
where comparable results might be obtained. 

The element of charity in free medical treatment, whether 
provided from the public purse or by charitable organizations, 
has prevented a certain portion of the community from accept- 
ing free treatment even when it is offered. There is a certain 
portion of the population, perilously near the poverty line 
which resents the implication that it is unable to pay for med- 
ical care. This follows closely on the experience of the early 
days of education. The *^free school" was for the very poor, the 
pay school for the well-to-do and nothing for the middle class. 
Many children were denied the benefits of education because 
their parents refused to send them to the free school. It is 
the same today with regard to medical care. Free medical care 
is available to a limited extent but self respecting wage earn- 
ers often prefer to do without treatment rather than to deprive 
others who may be more in need of help. 

It is easy to determine for yourself the effect of prolonged 
illness as a cause of poverty and want. Examine a given num- 
ber of wage earners, say twenty or thirty, and find out how 
many of them could stand the financial strain, of a disability 
lasting six months or longer. Such a disability might easily 
occur as a result of a broken thigh or an attack of nephritis 
and yet only a few have enough money in bank to begin to 
pay the necessary expenses of such a long illness. Yet scat- 
tered over the entire population such a period of disability 
occurs comparatively seldom and could be easily met by some 
form of insurance. 

•Review of the Work of the Rockefeller Ponndatlon for 1918. Pob- 
llBhed by the Rockefeller Foundation, New York, 1919. 



SICKNESS AS A CAUSE OF POVEKTY 31 

The advocates of health insurance, believing in the princi- 
ples of insurance and in its application to the distribution of 
economic loss due to disease, contend that the enactment of a 
health insurance bill will diminish poverty which may arise 
because of ill health. They point to the experiences of Ger- 
many, where poverty, in the sense in which we see it in our 
larger cities, was practically unknown before the war, as an 
example of what health insurance can accomplish for the 
economic regeneration of the communties. Because of the 
high overhead charges of any form of voluntary insurance, 
and because of the fact that in commercial voluntary health 
insurance, policies are seldom taken out except by the "dan- 
gerous risks" thus greatly increasing the premium, it is 
claimed that if health insurance is to be successful it must 
be made compulsory and administered by the state. 

The opponents of health insurance, while admitting the 
value of insurance in general, claim that the word "compul- 
sory" is objectionable, that the idea of compulsion is 
un-American and that health insurance is impracticable and 
unfair to the physician and to the individual. 

Theoretically, if we accept nine days as correct for the 
average yearly disability for all workers it would seem that 
if each worker contributed nine days' wages to a general fund, 
to be expended in benefits to those disabled by injury or dis- 
ease, the figures should balance and sickness would cease to 
act as a cause of poverty. 

While the workman has been willing to purchase fire insur- 
ance on his home and life insurance on his person he has 
never taken to sickness insurance and his savings against 
future sickness are usually entirely inadequate. 

There must be found for the benefit of all a workable 
method which will greatly diminish the economic loss to the 
individual arising out of serious injury and protracted illness, 
and the search for such a method constitutes a large part of 
the community health problem as it is presented to us today. 
Workmen's compensation insurance, which applies to injuries 



22 THE COMMUNITY HEALTH PROBLEM 

incurred during employment, has done a great deal to diminish 
part of the poverty arising from injuries, and it is possible 
that similar measures may be applied to non-industrial 
injuries and to at least a part of the disability due to disease. 

The following is taken from the Report of the Special Committee on 
Social Insuriint-e of the American Medical Association: "As a result of 
an investigation covering fortj'-three cities and over 30,000 charity cases, 
the United States Immigration Commission found that illness of the 
bread-winner or other member of the family was a factor in 3S.3 per 
cent, of the cases of those seeking aid. In New York City sickness or 
deformity was present in two-thirds of the .S.OOO families assisted by the 
charity organization in 1916; in Chicago, sickness is reported as the 
primary factor in 25 per cent, of the cases cared for in 1017 and as a 
contributory factor in 45 per cent, of the other cases; in San Francisco 
and Los Angeles, sickness was the primary cause of destitution in .50 
per cent, of over 5,000 charitable cases." (Social Insurance Series, 
Pamphlet No. XI, Americau Medical A^sociatiou, 1919). 



CHAPTER III 
THE PRIVATE PHYSICIAN AND COMMUNITY HEALTH 

If we accept as true the statement that there is constantly 
a large number of persons in every community who are seri- 
ously ill and that a certain considerable percentage of sickness 
is either preventable or requires treatment, it becomes neces- 
sary to examine the present facilities for prevention of disease 
and for the treatment of illness when it occurs, in order to 
determine whether every reasonable effort is being made to 
diminish preventable diseases and whether all cases of illness 
are receiving adequate medical attention. 

Medical practice in the United States is based primarily 
upon the work of the private physician. The laws of most of 
the states recognize the responsibilities of the private prac- 
titioner and, within certain limits, define the educational 
requirements which a physician must satisfy in order to prac- 
tice his professon. 

Within these limits, however, medical treatment varies 
according to the physician employed. In some states various 
schools of osteopathy, chiropractic, neuropathy, and mental 
healing all receive recognition and the patient may receive 
treatment by practitioners of any of these schools. There is 
often no general supervision of health conditions except in 
matters of infectious and contagious disease and even in such 
patients the measures enforced by the community often have 
to do with quarantine rather than treatment. As a rule, com- 
munity requirements are satisfied when a patient suffering 
from acute or chronic illness is under the care of a medical 
practitioner. In general, only in the case of contagious 
disease, and then only to a limited extent, does the state 
attempt to Qualify the character of the treatment given. 

23 



24 THE COMMUNITY HEALTH PROBLEM 

The interests of the community are, theoretically, under the 
care of the state and local departments of health, which as a 
rule, have an advisory relation to the private physician, and 
certain police powers affecting both the physician and the 
public. 

It is the purpose at this time to discuss chiefly the relation 
of the private physician to sickness in the community, disre- 
garding, for the time being, the limited control by the state 
and by voluntary associations. 

If we examine the history of medicine we see that there 
have been three stages of progress in the practice of medicine. 
During the first stage it was believed that illness was the work 
of evil spirits, and that charms and incantations would drive 
the evil spirits from those afflicted. At a later date disease 
was thought to be due to various 'Tiumors" which might be 
expelled from the body by the use of various medicaments. 
Examples of believers in the first stage still exist in the 
followers of so-called "faith" cures and of the second stage 
among' those who make possible the dividends of the patent 
medicine manufacturers. Tonics, blood purifiers, and other 
drugs of a similar nature are sold in tremendous quantities 
largely as a result of advertisements in newspapers and lay 
magazines with a resulting enormous amount of self medica- 
tion for which there is no scientific basis. 

"The third or modern stage," says Dr. William Brend,* is 
based upon scientific study of disease and the human body. 
Exact diagnosis of the malady is the first step and efforts are 
then made to cure it which bear, as far as possible, distinct 
relation to its cause. For these purposes medicine no longer 
blindly administers nauseous compounds, but calls to its aid 
physiology, anatomy, chemistry, physics and other sciences 
and at the same time studies the constitution of the patient 
and his surroundings including in its treatment suitable diet- 
ing, nursing care and hygienic surroundings." 

During the last fifty years there have been vast changes in 
medical science. The known facts have increased so rapidly 

•Brend, wniiam A.: Health and the State, LondoD, 1917, p. 1®. 



PHYSICIAN AND COMMUNITY HEALTH 25 

that it is impossible for any man to master the details of all 
branches of the profession. The technie of surgery has become 
so specialized that men spend years mastering the operative 
technie of a single part of the body such as the eye or ear. 
As a result specialism has rapidly developed and the import- 
ance of the general practitioner has steadily declined. 

The private physician practices little or no preventive medi- 
cine. He is ordinarily called only when the patient, of his 
own accord, decides that he is sick and requires medical 
attention. The physician seldom sees his patients unless they 
send for him. Except for vaccination against small pox, 
which is required by law, and advice to persons exposed in 
cases of infectious disease, his efforts are confined almost 
entirely to the cure of iUness. He has, as a rule, neither the 
experience nor the time to practice preventive medicine. 

For economic reasons preventive medicine as such must 
depend upon community effort either local or general. In the 
United States, most preventive measures have been under- 
taken either by the public health authorities or by voluntary 
organizations working for the public welfare. 

Admitting that it is impossible for the private physician 
to devote much time to preventive medicine, let us examine 
the present system of medical treatment which is largely 
under the control of the private practitioner. 

Does the present system of medical treatment supply ade- 
quate facilities for the care of disease? Does private practice 
supply modern scientific medical treatment to a reasonable 
extent for the bulk of the population? If these questions are 
answered in the affirmative then the community health prob- 
lem is limited to prevention and to the care of the pauper class 
only and is much simplified. If the large amount of sickness 
is unavoidable and is at present receiving every necessary 
attention then we have only to devote ourselves to the pre- 
vention of charlatanism and medical quackery, avoiding so far 
as possible any interference with the existing order. 

However, there is, unfortunately, considerable evidence that 
the private practice of medicine, except for its function of 



26 THE COMMUNITY HEALTH PROBLEM 

furnishing a livelihood for the doctor, is a partial failure, in 
that it fails signally to furnish either adequate medical care 
or modern scientific medicine to a large part of the popu- 
lation. 

The average physician practices medicine primarily as a 
means of livelihood. From the nature of his profession the 
humanitarian aspect of modern life is seen more clearly than 
in most other professions but, in the last analysis, he must 
receive adequate remuneration or cease to exist. Consequently 
he must either devote a small part of his time to patients 
financially able to pay large fees, thereby permitting him to 
give a part of his time to charity patients from whom he 
obtains his fund of clinical experience; or, he must make a 
large number of visits upon patients able to pay a small or 
moderate fee. Patients of this latter class are usually unable 
to bear the additional burden of the expense of specialists and 
laboratory fees required by modem medicine and are, as a con- 
sequence, deprived of the expert service which they often 
require. As a result they often lose confidence in the medical 
practitioner and, if unable to pay the fees of the specialist, 
resort to home remedies or patent medicines. It is among 
such patients that self medication is most widespread. 

In the families of workmen in New York City medical 
treatment costs from one to three dollars a visit. For ordinary 
cases this secures good treatment but for complicated cases 
where laboratory examinations and radiographs are required 
the additional fee becomes a heavy burden and consequently 
the necessary examinations are often neglected. This results 
in unscientific and unsatisfactory medical treatment and often 
in lasting injury to the patient. 

In the sickness surveys made by the Metropolitan Life In- 
surance Company" from 1915 to 1917, in widely separated 
communities, from 27 to 39 per cent, of the persons ill were 
found to be without a physician in attendance, these surveys 
including only "serious" illnesses. In six surveys covering 

•Social iTisiirnnre: Ueport of the Special Committee of the American 
Medical ABSOClation for 1019, p. 45. 



PHYSICIAN AND COMMUNITY HEALTH 27 

some 13,000 persons seriously ill, almost 4,000 or about 30 per 
cent, were having no medical care whatsoever. 

In a somewhat similar survey made in Dutchess County, 
New York, in 1913-13 and covering approximately 10,000 
persons, only 7G per cent, of those ill were under the care of 
a physician. An examination of those sick in Framingham, 
Mass., showed 81 per cent, under a physicians's care, while in 
the rural districts surrounding Framingham more than 53 
per cent, of those sick were receiving absolutely no medical 
attention. 

Of 1726 dispensary patients studied in Boston, 72 per cent, 
had had no previous medical care and, of these, 35 per cent, 
had been sick more than three months. 

It would be possible to continue similar statistics almost 
indefinitely. While the percentage varies there is regularly a 
large portion of the population who receive no medical care 
when ill. ^ 

The causes of this failure may be classed under three head- 
ings: 1. Economy; 2. Distrust; 3. Ignorance. 

Economy is no doubt the most potent factor. Expenses 
devoted to medical care are seldom foreseen and consequently 
their burden is doubly hard to bear. Moreover, the working 
man feels that a charge of two or three dollars represents 
more than he can afford and he puts off calling the physician 
as long as possible, trusting that he will escape serious con- 
sequences. 

Distrust of the physician or of the medical profession in 
general is a fairly frequent cause of lack of medical care. 
Some persons, because of a previous disagreeable experience 
at the hands of an unscrupulous doctor, will delay calling a 
physician when next they become ill. General distrust such as 
is fostered by patent medicine interests, and medical cults, 
also accounts for a certain number of non-treatment cases. 

Ignorance both of the cause and symptoms of disease is a 
rather potent factor. It is not uncommon to see a patient 
suffering from pulmonary tuberculosis with a temperature of 
102 degrees, or over, who for months attempts to cure his 



28 THE COMMUNITY HEALTH PROBLEM 

condition by exercise under the impression that his symptoms, 
weakness and loss of weight, are the result of sedentary habits. 
Under this same heading may be placed the ignorance of the 
patent medicine advertisement reader "who knows a lot but 
knows it wrong." Their partial knowledge of the subject 
allows them to be made easy dupes of the clever advertise- 
ment writers so that pain in the back, occasionally an early 
symptom of tuberculosis of the spine, is treated for months 
with "Curem's Kidney Eemedy" so that when seen by the 
physician the disease has progressed beyond the favorable 
stage. 

The medical profession devotes an enormous amount of 
time to the care of cliarity cases but in spite of this is failing 
to fulfil its full duty to the community. It fails not because 
it does not give its best efforts to the sick but because it does 
not, as a whole, appreciate the community problem and has not 
succeeded in reaching the bulk of the population with any 
marked degree of success. 

Cabot has drawn attention to what was, until recently, the 
prevailing method of treating heart disease in the best type 
of metropolitan hospitals. The patient, admitted in bad con- 
dition, after several weeks of treatment was usually sufficiently 
improved to be able to be up and around the ward without 
shortness of breath or subjective evidence of his leaky valve. 
He was then discharged from the hospital with the advice 
to "take things easy." In most cases, however, for eco- 
nomic reasons, he was obliged to seek work, and attempt- 
ing work which was too hard for the weakened condition 
of his heart he soon broke down and was obliged to return 
to the hospital for further treatment. This process was 
repeated over and over again to the economic loss of the- 
man, the community and the hospital. Recently this has 
been changed by the follow-up system of after-care intro- 
duced in many hospitals which not only provides the sub- 
normal individual with medical advice but actually under- 
takes the placing of such persons in suitable occupations. 

With the advance of medical science the mortality rates of 



PIIYSICIAJSr AND COMMUNITY HEALTH 29 

most great cities have steadily fallen and the span of human 
life has generally increased. This is largely the result of the 
application of what wise physicians and skilled surgeons have 
taught regarding the cure of disease. Men of science are devot- 
ing their lives to the problem of disease and may be expected 
in the future to develop new methods of prevention and cure. 
Typhoid, small-pox, malaria, and diphtheria are rapidly dis- 
appearing. Many other diseases such as tuberculosis and dia- 
betes, are more successfully treated today than ever before. 
Cancer is only partially conquered by surgical measures, but 
experimental results obtained give hope that sooner or later 
a clear understanding of the cause and a rational method of 
treatment may be discovered. 

The community problem today is not concerned with the 
search of new ways and means for the cure of existing disease, 
such search may well be left to hospitals and scientific insti- 
tutions. The real problem before the commimity is that of 
making proper use of the tools at hand, so that modern sci- 
entific methods of treatment may be available to each and 
every citizen, whether rich or poor.* To this end the medical 
service must be reorganized so that the services of the gen- 
eral practitioner, the specialist and the medical laboratory 
may be secured by the sick in the community at an equable 
cost. The present system of charging what the traffic will bear 
must be discarded. 

•"The remedv for this situation (labor scarcity due to injury and 
disease), lies economically in a redistribution of costs, not of adding 
new costs, but rearranging the present method of expending the costs 
alreadv beinz expended . . . Improved medical care must come from 
morfco-operlt^ve^and^less purely Individualistic care from the medical 
profession •• (Report of Special Committee on Social Insurance. Ameri- 
cau Medical Association, 1919). 



CHAPTER IV 
HEALTH DEPARTMENTS AND COMMUNITY HEALTH 

In the prevention of disease, much depends upon the puhlio 
health authorities. As ordinarily used the term public health 
includes all forms of federal, state, county, or municipal activi- 
ties which may influence the morbidity or mortality rates of a 
community. A public health officer is usually an employee of 
the local or state government by which he is paid and from 
which he receives his authority to act. Under our present 
system the public health official devotes his time almost 
entirely to prevention and sanitation. 

Until comparatively recently, public health officers were 
poorly paid and served mainly as police officers to enforce 
sanitary regulation. In recent years, however, the work of the 
public health officer has broadened in its scope and is now 
concerned not only with sanitation in the narrower sense, 
but also with hygiene, housing, child welfare, and numerous 
other health measures for the prfevention and control of 
disease. 

Professor Winslow, of Tale, has expressed this broader view 
of public health in an address before the American Association 
for the Advancement of Science.* *Tublic health," he says, 
"is the science and art of preventing disease, prolonging life, 
and promoting health and efficiency through organized com- 
munity efforts for sanitation, the control of infection, the edu- 
cation of the individual in the principles of personal hygiene, 
the organization of the medical and nursing service for the 
early diagnosis and preventive treatment of disease, and the 

•winslow, C. E. A.: The Untilled Fields of Public Health, Science, 
Jan. 9, 1920. 

30 



DEPARTMENTS AND COMMUNITY HEALTH ;il 

development of social machinery which will insure to every 
individual in the community a standard of living adequate 
j6or tka maintenance of health." 

THE UNITED STATES PUBLIC HEALTH SERVICE 

The federal health service has grown rapidly during recent 
years, especially during the war period. Originally concerned 
chiefly with quarantine and the administration of marine 
hospitals and with an appropriation of less than a million 
dollars yearly, the service has rapidly increased, so that in 
1920 the annual appropriation was approximately $18,000,000. 

In J919 the commissioned personnel of the Public Health 
Service consisted of a Surgeon-General and 217 medical oflS- 
cers of various grades. In addition there were 526 commis- 
fiioned to the reserve of whom 222 were on active service. 

Since the war, the work of the service has greatly increased, 
due largely to the fact that all medical care of discharged 
soldiers, sailors and marines, made necessary as a result of 
injuries or diseases incurred in service, was tiimed over to 
the medical officers of the Public Health Service. In addition 
the medical examinations required by the Bureau of War Eisk 
Insurance were made chiefly by commissioned or reserve pub- 
lic health officers. 

Space does not permit more than a brief outline of the after- 
the-war program planned by the Public Health Service.* The 
program in brief is as follows: 

1. Industrial hygiene : — Health surveys in industry are to 
be continued and extended and minimum standards are to be 
established. Co-operation with state and local officers in the 
sanitation of industrial communities is to be developed. 

2. Rural hygiene : — Federal aid is to be made available for 
the maintenance of adequate county health organizations. 
Such aid is not to exceed one-half the expense of intensive 
rural health work. Investigation and trained assistance is to 
be given in campaigns for better rural sanitation. 

•Annual Report for 1919, U. S. Public Health Service, Washington, D. C. 



33 THE COMMUNITY HEALTH PEOBLEM 

3. Prevention of the diseases of infancy and cliildliood : — 
There has been a comprehensive program arranged including 
pre-natal care, child welfare, physical examination of children 
and supervision of children during the school age. 

4. Water Supplies: — Surveys of water supplies are to be 
made and recommendations are to be made to local authorities 
for the improvement of the local water supply. 

5. Milk supplies: — This part of the work includes a cam- 
paign for universal pasteurization and adequate inspection of 
all milk supplies. 

6. Sewage disposal : — It is believed that proper sewage dis- 
posal will greatly diminish intestinal diseases such as typhoid 
fever, dysentery, etc. 

7. Malaria : — National development of measures to control 
malaria is contemplated. 

8. Venereal diseases : — A comprehensive campaign against 
venereal disease is planned. 

9. Tuberculosis: — The control of tuberculosis is to be at- 
tempted through the stringent provision for reporting cases, 
adequate instruction for families and patients, and hospitali- 
zation of cases wherever practicable. 

In addition to the above there is a plan for the develop- 
ment of better railway and municipal sanitation together with 
the promulgation by the Public Health Service of health 
standards and other subjects connected with health and sani- 
tation. They also hope to increase the available morbidity 
reports by records obtained from the industrial group of the 
population through the appointment of industrial surgeons 
as special sanitary officers. 

It may be seen from the above that the Public Health Serv- 
ice should be an active factor in the solution of the com- 
munity health problem. Like the Eockefeller Foundation the 
Public Health Service does not, except in a few cases, attempt 
the actual care of the individual but attempts to demonstrate 
to the local community the modern and scientific method of 
health controL 



(DEPARTMENTS AND COMMUNITY HEALTH 33 

STATE HEALTH DEPARTMENTS 

' Public health, under the etate Bystem of government, is 
largely a function of t^Q State^ Theoretically the Federal 
health service has to do only with interstate health problems 
and tlie care of employees of the Federal Government. 
Actually through the control of interstate commerce the 
United States Government can take a considerable part in 
shaping the health policies of the various states. 

State Departments of Health are ordinarily under the con- 
trol of a commissioner who is appointed by the Governor. 
They receive tlieir power from the state legislatures and as a 
consequence their functions vary considerably in different 
states. In the more progressive states their powers and func- 
tions are broad and their control over community health is 
considerable. In other states their duties are confined almost 
entirely to the recording of statistics and more or less per- 
functory efforts to control disease. In many states the health 
boards are notably lax so that statistical data, even in refer- 
ence to births and deaths, is so incomplete as to be without 
value. 

Until recently it has been very difficult to organize an 
eflBcient state health department. There have been several 
reasons for this. In the first place it has been difficult to get 
sufficient appropriations so that the department is frequently 
limited in its activities because of lack of fimds. In the next 
place the health laws are often not correlated, the powers of the 
department being limited, and health functions often divided 
among several different commissions. And finally it has been 
difficult to secure efficient health officers because positions are 
frequently under political control and the financial rewards 
are much less than could be obtained from private practice. 

In spite of these difficulties there has been a steady advance 
in the standing of the state health departments and within 
the last few years certain states, notably Ohio and North 
Carolina, have imdertaken progressive measures for the state- 
wide improvement of public health. 



34 THE COMMUNITY HEALTH PROBLEM 

LOCAL HEALTH DEPAETMENTS 

In the community, health functions are usually under 
the control of the municipal or township health board which 
receives its powers in part from the state and in part from 
local sources. Such health boards are often very well de- 
veloped in large vities such as Chicago and New York. In 
smaller cities the health activities are often very inadequate 
and in villages and rural communities of some states there 
is often no community health effort worthy of the name. 

An examination into the expenditures for public health in 
various localities shows great variations. Indeed it is ex- 
tremely hard to compare the expenses in different cities 
because of the fact that in one city the expenses of the health 
department may include such items as removal of garbage, 
or disposal of sewage, and in another these items are charged 
to other departments. However, even allowing for these 
factors there is still a great difference in expenditures for 
health in different localities. 

In some states annual appropriation of the state health 
department is less than five cents per capita. It is rarely over 
ten or fifteen cents per capita even in states otherwise most 
progressive. In the large cities the expense of the health 
board is considerably higher. In Chicago, for example, the 
yearly health expenditures amount to over foriy-five cents per 
capita. In some of the smaller cities the amount drops to a 
few cents per capita and in certain rural communities practi- 
cally nothing is spent for public health. 

Money spent in the prevention of disease should be looked 
upon as insurance. From statistical studies it is certain that, 
up to a certain amount, money spent for better health is 
returned to the community in terms of diminished disability 
and decreased financial loss due to sickness. 

However it is often hard to prove this to the taxpayers prin- 
cipally because the money must be expended largely for per- 
sonal service and the results are difficult to visualize. Certainly 
much larger expenditures should be made for public health. 



DEPAETMENTS AND COMMUNITY HEALTH 35 

The total even of several dollars per capita does not sound 
excessive viewed in the abstract but when it comes before the 
state legislature, or local government, for appropriation it 
appears enormous. The health officer of today must do his 
best to demonstrate what can be done with small appropria- 
tions and trust that public opinion will support him in requests 
for more funds in the future. 

Doctor Hemenway has studied the expenses of some of the 
cities of Illinois. By a rather elaborate computation he has 
compared the expenses for health with the estimated losses 
due to communicable disease. While it is possible to criticize 
his results because of the difficulty in arriving at a definite 
figure representing financial losses due to sickness, the figures 
are accurate within certain limits. 

The result of his inquiry is shown by the following table: 

TABLE OF PEE CAPITA APPROPRIATIONS AND LOSSES* 

Health Sickness Per Capita 

City Appropriation Losses Annual Valuation 

Evanston $0.31 $12.83 $473. 

Bloomington 0.13 23.60 332. 

Rockford 0.80 22.74 433. 

Waukegan 0.08 17.45 174. 

North Chicago 0.03 41.40 216. 

East St. Louis 0.13 28.05 192. 

Belleville ? . . 0.14 26.83 239. 

Alton 0.08 38.41 193. 

Springfield 0.14 24.32 251. 

Decatur 0.177 17.48 234. 

Chicago 0.454 26.21 421. 

While a strict comparison of figures in the above table is 
not possible, because so many other elements may effect public 
health, yet it is apparent that, in general, money appropriated 
for public health resulted in diminished losses. It is pointed 
out that Waukegan and North Chicago are contiguous and 

•Hemenway, Henry Bixby : Kconomlcs of Health Administration. 
American Journal of Public Health, February, 1920. 



3G thp: co:\rMUN'iTY health peoblem 

represent similar communities, j-et Waukcgan at an expense 
of 5 cents more per capita shows a loss of only $17.45 per 
capita, $23.95 less than North Chicago. The table would 
also indicate that in smaller cities, such as Rockford and 
Springfield, a smaller expenditure is required than in a 
large city such as Chicago. 

The modern tendency is toward the concentration of public 
health activities in communities large enough to secure the 
services of a full time medical officer. In Ohio the state health 
department was reorganized through what is known as the 
Hughes Act which divided the state into various administra- 
tive districts. The village and township health officers who 
■were previously paid very small salaries were to have been re- 
placed by district health officers who were to be paid salaries 
sufficiently large to secure a full time health officer. One or 
more visiting nurses and a clerk were recommended for each 
district office. The district supplies a part of the fund and 
the state aids by a subsidy which varies in amount according 
to the district appropriation up to a maximum of $2,000 
yearly. In general the districts follow county lines except 
that cities usually represent a separate administrative dis- 
trict. Unfortunately just before the Hughes Act went into 
effect it was amended so that many of the expected benefits 
■were nullified. It is understood that the changes were made 
because the local communities rebelled at paying the addi- 
tional taxes required in order to carry out the provisions of 
the original act. 

North Carolina has also made considerable advance along 
similar lines aided by expert advice and financial assistance 
from the Rockcfoller Foundation. In many rural districts 
the North Carolina Board of Health has gone out of its way 
to seek out school children who are in need of treatment. 
Traveling free dental clinics and free operative clinics for 
the removal of tonsils and adenoids have reached an enormous 
number of children throughout the state. In an editorial in 
the monthly Health Bulletin* the following statement is 

•The Health Bulletin, North Carolina State Board of Health. Novem- 
ber, 1010. 



DEPAETMENTS AND COMMUNITY HEALTH 37 

made : "The State Board of Health is finding daily what every 
physician practising in the smaller towns and in the country 
has always known, and that is the urgent necessity for hos- 
pital and medical service which will reach the great majority 
of the people in time to prevent neglect and suffering espe- 
cially among children. It is one of the great sociological 
problems which must be settled." 

The new departures in North Carolina and Ohio are 
breaking a path which must be followed by the health depart- 
ments of other states. Whether the road leads to state medi- 
cine or to health insurance or to some other form of com- 
munity effort for the prevention of disease is not clear. At 
all events it is a step in the right direction. 






CHAPTER y 

PUBLIC HEALTH NURSING 

The development of nursing has led to the classification of 
trained nurses in three distinct groups ; institutional nurses— 
those working in hospitals, sanitaria and other similar insti- 
tutions; private nurses — those giving continuous care to pri- 
vate patients ; and public health nurses — who are in the main 
engaged in some form of social work closely related to public 
health. The work of the last group is classified under the 
heading "public health nursing" and includes visiting bed- 
side nursing, industrial nursing, infant welfare, school nurs- 
ing, tuberculosis nursing, social service work and many other 
similar activities, each closely related to the improvement of 
public health. 

The term public health nurse is usually understood to mean 
"a graduate nurse who is devoting her time and energies to 
social work aiming toward the improvement of the health and 
welfare of the public." Her training as a nurse is essential 
to the work although actual bedside nursing, as it is ordinarily 
understood, may represent only a small part of her daily 
duties. It is impossible to outline definitely all the various 
forms of work which a public health nurse may engage in. 
Indeed every year new forms of social health activities are 
added to the duties of the nurse under the general heading of 
"public health nursing." 

DEVELOPMENT OF PUBLIC HEALTH NURSING 

Some form of what is now knovm as public health nursing 
has been in existence for many years, usually in connection 
with the visitation of the sick by nuns, deaconesses and others, 
who were, as a rule, almost always under the control of the 

38 



PUBLIC HEALTH NURSING 39 

Church. It was not until comparatively recently, however, that 
public health nursing, in a form approaching the present, has 
been systematically carried out. In England there are authen- 
tic records of visiting nursing under a centralized control as 
early as 1875, but in America the movement did not start until 
considerably later and in the beginning there was little 
attempt made to co-ordinate the work, every organization or 
municipality starting the work in its own way and according 
to its own ideas and ideals. 

During the last twenty years, public health nursmg has 
developed by leaps and bounds so that in 1919 there were 
nearly 9,000 trained nurses who devoted their entire time 
to this type of work. Some idea of the growth of this move- 
ment since 1891 may be obtained from the following table: 



* 



GROWTH OF PUBLIC HEALTH NURSING IN THE UNITED STATES 

Year Organizations Nurses 

1891 58 130 

1905 200 400 

1914 1992 5152 

1919 3094 8770 

During the first decade of this century, this particular kind 
of nursing was largely developed by local organizations which 
were known as district, or visiting, nursing associations and 
the nurses working under such organization were termed 
visiting, or district, nurses. With the growth of public health 
nursing, however, the names were outgrown and such associa- 
tions are now recognized as merely special branches of gen- 
eral public health nursing. 

» 

NATIONAL ORGANIZATION FOR PUBLIC HEALTH NURSING 

As the result of the very evident need for some centralized 
body which might speak with authority on subjects having to 
do with public health nursing, the National Organization for 

•statistical Department, National Organization for Public Health 
Nursing, 1920. 



40 THE COMMUNITY HEALTH PROBLEM 

Public Health Nursing was formed in June, 1912, This 
organization does not undertake actual administrative work 
but acts as an advisory body, collecting and disseminating 
information, maintaining standards, and stimulating new 
endeavor. The objects of this association as stated in a cir- 
cular sent out from the central olfice are: "to stimulate the 
extension of public health nursing and eventually to main- 
tain service bureaus employing a staff of secretaries whose 
services are available to both private and public agencies doing 
public health nursing work." A magazine "The Public 
Health Nurse" is published monthly. 

RED CROSS PUBLIC HEALTH NURSING 

Before the war the American Eed Cross had adopted a 
comprehensive plan for the development of public health nurs- 
ing especially in rural districts. "While this program was some- 
what interfered with, because of the shortage of nurses during 
the war period, the Eed Cross has adopted a peace-time pro- 
gram which includes the extension of public health nursing 
into local communities. Local initiative and control is en- 
couraged under the Eed Cross plan but a certain amount of 
general supervision and guidance is retained by Division and 
National Headquarters. 

TRAINING 

While it is essential that the public health nurse be a trained 
nurse, in the sense that she has completed her hospital train- 
ing, it is also required that she be especially trained in the 
public health aspects of her work. This may be accomplished 
at the present time by special field work in connection with 
her hospital training or by post-graduate studies either at a 
college or in connection with one of the existing district nurs- 
ing associations. A few excellent nurses have received their 
' training in this phase of nursing through practical work in 
the field under the instruction of a trained supervisor, but in 
general such training is inferior to the combined theoretical 



PUBLIC HEALTH NURSING 41 

and practical training courses offered by colleges and schools 
for public health nursing. 

Many of the representative colleges offer courses leading to 
a certificate in public health nursing. Teachers College, 
Columbia University, offers a full year's course consisting of 
eight months' work in the college and four months' training at 
the Henry Street Settlement, as well as several shorter courses 
which do not, however, qualify for a certificate. Undergradu- 
ate nurses from approved hospitals who are taking the train- 
ing course at the Henry Street Settlement may be admitted 
to special classes. Similar courses are offered at the Uni- 
versity of Michigan, the University of Pennsylvania, the 
University of California, and Western Reserve University. 

It thus becomes evident that there is a steady movement 
to increase the requirements while at the same time the work 
is being constantly extended. It is pointed out that while in 
the hospital the nurse learns to care for the sick, she usually 
has little experience in the solution of either family or com- 
munity problems which, in many cases, constitutes a large 
part of the work of the public health nurse. The present 
shortage of public health nurses has caused a few to protest 
against what they consider to be "over-training" but among 
those who may be expected to speak with authority in public 
health circles a short period of special training is considered 
not only desirable but absolutely necessary. Indeed the state- 
ment is frequently made that, in this field, a nurse without 
special training is worse than none. 

If we remember that the first district nurses limited their 
werk almost entirely to bedside care, and if we stop for a 
moment and consider the problems which must have con- 
fronted such nurses, we may possibly appreciate more clearly 
the necessity for special training in public health nursing. 
The early district nurses sent out to give medical care only, 
soon discovered that the giving of medicine had little effect 
if there were no food in the house; learned that to secure 
cleanliness required more than an order from the physician 
or nurse ; and that medical treatment and preventive measures 



43 THE COMMUNITY HEALTH PROBLEM 

required not only nursing skill but an immense amount of 
tact and social understanding. Slie soon found that she was 
making a certain number of visits which were entirely social 
in character and that in order to improve the health of a par- 
ticular patient her work might require a knowledge of eco* 
nomic, financial, industrial or social conditions, which carried 
lier a long way from the therapeutic principles she had learned 
in the hospital. 

THE KELATION OF THE VISITING NDESE TO THE PHYSICIAN 

Bedside nursing, as such, should always be carried out 
under the direction of a physician. The public health nurse 
who has the welfare of the patient at heart will always insist 
that, if possible, a physician be secured to prescribe for every 
individual who appears ill, the nurse devoting her efforts to 
the training of the patient, or attendants, in simple measures 
for carrying out the instructions of the attending physician. 

It would seem that this ser\ice might be considered as 
interference with the work of the physician, and in certain 
isolated instances it has been so considered but, in the main, 
physicians have appreciated the help and co-operation of the 
district nurse and have not hesitated to say so. Mary Sewall 
Gardner* states the attitude of the medical profession to 
visiting nursing as follows: "The finer and more broad- 
minded physician has always recognized the public health 
nurse as a helpmeet who strengthens his hands and helps him 
to produce results impossible alone. The poorer and narrow- 
minded members of the profession have regarded her with 
suspicion and feared her interference at every turn. Men 
whose minds have been steadily fixed on the welfare of the 
people, not on circumstances affecting themselves, have from 
the first gladly given to the nurse a helping hand and with 
a fine loyalty sought to strengthen her position with the 
patients. Men occupied chiefly with their own personal careers, 
who have feared that the public health nurse might jeopardize 
either their authority or the amount of their work, have per- 
•Gardner, Mary 8«wall : Public Health Nursing, p. 43, New York, 1914 



PUBLIC HEALTH NURSING 43 

sistently denied her the loyalty which they 80 rigorously 
demanded for themselves," 

lu any community which contemplates the establishment of 
a district nursing service there is apt to be a certain amount 
of antagonism among the local physicians. This can be 
greatly diminished if the service is started with the co-opera- 
tion of the profession and if the nurses make special efforts 
to observe the ordinary rules of professional ethics. These 
rules, simply stated, mean merely that the physician and not 
the nurse is in charge of the case and that the nurse must 
not take upon herself the duties and responsibilities rightly 
belonging to the physician. 

Miss Gardner interprets the rules of professional ethics to 
mean, "that she (the public health nurse) should not diagnose, 
should not ppescribe, should not recommend a particular doc- 
tor or a change of doctors, should not suggest a hospital to a 
patient without the concurrence of the doctor and should 
never criticize, by word or unspoken action, any member of 
the medical prpofession.-" These rules appear to me too 
severe and I believe that in time they may be modified so 
that a nurse will not be compelled to serve under a physician 
who is palpably ignorant or dangerously careless. In such 
cases the nurse should report to her immediate superior who, 
if she is experienced and resourceful, can usually find a way 
out of the difficulty. 

SPECIALIZATION IN PUBLIC HEALTH NUESINO 

The anti-tuberculosis campaign required nurses of special 
training and with a special k-nowledge of the care and man- 
agement of the tuberculous, so that there gradually developed 
nurses who were specialists in this work. About the same time 
there was an extension of school nursing so that in this field 
there were also nurses who by virtue of their training had 
become specialists. In the same manner various other branches 
of medicine and a variety of social welfare movements led to a 
number of other specialties so that at one time it is said to have 



44 THE COMMUNITY HEALTH PROBLEM 

been difficult to find a nurse who was doing ordinary bedside 
nursing. It has been felt by some that so much specialization 
is undesirable because it tends to narrow the field of vision and 
interferes with the broad grasp of the public health problem 
as a whole. 

While specialists are certain to remain and while they, 
without doubt, fill a distinct place in the public health pro- 
gram the tendency of the recent graduate to specialize should 
be discouraged. It is far better to limit the work to certain 
physical boundaries, such as a group of city blocks, or a rural 
township, than it is to limit the services according to the 
type of disease under treatment. The public health nurse 
accomplishes most through personal contact, obtaining thereby 
the confidence of the family. Cases have been reported where 
as many as five different nurses were visiting the same family. 
Such a procedure cannot fail to result in duplication of effort 
and confusion and should of course be avoided. In this con- 
nection it is desired to point out to those doing health work 
that in dealing with patients it is always much better to 
arrange the visits so that, in so far as practicable, all instruc- 
tions are ?iven by the same person. It frequently happens that 
inconsequential variations in the details of instructions given 
by two different nurses lead the patient to distrust them both. 

Certainly it would appear best if there are to be specialists 
in the field of public health nursing tliat they should be 
limited in number and that they should devote their time 
largely to research, teaching and supervision, rather than in 
the more intimate details of social welfare. 

TUBERCULOSIS AND PUBLIC HEALTH NURSINO 

Among the first of the specialists in public health nursing 
was the tuberculosis nurse. It has been stated that this work 
began in New York about 1902 and extended rapidly in New 
York and to many other cities. 

Tuberculosis is a disease which is peculiarly adapted to 
the work of the public health nurse. It is a chronic disease, 



PUBLIC HEALTH NURSING 45 

continuous treatment is required, physicians visits are infre- 
quent (usually once in two weeks or thereabouts), the social 
problems are numerous, and the field of preventive medicine 
is almost unlimited. 

In such cases the nurse sees that the physician's orders 
are carried out, aids in the securing of sanitarium treatment 
for suitable cases, does what she can to prevent contact 
infection and aids in the economic rehabilitation of the family. 
She helps children in tuberculous families to secure vacations 
in the country, tries to influence the working members of the 
family to secure suitable occupations, insists on the systematic 
routine medical care of the patient, and teaches the home 
attendants simple methods to prevent the spread of the 
infection. 

INDUSTRIAL NURSING 

As the term implies, industrial nurses are nurses employed 
by mercantile or manufacturing establishments for the bene- 
fit of sick or injured employees. The industrial nurse is a 
specialist but she specializes by limiting her attention to the 
employees of a certain industry rather than in any limited 
field of medicine. Her duties vary according to the demands 
made by the particular industry concerned and the various 
problems presented by the sick or injured. 

Industrial nursing has been greatly stimulated by the intro- 
duction of the workmen's compensation principle, although 
many nurses were employed by industrial establishments be- 
fore this law went into effect. The work of course varies 
greatly with the nature of the business and with the require- 
ments of the employer. In some cases it is limited to first aid 
during business hours at the plant dispensary and in others a 
complete visiting nursing system available to both employees 
and their families is carried out to the last detail. The 
value of the services of the nurse in factory first aid rooms 
has been clearly demonstrated to employers of a thousand or 
more persons although the need is less evident to those who 



46 THE COMMUNITY HEALTH PROBLEM 

employ a smaller number.* The need of a nurse for the care 
of the sick and for the prevention of disease is not, however, 
60 generally admitted among employers of labor. While many 
of the larger plants have adopted a fairly thorough health 
service with a public health nurse in charge, there is still a 
large field in which no effort is made by the employer to 
improve either personal health or community social condi- 
tions. However the industrial nursing movement has had a 
remarkal^le stimulus during the post-war period and promises 
to spread rapidly. 

SCHOOL NURSIIfG 

With the development of inspections in schools came the 
school nurse. It was found that to accomplish definite results 
personal contact with the parents and follow up efforts were 
necessary. Few physicians could be found who had the time 
for this work and few teachers who had either the time or the 
required training, so that school nurses were required almost 
from the first. The most striking result of the introduction 
of nurses in schools was the increased attendance. This was 
brought about by the fact that the nurses cut down the 
number of exclusions from school for minor easily curable 
troubles, such as ring worm, pediculosis, etc. In the nest 
place efforts were directed toward the cure of such simple 
diseases as enlarged tonsils, dental diseases, and mild coughs 
and colds, and more recently efforts have been made to over- 
come under-nutrition and mal-development in children of 
school age. 

The school nurse is sometimes under the direction of the 
board of education and sometimes under the health authori- 
ties. In the broader sense of her duties the nurse is largely 
concerned with health education rather than actual treatment 
so that those who insist that her duties are properly a part 
of the department of education have very strong arguments. 

•m states where compensation laws are !n efftrt. the Insnrance com- 
panies recognize the value of a first aid station with a nurse in charge 
and make a reduction in the insurance rates to employerB adopting this 
plan. 



PUBLIC HEALTH NURSING 47 

In many scliools tlicro are classes in home hygiene and the 
eare of the sick, dietetics, and first aid, which aro taught, in 
part at least, by the school nurses. 

OTHER SPECIALTIES 

There are many other specialties which have become part 
of public health nursing. Among these are child welfare 
nursing, maternity nursing, pre-natal nursing, venereal disease 
nursing, mental hygiene nursing and many others. It will 
be noted that in some cases the special field takes its name from 
the special field of medicine with which it deals and in others 
from the name of the establishment in which the nursing is 
done, so that it is often difficult to say just where one specialty 
leaves off and another begins. Thus the school nurse does 
bedside nursing when she visits a sick child in his home and 
the industrial nurse invades the field of tuberculosis nursing 
when the disease occurs in an employee of a particular estab- 
lishment. 

PUBLIC HEALTH NUBSINO UNDER PUBLIC AUTHORITY 

State or municipal control of public health nursing is 
considered by many as essential for the wide and thorough 
development of the nursing program. While there has been 
considerable opposition to this view the movement is gradually 
spreading so that the employment of nurses is now considered 
an essential part of every comprehensive municipal health 
program. Especially in schools, the employment of nurses has 
become general and is bound to spread because the need is 
recognized and, in the end, it is felt that the solution of the 
problem of child welfare is the duty of the community rather 
than of certain individuals. This being the case, is not muni- 
cipal or state control the most practicable method which we 
have to accomplish tangible and permanent results by means 
of community effort? 

In some cities tuberculosis nursing has been taken over 
either wholly or in part by the local health department and 



48 THE COMMUNITY HEALTH PEOBLEM 

in other localities bedside nursing has been placed under the 
same control. In New York City as in many other places, 
during the influenza epidemic of 1920 large numbers of vol- 
unteer nurses were employed by the City Department of 
Health in tlie eti'ort to control the epidemic. 

It is plainly apparent that there is a strong tendency for 
the state or municipal health authorities to take over certain 
parts, at least, of the public health nursing program, and in 
some localities this has been opposed on the ground that 
the work was better done under private control. 

However, those who fear that the loss of control by private 
enterprise will result in a deterioration of the service need 
not regret the change, for the entire health program is so large 
that private enterprise may be successfully utilized to its 
fullest extent in other fields if it can be relieved, in part at 
least, of the load it is now carrying. Every health movement is 
of necessity largely limited as to available funds and the 
broad application of any welfare movement can only take place 
through the movement becoming part of the local or state 
government. 

THE PUBLIC HEALTH NUBSE IN THE COMMUNITY 

It is a generally accepted principle that organizations em- 
ploying public health nurses should be non-sectarian; that 
association with a church even to the extent of having offices 
in the church, or parish house, tends to prevent the fullest 
utilization of the nurses' services. For self-evident reasons 
the nurse should never interfere with the religious views of her 
patients. Churches may contribute to the support of the 
nursing association which should in turn care for the entire 
community without sectarian limitation. 

Limitation of the nurses' services to a certain prescribed 
district is not open to the same objection. Indeed, in spite 
of arguments which have been advanced to the contrary, the 
writer believes that in practically every case the district cov- 
ered by the nurse should be definitely limited in extent. Occa- 



rUBLIC HEALTH NURSING 49 

sionally the work of visiting nurses has been greatly inter- 
fered with because of the enormous districts which must be 
covered, in some cases so great that not more than three or 
four calls could be made in the course of the day's work. 
The value of the services* of a public health nurse lies, in part 
at least, in her ability to supply medical supervision at a rea- 
sonable cost and this element of cost is greatly increased when 
a long trip is made to see a single patient. 

Before the war the services of a public health nurse were 
figured at from fifty to seventy cents per visit. With the 
increase in salaries and the cost of supplies the figure today 
is increased possibly to the neigli])orhood of seventy-five cents, 
or more, for each visit. If the districts are unlimited in area 
the cost may increase alarmingly. 

Of course the geographical boundary should be based on the 
population which might be expected to require the nurses' 
services. The nature of the nurses' work and the ability of 
inhabitants of a given district to employ private nurses, both 
so greatly influence the population which may be satisfac- 
torily served by a single nurse that one hesitates to give exact 
figures. It may be safely said, however, that in a community 
of 3,000 inhabitants representing all classes there will be 
found sufficient work to require the full time of a public 
health nurse. In rural districts this number would probably 
be smaller. 

The question of payment is rather a vexatious one. It la 
ordinarily the custom to charge a fixed fee to patients able 
to pay — usually fifty cents or thereabouts — scaling the fee 
down for those less able, in some cases to as low as five cents, 
eventually treating some cases for nothing. The arguments 
advanced in favor of this plan are that it avoids the idea of 
charity to which most people object, and helps pay the 
nurses' expenses. Others claim that, like education, the 
nurses' services should be free to all. Possibly the middle 
ground is best, the nurse giving her services when she is 
paid by the state or municipality and receiving a fee when she 
is supported by private organizations. Of course, in industrial 



50 THE COMMUNITY HEALTH PEOBLEM 

or insurance nursing, sufficient fees should be charged to 
cover not only the nurses' time but overhead expenses as well, 
but such fees should be paid by the employer or insurance 
company, rarely, if ever, by the patient. 

THE HENEY STREET SETTLEMENT 

Of interest because it represents a large and interesting 
visiting nursing association, the Henry Street Settlement may 
profitably be discussed in some detail. Started twenty-six 
years ago by two nurses it has expanded its activities so that 
at present nearly two hundred nurses are employed in the 
work and during a single year 43,946 patients were cared for. 

The senice was started in the Henry Street district, one of 
the poorer sections of New York City in which the inhabi- 
tants are almost all of foreign birth. It increased so rapidly 
that, in 1919, there were in operation twelve district branches 
throughout the city at each of which there were a supervisor 
and two or more nurses. The service, in the main, consists of 
general bedside nursing and it is given chiefly to those who 
are unable because of economic circumstances to provide ade- 
quate attention for their families in time of illness. 

The expenses of the organization are met by small fees paid 
by those treated, by payment for services rendered to em- 
ployees of industrial corporations and policy holders of insur- 
ance companies, and by voluntary contributions. 

During the epidemic of influenza in 1920 a total of 30,555 
visits were made between January twenty-fourth and Feb- 
ruary eighteenth. Many cases of pneumonia received nursing 
care in their homes with a mortality which, it is claimed, 
was considerably less than that of the city hospitals. A large 
proportion of the patients are children, the result being that 
no small part of the nurses' work is devoted to education of 
the mother in simple rules for the improvement of the health 
and welfare of the small sufferers. A maternity center is 
established in one district which in a single year had a record 
of 28,982 visits to mothers and babies.* As a result of this 

•From Btatlstlcg fnrnlshed by the Henry Street Settlement. 



PUBLIC HEALTH NUKSING 51 

intensive work it was felt that infant mortality was distinctly 
diminished. 



INSURANCE NURSING 

Closely related to industrial nursing is the program insti- 
tuted by the Metropolitan Life Insurance Company for its 
industrial policy holders. 

This service was started in 1909 in conjunction with the 
Henry Street Settlement, Department of Nursing, in New 
York City, and is limited entirely to industrial policy holders ; 
that is those holding life insurance for small amounts, most 
of whom are persons employed in industrial occupations. 
The service increased rapidly in New York and soon spread 
to other cities so that today it may be said to be applied uni- 
versally by this company to all industrial policy holders who 
are ill and require bedside treatment. In some cases, in cities 
outside of the New York City area, visits are made by com- 
pany nurses but as a rule it employs the nurses of the local 
visiting nurses' association. The total cost for the service to 
the company during the year 1918 was $810,387.86 and the 
average cost per visit was 53.5 cents.* 

The average number of visits per patient was 4.9. Based 
upon the entire number of industrial policies in force the 
cost per policy was 4.6 cents. 

The Metropolitan Company have prepared a table showing 
the influence of the nursing service and other welfare activi- 
ties upon the mortality rate. 

•Prankel, Lee K. : The Welfare Work of the Metropolitan Life Insnr- 
ance Company for its Industrial Policy holders. Report for 1918. 



52 THE COMMU^S^ITY HEALTH PROBLEM 

INDUBTEIAL EXPERIENCE, METROPOLITAN LIFE INSURANCE CO. 

1911-1917 

Deaths per 1,000 

Per cent. 
Age Period 1917 1911 Decline 

AU ages 11.6 12.5 7.2 

1 to 4 10.5 12.8 18.0 

1 20.4 25.2 19.1 

2 13.5 16.6 18.7 

3 7.7 9.3 17.2 

4 5.6 6.6 15.2 

5 to 9 3.4 2.7 3.7 

10 to 14 2.6 2.7 3.7 

15 to 19 4.8 4.7 *2.1 

20 to 24 6.6 7.3 9.6 

25 to 34 8.4 9.5 11.6 

35 to 44 12.4 13.7 9.5 

45 to 54 19.6 19.8 1.0 

55 to 64 35.8 36.0 6 

65 to 74 76.4 74.5 *2.6 

74 and over 142.6 139.3 *ZA 

•Per Cent, increase in seven years. 

There is shown by the above table, for all ages, a decline 
of the mortality rate of over 7 per cent, in seven years. The 
decline is most marked and most significant during the 
early years, being over 19 per cent, for the first year of life. 
When the rates for the principal causes of death of policy 
holders are compared with general death rates for the com- 
munity at large as obtained from government sources, the 
results are distinctly in favor of the policy holders. It is 
fair to assume that a part of the decline in mortality, and 
improvement in general health, was due to the program of 
visiting nursing established in 1909. 

EFFEfcT OF THE VISITING NURSE ON PUBLIC HEALTH 

It has been pointed out that approximately only one-tenth 
of all illness is treated in the hospital, the remainder being 



PUBLIC HEALTH NUESING 53 

cared for in the patient's liomc. Consequently in order to 
reach every sick individual, nine-tenths of the sick must 
receive medical care in the home. Such visits may be made 
either by physicians or public health nurses or by both. In 
acute illness, and to diagnose disease and outline treatment, 
the services of a physician cannot be dispensed with, but for 
the routine care of chronic illness and for prevention of 
disease there is at present no one better qualified than the 
public health nurse. 

The medical problems connected with the supervision of 
health within the limits of the home are, frequently, compara- 
tively insignificant; but the social and economic problems 
which must be solved in every home, before the greatest benefit 
may be secured through the application of the lessons learned 
from recent advances in the field of preventive medicine, are 
such that the services of a trained public health nurse are 
almost essential. This is especially true among the poorer 
classes. 

If there has been one single factor more than another which 
has made for general improvement in health conditions in 
the larger cities during the last quarter century, that factor 
is without doubt the rapid spread of public health nursing. 
Actual services during illness represent only a small part of 
the nurses' work. Education of the bedside attendants in 
proper methods of caring for the sick, education of the 
patients as to the necessity of early treatment, and education 
of the public as to the importance of cleanliness and sanita- 
tation are all considered a part of her duties. It is the general 
concensus of opinion that no program for the betterment of 
community health will be satisfactory unless the public nurs© 
plays a major part in its execution. 



CHAPTER VI 
THE CAMPAIGN FOR BETTER HEALTH 

In outlining a plan for the improvement of community 
health it is necessary to consider the problem as a whole and 
outline a plan of action much as a general plans his action 
against an enemy force. The information which is gained 
from health sun'eys, from vital statistics, and from com- 
munity records, corresponds to the army oflBcer's map of the 
terrain; the methods and practice of modern scientific med- 
icine are in a sense, the ammunition to be used ; the co-opera- 
tion of the citizens, physicians, civil authorities and workers 
is represented by the morale of the troops; and the success 
of the campaign depends upon the intelligent use of all these 
factors by a keen administrator. 

Back of the battle lines there must be a dependable source 
of supply, and in the same manner back of every community 
health effort there must be adequate and available funds sup- 
plied either by public authority or private individuals. Un- 
limited funds are practically never available and it conse- 
quently becomes the duty of the administration to accomplish 
the greatest possible result with the least practicable expen- 
diture. 

HEALTH ADMINISTRATION 

If there is one element more important than another in the 
solution of the community health problem it is the question 
of administration. Enormous amounts have been spent for 
the benefit of public health which have been wasted because 
the funds have been poorly administered. Health administra- 
tion includes not only the expenditure of money but the con- 
trol of executives as well. It should work for co-operation and 

54 



CAMPAIGN FOR BETTER HEALTH 55 

team work of all existing health agencies and should aim to 
encourage the interest and entliusiasm of the citizens of the 
community. 

There are several different forms of control of health ad- 
ministration. It may be under the control of the state, as 
■would be expected under a purely socialistic or paternalistic 
form of government. Of this form there is considerable to be 
said in favor and comparatively little against. From a health 
viewpoint a paternalistic form of government can accomplish 
wonders. While sanitary defects cannot be corrected by de- 
cree they can be greatly discouraged by laws creating mod- 
erately severe fines for offences against sanitation. Improve- 
ment of health conditions under military authority which is, 
in its essence, paternalistic, has been sufficiently well demon- 
strated (for example the elimination of typhoid fever during 
the recent war) to indicate the wide range of its possibili- 
ties. Complete socialistic health control will probably never 
occur in America and there is some doubt as to its success 
even if it should occur, but a certain measure of socialistic 
control — using the term in its broadest sense — is inevitable. 
Indeed our present state health departments are in a sense 
socialistic forms of governmental control. 

The second alternative is the administration of health ac- 
tivities by a private organization such as the Rockefeller 
Foundation, the Red Cross, or one of the various other wel- 
fare organizations which are working for better community 
health. The disadvantage of private control is that there are 
usually insufficient funds to reach more than a small part of 
the population so that financial aid furnished by such organi- 
zations must be devoted to only a few localities where experi- 
ments may be made and the results demonstrated to the coun- 
try as a whole. 

The third plan of administration presupposes the control by 
the community itself through representatives elected by its 
citizens. It is this plan which is being studied in Cincinnati 
by the National Social Unit Organization, The difficulty asso- 
ciated with such a plan is that members of the community 



56 THE COMMUNITY HEALTH TROBLEM 

rarely have sufiBcient broadness of vision and experience to 
visualize the results of better health and that from a practical 
standpoint, communities up to the present have not made full 
use of preventive medicine as it exists. 

As a matter of fact all these forms of administration are 
being used today. It is probable that the state will take the 
initiative in health matters and tliat in the end they will be 
administered largely by local authorities under the control 
of the state or federal government. Private funds should be, 
and are, nsed to direct research and to demonstrate the value 
of remedies and preventive measures. Their influence will be 
felt in concentrating the attention of the community on cer- 
tain conditions such as infant welfare, pre-natal care, or 
other similar conditions, which might otherwise be overlooked. 

It matters not from whence tlie administration derives ita 
powers, it must work with the people, not at them. It must 
have the good will of its executives and must, by unceasing 
effort, secure and keep the sympathy and understanding of 
the people or the full measure of success will not be attained. 

PEEVENTION OF ACCIDENT AND DISEASE 

Health work should start with prevention. While the im- 
portance of preventive medicine is well recognized by modern 
medical science it is difficult for public health authorities to 
secure adequate appropriations for prevention of disease. The 
effects of measures for prevention are not always plainly seen 
and consequently not appreciated. Often it takes the scourgd 
of a widespread epidemic before appropriate measures for the 
prevention of such diseases as typhoid fever and yellow fever 
are instituted. The cost of good water, and of efficient sewage 
disposal are high but not nearly so high as the costs of those 
diseases caused by the neglect of well-recognized sanitary re- 
quirements. This is well known, yet comparatively few com- 
munities have appropriated sufficient funds to wipe out entirely 
typhoid and diarrheal diseases, which are largely carried by a 
polluted water supply. 



CAMPAIGN FOR BETTER HEALTH 57 

Preventive measures include the prevention of accidents. 
The enactment of workmen's compensation laws has done 
more than any other one thing to promote the "Safety 
First" movement. These laws place the cost of injury 
directly upon the industry concerned so that it is to the 
financial advantage of the employer to prevent as many acci- 
dents as possible. As a consequence of these laws many devices 
have been installed to prevent accidents, and strict rules 
adopted to prevent employees from "taking chances." It is 
rather an odd commentary on the operation of the human 
mind that men will avoid danger because of a factory rule and 
fear of losing their jobs when they will not avoid the same 
danger for fear of loss of life or limb. 

Statistics show a rapidly increasing number of street acci- 
dents, especially those due to automobiles. The community 
can do much to decrease the number of such accidents both 
by carefully considered laws, and publicity widely dissemi- 
nated so as to direct the attention of the public, both drivers 
of machines and pedestrians, to the extent of the dangers 
which exist. 

Industrial diseases, such as lead and arsenic poisoning, 
should be reduced to a minimum. Sufficient testimony is at 
hand to indicate a method of preventing nearly every form 
of industrial disease. Education of the public and the inclu- 
sion of such diseases under the provisions of compensation 
laws should be the first moves for prevention. 

Diseases spread by social contact — and I use the term in 
its broadest sense — are much more difficult to deal with than 
are either industrial diseases or those due to gross sanitary 
defects. People resent any attempt to control their health by 
taking away anything which may be considered liberty of 
action. The enactment of prohibition will no doubt prevent 
many diseases, but it is looked upon as an affront to personal 
liberty. Venereal diseases are spread broadcast in nearly every 
community, but efforts to prevent their spread are met with 
opposition. Contagious diseases are often disseminated be- 
cause it is hard to make people observe rules of quarantine. 



58 THE COMMUNITY IIExlLTH PliOBLEM 

The danger of the public drinking cup has long been recog- 
nized but it required years of education and the passage of 
state laws before it was discarded. 

Two special measures are at our disposal to combat the 
spread of disease caused by social contact: 1, Education, 
which is slow but accomplishes results if persistently carried 
out. 2, Legislation, which must be carefully planned, and 
enacted only after a period of education. 

CURATIVE TREATMENT OF INJURY AND DISEASE 

' In every community the question should be asked, *T)o 
the citizens of this community receive adequate medical care?" 
The establishment of a modern hospital, the location of ex- 
cellent physicians in the community and the expenditure of 
money for poor relief do not necessarily constitute adequate 
community treatment. Investigations must be made to deter- 
mine whether the money is spent to the best advantage and 
whether local couditious either in reference to ])hysicians or 
to hospital service are such as to interfere with the best type 
of service. 

Frequently a community will be found where there are a 
number of excellent physicians but no facilities for laboratory 
or x-ray work, thus seriously crippling the medical service. 
Again where there may be no nursing service, physicians being 
obliged to devote a large part of their time to this work which 
could be done better and at less cost by a visiting nurse. 

There is a certain amount of lost energy in private prac- 
tice. Physicians do not limit the area in which they work 
but spend much of their time traveling from patient to 
patient, causing therc])y a certain amount of duplication of 
effort. This is due largely to the personal equation, it being 
regarded as the right and ])rivilcge of any sick person to 
choose his own physician. Thus Doctor A. drives ten miles 
to see a patient who lives next door to Doctor B. While at 
the same time Doctor B. may travel the same distance to see 
his patient who lives near Doctor A. This represents an enor- 



CAMPAIGN FOR BETTER HEALTH 59 

moiis waste of time and energy but this right of free choice 
is zealously guarded by the medical profession, and demanded 
by the public. It is believed that this demand for free choice 
is not as important as it appears to be and that if physicians 
would agree to co-operate, working together for the public 
good, much of this duplication of effort could be eliminated. 
It is certain that under the present system physicians have 
little time to devote to preventive medicine or public health. 

Much wasted energy could be avoided and a considerable 
saving of the physician's time accomplished by a wider use 
of the visiting nurse in private practice. 

The importance of the visiting nurse in the cure of disease 
cannot be overestimated. It has been stated that over 90 per 
cent, of illness occurs in the home and must be treated there. 
It is in such cases that the visiting nurse finds her work. 
Her services should be made available for rich and poor alike, 
and above all her work should bo limited to certain well- 
defined areas from the start so that duplication of effort may 
be avoided. If the area in which she practices is limited she 
will be able to accomplish much more than if required to 
spend a large part of her time traveling from place to place. 

REHABILITATION 

After the storm the salvage of wreckage must begin. After 
injury or disease there is nearly always a more or less pro- 
longed period of partial disability which calls for rehabilita- 
tion. In the mildest cases, disability can be overcome by a few 
weeks' trip to the country or a short stay in a convalescent 
home. In some cases the disability may last for months or 
years and, in such cases, idleness is neither good for the 
patient nor the community. In many cases there is left behind 
a permanent disability whicli forever prevents return to the 
former vocation. 

The workman who has had pneumonia, unless he is warned 
against it, is apt to return to some form of laborious occupa- 
tion which, following pneumonia, may result in permanent 



GO THE COMMUNITY HEALTH rKOBLEM 

injury to the lieart. Tt is not enough to advise such a man 
against hard work. He must be guided toward other work 
for which he is better adapted. The cripple, who has lost an 
arm, easily becomes a permanent object of charity unless he 
is taught another form of occupation which he is able to 
carry on in spite of his disability. The man who has been 
a skilled workman and lost his arm is apt to feel that he 
has lost his chance and will never again be able to sup- 
port his family. The change in his mental attitude toward 
the world is remarkable when he finds that he may be trained 
for another position, which will not alone make him self 
supporting, but will enable him to earn as much or more than 
before his injury. The Institute for Crippled and Disabled 
Men in New York City makes a specialty of rehabilitation 
of disabled men. 

The Ford Motor Company boasts that a man is never dis- 
charged from their employ because of physical disability. If 
he is unfit for his former occupation he is trained for another. 
The entire plant was studied with this in view and it was 
found that, in a comparatively short time, the man with a 
handicap could be trained for some form of work for which 
his physical condition fitted him. In 1918 it is said that in 
the Ford factory there were over 9,000 men at work all of 
whom had some form of physical disability. On the pay roll 
were men without one or both feet, men blind of both eyes, 
men with one or both hands missing, and men with arms 
or legs hopelessly crippled. Not a few cripples but literally 
thousands of them. 

It is stated that, in the Ford factory, this is not done as 
a work of charity but as a business proposition and that it 
pays. Even patients with tuberculosis when unsuitable for 
sanitarium treatment are kept at work in the factory 
under medical supervision. These patients work in a specially 
constructed building, and are able to support their families 
while they are taking the cure. 

There is probably no other large corporation which has fol- 
lowed this plan as extensively as the Ford Company but the 



CAMPAIGN FOR BETTER HEALTH 61 

Federal Board for Vocational Training which has charge of 
the rehabilitation of disabled soldiers is extending the work 
along somewhat similar lines. The work of vocational train- 
ing for industrial cripples, of whom there are an enormous 
number, has received a tremendous impetus through the 
efforts of the Federal Board. Congress has appropriated a 
sum of money for the purpose of encouraging state activitiea 
in this line. This money is available to states, in order to 
encourage the institution of vocational training, on the condi- 
tion that the state appropriate an equal amount for the same 
purpose. 

CARE OF THE TOTALLY DISABLED 

There will remain even under the best conditions of medical 
care a certain number of the inhabitants of every community 
who are totally disabled as far as any gainful occupation is 
concerned and hopelessly invalided according to the present 
state of medical knowledge. I say "according to the present 
state of medical knowledge" advisedly because there are hun- 
dreds, previously considered incurable, now easily cured by 
well recognized methods of medical and surgical treatment. 

The totally disabled includes the insane, certain classes of 
epileptics, persons in the advanced stages of tuberculosis and 
inoperable cancer, and a few others. The community must 
recognize that these persons must be considered a charge on 
the community as a whole and not merely on their nearest 
relatives or their acquaintances. 

How shall we care for this group of so-called "incurables"? 
A few may be left in their home surroundings, especially 
when this course assures reasonably good care. It is reasonable 
to presume that when necessary the state, might pay for the 
maintenance of such persons in their homes rather than 
undertake the expense of institutional care. However, the 
larger part of the totally disabled, especially the insane, should 
be treated in institutions. The concenixation of various types 
of chronic mental and physical disorders ixi a large institution 



G3 THE COMMUNITY HEALTH PROBLEM 

permits of their treatment at comparatively low cost and gives 
promise of the discovery of some form of cure for at least a 
part of the diseases under treatment. It has been only a few 
years since cretinism was considered incurable and patients 
with this disorder spent their lives in asylums. Now the dis- 
ease is recognized as a disorder of the thyroid gland and easily 
cured by appropriate thyroid treatment. As much may pos- 
sibly be accomplished in the future for other diseases now 
considered incurable. 

There is another very potent reason for institutional care 
of the so-called incurables, ^lost of them do much better 
when removed from the excitement of modern life and in 
institutions arrangements can be made so that many of the 
unfortunates may be kept busy with some form of light occu- 
pation which keeps the mind busy and body healthy. 

LINES OF ENDEAVOR 

/ In attacking the problem of community health there are 
certain lines of endeavor along which efforts for better health 
may be carried out. Most of these have been already studied 
with great care and as a result of the experience of others 
there is considerable cumulative information available. Along 
eome of the lines which will be mentioned there are already 
national organizations with many branches. Others have been 
developed by the state or local departments of health or local 
welfare organizations. 

, In the organization of any form of community health move- 
ment it is well to divide the work so that various workers have 
their duties definitely outlined. In large communities a sepa- 
rate committee can be appointed, if thought desirable, for 
each separate health problem. 

The prevention of accidents, both industrial and non- 
industrial has recently been emphasized by the "Safety First" 
movement. Much may be accomplished by a study of the acci- 
dents occurring during a given period, and by legal measures 
adopted to diminish such accidents. Closely related to acci- 



CAMPAIGN FOR BETTEK HEALTH 63 

deut prevention is the prevention of industrial disease. If a 
survey of industry clearly shows the prevalence of diseases 
caused by working conditions it should be a comparatively 
simple measure to institute reforms leading to their cor- 
rection. 

The prevention of infection through the transmission of 
food and water-borne diseases is ordinarily considered among 
the duties of the local board of health. If such diseases are 
occurring to a greater degree than in other similar communi- 
ties popular appreciation of the fact will lead to action by 
the local authorities. 

Pre-natal care^ maternity care and infant welfare work may 
well be associated. There is a strikingly large number of still- 
births, and deatlis during the first month of life, in the United 
States. Too many by far, in view of the fact that it has been 
shown that by proper care this number can be greatly de- 
creased. The records of the Henry Street Settlement show- 
ing the effects of district nursing upon infant mortality rates 
have been most instructive. Is your community doing all 
that it should do for expectant mothers and for newly arrived 
infants ? 

During the first few years of life, before the school age, is 
a period which is often neglected. Children as a rule appear 
healthy and parents are apt to dismiss signs of illness in the 
hope that "the child will outgrow it." 

Children's welfare during the school period is of extreme 
importance. This offers an especially favorable occasion to 
oversee the child's health because children are easily reached 
in the public schools and many can be kept under super- 
vision for a comparatively small expense. Mal-nutrition is 
possibly the most common serious affection which occurs at 
this age. Enlarged tonsils and adenoids and defective teeth 
should be cared for at this time in order to obtain the best 
results. During the same ])criod the training of crippled 
children for gainful occupations should begin. 

About the time the child leaves grammar school the war 
against diseases of venereal origin should be begun. Instnic- 



64 THE COMMUNITY HEALTH PEOBLEM 

tion of the child as to sex dangers and ether measures to pre- 
vent the spread of these diseases should not be neglected. It 
is not the intention here to oiler a solution of tlie problem of 
venereal disease but rather to impress upon the reader that 
in any community the problem must be met and that a 
definite policy, especially adapted to the needs of that par- 
ticular community, should be rigorously carried out. The 
National Social Hygiene Society is prepared to give advice 
and to indicate measures which may be expected to produce 
results. The almost complete elimination of tliis disease in 
the American Expeditionary Forces would indicate that a solu- 
tion of the venereal problem is possible. Can we make prac- 
tical use of the same solution in a given civilian community ? 
Tuberculosis we have always with us. It is estimated that 
about one death in ten in the United States is due to pul- 
monary tuberculosis. Worse than this is the fact that most 
of the deaths occur in young adults. While a cure is in many 
cases possible it is a tedious procedure and, for economic 
reasons, difficult to accomplish. It is not enough to tell the 
sufferer tliat he must move to a "high, dry climate," or the 
arrested case that he must secure "light out-door work" and 
then to dismiss the subject. Every case of tuberculosis is a 
potential source of infection and the problem is a community 
problem and must be met as such. The National Tuberculosis 
Association is ready to furnish almost unlimited information 
on the care of these cases and can render valuable assistance 
in fighting the disease. The Metropolitan Life Insurance 
Company has been making a three-year experiment on com- 
munity control of pulmonary tuberculosis at Framingham, 
Mass., where results would indicate that there are several 
unrecognized cases of the disease for every one which ordi- 
narily comes under treatment. Tho work of the Ford Com- 
pany in taking an active interest in such patients and put- 
ting them in employment commensurate with their physical 
abilitv has already been mentioned. The experiment will bear 
watching. 



CAMPAIGN FOR BETTER HEALTH 65 

HOSPITAL AND HOME CARE 

The hospital care of acute illness has been fairly well 
worked out, especially in the larger cities. In rural districts 
and smaller cities hospital care for the poor is often unob- 
tainable. 

The home care of the seriously ill is much less satisfactory 
if we consider the community as a whole. Visiting nursing 
can accomplish a great deal to make for better treatment. 
It is said that even under the bes^t conditions nine persons 
are cared for in the home to each one taken to a hospital. 
Look through the homes of the poor and see if they receive 
even reasonably good care. Question the self-supporting wage 
earner and see if he is taking advantage of the benefits of 
modern scientific medicine. See how much money he spends 
for medical care and medicines and stop and figure if he 
actually gets full value for his money. I have no figures avail- 
able for the amount spent annually for patent medicines, 
which seldom do good and often cause serious injury, but 
I am sure the total must be enormous. 

It has seemed to me that routine medical and dental care, 
that is, the care required by the individual for most of the 
minor ills which flesh is heir to, has been better met in cer- 
tain up-to-date industrial communities than under the charity 
dispensary system of our large cities. The Endicott-Johnson 
Company, of Binghamton, N. Y., the Standard Oil Company 
of New Jersey, Cheney Brothers, of Manchester, Conn., and 
many others have undertaken almost complete care of their 
employees apparently with excellent results and at a minimum 
cost for the service rendered. Health Insurance undertakes 
the same daily care of the sick and has worked fairly well 
in Germany and England. It has not been tried as yet in the 
United States although several commissions in various states 
have been appointed to study the question and health insur- 
ance acts in some form have been introduced in the legislatures 
of several states. 



66 THE COMMUXITY HEALTH PROBLEM 

Another question wliieli must be met and which is at pres- 
ent receiving comparatively little attention is the placing of 
individuals seriously handicapped by disease in gainful occu- 
pations. War cripples are being trained, industrial cripples 
are soon to be trained, but persons handicapped by chronic 
diseases are seldom given the attention, with reference to 
industrial classification, which the seriousness of their con- 
dition surely deserves. 

In mapping out the lines of endeavor as outlined above, no 
attempt has been made to cover the entire field. An indication 
of certain well-marked paths, which have been more or less 
successfully followed in the past should be sufficient as a 
working basis for a start in any form of health movement. 
The broadening out of the scope of the work will become self 
evident once the movement has been started. WTien funds and 
personnel are limited it is better to choose one aspect of the 
health problem and seek for improvement by intensive effort 
in a limited field rather than to spread the effort over too 
mncli territory and accomplish few if any tangible results. 



I 



CHAPTER VII 

WORKMEN'S COMPENSATION INSURANCE 

During recent years there has been a rapid development 
throughout the United States, of what in this country is a 
new principle, the state control of compensation for industrial 
injuries. Since April, 1911, when the first general state com- 
pensation law went into effect, the movement has steadily 
spread from state to state so that, today, there are only six 
states which have no statutory provision for workmen's com- 
pensation. In addition, the federal government has enacted 
a comprehensive compensation law for the protection of its 
civilian employees. 

Briefly, workmen's compensation legislation is a legal meas- 
ure to compel industry to repay, in terms of cash benefits, 
physical losses sustained by workmen in pursuit of their voca- 
tions. In other words, it is the recognition by the State of the 
responsibility of industry for the wear and tear of the human 
machine. 

For many years it has been the custom in every well- 
managed industrial organization to charge off a certain per 
centage of income for repairs and depreciation of buildings 
and equipment, but, until the advent of compensation, em- 
ployers were not compelled to suffer any loss for broken and 
injured human machinery. The crippled workman, who be- 
cause of an injury was unable to continue his work, could be 
tossed into the discard if the employer so desired, even if the 
injury had arisen as a direct consequence of a hazardous occu- 
pation. 

LIABILITY LAWS 

It is not strictly true that there was absolutely no redress 
for industrial accidents before the enactment of compensation 

67 



68 THE COMMUNITY HEALTH PKOBLEM 

laws. There was, it is true, the principle of liability for acci* 
dent under which the workman might bring legal action to 
recover damages. However, in most states it was required 
that in order to collect damages the employee must show that 
there had been negligence on the part of the employer. 

This was, as a rule, difficult to prove and often required 
years of litigation before the workman received a verdict. 
Meantime during the course of the trial he had been put to 
considerable expense of both time and money. Few employees 
had sufficient funds to carry through such prolonged litiga- 
tion and, as a consequence, they were usually forced by cir- 
cumstances to employ a lawTer who would finance the case 
from his own pocket in the hope of a favorable verdict. 
ISTaturally the legal fees wore very high. Under such condi- 
tions there developed a group of so-called "ambulance chasers," 
unscrupulous lawyers who were anxious to exploit the injured 
workman for their own benefit. Fees of fifty per cent, of the 
total were common; and fees and expenses equivalent to 
eighty per cent., or more, were not rare. The result of this 
was that the injured workman had slight incentive to appeal 
to law and it often happened that he preferred to shoulder 
his loss without attempting to recover for either the loss of his 
time or for his physical disability. 

The sum total was that the companies were obliged to spend 
large sums for liability insurance, the courts were crowded 
with accident cases, the surgical care of the injured workman 
was thrown on medical charity and the patient became a 
charge on the community. No one benefited except certain 
members of the legal profession. In all fairness to the legal 
profession it should bo said that, as a whole, they strongly 
objected to such a condition and legislation for its correction 
was urged. 

Some of the larger employers, to their credit, accepted the 
responsibility and voluntarily took every measure to prevent 
accidents and compensate injured workers. However, in the 
main, conditions may be said to have been almost uniformly 
bad. 



WORKMEN'S COMPENSATION INSURANCE 60 

WHAT COMPENSATION ACCOMPLISHED 

At one stroke the compensation acts did much to abolish 
these abuses. The difhculty of determining responsibility for 
accidents was recognized and consequently every accident was 
made compensable even in those cases in which it could be 
shown that there had been contributory negligence on the part 
of the employee. The law recognized the "ambulance chaser" 
nuisance and made the compensation act the only law appli- 
cable to industrial accidents, even, in some states, forbidding 
the payment of a fee for legal services in connection with 
compensation cases, unless it was clearly evident that such 
legal advice was required. The burden of disability was 
removed from the community and placed upon industry 
where it belonged. The disabled worker, instead of being an 
object of charity, became a pensioner of the industry which 
had crippled him. 

As a rule compensation includes medical and surgical care, 
medical supplies and a cash benefit during the period of dis- 
ability. In case of death there is a funeral benefit and a 
pension for the widow and dependent children. 

MEDICAL ATTENTION 

All the compensation laws except those of Alaska, Ari- 
zona and New Hampshire provide for medical attention. 
Most states require the employer to furnish in addition med- 
ical supplies and hospital services when needed. There is, 
however, considerable variation in the service supplied, some 
states limiting the amount to be spent and others limiting 
the period during which treatment is to be paid for. Aside 
from the humanitarian standpoint, the limitation of treat- 
ment to two or three weeks, as is the legal requirement in 
some states, is economically bad hecausc it prevents ade- 
quate treatment in the cases which need it most. There is 
the same objection to the limitation of medical fees to a 
comparatively small amount, such as fifty or a hundred dol- 



70 THE COMMUNITY HEALTU PEOBLEM 

lars, for this tends to prevent sufficient and adequate treat- 
ment lor the severe injuries. Unlimited treatment is apt to 
lead to abuse of the privilege, but medical care for at 
least two mouths should be given with additional treatment 
optional upon the decision of the accident board. The 
medical fees should be sufficient to insure adequate and skill- 
ful care. Excessive fees may be guarded against by careful 
regulations. 

CASH BENEFITS 

By far the best method of compensation for wage loss is 
a cash benefit up to a certain percentage of the weekly wage. 
For practical purposes this benefit has been fixed in most 
states at 66-2/3 per cent, during the period of total disabil- 
ity, continuing as long as the total disability exists. The 
cash compensation should always be considerably less than 
the weekly wage in order to discourage malingering and, in 
a sense, in order to compensate for the fact that contribu- 
tory negligence on the part of the employee does not deny 
him the right to compensation. 

For partial disability the workman should, theoretically, 
receive a part of the reward proportioned to the extent of 
his disability as measured by the wage loss, but from a prac- 
tical standpoint this loss is very difficult to estimate. In 
many cases compensation for partial disability — the loss of a 
finger or hand for example — is made by the payment of a 
lump sum. 

Deatli benefits payable to the widow or other dependents 
are usually figured at 35 per cent, of the decedent's wages at 
the time of death. To the widow the payments are kept up 
for life or until remarriage. The widow receives two years 
compensation in a lump sum on remarriage. Compensa- 
tion is also paid to dependent children and certain other de- 
pendents up to a weekly total of 66-3/3 per cent, of the wage 
at the time of death. 



WORKMEN'S COMPENSATION INSURANCE 71 

EMPLOYMENTS INCLUDED 

When the compensation hvrs were first introclucod efforts 
were concentrated upon what are known as the '^hazardous" 
employments and in most states the acts as finally passed 
included only this class of employees. In many states, how- 
ever, the law has been broadened to include all employees ex- 
cept farm and domestic labor. In some states the principle 
is applied according to the number of employees, those 
employers of less than a certain number, usually from two to 
ten, being exempted from the provision of the act. 

In some states casual labor, that is labor employed only for 
a few hours or a day or so at a time, has not been included 
in the act. This is because from an administrative stand- 
point it would be impracticable for employers to insure such 
cases, but when a firm habitually employs casual labor they 
should carry insurance to cover the group employed. If the 
principle of the act is a good one, and there be no doubt on 
this point, there can be no objection to the inclusion of all 
employees, even domestic and farm labor. The difficulties 
arise more from the complexities of the execution of such 
a law when applied to small employers than from any failure 
of the principle of compensation in all cases. 

ADMINISTRATION 

Most compensation laws are administered by a commission 
appointed by the Governor. In some cases the commission 
has power to increase or decrease the amount of compensa- 
tion and the period and cost of medical care. In others, 
their powers are limited to a considerable extent either by 
state laws or regulations. 

It is important that such a board or commission shall be 
composed of men who devote their entire time to the work 
and that the personnel include men of clear vision and keen 
understanding of modern social problems. As a rule, the 
findings of the accident boards are final and cannot be 
reviewed by the courts. 



72 THE COMMUNITY HEALTH PEOBLEM 

INSURANCE CARRIERS 

Insurance may be carried by a state fund, by a mutual 
insurance fund, by commercial insurance carriers or by 
various combinations. In some states- corporations are allowed 
to maintain their own insurance fund subject to the approval 
of the proper administrative authorities. 

In most states, insurance in a commercial company is 
permitted but this should be, and generally is, subject to 
restrictions and rigid supervision, in order to prevent insolv- 
ency. 

State insurance funds have been started in New York, 
Ohio, California and many other states. In general they 
have worked fairly well and are rapidly extending. Mutual 
insurance associations are permitted in many states. They 
have perhaps worked better than state funds not being con- 
fined so closely by laws and regulations. They should, of 
course, be carefully supervised by the state insurance authori- 
ties. 

INDUSTRIAL DISEASES 

As a rule industrial diseases have not been considered as 
injuries within the meaning of the various compensation acts. 
Thus, if a man contracts lead poisoning while at work as a 
painter he is awarded compensation in only four states; Cali- 
fornia, Connecticut, Massachusetts and Wisconsin.* 

There can be no doubt that all industrial diseases should be 

compensated for, just as are injuries, but the difficulty has 

been that, from a practical standpoint, it is very hard to 

say just when a man contracts a given disease. If a man 

finally contracts a chronic industrial disease, such as lead 

poisoning, after several years of work at his trade as a painter, 

it is probable that he has been absorbing small quantities of 

lead for many years and that the disease is the result of this 

process long continued which has finally resulted in disability. 

•Since the above was written the New York State Compensation Act 
has been amended to include diseases of industrial origin. 



WORKMEN'S COMPENSATION INSURANCE 73 

It seems hardly fair that liis last employer should suffer the 
entire loss. 

Many diseases may arise either from industry or from 
other unrelated causes. In such cases it is extremely difficult 
to make the distinction. From a theoretical standpoint there 
is no douht that industry should bear the costs of industrial 
diseases. From a practical standpoint it has been difficult to 
formulate satisfactory regulations to accomplish this result. 

COiirEXSATION HAS BEEN A SUCCESS 

There can be no doubt that the compensation laws have 
been successful, which is not to say that there has not been 
a great deal of dissatisfaction with tlie methods adopted in 
the execution of the various compensation acts. 

In some states, the provision for medical care is inadequate 
with the result that the medical profession feels imposed upon 
and physicians are consequently not inclined to give their 
best efforts to make the law a success; in certain states in- 
surance companies have apparently taken advantage of tech- 
nicalities of the law thereby diminishing the compensation 
and medical benefits in direct opposition to the spirit of the 
act ; and, worst of all, in some states there have been evidences 
of petty graft which has acted to deprive injured workers of 
their just rewards. Minor office holders have induced injured 
and ignorant workmen to promise them a percentage of the 
award on the false presumption that their influence would be 
required to secure a settlement, and other similar petty dis- 
honesties have been occasionally practised. 

In almost every state there were misunderstandings and 
delays due to untrained personnel which, at first, caused a 
great deal of dissatisfaction among workmen, employers and 
physicians. However, as experience increases, delays and mis- 
understandings are lessened and the law works more 
smoothly. 

On the whole the principle of compensation has been a 
success. The injured workman, today, receives, as a rule, 



74 THE COMMUNITY HEALTH PROBLEM 

better medical care than he received previously, together with 
a cash benefit which has no taint of charity. The legal con- 
flicts, with the consequent bad feeling on both sides, previ- 
ously exceedingly connnun, are now extremely rare. This 
in turn causes him to be more loyal to his employer and a 
better citizen in the community at large. 

New laws and modifications of the present laws should be 
carefully drafted so as to prevent injustice to any of the parties 
concerned. They should deal liberally with the employee, 
fairly with the employer, and justly with the state and the 
community. 

THE USE OF SAFETY DEVICES IJTCEEASED 

While compensation insurance is of too recent origin in 
this country to demonstrate fully, in all details, its value for 
the prevention of accidents, the rapid increase in the use of 
safety devices on all forms of dangerous machinery clearly 
indicates the tendency in this direction. Both the employer 
and the insurance carrier have a direct financial interest in 
the prevention of injury and this fact, together with the care- 
ful records which are now kept, has led to the adoption of 
many new and original forms of machinery safeguards. In 
certain cases the emplo3'er may obtain a lower insurance rate 
if he introduces approved forms of guards against acci- 
dents and, in many states, industrial commissions have ruled 
that extra hazardous machinery must be equipped with safe- 
guards of a design approved by the commission. 



CHArTER VIII 

COMPULSORY HEALTH INSURANCE 

With the introduction of Workmen's Compensation Insur- 
ance in this country, a new conception of community responsi- 
bility for health spread rapidly over the United States. What 
had been apparent to students of sociology and human welfare 
for many years suddenly became apparent to all. It was 
recognized that losses due to injuries arising as a result of a 
particular occupation should be borne by industry as a part 
of the costs of operation, and not by the individual, and it 
was further recognized that it was the duty of the various 
states to protect the worker against such losses by means of 
well considered constructive legislation. 

Eeasoning along similar lines the conclusion is soon reached 
that as all sickness arises from causes found either in the 
individual, or his work, or in the community at large, the 
costs of sickness, as a logical consequence, should be met not 
by the individual alone but by a common fund made up 
from equitable contributions of all concerned. 

Knowing that the sum total of disability is not large and 
that the expense of treatment can be easily met if the loss 
is distributed among all workers, whereas the cost of sick- 
ness is frequently overwhelming to the individual wage 
earner, the modern method of insurance against loss at once 
suggests itself. Consequently compulsory health insurance, 
or co-operative sickness insurance as it is sometimes called, 
has been advanced as the solution of the problem of untreated 
disease, and as a remedy for the relief of economic loss due 
to physical disability. 

Health insurance while new in the United States has been 
successfully carried out for many years in various European 



76 THE COMMUNITY HEALTH PROBLEM 

countries. It was introduced over thirty years ago in Ger- 
many and spread rapidly. In England, health insurance was 
introduced in 1911 but, because of the beginning of the World 
War in 1914, confusion has arisen in its administration so 
that it is now undergoing considerable re-organization in 
order that it may function smoothly on a peace basis. 

In 1916, the American xVssociation of Labor Legislation, 
after careful study of the health of the wage earner and 
of methods for the correction of poverty due to injury and 
disease, formulated a tentative draft of an act which would 
make the benefits of health insurance available to all wage 
earners. Legislative action based upon this tentative draft 
has been instituted in several states but up to the present 
no state has actually passed any form of law for the intro- 
duction of health insurance. Several state commissions have 
been appointed to investigate the need of such a law, and in 
general, the reports of these commissions have confirmed the 
premises assumed by the originators of the tentative draft, 
namely that there is an immense amount of untreated illness 
and that a considerable number of cases of poverty arise 
primarily as a result of economic loss due to physical dis- 
ability. In spite of these findings legislatures have failed to 
act, not as a rule, because the need was not apparent, but 
because they were uncertain as to the ability of health insur- 
ance measures favorably to influence existing conditions. 

WHAT HEALTH INSURANCE MEANS 

Health insurance as it has been advocated in this country 
includes three benefits: A cash benefit (based upon the 
worker's salar}-) during the period of disability; a death bene- 
fit which is usually a fixed sum; and medical and nursing 
care for all illness whether incapacitating or not. 

To these benefits have been added, in some drafts of the 
act, a maternity benefit for insured women workers or for 
the wives of insured male workers and a pension benefit for 
dependents of insured persons who become totally disabled. 



COMPULSORY HEALTH INSURANCE 77 

In some cases plans for insurance have been extended to 
include not only the Avorker but his family as well. 

The cost of health insurance is to be met by premiums paid 
in part by the insured, in part by the employer and in part 
by the State. The figures frequently quoted are 40 per cent, 
by the wage earner, 40 per cent, by the employer, and 20 
per cent, by the State, but there is no fixed rule for the divi- 
sion of the premium. 

The insurance may be carried either by: (1) The State; 
(2) Approved societies as in England; (3) Mutual associa- 
tions as in Germany, As a rule the American plan has dis- 
regarded the commercial insurance carriers. 

The cash benefit is usually limited to twenty-six weeks in 
any one year and medical and surgical supplies are furnished 
within certain prescribed limits. The maternity benefit in- 
cludes medical care and a weekly cash benefit for eight weeks. 
Hospital treatment and laboratory examinations are to be 
furnished when necessary. 

In order to prevent malingering or prolongation of dis- 
ability among those who find that "it pays to be sick" there 
is usually a waiting period of several days before the cash 
benefit begins and the amount of the cash benefit is fixed so 
as not to exceed two-thirds of the weekly salary. Medical 
treatment is given freely however at all times without regard 
to other benefits. 

The death benefit is usually a fixed amount, say $200, 
although this can be made to vary according to the size of the 
family if it is thought desirable. 

Administration is ordinarily left under the control of the 
organizations carrying the insurance but the expenditures are 
supervised by state authorities. 

WHY INSURANCE? 

It is hardly necessary to bring forth arguments for insur- 
ance as a protection against economic losses due to sickness. 
Insurance against fire, insurance against death, and insurance 



■JS THE COMMUNITY HEALTH PROBLEM 

against other losses are so firmly fixed in the American mind 
that no argument is required to sustain the soundness of the 
principle. 

It should be, theoretically, easy to compute the premiums. 
We know for example that the working man will on the 
average lose about nine days every year on account of sick- 
ness* and that from 20 to 30 per cent, of the workers will be 
sick every year. AYe know that 65 per cent, of those ill 
more than a week will be back at work within four weeks, 
that about half the balance will be back at work before the 
eighth week, that only about 10 per cent, will be sick more 
than three months and that only about three per cent, will 
be ill longer than six months. From an insurance stand- 
point, leaving out of consideration the human equation, the 
losses should be easily calculated. Practicall}'', this being a 
new form of insurance in this countr}% the calculated pre- 
mium would probably require considerable modification. 

It has been claimed that health insurance will favor malin- 
gering and that the loss will be greatly increased by pre- 
tended illness. This is of course possible and will no doubt, 
to a certain extent, increase expenditures, but to expect this 
tendency to be so prevalent as to nullify the insurance princi- 
ple is to lose faith in the bulk of the American people. Houses 
have been burned down to collect insurance and ships have 
been sunk for the same purpose but neither fire nor marine 
insurance has been considered theoretically at fault because of 
isolated instances of the abuse of the insurance privilege. 

WHY COMPULSORY INSURANCE? 

The word compulsory has been used in connection with 
health insurance and has given offense to many. The op- 
ponents of this form of health movement say that compulsion 
is out of keeping with American ideals, that Americans 
will not submit to it, and that while voluntary insurance may 
be all right compukory insurance is objectionable. Yet we 



COMPULSORY HEALTH INSURANCE 79 

have compulsory education, compulsory taxes and compulsion 
in the execution of our laws. 

Voluntary health insurance, unlike life insurance, has 
never been widely successful. Wage earners during early 
life do not take out voluntary sickness insurance so that most 
commercial insurance of this type is written for people over 
forty years of age, during the period in which sickness is 
most common. Moreover the cost of any form of commercial 
voluntary health insurance is very high, being increased 
largely because of commissions and overhead expenses. As a 
result, for the premium paid the benefits derived are com- 
paratively small in this form of voluntary insurance. Under 
the plans presented in this country for compulsory insur- 
ance the premiums would be collected directly from the 
employer so that the cost of collection would be greatly 
decreased ; all workers would be included, thereby making the 
premium comparatively small; and administration would be 
in the hands of mutual organizations thus making the per 
capita overhead cost almost negligible. 

THE ATTITUDE OF THE PHYSICIAN" 

The vast majority of all physicians are opposed to health 
insurance. While certain physicians of wide experience have 
advocated its adoption, most oppose it in any form. It is 
claimed that it will make all physicians government employ- 
ees, that they will be obliged to work for less than a living 
wage and that it will stifle personal initiative and hinder 
medical progress. 

Under health insurance the sick must of necessity be cared 
for by the body of the medical profession as it now exists. 
Medical attendance may be secured in one of three ways: 
(1) By free choice of physicians; (2) By a panel system such 
as is under trial in England; (3) By salaried physicians in 
the employ of the State. 

The physicians have stood firmly for "free choice" and this 



80 THE COMMUXITY HEALTH PROBLEM 

proviso was introduced into the Davenport Bill which was 
passed by the New York Senate in 1919. There is much 
to be said in favor of free choice and a great deal against 
it. If a patient is allowed to choose his physician from 
among all practising physicians who are willing to treat him 
he will have more confidence in his treatment than if he is 
forced to go to a special doctor or clinic. On the other luiiul 
free choice will put a premium on the advertising doctor. 
It will cause a considerable amount of so-called medical 
shopping. Patients will travel from physician to physician in 
order to secure a diagnosis which suits their own conveni- 
ence. It will vastly complicate the keeping of records and 
tend to increase expenses. 

In the panel system all physicians who are willing to 
practise under the health insurance act are placed on a panel 
and the workmen must choose a panel physician to care for 
him for a definite period — usually a year. The physician is 
paid a certain fixed sum per capita. The disadvantage of this 
system is found in the fact that the physician is required, 
for a limited fee, to give unlimited personal service, and serv- 
ice under such conditions is rarely found to be satisfactory 
either to the physician or the patient. 

There is the same objection to the salaried physician if 
his services are secured by contract. However if the salaried 
physician is made a state employee, given an adequate salary 
with a chance for promotion and a career as a public healtli 
official the objection is less potent and under such conditions 
many very able physicians might be induced to devote tlieir 
services to the public. 

However, at the present time, most physicians prefer to 
be independent and to work out their futures according to 
their individual desires and, for this reason, they strongly 
oppose the introduction of health insurance in any form. On 
the other hand there are a few among the medical profession 
who, seeing the vast amount of untreated sickness and pre- 
ventable disease, believe that health insurance offers a prac- 
tical remedy and urge its adoption. 



COMPULSORY HEALTH INSURANCE 81 

THE ATTITUDE OF THE PUBLIC 

Insurance against illness has been sponsored by welfare 
organizations and by many individuals but in the main the 
public has been unresponsive. 

Certain labor organizations have been impressed by the 
large amount of idleness due to physical disability and in 
New York the State Federation of Labor went on record a3 
in favor of the introduction of health insurance legislation. 

The sick and the needy, those who would be benefited, are 
not in a position to make their desires known. The healthy 
workman is not inclined to worry about sickness in the future 
and the so-called middle classes are not particularly touched 
by the problem of untreated disease and its consequences. 

The daily newspapers, which do much to influence public 
opinion, are, as might be expected, somewhat divided in 
opinion. However it may be stated without fear of con- 
tradiction that a part at least of the editorial opinion in the 
larger cities has come out unqualifiedly in favor of insurance 
of this type. 

In industrial plants, where a modified type of health in- 
surance has been instituted voluntarily by the employer, the 
employees have been almost universally in favor of this 
method of caring for all cases of injury and disease. 

In every great movement whether for better government, 
better sanitation, or better health there is usually a period 
of education before there may be said to be a general public 
demand. We have just seen that this was true in regard to 
suffrage and prohibition and it may be expected to apply 
equally in questions having to do with public health. The 
fact that there is no wide public demand for health insur- 
ance is not a legitimate argument against it, 

PUBLIC HEALTH A FUXCTIOX OF THE STATE 

There can be no question as to the responsibility of the 
community for the hcaltli of its citizens. While the extent of 
thiB responsibility may be debatable the fact remains that, 



83 THE COMMUNITY HEALTH PEOBLEM 

to a certain degree, the health of tlie individual is dependent 
upon community conditions which can be influenced only by 
public control. If this has in the past been met satisfactorily 
and in its fullest extent by the activities of the various public 
health authorities then there is loss necessity for any form 
of health insurance. If on the other hand, the community 
has failed properly to safeguard the health of the public, or 
if it has failed to make available to its citizens a reasonably 
adequate medical service for the care of injury and disease, 
then insurance against illness should be seriously considered 
as a means of securing better community health. 

Any form of health insurance must be closely related to 
our present public health administration, increasing its facili- 
ties and broadening its field of action. In a sense every physi- 
cian working under a system of health insurance should be a 
health officer working to diminish the sum total of prevent- 
able disease. He should consider himself a public official 
working to increase public welfare in the community and the 
State. 

"We have no definite data as to the costs of health insur- 
ance in the United States so that, to a certain extent at least, 
it would have to be begun with a tentative premium which 
could be easily changed as required by experience. 

In the consideration of insurance against sickness the fol- 
lowing points must be constantly borne in mind: (1) The 
cash benefit must be smaller than the average weekly wage. 
There must of necessity be no premium placed upon idleness ; 
(2) It must include a large group of workers so that the 
overhead expenses will be reduced to a minimum; (3) It 
must contain provisions for adequate pay for both physicians 
and nurses, so that the best professional talent will be drawn 
to the service; (4) The medical section must contain provi- 
sions for hospital treatment and for the services of special- 
ists; (5) It must be wisely administered and efficiently car- 
ried out so that delay in payment of premium will be avoided 
and there will be no question as to the ability or probity of 
the officials or salaried employees. 



COMPULSORY HEALTH INSURANCE 83 

If state officials, physicians, nurses and others concerned 
in the execution of a reasonably satisfactory form of health 
insurance have sufficient vision and strength of purpose to co- 
operate and work for the best interests of the public welfare, 
it is believed that such an act will be successful, and will 
represent an immense force for community betterment. If, 
on the other hand, any of the above group see in health 
insurance only a means for personal gain and self aggrandize- 
ment, failure is almost certain to result. 



CHAPTER IX 
INDUSTRIAL MEDICINE 

Industrial medicine has been defined as the interpretation 
of the productive capacity of an industrial plant in terms of 
the health of the workers. It is the science which treats of 
the prevention and cure of industrial injury and disease, 
increasing productivity through the promotion of better 
health. 

Twenty years ago the science of industrial medicine as it 
is known today was almost undreamed of. There were, it is 
true, a few firms who employed a "company doctor," who was 
on call for emergencies and who devoted only a small part 
of his time to the company work. In most cases when an acci- 
dent occurred the patient was sent to the city hospital and 
the responsibility of the employer ceased. Most employers 
kept no record of absence because of sickness and little or no 
knowledge was available as to the cost of illness either to 
the employer or employee. Men were accepted after a per- 
sonal interview and little or no attempt was made to deter- 
mine the physical qualifications of the applicants for the 
particular job. 

With the development of the larger corporations which 
necessitated a more complete system of records ft became evi- 
dent that the company had an investment in every one of its 
employees which would be lost in the event of disability. It 
was shown that there was a certain definite cost, which could 
be expressed in dollars and cents, associated with the train- 
ing of every new employee. It was also found that the mere 
absence of a skilled employee from work even for a few days 

84 



INDUSTKlxVL MEDICINE 85 

slowed down production and caused a certain financial loss. 

In largo corporations it u-as found that in the course of a 
year their losses reached enormous proportions. 

NEW METHODS NEEDED 

Some of the more progressive organizations such as the 
United States Steel Company, turned to the medical profes- 
sion for relief. It was realized that the old form of company 
doctor had. not been a success and it was also realized that 
employers as well as others had failed to grasp the full 
significance of the. importance of industrial health work. 
Physicians' salaries were inadequate, their offices were small 
and inaccessible, and the company physician had little official 
standing in the corporation. 

The attempt to correct such conditions gave rise to the 
new conception of industrial medicine in which the physician 
is well paid, is recognized as a company official, and devotes 
his time chiefly to prevention of injury and disease rather 
than cure. The medical offices should be commodious, centrally 
located and fully equipped for modern scientific methods. 
The industrial surgeon must be able to analyze the cause of 
accidents and indicate the need for modification of dangerous 
machines or mechanical processes; he must study his case 
records and indicate necessary public health measures for the 
correction of sanitary defects ; he must study the employees 
and the positions to be filled and attempt to make the man 
fit the job, thus increasing production. 

It may be said to the credit of the medical profession that 
they have fully demonstrated the value of industrial medicine 
from a business standpoint. Medical departments begun as 
experiments are being continued as paying investments. 
While the movement has spread rapidly during the last few 
years it may be said to have only just liegun. Only compara- 
tively few of the larger corporations have introduced what 
may be considered a truly comprehensive system of health 
protection. 



86 THE COMMUNITY HEALTH TKOBLEM 

However during the last few years the introduction of the 

principle of compensation for industrial accidents has done 
much to impress upon business men the importance of early 
and efiBcient medical care. Companies were obliged by law 
to insure under the workmen's compensation acts and those 
having an undue percentage of accidents found their pre- 
miums raised beyond the average for the industry. Insurance 
companies found that their costs mounted alarmingly when 
no provision was made for medical care. This led to the 
establishment of surgical first-aid stations in large plants 
with the employment of full time physicians and nurses. 
From such a nucleus a large number of more or less well 
developed industrial health centers have been developed. 

EXPENSES PAID BY INDUSTRY 

The essential feature of the industrial health movement, in 
contradistinction to other forms of health activity, is that 
the expenses are paid in the main by the industry concerned. 
This means of course that the community pays the bills in 
the end, for the employer spends on health measures the 
money which might have been devoted to extra wages. But it 
has been found that the increase in wages equivalent to the 
expenditures for health promotion does not materially increase 
either community health or company production. Health 
expenditures by industrial organizations must be compared to 
taxes for good roads or better water supply which reduce the 
individual income but act positively for the good of the 
community. 

The per capita cost of industrial medicine varies greatly 
according to the work done and the character of the industry. 
It includes part of the premium for compensation insurance 
and in addition whatever the employer may decide voluntarily 
to spend for the improvement of the health of the employee. 
Premiums for insurance under the various compensation acta 
vary in the different states and in the various occupations. 
In New York the rates for moderately hazardous occupations 



INDUSTRIAL MEDICINE 87 

run from five to twenty per cent, of the annual payroll. For 
non-hazardous occupations the rates may he as low as two or 
three per cent. These charges include a part of cost of any 
system of industrial medicine. 

Figures from a large numher of corporations show that 
the per capita cost of health work varies from less than two 
dollars per year up to fifteen or twenty dollars per year, or 
even higher, the variation being due largely to the difference 
in the service furnished. 



INDUSTRIAL HEALTH CENTER 

If, as a result of the study of various existing medical 
departments in large corporations, we attempt to make a 
composite picture of industrial health, activities we note at 
once that the health center forms a conspicuous part of every 
plan. Sometimes it is called the dispensary, sometimes the 
clinic and sometimes merely the doctor's office, but in all it 
is essentially the same, the headquarters for the medical work 
of the plant. 

Here the medical director should Tiave his office and 
records; here should be located the examining rooms; and 
close by should be the office of the visiting nurses. A drug 
room, a laboratory, an x-ray room and a record room should 
all form part of this central group. 

In some plants it is desirable to establish branch first-aid 
stations in buildings located some distance from the center. 
Many large plants go one step further and place a first-aid 
cabinet in every department so that it is immediately avail- 
able in case of accident. 

In connection with the health center, arrangements may 
be made for hospital facilities, convalescent accommodations, 
home treatment through a visiting nurse service, conserva- 
tion of children's health through day nurseries and other 
similar measures, and for co-operation with the local public 
health organization. 



88 THE COMMUNITY HEALTH PROBLEM 

PHYSICAL EXAMINATIONS 

Physical examinations should be made of all applicants for 
employment. The examination should be thorough in detail 
and should indicate the physical condition of the applicant 
and the necessity of treatment of physical defects, if any. 
It is exceedingly important that physical examinations be 
made by physicians who are tactful and understanding and 
who undertake to help the applicant to find a suitable posi- 
tion, avoiding carefully any action which would tend to 
antagonize the worker. The physician should take advantage 
of this opportunity to emphasize his sympathetic co-operation 
with the worker and to increase the mutual personal under- 
standing between the applicant and an official of the company. 

It becomes more and more evident that few should be dis- 
qualified because of physical disability. First, those wlio have 
contagious disease and are dangerous to other workers must 
of course be excluded. Second, those who are suffering from 
disease of such character as to render any sort of work dan- 
gerous to their health must be turned away. But further 
than this there should be few disqualifications. The old idea 
of disqualifying a man because of the loss of one leg, or a 
simple hernia, or deafness, or some other similar disability, 
should be discarded. It should be part of the duty of the 
examining physician to indicate the kind of work for which 
the workman with a physical handicap is best fitted and to 
make every effort to connect the man and the position. 

This has been done in a large automobile company in Detroit 
with great success. Nearly a third of all their workmen have 
some form of disability. The employment director and the 
surgeon make a careful survey of the plant and indicate, for 
example, what positions may be filled by one-legged men. 
Similar investigations lead to the classification of all positions 
according to the physical requirements with the result that 
the lame, the halt and the blind are actually placed in self- 
supporting employment. 



INDUSTRIAL MEDICINE 89 

MEDICAL CARE OP EMPLOYEES 

The treatment rooms should be open during the regular 
business hours and, in plants which are large enough, a 
physician should always be in attendance. It is of import- 
ance to the employer that every patient secure prompt and 
efficient treatment and return to work as soon as possible. In 
minor injuries a small dressing and light bandage which will 
not interfere with work may be applied. In cases of slight 
indisposition a half hour rest will often be sufficient for 
complete recovery. 

In complicated cases, x-ray and laboratory examinations 
should be made and, if necessary, the services of a specialist 
should be provided. When there are several surgeons on 
the staff they may divide the work so that one mny specialize 
in surgery, another specializes in diseases of the nose and 
throat, while others specialize in some of the other special 
departments of medicine. 

A nursing service is a necessary adjunct in the active 
medical care of the workers. A visiting nurse should visit 
all workers who report sick and the medical director should 
base his action upon the nurses' report. Many patients may 
be safely cared for at home with tb<^> aid of an efficient 
visiting nursing service. 

Dental care should also be a part of the medical service 
and the periodical examination of the teeth should be encour- 
aged. Simple fillings may be made without charge and more 
complicated bridge-work given for cost. 

Shall the treatment be made compulsory? Many workers 
object to compulsory treatment and it is much better not to 
insist upon it. The essential factor is that all workers in the 
plant must be included in the health plan. Medical advice 
must be made available to them all but there is no necessity 
of insisting upon treatment for this is apt to antagonize 
some employees. If the physicians are tactful and show 
sympathy with the worker there will be little difficulty. Most 
employees will be glad to accept treatment and it will soon 



90 THE COMMUNITY HEALTH PROBLEM 

become apparent to them that they not only secure free treat- 
ment at tho plant but that the treatment i?, as a rule, at 
least as good as that secured from private sources. 

CONTRIBUTES TO WELFARE 

Industrial medicine is today closely linked to industry. It • 
is recognized as a factor in continuous employment and pro- 
duction. It makes for community welfare and tends to pre- 
vent dissatisfaction and unrest. 

It is closely related to the community health movement 
and, when seen at its best, has seemed to come nearest to rep- 
resenting a practical form of sickness prevention and 
health control applicable with slight modification to the 
entire community. Its main disadvantage is that it is dif- 
ficult to adapt it to the needs of the small employer. As a 
rule at least 500 employees are required to justify the forma- 
tion of a medical department. However, if industry has 
shown us how much can be accomplished along health lines 
by a business-like medical service, it should be possible for 
the rest of us to find some way of adapting a similar service 
to the needs of the general community. 

INSURANCE 

In many cases industrial organizations have made sicknesa 
and life insurance available for their employees at a low 
price. This is accomplished through what is known as group 
insurance. In insurance of this type a large number of em- 
ployees are insured in a group at a flat rate. The premiums 
may be paid entirely by the employer, or entirely by the 
employee, or they may share the expense. In any event the 
employer makes the actual pa3'ment of the premium in a lump 
sum calculated from the pay roll. This reduces the charges 
for collection so that insurance of this type can be sold very 
much cheaper than when sold to individuals. 

Life insurance is issued in policies of from one to five 
thousand dollars, the larger amounts being carried by 



INDUSTRIAL MEDICINE 91 

t 

employees of several years service. Sickness insurance with 
a weekly benefit is usually written for a fixed period of from 
13 to 53 weeks. However in some cases the insurance may 
be based upon the salary, payable over a period of several 
years. It is ordinarily payable only during complete dis- 
ability. 

The Metropolitan Life Insurance Company insures its own 
employees against sickness disability practically for life. For 
the first twenty-six weeks' illness, two-thirds of the salary is 
paid. From the twenty-seventh week until the end of the 
fifth year one-half of the original benefit is paid and from 
this time until the employee reaches the age of 65, he receives 
one-quarter of the original benefit. 

The same company in its annual report on welfare work 
makes the following statement: 

"The company feels that it is conducting a social laboratory 
in the care that should be given working people. It has felt 
furthermore that if it could show the value of its efforts to 
other employers it would benefit its millions of policy-hold- 
ers at present engaged in industries of all kinds. If it could 
emphasize to the employers of these policy-holders the value 
of proper working conditions it would be able to secure for 
all workers longer lives and increased health.*' 

This insurance company which has had a long experience 
in industrial insurance, and close contact with industrial 
workers, has fcmnd that welfare work among its own em- 
ployees pays and it advises other employers to adopt similar 
measures. But it points out that health and welfare work 
must be given in addition to wages and not a substitute for 
them ; that welfare work is not a substitute for opportunities 
for development and advancement ; and that it must not inter- 
fere with the right of the employee to live his or her life 
without undue interference. 



CHAPTER X 

STATE MEDICINE 

For years many clear thinkers have insisted that the com- 
ing of a stato medical service was inevitable. In England 
progress toward this end has been more rapid than in Amer- 
ica. Some twenty odd years ago Havelock Ellis in his book, 
"The Nationalization of Health," suggested the need of 
national supervision of health with a well organized medical 
service based upon community needs and under national 
control. 

In 1917 he repeated his earlier view as to the inadequacy 
of the present system of private practice and voiced the need 
of a different form of medical service as follows: "It is 
inevitable'* he says "that we should some day have to face 
the problem of medical reorganization on a social basis. 
Along many lines social progress has led to the initiation of 
movements for the improvement of public health. But they 
are still incomplete and imperfectly co-ordinated. We have 
never realized that the great question of health cannot be left 
to municipal tinkering and to the patronage of Bumbledom. 
The result is chaos and a terrible waste, not only of what we 
call Tiard casli' but also of sensitive flesh and blood. Health, 
there cannot be the slightest doubt, is a vastly more funda- 
mental and ini|)ortant matter than education, to say notliing 
of such minor matters as the post oflSce or telephone system. 
Yet we have nationalized these before even giving a thought 
to the nationalization of health." 

In 1913, England introduced a comprehensive system of 
health insurance and recently there has been organized a 
Ministry of Health. If anything, the trend toward a state 

92 



STATE MEDICINE 93 

'medical service has been increased rather than diminished 
during the war. 

In America an r.ttcmpt which was made several years ago 
to establish a Federal Department of Healtli with a Secre- 
tary of Health at the head was unsuccessful and up to the 
present none of the states has adopted the principle of 
health insurance or other form of state controlled medicine. 

America is proceeding more slowly and conservatively than 
is England in matters which have to do with public health. 
Possibly an explanation for this is found in comparison 
of the living conditions of the two countries. Health is 
largely influenced by living ('(Mulitions and such conditions 
are apt to become less and less sanitary as the population 
increases . In cities the complexity of all problems of sani- 
tation is greatly increased and the evil eifects of high disease 
rates are more plainly evident than in rural communities. 
Moreover the close relation of employer and employee in in- 
dustrial communities tends to emphasize the money loss 
caused by physical disability. As a consequence, in a country 
like England, which contains many large industrial cities 
where there is much overcrowding, the health problem lonm-^ 
much larger than it does in the United States whore there 
is less crowding and less evidence of defective sanitation. 

In rural communities, the evil effects of disease are not so 
apparent as in the larger cities so that, even in the United 
States, public health efforts have, as a rule, been much bet- 
ter developed in large municipalities than in the outlying 
districts. 

STATE MEDICINE AND PRIVATE PRACTICE 

It has been stated that the system under which the private 
practice of medicine is now carried on is out of date, and 
that it fails to answer the needs of our time. This state- 
ment is substantiated by a variety of reasons which are slowly 
becoming more apparent to all. 

Medicine today has outgrown the capacity of the private 



94 THE COMMUNITY HEALTH PROBLEM 

practitioner. In order to give his patient reasonably adequate 
medical treatment according to modem standards, the physi- 
cian must not only have a general knowledge of medicine 
but must be qualified as an expert in a number of special- 
ties as well. He must not only acquire this knowledge by 
years of effort, but he should also have the elaborate 
mechanical equipment which is now necessary for efficient 
diagnosis and treatment. Such equipment may be found in 
great hospitals, where it is available for the benefit of the 
poor but it is far beyond the means of the average practi- 
tioner. Failing such expert knowledge and elaborate equip- 
ment, if he desires to give the best to his patient, the physi- 
cian must refer a large proportion of his practice to special- 
ists. As a result of the gradual disappearance of his practice 
the ambitious physician soon specializes himself so that he 
may feel qualified in at least one subject and, as a result, 
the general practitioner disappears. 

But the most weighty reason for the advance of the national 
idea in medicine in contradistinction to the further develop- 
ment of individual practice is that the present system is 
based upon Ifhe cure of disease rather than its prevention. 
The total spent for the cure of disease is enormous; the 
money spent for prevention is, in comparison, a sum of 
insignificant proportions. 

Today the student receives better instruction in the science 
of medicine than ever before. Magnificently equipped insti- 
tutions are endowed so that medical education may be secured 
at a minimum expense, and educational requirements have 
•increased so that a medical degree is obtained only after 
years of arduous training. When the young physician fresh 
from college tries to apply his science to practice he finds 
that the expense involved in the care of disease deprives a 
great number of people of the benefits of modern treatment. 

The question which arises in the mind of the recent 
graduate is whether there is not some method whereby the 
benefits of modem treatment could be made available to all 



STATE MEDICINE 95 

at a cost within the limits of reason. In answer to this query 
those who advocate the complete socialization of medicine 
point to the slow increase of the powers and activities of 
the public health authorities, to the enactment of the Work- 
men's Compensation Act, to the agitation for health insur- 
ance in some form, and to the establishment of a Ministry 
of Health in England, as evidences of a gradual cluinge which 
is taking place leading eventually to state medicine. 

State medicine, as the term is ordinarily used, indicates 
the complete control of health of the individual by govern- 
mental authorities. In practice such a system would probably 
work out along the same general lines as education. Every 
citizen would be entitled to free treatment if he desired it. 
Hospitals and sanitoria would be conveniently established 
and physicians would be either directly or indirectly in the 
employ of the government. Treatment would not be com- 
pulsory, except, as at present for contagious diseases, and 
patients desiring extra personal attention would be treated 
just as at present, by private physicians. 

PLAN FOR UNIVERSAL STATE SERVICE 

If, in the United States, there were organized a truly com- 
prehensive system of state medicine, along what lines would 
such an organization develop and of what would it consist? 

In the first place there would be required a United States 
Department of Health with a Secretary of Public Health. 
This department would include the present United States 
Public Health Service, now under the Treasury Department, 
the Board for Child Welfare now under the Department of 
Labor, the Indian Medical Service now under the Depart- 
ment of the Interior and the various other medical activities 
under the Federal Government. The duties of such a depart- 
ment would include the care of mpdical problems which arise 
in connection with national needs, all questions which have 
to do with immigration or emigration and the health 
aspects of interstate commerce. In addition the Federal 



96 THE COMMUNITY HEALTH PROBLEM 

Department of Health would act to correlate the health work 
of the various states. 

State medicine, as organized within state limits, would be 
divided according to the nature of its work somewhat as 
follows : 

(a) A division of preventive medicine. 

(b) A division of hospitalization. 

(c) A division of medical treatment. 

(d) A research division. 

(e) A division of medical education. 

Of course such a classification is entirely arbitrary and 
would be subject to considerable variation. Sanitation, child 
welfare, the prevention of accidents, social hygiene and many 
other similar subjects would fall naturally into one or the 
other of the above divisions. 

A state system would pre-suppose a headquarters and ad- 
ministration office in one of the larger cities of the state, 
which would control the general policy of the state medical 
service just as the Surgeon-General's office controls the poli- 
cies of the Medical Department in the United States Army. 
There would be established in various localities of not more 
than 25,000 inhabitants a medical center with facilities for 
hospitalization, laboratory examinations and consultations 
with specialists. Possibly, for purposes of administration, it 
might be desirable to group several of these centers into a 
single administrative unit. Physicians would be constantly 
in attendance at these centers and visiting nurses would be 
available for work in the district. The services of the physi- 
cians and nurses would be available for rich and poor alike. 
All divisions of the State Department of Health would of 
course be represented at each center and each center should 
be made as nearly as possibly an autonomous unit. 

Such a center would require from ten to twenty physicians, 
including specialists, with possibly, an equal number of 
nurses and there would be in the entire state of New York 
possibly in the neighborhood of three hundred such centers. 



STATE MEDICINE 97 

Physicians practicing the various specialties would be avail- 
able at each center and patients treated in their homes would 
be cared for by physicians assisted by visiting nurses. A 
clerical force would be available to relieve the professional 
staff of most of the purely clerical duties. 

PERSONNEL 

The personnel of such a system would of necessity be re- 
cruited from the physicians and nurses practicing in the 
state. It is claimed by many that the better class of physicians 
would not enter into any such scheme and that as a conse- 
quence it would surely result in failure. Without the 
ontluiaiasm iuul co-operation of the pbysieians and surgeons 
who would practice under such a system the service would 
be greatly handicapped but it is the conviction of the advo- 
cates of state medicine that, if the service were made 
attractive, if the salaries were adequate, and if the physicians 
were offered a career as public health officials, a satisfactory 
medical service could be furnished to the inhabitants of the 
state as a whole at a cost considerably less than under the 
present system. 

The question might reasonably be asked as to the ultimate 
effect of such a system on private practice. There is no 
doubt that private practice would be somewhat decreased but 
it is doubtful if the decrease would he appreciable at first. 
In spite of the fact that all persons would be entitled to free 
treatment, the rich, and to a certain extent those moderately 
well-to-do, would continue to employ private phvsieians and 
specialists as heretofore. The man who could afford the ex- 
pense would probably choose to occupy a private room in the 
hospital, and many persons would prefer not to accept free 
treatment from the State. The ultimate result would depend 
upon the quality of service offered and possibly in time private 
practice of medicine would decrease, but it is improbable 
that the time would ever come when there would not be a 
large number of persons who preferred to pay for medical 



98 THE COMMUNITY HEALTH PROBLEM 

attention. State medicine is not an attempt to oecure proper 
treatment for the rich. It is intended primarily for the pre- 
vention of disease and for the benefit of those who are unabl* 
to pay for treatment under the present system. 

To the best of my knowledge and belief, a state medical 
service as outlined above has never been carried out on a 
large scale. Health insurance as it is seen in some of the 
European countries is under government control and closely 
approaches state medicine, but could not properly be called 
public medicine in the same sense in which we use the term 
in referring to public education. 

Military medicine somewhat approaches the ordinary con- 
ception of a state system of medicine, and any contemplated 
state service might gain a considerable amount of information 
by a study of the organization and administration of the 
Army Medical Department, but there are too many other 
factors in military medicine, such as mobility of medical 
units, transportation, battle casualties, etc., to make it 
applicable to civilian needs without extensive changes. 

What is needed today is the scientilSc application to the 
problems of civilian life of what the physician has already 
learned by military experience. Competition in the practice 
of medicine has no place in military service and should have 
little if any place in civilian practice. Co-operation wliether 
it be for education, public welfare or better health will 
accomplish more for the citizens of a community than can 
possibly be expected from any system based largely upon 
individual competition. 



CHAPTER XI 
HEALTH CENTERS 

y During recent years, activated largely by the growing in- 
terest in community health an effort has been made, in widely 
scattered localities, to increase the efiSciency of the various 
local health agencies through the organization of community 
health centers. The development of the health center idea 
has been gradual and more or less spontaneous, originating 
coincidently in several widely separated communities at 
approximately the same period. Health centers were of pre- 
war origin but their growth was greatly accelerated during 
the war period, due largely to the enforced concentration of 
effort in order to overcome so far as possible the shortage of 
medical service, a result of the absence from the community 
of a large number of practicing physicians. 

It is not improbable that health centers were the natural 
outgrowth of the dispensary and that they were originally 
formed in cities too small for the establishment of elaborate 
dispensaries and public health laboratories, being instituted 
in an effort to afford relief and treatment for certain needy 
members of the community, especially the tuberculous. 

BED CROSS HEALTH CENTEBS 

After the war the American Eed Cross undertook the 
establishment of health centers as a peace-time activity. They 
describe a health center as "a physical center of some pro- 
ductive form of co-ordination of the health agencies and 
activities of a community." The plan as announced was 
not the introduction of a new organization but the establish- 
ment of a central agency by means of which team work 
could be secured. 

In a preliminary survey made by the Red Cross during the 
latter part of 1919 there were secured records of 79 existing 

99 



100 THE COMMUNITY HEALTH PROBLEM 

health centers scattered over the Fnited States.* In seven of 
the cities there was more than one center, so that, in all, 
forty-nine communities were represented. This number is, no 
iloubt, very ineomplcto because many centers, being more or 
less spontaneous in origin, are not on record as such and, in 
some places, the functions of a health center are taken on, 
in part at least, by existing institutions such as hospitals 
or dispensaries, and are so classified. In addition to the 
existing health centors, the Eod Cross found that there 
were thirty-three new centers definitely started in twenty- 
eight communities, and many others planned for early 
development. The Social Unit experiment, which is fully 
described in another chapter, is in many respects a form of 
health center. In New York City the Department of Health 
has established tuberculosis, industrial, and child welfare 
clinics, which represent in a somewhat modified form health 
centers for certain districts of the city. 

Analysis of the existing and proposed centers studied by 
the Red Cross shows that at the time of the report, (pub- 
lished in March 1920) thirty-three were administered 
entirely by the public authorities, twenty-seven were under 
private control and sixteen were under combined public and 
private control. The Red Cross was concerned in nineteen 
instances. 

There was considerable variance in the work and aims of 
the existing health centers. In forty communities having 
health centers in operation, thirty-seven contain clinics of 
some type, thirty-four do visiting nursing, twenty-nine do 
child welfare work and twenty-seven do anti-tuberculosis 
work. Twenty-two have venereal clinics, fourteen have dental 
clinics and eleven have eye, ear, nose and throat cUnics. In 
only ten are there laboratories and in only nine milk stations. 

WHAT IS MEANT BY A HEALTH CENTER 

/ It is evident from the above that the health center does 

•Tohey, James A. : The TToalth Tenter Movement in the United States. 
The Modern Hospital, March, 1920. 



HEALTH CENTERS lul 

not represent a fixed plan for the improvement of health but 
varies considerably according to tlie needs of the community, 
the available funds, and the ideas of its originators. In 
general, it means a building, or portion of a building, cen- 
trally 'located where various more or less closely related wel- 
fare and health activities are carried out. The grouping 
together of various health activities may be expected to make 
for better co-ordination and to prevent duplication of elTort.* 

In some cases the term "health center" is used to apply 
to two or more municipal hospitals and laboratories located 
in a group and under the control of the public health authori- 
ties. This is not, however, the sense in which the word is 
ordinarily used in speaking of the health center movement. 

In New York State the health center movement is expand- 
ing rapidly. In general, the plan in the smaller cities has 
been, apparently, to secure a building where the local health 
officer could have his headquarters, and to house in the same 
building the visiting nursing service, and various other health 
organizations located in the community. 

Theoretically two forms of health centers are possible, de- 
pending upon the extent of medical treatment, which may be 
limited or unlimited. The first, and the one which is most 
commonly seen under present conditions, would possibly in- 
clude: The public health workers; the Red Cross; the dis- 
trict nurses; and all charitable organizations interested in 
public welfare. Physicians may hold clinics, limiting treat- 
ment at the center to those patients unable to pay for the 

•Health Centers are described by the American Red Cross in a special 
circular of information as follows: "A health center is the physical 
headquarters for the public health work of a community. As such, it is 
the practical and concrete expression of the interest of the community 
in the health of its inhnhitaiits. It ronstitutes a business-like way of 
associating health activities, both public and private, under one roof, in 
daily touch and in complete mutual understanding. The health center 
thus represents the latest step in the evolution of community health 
work, and answers the demand for efficient conservation of effort la 
bringing together important but hitherto independent health campaigns. 
Buch as those for the prevention of tuberculosis, venereal diseases, 
mental diseases, indnstrinl disensps, and above all the vitally necessary 
modern effort for the conservation of child life. In turn, It offers new 
possibilities of properly relating these volunteer activities to the official 
health work of the citv, county, state, and Federal authorities." (A. R. C. 
Circular 1000, September, 1919.) 



103 THE COMMUXITY HEALTH PEOBLEM 

services of a private physician. The work would consist 
largely in disease prevention and education. In the second 
plan the health center will represent the medical center of 
the community for the unlimited treatment of disease as 
well as for prevention and education. Under such a plan phy- 
sicians would be on duty at all times, the services of special- 
ists would be available when required, and every patient ap- 
plying would be entitled to treatment whether "able to pa}-" 
or not. Laboratory facilities and x-ray apparatus should be 
a part of the equipment and there might be a staff of physi- 
cians and visiting nurses to care for patients in their homes.* 

How a health center is to be financed is a difficult ques- 
tion. One carved out according to the second plan is based 
essentially upon what has come to be known as "group medi- 
cine" which is acknowledged as more scientific and eflBcient 
than the general run of private practice. Such a health cen- 
ter might function either under the public health authori- 
ties, health insurance, industrial medicine, or under one of 
the various local or national voluntary organizations. 

Any form of health center which does not take into con- 
sideration the care of the large number of cases of sickness 
which now receive inadequate treatment, will fall short of 
accomplishing the maximum benefit for public health.** 

INDUSTRIAL CENTERS 

So far as is known none of the centers at present in exist- 
ence give complete medical service to all members of the 
community. The nearest approach to such a plan is found 
in certain industrial communities where a large industry has 
established an industrial health clinic for the care of its em- 
ployees. In some cases industrial clinics have reached a high 

• A plnn ■which closely approaches tliis has heon proposed for New 
York and a bill to this end was introduced in the 1920 session of the 
State Legislature. 

••Since the above was written a plan has been proposed to divide 
medical service in England into groups of "primary health centers" 
under the control of local physicians and "secondary health centers" 
where treatment by specialists will be available. It is stated that if 
this plan is carried out it will completely revolutionize medical practice. 



HEALTH CENTERS 103 

degree of dcvcbpment, with well equipped offices and several 
physicians (including specialists) on duty. Visiting nurses 
are employed and complete records are kept of illness 
occurring among employees. 

The work of the industrial physician is divided between 
preventive and curative medicine. Prevention of accidents 
as well as industrial diseases is included in his duties. He 
must also include in preventive medicine the elimination of 
those more or less ill defined conditions which are caused by 
monotony and fatigue. He watches not only the sick rate 
but bonus rate and, where bonuses are persistently not earned, 
he must search for a physical reason for this failure. He 
must assist the man with a physical or mental disability to 
secure proper employment ; he must weed out the misfits ; ho 
must properly interpret the effects of ill health upon produc- 
tion; and he must interest himself generally in the welfare 
of the employees. 

Under curative medicine the industrial physician is re- 
quired to treat injury and disease from the standpoint of 
economic loss to the individual and industry, as well as 
from the standpoint of scientific medicine. He must realize 
that a healthy body is necessary for efficient manual labor and 
that health is one of the most valuable assets of the com- 
munity. (See also Chap. IX, p. 84.) 

In the best type of modern industrial health center the 
community health problem has been met practically by the 
following provisions: (a) Medical care both at home and in 
the shop; (b) Visiting nursing service; (c) Hospital care 
either at the company hospital or a nearby general hospital; 
(d) Insurance benefits for disability and death; (ey Eecon- 
struction and rehabilitation of cripples; (f) Prevention of 
accident and disease — industrial, personal and social; (g) 
Welfare — including housing, child welfare, amusements, 
exercise, etc. 

Industrial health centers, unlike some other health activi- 
ties, are not largely theory with little or no practice. They are 



104 THE COMMUNITY HEALTH PROBLEM 

practical from beginning to end. They are started not as 
charity but because they pay and, inasmuch as they arise 
because of community needs, they must be paid for entirely 
by the combined resources of the employer and employee, thus 
in the end being paid for by the community wliich they serve. 
They represent excellent examples for other communities to 
follow, for it is a self evident fact that in the end every 
health activity should be supported by the community it serves. 
Temporary help may be given by the Eed Cross, by private 
charity or by the Federal or state government but such help 
is only a sort of demonstration, a try-out. In a wide move- 
ment for better health every representative community must 
be, to a large extent at least, self-supporting. 

HOSPITALS 

Health centers, whether industrial, public, or private in 
origin, may be affiliated Avith tiie community hospital and 
patients discharged from hospitals may be kept under j)ro- 
fessional observation by the staff of the health center. Every 
effort should be made to co-ordinate the work of the center 
and the hospital so that expenditure of the least energy will 
secure the greatest results. In many cases a community hos- 
pital may be made a part of the health center and this is 
especially true in villages and the smaller cities. 

ALAMEDA COUNTY HEALTH CENTEE 

One of the best equipped of the recently established health 
centers is located in Alameda County, California. The local 
committee have set forth their conception of the aims of a 
health center and the reasons for its existence as follows:* 

''The health center is defined as an institution which co- 
ordinates the public health work of the community in a cen- 
trally located building available to every man, woman and 
child. It conducts clinics — surgical, medical and dental — 
with the aim of making hospital care unnecessary. It pro- 

•Abstracted in the American Journal of Public Health, March, 1920. 



HEALTH CENTERS 105 

vides health instruction in personal "hygiene to both children 
and adults by means of popular lectures, lantern slides and 
the distribution of literature. It oilers instruction in mater- 
nity and child-welfare, thus reducing infant mortality. It 
serves as a clearing house for all public health information, 
thus eH'ccting a closer co-operation among hospitals. It 
divides the community into health districts, each with a defi-i 
nite health organization which can instantly be mobilized in 
case of threatened epidemic. It prevents overlapping, dupli- 
cation and waste because it co-ordinates all health and relief 
organizations." 

From the same source we are given ten reasons why every 
community should establish and support a health center. 
They are: (1) It promotes community health; your own 
safety depends on healthful surroundings. (2) It reduce!?- 
loss of income caused by sickness; earning power rests 
on health. (3) It decreases infant mortality. (4) It fostera 
health education; one scliool child out of two is defective; 
three out of four have defective teeth. (5) It reduces labor 
turn-over, making fewer hands to train. (6) It mobilizes the 
forces of public health and welfare. (7) It increases wealth. 
A healthy community is a good banking community. (8) It 
prevents epidemics. (9) It protects tlie liome; a healthy 
home produces a more efiBcient worker, a more contented cit- 
izen. (10) Public health is purcliasable ; a community to a 
large extent can determine its own death rate. 

It is understood that the Alameda County Board of Super- 
visors have made a liberal appropriation to carry out the 
health program. More than two thousand cases a month have 
been treated since the establishment of the center and the 
experiment gives every promise of success. 
/ In 1920, legislative action was started in New York for 
the state-wide application of the health center principle. Thifi 
movement had the endorsements of the State Charities Aid 
Association and the State Commissioner of Health. The bill, 
known as the Sage-lMachold bill, proposed, in brief, a healtli 



lOG THE COMMUNITY HEALTH PROBLEM 

center in every community consisting of a hospital, a labora- 
tory, and a dispensary, under the control of a local health 
board with the advice and approval of the state board of 
health. A full time medical director and paid attending 
physicians and nurses were to furnish medical care at a 
reasonable cost, or free, when necessary, to all members of 
the community. State aid in the form of fifty per cent, 
cash grants for buildings, a cash allowance for the treatment 
of free patients, together with certain allowances toward 
maintenance, were to be furnished to all communities fulfill- 
ing the requirements of the State Department of Health.* 

THE RED CROSS PROGRAM 

The plan for the extension of the health center movement 
by the American Red Cross may be best described by the offi- 
cial statement distributed from National Headquarters.** 
After discussing the program for the extension of public 
health nursing the plan for health centers is outlined as 
follows : 

"The time has come for the announcement of the second 
definite step in the Red Cross health program. This is to be 
the mobilization of Red Cross interest and influence for the 
establishment of health centers in every community where 
conditions make this desirable and possible. These modem 
community stations of health and social service not only 
promise greater efficiency in the public and volunteer activi- 
ties in this field but offer a particular opportunity for effec- 
tive Red Cross participation. In many communities, partic- 
ularly those without a health organization and where the 
Red Cross is now the only organized social agency, the health 
center may conceivably begin and continue as a purely Red 
Cross operation. In larger cities, with their well-established 
volunteer associations and committees and their more highly 

•For further details of the New York bill see State Charities Aid 
Association News, Aiiril, IDJO. This bill was introduced, but not acted 
upon^ during the 1020 session. 

•* American Red Cross Circular 1000, Sept. 20, 1919. 



HEALTH CENTERS 107 

organized official public health services, the health center 
may mean the practical physical means to bring about better 
co-ordination of these activities. In tliis case the lied Cross 
may initiate the movement or merely participate as one 
among other agencies, public and private. Indeed the health 
center idea is in itself capable of elastic definition to meet the 
circumstances and capacities of the smallest as well as the 
largest Chapters. A handbook will be issued later from 
National Headquarters covering the subject in fuller detail ; 
the present statement is intended to describe briefly the nature 
and purpose of health centers and to suggest in a preliminary 
way how the lied Cross may best promote their establish- 
ment." 



CHAPTER XII 

THE SOCIAL UNIT EXPERIMENT 

Those who accept the idea that there is a community health 
problem and believe that it is to a large extent capable of 
solution will find interesting and instructive reading in the 
reports of the Social Unit experiment at Cincinnati, Ohio, 

The Social Unit Organization has been described briefly 
as a "nation-Tride organization of people who have come to- 
gether for the purpose of finding some way to increase health, 
happine.-s and the other good things of the earth, and of help- 
ing to do away with poverty, misery, disease and preventable 
death." 

The ISTational Social Unit Organization was formed in 
April, 1916, with headquarters in New York City. The pur- 
pose of the organization is stated to be "to promote the type 
of democratic community organization through which the 
citizenslnp as a whole can participate directly in the control 
of community afl'airs, while at the same time making con- 
stant use of the highest technical skill available." 

After some deliberation, the Mohawk-Brighton districr of 
Cincinnati was chosen for the purpose of carrying out a 
Social Unit community experiment on a large scale and a sum 
of money was appropriated by the national organization for 
this purpose. 

THE SOCIAL UNIT PLAN 

The Social Unit plan aims to combine the citizens of a 
community into groups, the members of which will develop 
the activities of their own particular group for the benefit of 
the community organization as a whole. Thus the physicians 
and nurses of the district work for public health; the 

108 



THE SOCIAL UNIT EXPERIMENT 109 

employers and trade unionists are industrial experts; social 
workers form a committee on public welfare ; teachers repre- 
sent the Board of Education, etc. 

Decision as to various health measures is left la rifely to 
representatives of the people living in or employed in the dis- 
trict, but the execution of tlie suggested solutions of the 
health problems is referred to the Physicians Council, the 
Nurses Council, and the Social W^orkers Council. 

In an evaluation of the Mohawk-Brighton experiment made 
by Dr. Haven Emerson, former Commissioner of Health for 
New York City, the following statement is made: "Inquiry 
develops the practical unanimity of opinion of physicians in 
the district that the medical needs of the district have been 
better met than before, that medical practice had benefited — 
these are questions that I asked specifically of the doctors 
who were in service in the district and those outside the 
working group who had taken part at one time or another in 
the actions of the Medical Council — that the medical needs 
of the district had been better met than before, that medical 
practice had benefited and that if all taint of donation of serv- 
ices were removed by the assum])tion of costs by those who 
were served, there would be no further reservation in the 
willingness to praise and approve the organization and its 
results." 

While the population is too small and the duration oi the 
experiment too short to permit statistical conclusion based 
on morbidity records, certain very valuable results have been 
obtained, according to Dr. Emerson's report, and these results 
stand as tangible evidence of improvement in health condi- 
tions of the unit area. 

In the first place a very high percentage of expectant 
mothers were reached and pre-natal advice and treatment 
given when necessary. In addition early and continuous 
supervision of all babies born in the district was secured and 
adequate care given the mothers during the period immedi- 
ately following confinement. 

Children of pre-school age were examined and many physi- 



110 THE COMMUNITY HEALTH PEOBLEM 

cal defects discovered and corrected before the child entered 
school. It has been said that all children are entitled to edu- 
cation. It might be added that all children are entitled to 
begin education with the minimum degree of physical handi- 
cap. In the Mohawk-Brighton District many of the physical 
defects were discovered in early life and corrected by appro- 
priate treatment either by private or public medical agencies. 

SOCIAL UNIT XUESING 

Nursing in the district was largely carried out by the com- 
munity organization along lines similar to the district nurs- 
ing plan. "When the patient was able to pay from his own 
resources private nurses were em])loyed. In most cases, how- 
ever, visiting nurses were supplied without a fee. The nurs- 
ing service is divided into maternity, infant, pre-natal, pre- 
school, tuberculosis, and general bedside services. Much of 
the work done by the nursing staff, as might be expected, 
was educational in character. The aim was education in per- 
sonal hygiene through skilled nursing care for the ill and in- 
structive service for others. During the first year of the 
experiment Social Unit nurses reached and kept under ob- 
servation for varying periods 65 per cent, of all children under 
two years of age in the district, and it is claimed that 100 per 
cent, of all children having serious physical defects received 
nursing supervision. 

During the influenza epidemic of 1918 more than 3000 
visits were made by the nursing service within the district, 
and more than 350 outside of the district limits. 

Miss Zoe La Forge of the Federal Children's Bureau, in a 
report on the nursing situation, says,* ''The number of per- 
sons who have been reached compared with the number who 
might have been reached shows a completeness which is ex- 
traordinary in public health nursing organizations. This fact 

•La Forge. Miss Zoe: The Social Unit nnd Public Health Nursing, 
Report of Social Unit Conference. National Social Unit Organ. New 
Yorli, 1919. 



THE SOCLVL UNIT EXPERIMENT 111 

is even more impressive in view of the short time in which 
these results were obtained." 

TUBERCULOSIS ACTIVITIES 

Work in the field of tuberculosis was begun in May, 1918, 
in co-operation with the Anti-Tuberculo.sis League of Cincin- 
nati. Nurses were assigned to the district and it is probable 
that most cases of active pulmonary tuberculosis were discov- 
ered and brought under treatment. Of 179 new cases reported 
during the year 103 were located by those working within the 
unit itself. A large part of this increase was without doubt 
due to the general good will of the people toward the unit- 
workers combined with the ability of the block-workers to 
win the confidence of their families. Many cases of pulmo- 
nary tuberculosis were discovered during the early stage and 
as a result were suitable for sanitarium treatment. Arrested 
cases remained at home under expert medical and nursing 
supervision. 

MEDICAL CARE 

The medical services of the unit are directed by the Medi- 
cal Council which is composed of 32 of the 38 physicians 
living or practising within the district. Sixteen of these phy- 
sicians are employed on part time at $3 per hour in profes- 
sional work at the center, cliiefly examining children or 
adults. Treatment at the center is given by these physicians 
only in emergencies. AVhen the need of medical treatment 
arises patients are referred to their own physicians, or to the 
free dispensary or hospital. When needy patients require 
treatment at home the service is rendered by a physician from 
the City Health Department. Medical service in the homes 
is not considered to be within the province of the health ac- 
tivities so far called for by the Citizens' Council. The family 
physician is informed of the need for treatment and the 
patient notified that medical care is required. The free choice 
of physicians is encouraged. 



112 THE COMMUNITY HEALTH PEOBLEM 

BENEFITS OF HEALTH SERVICE 

The benefit derived from periodical examinations and 
medical supervision cannot be overestimated. As a result of 
this service combined with nursing service and the health 
educational activities of the center, physical defects receive 
early attention by both patients and physicians. The relation 
between patient and physician is not disturbed but is as a 
rule greatly improved. The physician is stimulated to do his 
best work and the patient is taught just what he may ex- 
pect from a given remedial measure so that there is consid- 
erably less criticism of the methods employed, when illness 
results unfavorably, than is the case in ordinary private prac- 
tice. Exploitation of the sick by unscrupulous physicians is 
reduced to a minimum. 

As a whole the health service may be said to be divided into 
three sections. 

(a) Medical Service furnished in part by private physi- 
cians with the co-operation of private and public hospitals and 
the Department of Health. This part of the service is no dif- 
ferent from that of any other section of the city. The only 
new element in the unit experiment is medical supervision 
by a medical council. 

(b) Nursing service furnished on the district nursing plan 
free to all who will accept it. 

(c) Public health service furnished in part by the citizens 
themselves, in part by the public health authorities, in part 
by w^elfare workers of the Social Unit, and in part by certain 
other outside organizations. 

Tlie health service indicated certain .srross sanitary defects 
which were corrected through co-operative action of citizens, 
landlords and tenants. The education of the mass of the pop- 
ulation in health matters, having led apparently to a desire 
for general sanitary cleanliness combined with an under- 
standiug of the relation of health to their own and their chil- 
dren's welfare, wvts an important factor in spouring prompt 
action leading to the correction of sanitary defects. 



1 



THE SOCIAT. UXIT EXPFJ^niENT 113 

Among the citizens themselves the results have hecn ex- 
cellent. The public has been educated in the possibilities of 
increased happiness through increased health and especial 
emphasis has been placed upon the firm establishment of the 
belief that reasonable efforts spent for the improvement of 
health are not wasted but bring results out of all proportion 
to the expense incurred. 

CRITICISM OF THE SOCIAL UNIT PLAN 

The Social Unit experiment has been severely criticised. 
While its critics admit that it has done much good they con- 
tend that this has only been accomplished because the unit 
has been experimental and that all parties, citizens, execu- 
tives and workers are working largely on the enthusiasm of 
new ideas and novel conceptions of public welfare. They 
believe that over a large territory, lacking this enthusiasm 
and the inspiration of a unique experiment, the workers 
would lose interest and the results would consequently be 
negligible. It is claimed by some that the Social Unit is rev- 
olutionary and represents a dangerous competitor to existing 
political institutions. 

Others, notably the inhabitants of the Mohawk-Brighton 
District, favor the experiment. "Welfare workers as a rule 
favor the project and believe that actual results obtained have 
been amazing. 

Besides being a health experiment the Social Unit is dis- 
tinctly a social experiment. Social and health activities are 
based largely upon decisions of the citizens themselves acting 
through tlieir councils and executives. There is no disputing 
the fact that some remarkable results have been obtained. 
Whether another group of citizens would do as well is pos- 
sibly debatable. 

At all events a reasonably satisfactory partial solution of 
the community health problem has been obtained. Whether 
this is the result of the Social Unit plan of community gov- 
ernment or whether it is largely due to the intelligence and 



Hi THE COMMUXITY HEALTH PllOBLEM 

energy of the executives sent to Cincinnati by the National 
Social Unit Organization is at present undetermined. Every 
community is entitled to health conditions at least as good 
as those in the Mohawk-Brighton District. Possibly com- 
munity organization is the only way to obtain it. 

The residents of this district in the face of a newspaper 
criticism by the IMayor of Cincinnati, recorded their desire 
that the Social Unit should continue its work by a vote of 
4434 to 120. 



CHAPTER XIII 

TUBERCULOSIS 

Tuborfnlnsis has boon called the burden of modem civili- 
zation. It is without doubt the most widespread of all major 
illnesses. Coming as it does during an early period in life, 
attacking members of every strata of society and causing a 
tremendous annual loss of life, it presents the most im- 
portant menace to community health which modem society 
must face. 

Approximately 150 individuals in every 100,000 die annu- 
ally from pulmonary tuberculosis. In some of the larger 
cities this number is increased to 200 or even higher. Wlien 
we consider that tul)erculosis is a disease of several years* 
duration and that many persons suffering from the disease 
are, except during the later stages, usually up and about at- 
tending to their normal occupations, together with the fact 
that comparatively few cases are reported to the public health 
authorities during the early stage, it becomes at once evident 
that there must be a large number of untreated and unsus- 
pected cases in every community. It is ordinarily estimated 
that there are at least nine active cases for every death from 
the disease. 

DTSTRIBUTIOX OF TUBERCLE BACILLI 

The distribution of the tubercle bacilli is almost universal. 
Pathologists tell us that practically 100 per cent of all adults 
dying from accident show evidences of tuberculosis. The 
signs of the disease, it is true, are in most cases only minor 
lesions and have little or no clinical signiticance except for 
the fact that they point to the wide distribution of the causa- 

115 



116 THE COMMUNITY HEALTH PEOBLEM 

tive organism. From a medical standpoint sucli cases are not 
considered clinically as tuberculosis. Only when the disease 
becomes progressive, or when the growth of the organism 
tends to overcome the rcgistance of the individual do we 
speak of the condition as tuberculosis. 

We know the cause of tuberculosis, we know how the dis- 
ease is spread, and we know that it can frequently be arrested. 
"We have therefore a condition which should be peculiarly 
susceptible to control, and to a degree we may say that ef- 
forts to this end have been fairly successful. In the registra- 
tion area of the United States there has been an almost con- 
stant decline in the tuberculosis mortality rates from 200,7 
per 100,000 in 1904 to 146.4 per 100,000 in 1917. This de- 
crease has been due largely to existing public and private 
agencies for the control of tuberculosis and to improvement 
in the social and medical treatment of patients suffering 
from the disease. 

THE CONTROL OF TUBERCULOSIS 

In attempting to control tuberculosis one of two alterna- 
tives may be adopted. .We may discard the existing agencies 
and with a new broom make a clean sweep of all society, at- 
tempting the complete removal of all infectious individuals 
from their surroundings and starting anew with the re- 
mainder to create a new civilization. Such a plan has been 
proposed, including the complete isolation of the tuberculous 
and legal restrictions against marriage, but fortunately for 
the peace of the world the attempt has never been made to 
put this proposed plan into execution. The other alternative 
is to continue what we have been doing, only expanding 
our energies so that what we already know may be carried 
to every corner of the country; so that every individual will 
have placed before him the best that our present knowledge 
has to offer, while at the same time we make every effort to 
improve our methods, to correct our mistakes and develop a 



TUBERCULOSIS 117 

spirit of co-operation between the scientist, the physician, the 
patient, the legislator and the man on the street. 

Much that is said of the control of tuberculosis may be 
said of almost any health prol)lom in the community. The 
campaign against this disease in the past has been, and is 
apt to continue, under the joint control of the state, or 
municipal, authorities and various private organizations. 
Each has its own part to play and none could function ade- 
quately to the exclusion of the others. 

Private organizations should be devoted largely to re- 
search, experimentation, education and observation. They 
should be depended upwn to stimulate interest, to point out 
new fields and to indicate methods of procedure. Govern- 
mental activities should be devoted largely to the execution 
of plans previously initiated by private organizations. 

The following is the general plan of a tuberculosis pro- 
gram which has been outlined by Dr. Donald B. zVrmstrong:* 

1. Organization : Lay and professional organizations, in- 
terest, co-ordination, education, public service, ideals. 

2. Legislation: Sanitary, epidemological, institutional 
provision and appropriations. 

3. Sanitation: Cleanliness, respiratory hygiene, food pro- 
tection, control of spitting, etc. 

4. Disease Detection : Reporting of disease by physicians 
and clinics, the establishment of new clinic facilities, infant 
welfare and school hygiene, special consultation service, etc. 

5. Classification: The standardization of reports and clas- 
sifications. 

6. Treatment: (A) Home treatment including nursing, 
relief, etc.; (B) Institutional treatment, including sanitoria, 
day camps, etc. 

7. Subsequent observation : Follow-up work with economic 
adjustment and the conservation of health. 

8. Prevention: By sanitary hygiene, education, by the pre- 

•Armstrong, Donald B. : Journal of Outdoor Life, Jan., 1920. 



lis THE COMMUNITY HEALTH PROBLEM 

vention of the spread of infection, and by general efforts to 
increase resistance. 

9. Eesearch and Demonstration : The development of a 
scientific inquiry' into the methods of prevention and cure, 
and into social questions combined witli the demonstration 
of methods. 

A program such as the above can, with slight modifica- 
tion, be adapted to many other diseases. In a community 
where health work is being- started from the beginning, and 
especially where there are only limited funds available, it is 
sometimes desirable to limit the work temporarily to meas- 
ures to combat tuberculosis. This disease lends itself par- 
ticularly to welfare work because: (1) The disease is chronic; 
(2) A large amount of preliminary work has been done so 
that there need be little lost energy; (3) There is a flourish- 
ing national organization willing and anxious to furnish 
assistance and guidance. 

In carrying out a tuberculosis program there will be dis- 
covered a tremendous number of otlier diseases which, because 
they undermine the general health, predispose to tuber- 
culosis. By concentrating on tuberculosis in the begin- 
ning the other unfavorable conditions are soon brought to 
light. 

In the treatment of the tuberculosis problem there arise 
many closely related problems of sanitation and general 
health which in many cases are capable of easy solution but 
which in most communities are being handled indifferently 
or not at ail. 

THE DISCOVERY OP EVERY CASE 

The most important phase of the tuberculosis problem has 
to do with the discovery of all existing cases, that is, the 
bringing of all tuberculous individuals and all suspects under 
competent medical care. 

The experience of Dr. Donah! B. Armstrong in Framing- 
ham, Mass., a city of about 17,000 inhabitants, has been 



TUBERCULOSIS 119 

interesting as showing how many cases may bo brought to 
light by a careful medical survey. On January 1, 1917, there 
were, according to the official records, 27 cases under obser- 
vation in the city. On November 15, 1918, as a result of 
the survey, there were under observation 181 cases and 69 
suspects. During this period there were 29 deaths and 33 
patients moved to other localities. The source of the 242 
positive cases was as follows: 

TABLE OF ORIGIN OF TUBERCULOSIS CASES* 

Previously known 27 

Medical examination drives 96 

Draft • 13 

Consultation 53 

Private physicians* reports 40 

School medical work 11 

Factory medical work 2 

Total 242 

From the above table it is evident that a careful medical 
survey may demonstrate, at a very conservative estimate, at 
least one undiscovered case of tuberculosis for every reported 
case in a typical American community. It is probable that 
this estimate errs on the side of conservatism and that in 
fact, there are nearer two undiscovered cases for every 
reported case. 

MEDICAL CARE FOR THE TUBERCULOUS 

The nest major problem has to do with the securing of 
treatment for every active case of pulmonary tuberculosis. 
Let us suppose that every case has been discovered, how then 
are we going to secure the maximum benefit of treatment for 
each and every patient? This becomes at once an economic, 

•Armstronc. DonaM B. : Tuberculosis Findings, Framlngham Mono- 
graph No. 5, March, 1919. 



120 THE COMMUXITY HEALTH TEOBLEM 

as well as a social and medical problem. A certain percent- 
age of the patients will be able to continue their old occupa- 
tions and will require a minimum of medical attention. A 
somewhat larger proportion will not improve in their present 
occupations, but will improve if they are placed in more 
favorable surroundings. Many will be unable to do any work 
and must be either treated at home or sent to a sanitorium. 
The economic problem becomes most acute when the bread 
winner is attacked and unable to support his family. It is 
useless to tell such a man that he must "get away and take a 
long rest." Unless provision is made for his family he will 
be unable to stop work until the disease has progressed so far 
as to render him physically unfit. At this stage the disease is, 
of course, unfavorable for treatment. 

AFTER-CARE OF THE TUBERCULOUS 

The third phase of the problem has to do with the care of 
the arrested case. It is customary in such cases to tell the 
patient that he may now return home and "to secure some 
.form of light out-door work." For the average man such 
advice is worse than useless. Those who have tried say that 
light out-door work practically is non-existent. The chief 
out-door occupation is farming which is far from a light 
occupation. If an arrested case is allowed to go back to hard 
manual labor immediately upon discharge from the sani- 
torium a relapse of the disease is almost certain to occur and 
the results of treatment are completely counteracted, thereby 
causing economic loss both to the man and the community. 

The problem has been solved in a large way only in a few 
communities. Certain industrial organizations, notably the 
Eord Company, have established special work rooms for 
arrested cases of tuberculosis where they are given light work 
in hygienic surroundings, mader the care of a physician. The 
results of this plan have been most successful and the future 
of what might be called "occupational therapy" for incipient 
and inactive tuberculosis in carefully selected cases is most 
promising. 



TUBERCULOSIS 121 

The U. S. Public Ilealth Service lias outlined a program* 
for 1920 which includes: (a) Stringent provisions for the 
proper reporting of cases of tuberculosis; (b) Adequate 
instruction of families and patients, especially in families 
where there is an advanced case; (c) Hospitalization of 
cases, wherever practicable, either through city institutions, 
or by arrangements with state and district tuberculosis hos- 
pitals; (d) Co-operation with national societies and agencies 
having for their object the prevention of tuberculosis or the 
improvement of economic conditions; (e) Improvement of 
industrial conditions predisposing to tuberculosis, such as 
dusty occupations, defective ventilation, etc. 

For the average community where it is desired to make a 
beginning in constructive health work the campaign may 
often be centered about the tuberculosis problem. So many 
welfare measures, such as better housing, child welfare, nutri- 
tion, etc., are so intimately connected with the control of 
tuberculosis that activities undertaken with the aim to pre- 
vent the spread of this disease serve to direct attention to 
community sickness, and at the same time, tend to improve 
general conmiunity health. 

•Annual Report, 1919, U. S. Public Health Service, Washington, D. C. 



CHAPTER XIV 

SOCIAL HYGIENE IN ITS RELATION TO COMMUNITY 
HEALTH 

/ In every community there is what has come to be known 
as a "social hygiene" problem, meaning thereby a problem 
which has to do, in part, with the prevention of venereal 
diseases. In many of the smaller communities the presence 
of sex diseases may be denied but if a careful search be made, 
in every group containing several thousand persons, evidence 
of sex disease, either past or present, will almost certainly 
be found in a fairly definite proportion of the total. 

No plan of health improvement can be considered com- 
plete unless the question of social hygiene receives due con- 
sideration. The prevention of sexual diseases has been fre- 
quently attempted and for the most part attempts have met 
with little or no success. The problem is so complicated by 
personal habits, social institutions, and by community and 
national customs that the medical aspects of the question 
become obscured by the sociological and economic problems 
which present themselves. 

MEDICAL CONTBOL POSSIBLE 

As far as the science of medicine is concerned there is no 

mystery in any of the various sex diseases. They are all of 

them transmitted only by direct contact, they are all more 

or less easily curable and their transmission from one person 

to another is comparatively difficult. They are not spread 

by air currents as are measles and smallpox,* they are not 

disseminated through infected water or food as are typhoid 

•The epread of measles and smnllpox by air currents Is not definitely 
proven. Some writers deny that this can occur. However, infection 
does occur from very slight contact in both of these diseases, possibly 
carried. In some cases at least, in minute droplets of moisture 
expelled in coughing or sneezing. 

122 



HYGIENE IN ITS RELATION TO HEALTH 123 

and dysentery, and they are not carried by insects as are 
malaria and typhus. Moreover the micro-organisms are not 
'scattered broadcast as are the germs of pus-forming infections 
but, in practically every case, the disease must be spread 
directly from person to person and the contact must be 
intimate and prolonged. 

Even when such is the case an abrasion or wound of the 
surface is in certain cases necessary for the introduction of 
the infective material. 

Here then from a medical standpoint we have disease which 
should be very easily controlled. All that is necessary is to 
quarantine every case during the infectious stage, and the 
disease will disappear. But this is more easily said than done. 
In the first place venereal diseases exist to such an extent 
that quarantine is impracticable. In the next place the 
social disgrace of sexual infection is so great that many per- 
sons will do their utmost to prevent the discovery of the 
fact that they are suffering from such disease. And last, and 
in my opinion most important of all, is the fact that these 
diseases are often so mild as to escape the knowledge of the 
patient himself or at least so mild as to permit him to delude 
himself into believing that his disease is not serious. If 
venereal diseases occurred in acute attacks, as severe as typhoid 
fever or smallpox, detection would be easy, all cases would 
come under treatment, the spread of infection would auto- 
matically stop, and the venereal disease problem would soon 
become comparatively insignificant. 

MILITARY CONTROL OF SEX DISEASES 

In a military community where all the members of the 
community are under strict control sexual diseases may be 
reduced to a minimum. This has been frequently proven in 
the United States, and was demonstrated on a tremendous 
scale in the American Expeditionary Forces where the 
venereal admission rate was extremely low. However the 



•124 THE COMMUNITY HEALTH PROBLEM 

methods whicli "were used in tlie Army are for many reasons 
considered impracticable in civil life. 

Nevertheless the study of social hygiene received a great 
stimulus during the war period. It was realized that here 
was a live problem which must be recognized and faced be- 
fore conditions could be bettered. In the past there has 
always been a strong tendency to deny what was considered 
objectionable and, in America especially, many persons con- 
sidered that it was immoral even to admit that such dis- 
eases existed. 

For some years the American Social Hygiene Association, 
the U. S. Public Health Service, the American Eed Cross, 
and various city and state health departments have been 
attempting to stimulate interest in the problem of social 
hygiene in order to diminish all forms of veneral disease, 
without however meeting with any great amount of co-opera- 
tion from either the public or the medical profession. 

PUBLIC HEALTH SERVICE CAilPAIGN 

During the war however the United States Public Health 
Service outlined a nationwide campaign against venereal 
diseases to be carried out in co-operation with state and local 
health authorities and various welfare organizations. In July, 
1918, the Chamberlain-Kahn bill was passed by Congress es- 
tablishing a Division of Venereal Diseases in the Public 
Health Service and an Interdepartmental Social Hygiene 
Board. The Surgeon-General of the Public Health Service 
characterized the bill as the most important public health 
legislation ever enacted by law. 

The duties of the Division of Venereal Diseases were out- 
lined as follows : 

1. "To study and investigate the cause, treatment and pre- 
vention of venereal diseases ;" 

2. "To co-operate with State Boards of Health for the pre- 
vention and control of such diseases within the states; and" 

•Plercfi, C. C. : The PnbUe Health Campaign against Venereal Diaeasef, 

Social Hygiene, October, 1919. 



HYGIENE IN ITS RELATION TO HEALTH 125 

3. 'To control and prevent the spread of these diseases in 
interstate traffic." 

In addition to interstate quarantine regulations which for- 
bid interstate travel of persons infected with venereal dis- 
ease except under a permit of the local health officer, a bill 
was introduced to make certain United States appropriations 
available to local health authorities who would co-operate 
with the Public Health Service for the prevention of vene- 
real disease. Definite minimum requirements were estab- 
lished which must be met before such appropriations are 
available for local or state health activities. The nunimum 
requirements are, briefly, as follows: 

(a) "Venereal diseases must bo reported to the local health 
authorities in accordance with state regulations approved by 
the United States Public Health Service." 

(b) "Penalty to be imposed upon physicians or others 
required to report venereal infections for failure to do so." 

(c) "Cases to be investigated, so far as practicable to dis- 
cover and control sources of infection." 

(d) "The spread of venereal disease should be declared 
unlawful." 

(e) "Provision to be made for the control of infected per- 
sons who do not co-operate in protecting others from infec- 
tion." 

(f) "The travel of venereally infected persons within the 
state to be controlled through state boards of health by defi- 
nite regulations that will conform in general with the inter- 
state regulations to be established." 

(g) "Patients to be given a printed circular of instructions 
informing them of the necessity of measures to prevent the 
spread of infection, and the importance of continuing treat- 
ment." 

TREATMENT SHOULD BE MADE AVAILABLE 

Prom a medical viewpoint every case should have the oppor- 
tunity of securing expert treatment at a moderate price. 



/ 



126 THE COMMUNITY HEALTH PROBLEM 

There has been a tremendous amount of exploitation of 
patients by the so-called "advertising specialists." It is even 
argued by certain conservative physicians that, because men 
develop these diseases mainly as a result of their own mis- 
conduct, they should be made to pay high fees. Many pri- 
vate practitioners take little interest in such cases and prefer « 
to send them elsewhere for treatment. This together with the 
stigma of disgrace which is attached to venereal infection 
has driven many men to the advertising specialist for treat- 
ment or has resulted in self medication. Drug manufacturers 
have become enormously rich from dividends derived from 
the sale of patent medicines for the cure of sex diseases. 

It is most important that every community recognize that 
it is better to treat these diseases at the expense of the public 
than to allow them to remain untreated. This is best accom- 
plished by the establishment of a dispensary where treatment 
can be had for the asking for a nominal charge, or for no fee 
at all if requested. 

In general the campaign should be laid out along the fol- 
lowing lines: (a) Education; (b) Treatment; (c) Legisla- 
tion; (d) Recreation. If the need is recognized and advan- 
tage is taken of efforts of the Public Health Service, and the 
various local and state health authorities, a great deal may be 
accomplished. If on the other hand, the presence of a 
venereal problem is denied or if the subject is shelved because 
it is considered indecent and immoral, and consequently unfit 
for discussion, the contagion will continue and the coming 
generation will pay the price. Still-births, blindness, paraly- 
sis, insanity, and many chronic partially-incapacitating 
diseases frequently follow -untreated veneral diseases. Such 
bad results can nearly always be prevented by early and ef- 
ficient treatment. Social ostracism as a thereapeutic measure 
in the cure of venereal disease has always been, and always will 
be, a failure. It is in line with modern social progress to 
divorce entirely the moral from the medical in the treatment 
of disease. It is impossible to deny the presence of venereal 
diseases in the community; it is criminal to ignore them. 



HYGIENE IN ITS RELATION TO HEALTH 127 

Various other measures for the control of venereal diseases, 
such as the elimination of the so-called "red light district," 
the segregation of prostitutes, compulsory quarantine during 
the infectious stage, and other similar measures which have 
been advocated from time to time are not considered within 
the scope of this chapter. For a further discussion of this 
question, especially in its social and economic aspects, the 
reader is referred to the various publications of the Ameri- 
can Social Ilygieue Association. 



CHAPTER XY 
REHABILITATION OF THE DISABLED 

It is self evident that the soldier who has done his duty in 
military service and returned to his home wounded and per- 
manently disabled must not be allowed to resign himself to 
a life of idleness, depending solely upon his government pen- 
sion for support. Such a procedure is demoralizing both to 
the discharged soldier and to the community. 

Neither should he be encouraged to depend U])on irregular 
work of an unskilled nature if he has within him capabili- 
ties of something better. 

Following the activities of the war and the long period of 
idleness in the Army hospitals there is often a period o?. 
depression. The wounded soldier is apt to decide that he is a 
''has been," that he is seriously handicapped, and cannot hope 
to compete with the physically fit and that he will be unable 
to earn a satisfactory living. He feels that there is nothing 
left to do except resign himself to the inevitable. This men- 
tal condition is, in some cases, a state of depression, so marked 
that it causes the man to avoid his friends and acquaintances, 
to become morose and to be considered moody and unfriendly 
by those with whom he is brought in contact. Place this 
same man in a gainful occupation, make it possible for him 
to support a family, let him feel that he has a place in the 
community, and immediately his whole character changes, he 
is able to look his fellow in the eye without a feeling of 
humiliation and, as a consequence, when at work he often 
makes faster progress and does better work than his uninjured 
co-workers. 

Douglas C. McMurtrie has pointed out that, throughout 
history, the disabled and deformed man has been a castaway 

128 



REHABILITATION OF THE DISABLED 129 

of society, that the trihes of ancient India turned out their 
deformed members to wander in the wilderness, and that the 
ancient Hebrews banished cripples and forced them to beg 
at the roadside. Ridicule and suspicion were frequently 
directed against the deformed, and at one time it was widely 
believed that some evil power rested in the deformed or crip- 
pled body.* During the last century however there has been 
a rapid change for the better, beginning with pension laws 
and toward the end expanding, with the broadening concep- 
tion of the responsibility of the community, through the enact- 
ment of compensation laws and laws for vocational training. 
It is to be hoped that the problem of the disabled soldier 
is not to be a permanent one and that the splendid efforts 
which have been made by the Federal Government will nort 
soon again be required for those injured in war. The lesson 
once learned, however, must not be forgotten and the obvious 
advantages of vocational training for the war cripple must 
be adapted to civilian problems and made available for the 
cripples of industry of whom there are an enormous number. 

MANY CRIPPLES FEOM INDUSTRIAL ACCIDENTS 

It is stated that in eighteen states, from which we 
have complete statistics, there are injured in industry 
750,000 persons per year, over 35,000 of these accidents 
representing disability either partial or total; and in the 
course of the year, there are more than 28,000 amputations 
as a result of accidents in the entire country. No solution 
of the community health problem is complete unless it takes 
into consideration the training of disabled men, whether 
such disability is a result of injury or disease. This problem 
must of necessity vary in different localities. 

There being, unfortunately, comparatively little informa- 
tion available for the use of the civilian community which 
plans the rehabilitation of the industrial cripple, it becomes 
necessary to study what has been done for the disabled 

•McMurtrie, Douglas C. : The Disabled Soldier, New York, 191». 



130 THE COMMUNITY HEALTH PROBLEM 

soldier and to make use of this information in the care of 
the civilian cripples. 

The beginning of the movemont for the training; of soldiers 
was definitely established by the organization of the first 
training school for invalided soldiers in Lyons, France, in 
December, 1914. It is said that Edward Herriot, Mayor of 
Lyons, noted that in the streets of the city there were a 
large number of strong and rugged appearing soldiers who, 
except for a specific injury, appeared physically sound. While 
these men sat about and sunned themselves in the streets of 
the city the nation cried for munition workers to man the 
nearby factories. When Mayor Herriot examined into the 
question of employing these men, many of whom had been 
skilled mechanics, he found that they were unable to resume 
their former occupations because of physical handicaps. 
It was necessary to teach them new occupations before they 
could be employed. As a result of his efforts a school wa8 
opened at Lyons in December, 1914, with three pupils. In a 
few months it became necessary to turn applicants away. 

With the example of the French before them the move- 
ment soon spread to England, Belgium and other allied 
countries. 

Before the entry of the United States into the war there had 
been comparatively little study of the vocational training of 
cripples in this country. While the need had long been recog- 
nized, practically no serious effort had been made to meet the 
need and very little information as to the character of the 
work being done in France, Great Britain and Italy was 
available. 

The first serious effort made in America was inaugurated 
by the Institute for Crippled and Disabled Men which was 
started by the American Red Cross in New York City during 
the summer of 1917. This was nearly a year before the pro- 
vision for the training of disabled soldiers, sailors and 
marines became a law (June 27, 1918). Vocational training 
in the United States was placed under the supervision of the 



REHABILITATION OF THE DISABLED 131 

already existing Federal Board of Vocational Education, a 
new division of which was created for this purpose and termed 
the Division of Rehabilitation. 

The Board established ofllces throu.^hout the country and 
an attempt was made to secure contact with all injured sol- 
diers, and to approve for training those who were handicapped 
for tlieir old occupations, and who would benefit by a course of 
vocational training. Unfortunately there was a great deal of 
delay, due largely to the fact that the Federal Board was 
handling an enormous work and that it was practically 
impossible to secure for the divisional offices, employees who 
had been trained in work of this sort. Consequently the train- 
ing of many disabled men was delayed for weeks or months 
through no fault of their own. 

EARLY TRAINING NECESSARY 

Training should start before the patient is discharged from 
the hospital. This is very important and is too often 
neglected. During the long period of convalescence the sol- 
dier becomes tired of the monotonous existence he is forced 
to undergo. He smokes too much, is apt to drink too freely 
and is generally at odds with his surroundings. Healthful 
daily occupation not only aids in dispelling ennui but actu- 
ally hastens healing. This part of the work must necessarily 
be undertaken in an institution where teaching facilities for 
a large number of pupils can be easily secured. Medical 
attention must also be available so that, when dressings are 
required, only a small amount of time need be lost. It is not 
necessary for all the men to live at the institution, many 
can live at home and take the daily trip back and forth for 
medical care and instruction. Only in very exceptional cases 
should men be permitted to enter ordinary schools until the 
maximum benefit from medical treatment lias been obtained. 
The United States law failed to insist upon hospital train- 
ing, so that, as a consequence, after the patient left the hos- 
pital there was a grievous delay before vocational training 



133 THE COMMUNITY HEALTH PROBLEM 

could be started. This was largely due to the overwhelming 
of the Federal Board with more cases than they could pos- 
sibly handle, and to other causes which apparently are inher- 
ent in government undertakings. The Medical Depart- 
ment of the Army, or Navy, discharged the man, when in the 
opinion of the surgeons the maximum benefit had been 
attained. He then had to apply to the War Risk Insurance 
Bureau for a pension and to the Federal Board for vocational 
training. This required applications, proofs of identity, 
repeated medical examinations and, as a consequence, long 
delays in many cases. This has caused much criticism of the 
Federal Board. The discharged soldier felt, not without rea- 
son, that he was not receiving a square deal. When he was 
asked to go over the top and risk his life it was not necessary 
to wait for a special communication from "Washington. Why 
should there be so much delay when the country was asked to 
repay the debt? As the work has progressed the machinery 
of the law is acting more smoothly and there has been less 
cause for complaint. 

PHYSICIAN PLAYS IMPORTANT PART 

The role of the physician in the training of the war crip- 
ple is an important one.* In the first place the physician 
must pass on the physical condition of the applicant, to 
decide if he has actually obtained the maximum benefit from 
treatment. If no further treatment is required it is neces- 
sary to decide whether his disability actually disqualifies him 
for following his old occupation. It is not enough to con- 
clude that he may, by extra effort, continue in his old employ- 
ment. The questions must be asked, "If this man returns to 
his old occupation will he be handicapped as compared with 
the normal worker?" and "Will this man, if he returns to his 
old work, be able to carry on as long as the normal worker?" 

•The anthor has discussed thl3 phase of the subject more In detail 
In an article entitled Rehabilitation in its Relation to the Physician, 
Modern Medicine, February, 1020. 



REHABILITATION OF THE DISABLED 133 

If ho compares unfavorably with the normal worker it is 
necessary to give the man some form of training so that, by 
his skill, he may be able to compete with the normal worker 
on equal or nearly equal terms. Thus, a mechanic may be 
taught special mechanical processes which require special 
technic, thus making it easy for him to secure employment 
in spite of a wooden leg or a partially crippled arm. That is, 
the man may be given additional training in his old occu- 
pation if this is considered practicable. This is, however, not 
always possible. A policeman who had both feet frozen was 
found no longer fit for his old occupation and consequently it 
was necessary to train him in an entirely new line of work. 
He became a wireless operator. A physician became stone 
deaf as a result of a shell explosion which left him otherwise 
uninjured. This disability made it impossible for him to con- 
tinue private practice but he was trained as a laboratory 
worker, and was able to take full charge of a hospital 
laboratory. 

In the choice of a vocation, the man consults with the 
vocational advisor and between them they come to an under- 
standing which is based upon the man's previous education 
and training, his desires, the openings available and the opin- 
ion of the advisor as to the man's aptitude and capabilities. 
After the choice is made the man is sent to the medical ad- 
visor to decide whether there is any objection from a physical 
standpoint to the proposed course of training. 

In the United States every disability, whether due to in- 
jury or disease, which arose from, or was increased by mili- 
tary service, is to be considered from a vocational view- 
point. The handicap from a vocational standpoint is classi- 
fied eitlier as major, minor or negligible. If there is a major 
handicap, according to the Act, the man receives training 
and an allowance for expenses varj-ing from $80 to $115 
monthly,* depending upon the number of dependents who look 
to him for support. A minor handicap entitles a man to 

'This amount is sometimes increased by the Federal Board- 



134 THE COMMUNITY HEALTH PROBLEM 

training, but to no allowance, and a nogligiblc handicap 
entitles him to placement in a position but no allowance and 
no training. 



CLASSIFICATION OF HANDICAP 

The instructions issued by the Federal Board on this point 
are as follows : 

(a) "Major Handicap" includes cases in which, from the 
point of view of the entry in question, the disability will be a 
real and permanent handicap in the occupation such as to 
effect employability and earning power. 

(b) "Minor Handicap" includes cases in which, from the 
point of view of the entry in question, disability involves 
some inconvenience that does not interfere in any real way 
with the employability or earning power and that frequently 
may become negligible after a brief experience in the voca- 
tion. 

(c) "Negligible Handicap" includes cases in which, from 
the point of view of the entry in question, the disability may 
be disregarded in considering the man's employability and 
earning power. 

In some cases the question of handicap presents a difficult 
problem. Especially is this so of those who complain of dis- 
ability with indefinite or ill defined symptoms. In such cases 
the District Medical Officer may send the man to a specialist 
for consultation, to a radiographer for an X-ray or to a labo- 
ratory for a special analysis. Here the physician has at his 
command aU the methods required by modern practice 
for the diagnosis of disease. For example, a man com- 
plains of weakness in his hand following a gunshot wound of 
the arm. A neurological examination shows that he has a 
partial paralysis of one of the nerves of the arm and that his 
disability is probably permanent. Such a man will be classed 
as a major handicap. Another complains of pain in the elbow 
when the elbow is bent, following an old fracture. An X-ray 



KEHABILITATION OF THE DISABLED 135 

of the elbow shows a small spicule of bone projecting into 
the joint. Operation is not considered advisable and the man 
is given a "major handicap, probably permanent." 



MEDICAL ATTENTION NECESSARY DURING TRAINING 

'Any plan for vocational trainini:^ should include medical 
attention for the man during the period of training. Under 
the plan adopted in this country this care is given by the 
U. S. Public Health Service. This has not worked very well 
because the applicant is not in touch with the Public Health 
Service, as a rule, and the physicians of this service are, in 
turn, not in close touch with the Federal Board. It is a ques- 
tion if better results would not have been obtained if the entire 
work had been undertaken by a medical organization such 
as the Medical Department of the Army or the U. S. Public 
Health Service, instead of dividing the medical care and 
educational supervision between the Public Health Service, 
on the one hand, and the Federal Board, on the other. At 
present there is considerable duplication of eifort. Many of 
the difficulties of the Federal Board arise because of this 
duplication and because of the enormous amount of work 
which it handles. With untried methods and inexperienced 
employees, many mistakes were certain to occur in the rush 
of applicants, beginning directly after the armistice, which 
would not occur in a community effort on a small scale. 

There is a problem of considerable human interest in the 
examination of applicants for training. There may be seen 
some of the terrible results of war, met with a spirit of brav- 
ery and heroism worthy of the cause. Some men appear 
determined to belittle their disability and have to be argned 
into accepting training. Such men succeed with a small 
amount of help and jruidance. On the other hand, cases are 
seen in which a simple injury with no apparent disability has 
so unsettled the soldier's mind that he is unable to undertake 
any form of vocational education. These latter are the hard- 



136 THE COMMUXITY HEALTH PROBLEM 

est cases to deal with, the men being mentally unsettled and 
not to be depended upon. It is hoped that in time they will 
find themselves and become useful citizens. 
The following three cases are typical : 

F. B. 24 years— Sergt. Field Artillery. Irish parentage. Enlisted 
April 19, 1017. Discliarged Oct. 7. 1010. Diagnosis: Old scar following 
mastoid operation, left side. In hospital months. Discharged from 
hospital Oct. 7, 1019. Disability: Deafness left ear. Previous occu- 
pation: Student, self supporting. Unable to continue course for lack of 
funds. In this case the handicap i.s consiiiered as 2.5 T'cr cent. If this 
man is allowed to complete his course in electrical engineering, he will 
be able to overcome his handicap. Recommended for course in Massa- 
chusetts Institute of Technology. 

E. W. 24 years — Serbian parentage. Enlisted in Infantry, December, 
1917. Wounded — July, 1918. In U. S. Army hospitals eleven months. 
Discharged June, lOiO. War Risk Bureau gives disability as 75 per 
cent. Previous occupation — laborer. Examination shows multiple gun- 
shot wounds completely healed. Complete blindness right eye, follow- 
ing wound of temple. Deformity of right hand following G. S. W. Is 
nnable to use hand for finer movements but has strong grip and will be 
able to do heavy work. New occupation advised — vulcanizing. This man 
will Vie sent to a trade school to learn vulcanizing. As a skilled worker 
he should receive more pay than previously and be able to overcome 
his handicap. As a laborer he would probably end by becoming a charge 
on the community. 

R. S. G. 26 years — American — First-class seaman. Enlisted November, 
1917. Served as armed guard on commercial liner. Discharged January, 
1919. Old occupation — machinist's helper. Diagnosis (Feb., 1919) : 
Nephritis, chronic parenchymatous. Disability complete, nnable to per- 
form any work. Referred to Marine Hospital, Staten Island, for treat- 
ment. Oct. 8, 1919: Man has been in hospital for nearly eight months. 
Returns anxious to go to work. Examination shows that he is still 
Buffering from nephritis and able to do only very light work. If this 
man does hard work his trouble will be aggravated and he will become 
a charge on the community. He should be sent away where he can do 
light work and be under medical supervision. 

When the work of the Federal Board is finished an enor- 
mous amount of statistical data will be available both from a 
medical and a vocational standpoint. In instituting vocational 
training for industrial cripples the experience of the Federal 
Board should be made use of, mi.stakes being avoided by a 
careful study of methods employed by the board and of the 
experiences of foreign countries in the same field. 

For those who are interested in this phase of social welfare 
work the government publishes a monthly magazine, the 
Vocational Summary, which may be secured by application to 
the Federal Board of Vocational Education, "Washington, 
D. C. 

* The case histories and a part of this chapter, dealing especially with 
the medical aspects of the work of thp Federal Board, are reprinted, by 
permission, from an article by the author in Modern Medicine, Feb., 1920. 



EEHABILITATION OF THE DISABLED 137 

REHABILITATION OP THE CIVILIAN CRIPPLE 

While the training of the disabled soldier has been care- 
fully worked out the training of the crippled civilian is pass- 
ing through the formative period, so that it is difficult or 
impossible to outline its present status. What is true at the 
time tkis is written may be clianged before it appears in 
print. It is therefore impossible to make definite statements 
in reference to the details of the movement. 

In general, the Federal Government plans to encourage 
iho. development of re-education for industrial cripples 
through an appropriation, a part of which is made available 
to the various states upon the condition that they appropri- 
ate a similar amount and carry out the details of the work 
in accordance with definite standards established by the Fed- 
eral Board. Many states are co-operating in this work but 
the methods of procedure have not yet been worked out. 

It is the opinion of the writer that civilian methods of 
vocational re-education can be most successfully developed in 
the various states, through the grouping of the disabled work- 
ers in certain definite localities for training. This will per- 
mit the grouping of students and instructors in an institu- 
tion and will thus allow for a more direct contact between 
the student and the trained instructor. In other words it is 
believed that one or more schools should be established in 
appropriate locations in each state, rather than to attempt 
to provide instruction in various already existing industrial 
establishments, where, in many cases, as has been shown by 
experience, the training of disabled workmen has become side- 
tracked by the pressure of routine work. 

Each institution should provide facilities both for func- 
tional re-education, that is the training of the muscles to 
overcome as far as possible the physical handicap, and voca- 
tional re-education or the training of the disabled worker for 
a new vocation. Functional re-education falls naturally under 
the supervision of an orthopedic surgeon, while vocational 
training would be under the control of those skilled in voca- 



138 THE COMMUNITY HEALTH PROBLEM 

tional subjects. Often these two forms of re-education may 
be carried on at the same time. 

After the institutional training has been completed, the 
student may be profitably sent out for a period of practical 
field experience. 

Until statewide plans are carefully worked out, commun- 
ities may attempt to secure training for industrial cripples 
in various local industries. In a few cases this has been very 
successful but, in the main, if there is a school available for 
this purpose within the state, much better results may be 
expected to follow the institutional plan of training than can 
be hoped for under any fonn of local community effort. 



CHAFER XVI 

ENDOWED HEALTH DEMONSTRATIONS* 

The methods employed by the Rockefeller Foundation are 
of interest to students of community health because the enor- 
mous financial resources of the organization permit it to 
make experiments in health control which for economic rea- 
sons could seldom be attempted by the average community. 

As expressed in its charter the purpose of the Rockefeller 
Foundation is the promotion of "the welfare of mankind 
throughout the world." This is a big undertaking even for 
an organization with an endowment fund of over one hun- 
dred million dollars and a yearly income which, including 
gifts, amounted to $8,609,710.86 in 1918. 

In order to secure the greatest benefit from this income 
the trustees of the Foundation have followed a program of 
education and diffusion of knowledge so that each country 
may "contribute its best achievements to a common fund 
from which all lands may draw." In the report for 1918 it is 
stated that, "in this commerce of culture, science, sympathy 
and idealism, the Rockefeller Foundation desires to put its 
policies, personnel and resources at the service of the world." 

The Rockefeller Foundation bears the same relation to 
public health as a state agricultural college does to farming. 
The Foundation may indicate methods for health improve- 
ment, and even actually put such methods into practice in 
certain selected communities, but in the main it has always 
been the desire of this organization to withdraw from the 
field when adequate methods, whether for prevention or 
cure, are once established on a firm working basis by local 
authorities. 

During the year 1918 large amounts were expended for 

•The statistics In this chapter ^TC^e taken In part from the Annaal 

l;oports of the Kotkcfoller Foundation. 1917 and I'JIS. 

139 



140 THE COMMUXITY HEALTH PROBLEM 

war relief largely through the American Eed Cross, and 
the United War Work Fund of the Young Men's Christian 
Association. These two organizations received over $9,500,000 
during the war and about $1,000,000 in addition was devoted 
to other organizations. During the same year approximately 
$350,000 was appropriated for medical research and relief 
in connection with war activities. 

In spite of this tremendous sum which was spent for war 
relief, the rcguhir expenditures for public health, medical 
education and research amounting to $3,600,000 were 
continued. 

From the standpoint of community health the greatest 
interest is found in the work of the campaign against tubercu- 
losis in France, the Avork of the International Health Board, 
and the researches of the Rockefeller Institute of Medical 
Research. 

THE FRENCH CAMPAIGN AGAINST TUBERCULOSIS 

The campaign against tuberculosis in France, as has been 
pointed out by Dr. George E. Vincent, President of the Foun- 
dation, was not undertaken because the French are less skilled 
in the treatment of tuberculosis or because the scientific 
knowledge of the disease in France is second to any other 
country. It was found that in France there were sanitoria 
which, as regards buildings, scientific equipment, personnel 
and surroundings, were as good if not better than anything to 
be found in America. The Leon Bourgeois Dispensary in 
Paris was found well organized, with visiting nurses, trained 
physicians, free public lectures, and everything that goes to 
make up a modern scientific dispensary. 

If America had anything to contribute to the French it 
was a demonstration of organized team work. In France 
ideas do not spread so rapidly as they do in this country, 
possibly because there are few national organizations whicfi 
can quickly inform each community what is being done in 
every other. 



ENDOWED HEALTil DEMONSTRATIONS 141 

There has been, in France, a rapidly increasing interest in 
the question of public health since the work was begun. 
Clever advertisements were read by all and, partly because of 
the advertisements themselves and, partly because the advertis- 
ing of public health was a new idea which originated with "les 
Americains," the movement created great interest. Work was 
begun intensively in two communities and gradually increased 
until, at the end of 1918, the campaign had been extended to 
twenty-seven departments. French visiting nurses, les vis- 
itcuf^es d'liygicne, were trained at the various dispensaries and 
arrangements made to bring a group of physicians to the 
United States to give Ihem an opportunity to study American 
institutions and methods. In the yearly report the following 
statement is made in reference to the campaign against 
tuberculosis in France: "Within a reasonable time, therefore, 
the Foimdation expects to withdraw, confident that the work 
will go on until a nationwide system of combating tubercu- 
losis has become a permanent part of the policy of France." 

The method of handling this campaign is typical of much 
of the work done by the Rockefeller Foundation. To move in, 
to create interest, to demonstrate what can be done by a rea- 
sonable expenditure of time and money, and then to withdraw 
and leave the Avork to be carried on by local organizations 
apparently is the general policy. 

/ THE HEALTH CAMPAIGN IN" NOKTH CAROLINA 

This policy is also seen in the work done in North Caro- 
lina in conjunction with the State Department of Health. A 
three-year program was laid out, the appropriations gradu- 
ally decreasing during the period. North Carolina was the 
first state in the South to attempt to meet its rural health 
problems by effective organization on a county basis. Cam- 
paigns have been carried out against typhoid fever, hook- 
worm, dysentery and many other diseases. Child welfare, the 
prevention of tuberculosis and the medical inspection of 
school children are all included in the plan. The State Board 



142 THE COMMUNITY HEALTH PEOBLEM 

of Health is in charge, the local work is largely done by the 
county health authorities and the expenses are met by the 
state, the counties, and the Rockefeller Foundation. After 
three years the Foundation is to withdraw and the program 
is to be continued by the counties and the state. 

This experiment in North Carolina will bear further 
watching. It is proposed to see that every child attending 
school receives any necessary medical treatment which may 
be required. Trips are made to out of the way districts so 
that all cases may receive treatment and the effort gives 
promise of excellent results. 

The experience in the prevention of t}-phoid fever has been 
most instructive. "In nine counties of North Carolina, dur- 
ing the four year period from 1914 to 1917 the total deaths 
from typhoid fever were 478. This is a yearly average of 
119.5 deaths, or 35.3 deaths per hundred thousand. During 
1918 as a result of a crusade against soil pollution in these 
nine counties, a total of 6,480 fly-proof privies were erected. 
Typhoid fever statistics for the year 1918 show that out of an 
aggregate population of 305,016 in these counties there were 
only 24 deaths from this disease, a rate of 7.8 per hundred 
thousand. 

It is possible that North Carolina will actually solve some 
of the more troublesome problems of community health while 
the northern states are still discussing them. The experi- 
ment is one of widening influence of the state in the domain 
of health and approaches state medicine. So far, in North 
Carolina at least, the venture has been most successful. 

The Kockefeller Foundation is using its influence to 
advance medical education. The School of Hygiene and Pub- 
lic Health at Johns Hopkins was organized largely through its 
efforts and a similar school has been organized in connection 
with the medical university at San Paulo, Brazil. Students 
from Brazil, China and France have been granted fellowships 
in order to study in the United States and members of the 
medical staff of the Foundation are granted "study leave" in 



ENDOWED HEALTH DEMONSTRATIONS 143 

order to pursue special courses in public health at leading 
American or foreign institutions. In China a medical school 
is now in course of construction. 

nOOKWORil INFECTION 

For several years experiments have been condnrted in an 
effort to combat hoolvworm infection. This disease, widely 
prevalent in our soutiiem states, has been found to be of 
almost worldwide occurrence. Hookworm disease exists wher- 
ever the larva3 of the Avorm find favorable soil conditions. 
Thoy require shade, moisture and warmth for their propaga- 
tion and growth such as found in tropical or subtropical 
countries. They are not found in cold countries or in very 
dry countries, such as Arizona or northern Mexico. 

In India, Brazil, the West Indies, Central America and 
Australia, widespread infection has been demonstrated by 
the work of the International Health Board. In many of the 
areas studied, between 80 and 100 j-er cent, of all inhabitants 
were found infected. Work done by U. S. Army surgeons 
during the recent war indicated that a large percentage of 
southern troops, both white and colored, were suffering from 
hookworm infection of more or less pronounced degree. 

Hookworm disease results from the presence of hookworms 
in the human intestine. It begins insidiously and may not 
make itself felt for several years. For a time the body is 
able to resist the disease, but the cumulative effect finally 
becomes evident. The physical strength is slowly sapped by 
imperceptible degrees, so that there is finally a distinct 
retardation of physical development and the mental capacity 
is gradually undermined, the result being that in the later 
stages the impairment of the intellectual character is plainly 
evident. Anemia, loss of flesh and strength, and defective 
mentality arc the characteristic symptoms. Persons suffering 
from the infection although showing few if any symptoms 
are more susceptible to other infections than are healthy 
individuals. In Camp Bowie the sickness records from Octo- 



144 THE COM^rUNITY HEALTH PROBLEM - 

ber, 1917, to May, 1918, demonstrated that resistance to 
other diseases was the lowest and mortality rates were the 
highest in those organizations in which hookworm disease was 
the most prevalent. 

The diagnosis is easily made from the examination of the 
stools and the cure is simple, being accomplished often by a 
single treatment with a strong intestinal antiseptic followed 
by a purge. Yet in spite of this there are huge districts in 
the United States where no concerted efforts have been made 
to rid the community of the aflfliction. 

INFECTION SURVEY OF JAMAICA* 

The methods of the International Health Board may be 
illustrated by the following survey: 

The infection survey of the Cayman Islands (a dependency 
of Jamaica) made during the spring of 1917, resulted in the 
Government appropriating approximately $12,000 for carry- 
ing out a co-operative campaign against hookworm disease in 
Jamaica proper. As an initial step in the measure of control, 
an infection survey of the Island was made during June and 
July, 1918. [ 

The survey indicated that probably two of every three 
inhabitants of Jamaica have htokworm disease. High infec- 
tion rates were also recorded for round worms and thread 
worms, the former being found in 67.2 per cent, of 10,926 
persons examined, and the latter in 35.9 per cent. In the 
larger towns and cities, which are located along the coast, a 
beginning has been made toward the proper disposal of the 
excrement, but in the rural districts soil contamination is 
practically universal. There are laws requiring a latrine at 
every home, but no serious attempt has been made to enforce 
them. 

INAUGUKATION OF CONTEOL MEASTJEES 

The survey is to be followed by a series of demonstrations i 
in control measures. The working arrangement provides that 

•From the Appendix of the Report for 191& Rockefeller Foundation, 
Kew York. 



ENDOWED HEALTH DEMONSTIIATIONS 145 

the Government is to share the expense of the initial field 
posts and to have suitable latrines installed in all areas in 
advance of examination and treatment. The Government has 
available approximately $7,500 as a first appropriation for 
this purpose. 

It is to be expected that the Foundation will, in a case such 
as the above, furnish the funds and personnel for the proper 
demonstration of the control of the disease in one or more 
sections of the Island, leaving the balance of the Island to 
be cared for by the Government. Complete control of the 
disease is difficult and the prevention of reinfection is impos- 
sible unless modern sanitation is introduced and maintained. 

THE CONTROL OF MALARIA 

The Foundation, through the International Health Board, 
has carried out a series of demonstrations on the control of 
malaria in various localities. We know that malaria is car- 
ried by a certain species of mosquito and we know that if we 
can eliminate the mosquito the spread of tlie disease will 
automatically stop. This has been known for many years and 
yet there are literally thousands of communities which are 
aflBicted with this disease and yet make no concerted effort to 
be rid of it. It has remained for the Rockefeller Foundation 
to demonstrate that it is cheaper to be rid of malaria than to 
have it. 

EXPERIMENT AT CROSSET, ARKANSAS, 1916* 

The first of the tests was undertaken at Cresset, a lumber 
town of 2129 inhabitants situated in Ashley County in south- 
eastern Arkansas, about twelve miles north of the Louisiana 
line. It lies at the edge of the "uplands" in a level, low lying 
region (elevation 165 feet) with sufficient undulation to pro- 
vide reasonably good natural drainage. Climatic conditions 
and abundant breeding places favor the growth of the ano- 
pheles mosquito. Malaria in a severe form ^ widely preva- 

•Quoted from the Report for 1918. 



146 THE COMML'XITY HEALTH PROBLEM 

lent as an endemic infection and, according to the estimate 
of tlic local physicians, is responsible for about GO per cent, 
of all illness throughout the region. TVithin the town itself 
the malaria rate was high and was recognized by the lumber 
corporation and the people as a serious menace to health 
and working efiBciency. 

The initial step in the experiment was a survey of the com- 
munity to determine the malarial incidence, to ascertain the 
species of mosquitoes responsible for the spread of the infec- 
tion and to locate the breeding places of ilio-'C mo^^quitoes. 
Breeding places were exhibited on a community map, and an 
organized effort was centered on their destruction or control. 
The program of simple measures excluded all major drain- 
age. Shallow ponds were filled or drained; streams were 
cleared of undergrowth where necessary to let the sunlight in ; 
their margins and beds were cleared of vegetation and obstruc- 
tions; and they were drained to a narrow channel pro- 
viding an unobstructed water flow. Artificial containers were 
removed from premises ; water barrels on bridges were treated 
with nitre cake. All remaining breeding places were regu- 
larly treated by removing vegetation, opening up shallow mar- 
gins to give free access to small fish, and spraying once a 
week by means of automatic drips or a knapsack sprayer. All 
operations were under the control of a trained lay inspector. 
Care was exercised to avoid all unnecessary effort, and to se- 
cure, not the elimination of the last mosquito but a reason- 
ably high degree of control at a minimum cost. 

The first conspicuous result apparent to every person living 
in the community was the practical elimination of the mos- 
quito as a pest. The reduction of malaria as shown by a 
parasitic index taken in May, 1916, and again in December 
of the same year, was 72.33 per cent. The reduction in phy- 
sicians' calls as compared with the number of calls for the 
previous year (company's record) was 70.36 per cent. The 
per capita cost of the work — omitting overhead — was $1.24. 
During the year the lumber company had repeated these 



ENDOWED HEALTH DEMONSTRATIONS 147 

measures at two of its largo logging camps with results that 
were convincing as to the soundness of the investment. 

At the end of 1916 the community took over the work and 
for two years has maintained it at its own expense and undei 
its own direotit)ii. The same measures have boon continued 
under the supervision of a trained native lay inspector. The 
following table shows the yearly results and the per capita 
cost: 

physicians' calls for malaria 
Population 2129 

1915 Calls (Company's records) 2500 

1916 " " 741 

1917 « « 200 

1918 " " 73 
Eeduction for tte three years, 97.1 per cent. 

PER capita cost 

1916 (omitting overhead) $1.24 

1917 (total cost) .63 

1918 (total cost) .53 

These results were confirmed in other localities where sim- 
ilar figures were obtained. 

The methods used by the Rockefeller Foundation have 
been described in some detail in order to give some idea 
as to what may be accomplished in a community by a con- 
certed effort for better health. It is not to be expected that 
the Foundation -will undertake this work for every commun- 
ity. It can merely demonstrate methods of control, and the 
various communities may accept them or reject them as they 
see fit. 

The American Red Cross, the American Child Hygiene 
Association, the National Tuberculosis Association and many 
other public and semi-public organizations are working along 
the same general lines as the Rockefeller Foundation. Some 
are endowed and others secure their funds largely through 



148 THE COMMrXITY HEALTH TEOBLEM 

public subscriptions. The)' should all be looked upon as 
merely auxiliary organizations and should in no case replace 
public health activities or community health effort. 

The American Red Cross as part of its peace-time program, 
places special emphasis upon community service for better 
health. This work is to be in addition to the already estab- 
lished activities for military and civilian relief and is to 
supplement them in local communities. For this purpose a 
new department has been organized, the Department of Health 
Service, the purpose of -which is to give national and com- 
munity service for the development of better health. ''The 
opportunity and responsibility have been brought home to our 
chapters," says the Red Cross Bulletin,* "T)y the widespread 
demands for help along health lines in the several com- 
munities, as well as by the national conviction that we face 
an emergency and continuing disaster in the health field not 
less alarming than the emergency of war.^' 

The health service, briefly, includes: (1) Service for the 
extension of public education through health lectures, posters, 
pamphlets and books, together with the collection and dis- 
tribution of health information and statistics; (2) The 
establishment of health centers in the effort to co-ordinate 
official and other health agencies serving the community; 
(3) The promotion of community health studies; (4) The 
organization and promotion of classes in first aid and life 
saving, thereby tending to prevent accidental injury and 
death. 

The Eed Cross nursing service has already been referred to. 
The activities of the Department of Nursing have been out- 
lined as follows: — "(1) Pro\'iding a public health nurse for 
your community, if you have none; (2) Conducting class in 
home care of the sick; (3) Assisting in organizing and super- 
vising any health activity pertaining to nutrition." 

The peace-time health program of the Red Cross, as 
outlined above, is too recent in origin to permit of con- 
clusions as to its efficacy for community health betterment 

•January 5, 1920. 



ENDOWED HEALTH DEMONSTRATIONS 149 

but, if we may judge from past performances, the American 
Red Cross may be expected to accomplish appreciable results 
and to play an important part in the movement for better 
health. 

However, it is to be remembered that the Rod Cross is 
not to be considered as a sort of enlarged health department 
which undertakes to solve the health problems of the world 
but rather that the health movement is simply an attempt 
to make the resources of experience and information of this 
vast organization available to each and every community 
where the health is appreciated and where serious efforts are 
being made for its ultimate improvement. 

The Russell Sage Foundation is an endowment fund which 
is devoted in part to the development of public health. The 
purpose of the Sage Foundation is "the improvement of so- 
cial and living conditions in the United States of America." 
The endowment consists of $10,000,000 donated by Mrs. Rus- 
sell Sage. It is apparently the policy of the trustees of the 
fund to devote the income largely to research, but they have 
in several instances taken an active part in health movements 
among which may be mentioned the anti-tuberculosis cam- 
paign, medical inspection in schools, and the management of 
children in institutions. A publication department is main- 
tained and many books and pamphlets on subjects dealing 
with health and welfare are published. 

The New York Department of Health has a slogan to the 
effect that within limits health is purchasable. Certainly the 
studies and experiences of these organizations would seem to 
justify this statement and to show that, in some cases at 
ieast, it may be purchased at a comparatively low price. 
However, in spite of the evidence at hand, it has taken many 
years and much labor to induce legislatures to adopt a broad 
conception of the health problem and to appropriate funds for 
health purposes in amounts sufficient to permit the public 
authorities to wage most effectively the fight against prevent- 
able disease. 



I 



REFERENCES 

A PARTIAL LIST OF RECENT PUBLICATIONS 

Amar, Jules: Physiology of Industrial Organization and the Re- 
Employment of the Disabled, 1919. 

American Red Cross: Health Centers, A Field for Red Cross 
Acitivity. Booklet, Washington, Sept., 1919. 

Andreas, J. Mace: Health Education in Public Schools, 1919. 

Ayres, May; Williams, Jesse F.; and Wood, Thomas D. : Healthful 
Schools, 1918. 

Barton, George Edward: Teaching the Sick. A Manual of Oc- 
cupational Therapy and Re-Education, 1919. 

Best, Harry : The Blind, Their Condition and the Work Being Done 
for Them in the United States, 1919. 

Bishop, Robert H.: Health Center in a Large City, American 
Journal of Nursing, July, 1917. 

Brainerd, Annie M.: Organization of Public Health Nursing, 1919. 

Brend, W. a.: Health and the State, 1918. 

Broadhurst, Jean: Home and Community Hygiene. A Text-book 
of Personal and Public Health, 1918. 

Btington, Margaret F. : What Social Workers Should Know About 
Their Own Communities, Russell Sage Foundation, 1918. 

Cabot, Richard C: Social Work, Essays on the Meeting Ground 
of Doctor and Social Worker, 1919. 

Camus, Jean: Physical and Occupational Re-Education of Maimed, 
1919. . . 

Catlin, Lucy Carmelia: The Hospital aa a Social Agency in the 
Community, 1918. 

Dawson, Bertrand: The Nation's Welfare. The Future of the 
Medical Profession (Cavendish Lectures), 1918. 

Devine, Edward T.: Disabled Soldiers and Sailors Pensions and 
Training, 1919. , ^ ^ j 

Dublin, Louis I. : Mortality Statistics of Insured Wage Earners and 
Their Families. Experience of the Metropolitan Life Insurance 
Company, Industrial Department, 1911-16. 

E%^rett, Ray H. : The cost of Venereal Disease to Industry, Jour, of 
Industrial Hygiene, September, 1920. , -ot • i 

Faries, John Culbert: The Economic Consequences of Physical 
Disability, Red Cross Institute for Crippled and Disabled Men, 
New York, 1918. ^ 

Framingham Community Health and Tuberculosis Demonstra- 
tions: Monographs, Community Health Station, Framingham, 
Mass., 1918-1919. , r. , ,. ^ u .• 

GoLER, George W.: Rochester Bureau of Health Consultation, 
Public Health Journal, July, 1917. 

Hall, Herbert J.: Bedside and Wheel-Chair Occupations, Red 
Cross Institute for Crippled and Disabled Men, New York, 1919. 



EEFEEENCES 

Harris, Garhard; and Billings, Frank: The Redemption of the 

Disabled. A Study of Programs of Rehabilitation for the Disabled 

of War and of Industry, 1919. ... 
Hoffman, Fredeuick L.: Industrial Accidents in the United States 

and Their Relative Frequency in Different Occupations, I*rudential 

Life Insurance Company, 1918. 
: A Plan for More Effective Federal and State Health 

Administration, Prudential Life Insurance Company, 1919. 
HoGAN, F. B.: Schools for Health Centers, Survey, Dec. 14, 1918. 
League op Red Cross Societies Bulletin: The Public Health 

Program, July, 1920. 
LippiTT, Louisa C.: Personal Hygiene and Home Nursing, 1919. 
Mackenzie, James: The Future of Medicine, 1919. 
McDill, John R. : Lessons from the Enemy. How Gennany Cares 

for Her War Disabled, 1918. 
McMurtrie, Douglas C: The Disabled Soldier, 1919. 
: The Evolution of National Systems of Vocational Re- 
habilitation. Issued by Federal Board, 1918. 
Medical Research Committee: National Health Insurance, Third 

Annual Report, London, 1917. 
: An Inquiry into the Prevalence and Etiology of Tuberculo- 
sis Among Industrial Workers, London, 1919. 
Meyer, Ernst C. : Hospital Service in Rural Communities, Journal 

American Medical Association, April 19 and 26, May 3, 10, and 17, 

1919. 
Mock, Habry E.: Industrial Medicine and Surgery, 1919. 
National Industrial Conference Board: Hours of Work as 

Related to Output and Health of Workers, Boston, 1919. 
National Social Unit Organization: Bulletins 1 to 5, New York, 

1919. 
New York State Department op Health : Health Centers, Monthly 

Bulletin, Aug. and Dec, 1918; Feb. and June, 1919. 
Pattison, H. a.: Productive Vocational Workshops for Rehabilita- 
tion of the Tuberculous and Other Disabled Soldiers, Federal 

Board for Vocational Training, 1919. 
Peterson, Erwin A.: The Program of the Red Cross, Journal Amer. 

Med. Assn., Aug. 28, 1920. 
Ross, Elizabeth: Health Activities at a Civic Center in a Small 

Community, American Journal of Nursing, August, 1917. 
ScHAFER, A. C. : PubUc Health Center Field Work, New York State 

Journal of Medicine, April, 1917. 
Stokes, John H.: Today's World Problem in Disease Prevention. A 

Non-Technical Discussion of SyphiUs and Gonorrhoea, U. S. 

Pubhc Health Service, 1919. 
Wright, Florence Swift: Industrial Nursing, 1919. 
Government Documents 

Reports and special articles bearing on community health are 
published by the Children's Bureau and the Labor Statistics Bureau of 
the Department of Labor; by the Pubhc Health Service of the Treasury 
Department; and by the Bureau of Education, Department of the 
Interior. The Federal Board of Vocational Education pubUshes a 
monthly magazine and a scries of bulletins on rehabihtation. 



INDEX 

Accidents, Prevention of 56, 62 

Accidents, Industrial, and Liability Laws 67 

Adults, Sick Rates 9 

Administration of Componsation Laws 71 

Alameda County Health Center 104 

American Association of Labor Legislation 76 

American Ked Cross Health Centers 99 

American Red Cross, Peace Time Program 148 

Appropriations for Public Health 35 

Bedside Nursing 42 

Benefits, of Compensation Acts 70 

Benefits, of Health Insurance 82 

Board of Health, Appropriations for 35 

Board of Health, Local 33 

Board of Health, North Carolina 36 

Board, International Health 143 

Bureau of Child Hygiene 8 

Campaign for Better Health 54 

Care of Employees 89 

Case Histories, Disabled Soldiers 136 

Cash Benefits of Compensation Laws 70 

Center, Maternity 50 

Centers, Industrial neallli 102 

Centers, Health 99 

Centers, Red Cross 99 

Children, Examination of School 8 

Church Control of Nursing 48 

Civilian Cripples, Rehabilitation of 137 

Colleges Teaching Public Health Nursii^g 41 

Community Health, The Private Physician and 23 

Community Nursing 48 

Compensation Insurance, Workmen's 67 

Compensation Laws, Effect on Use of Safety Devices. 74 



INDEX 

Compulsory Health Insurance 75 

Crippled and Disabled Men, Institute iur 60 

Crippled Employees of Ford Motor Company 60 

CrippleS) Civilian, Kehabilitation of 137 

Cripples, Industrial 129 

Death Benefits Under Cunipeu^iation Laws 70 

Defective Children in New York State 8 

Demonstration, Framingham Health 10 

Demonstration, Health 54 

Departments, Health 30 

Departments, Local Healih 34 

Departments, State Health 33 

Disabled, Eehabilitation of Gl, 128 

Disabled Soldiers, Case Histori.-s 136 

Disabled Soldiers, Eehabilitation of 61 

Disability As Cause of Mental Depression 128 

Disabled in Selective Draft 4 

Disability Insurance for Employees 91 

Disability, Percentage in Community 12 

Disability, Percentage in Draft Examinations 6 

Disability Table of Defects Found in Draft 5 

Disease, Hookworm, Methods Used Against 143 

Disease, Prevention of 56 

Disease, Treatment of 58 

Diseases, Cause of 3 

Diseases, Industrial and Vrorkmen's Compensation. ... 72 

Draft Army, Percentage of Defects in 6 

Draft, Disability Discovered by 4 

Draft, Table, Disability Discovered by 5 

Dumferline Scale 8 

Dutchess County Survey 27 

Education Influenced by Rockefeller Foundation 142 

Employees, Medical Care of 89 

Employments Included Under Workmen's Compensation 71 

Endowed Health Demonstrations 139 

Examination of School Children 7 

Expenditure for Sickness 17 

Expenditures of Local Healtli Departments 34 

Expenditures, Yearly for Sickness 18 

Experiment, Social Unit 108 

Federal Board of Vocational Training 131 



THE COMMUNITY HEALTH PROBLEM 

Federal Department of Health 93 

Fees for rublic Heultli Nursing 49 

Ford Motor Company and Disabled Employees GO 

Framiugliam, Health Demonstration in 10 

French Campaign Against Tuberculosis 140 

Government, Expenditures for Health 34 

Government, Federal, and Disabled Soldier 131 

Handicap, in Vocational Training 134 

Health Appropriation Per Capita 35 

Health Board, International 143 

Health Campaign in North Carolina 141 

Health Center, Definition of 101 

Health Center of Alameda County 104 

Health Centers 99 

Health Centers, Aims of 100 

Health Centers and Hospitals 104 

Health Centers, Industrial 87 

Health Centers, Red Cross Program 106 

Health Centers, Sage-Machold Bill for 105 

Health Centers, Ten Reasons for 105 

Health Conditions in U. S. Army 11 

Health Demonstration 54 

Health Demonstration in Framingham 10 

Health Demonstrations, Endowed 139 

Health Departments 30 

Health Departments, Local 34 

Health Departments, State 33 

Health Insurance 21 

Health Insurance and the Public 81 

Health Insurance, Cash Benefits in 82 

Health Insurance, Compulsory 75 

Health Insurance for Industrial Workers 90 

Health Insurance, Growth of 75 

Health Insurance, Meaning of 76 

Health Insurance, Medical Care in 79 

Health Insurance Premiums "^8 

Health Program of American Rod Cross 148 

Health Service in Social Unit Experiment 113 

Health Study by Metropolitan Life Insurance Co 9 

Henry Street Settlement 50 

Home Care ^^ 



IXDEX 

Hootworm Disease Combated by Rockefeller Founda- 
tion 143 

Hookworm Survey in Jamaica 144 

Hospital Care 65 

Hospitals and Health Centers 104 

Hygiene, Social 123 

Industrial Cripples 129 

Industrial Diseases Under Compensation Laws 72 

Industrial Health Centers 87, 103 

Industrial Hygiene in Public Health Service Program 31 

Industrial Medicine 84 

Industrial Medicine and Home Care 65 

Industrial Medicine, Expenses of 86 

Industrial Medicine, Methods 85 

Industrial Nursing 45 

Industrial Physician, Work of 103 

Industr}--, Physical Examination in 88 

Infancy, Disease of, in Public Health Service Program 33 

Infant Welfare 63 

Injury, Treatment of 58 

Insurance Carriers for Proposed Health Insurance... 77 
Insurance Carriers for Workmen's Compensation In- 
surance 73 

Insurance, Compulsory Health 75 

Insurance for Industrial Workers 90 

Insurance, Health 31, 73 

Insurance Nursing 51 

Insurance, Workmen's Compensation 67 

Institute for Crippled and Disabled Men 60, 130 

International Health Board 143 

Jamaica, Hookworm Survey in 144 

Kensington Sun-ey 17 

Liability Laws and Industrial Accidents 67 

Life Insurance Nursing 51 

Loss of Wages Due to Sickness 17 

Major Handicap in Vocational Training 134 

Major Ills in Framingham Survey 11 

Malaria, Arkansas Experiment 145 

Malaria, Control of 145 

Malaria, Expenses for Extermination of 19 

Mal-nutrition in School Children 8 



THE COMMUNITY HEALTH PROBLEM 

Mal-nutrition, Public Health Service Program 32 

Maternity Care 63 

Maternity Center 50 

Medical Attention During Vocational Training 135 

Medical Attention Under Compensation Laws 69 

Medical Care in Social Unit Experiment Ill 

Medical Care, Failure to Secure 27 

Medical Care of Employees 89 

Medicine, Industrial 84 

Medicine, State 92 

Mental Depression Caused by Disability 128 

Metropolitan Life Insurance Co., Sickness Surveys by.. 9,26 

Metropolitan Life Insurance Nursing 51 

Minor Handicap in Vocational Training 134 

Minor Ills, Table of 11 

Mohawk-Brighton Experiment, Evaluation of 109 

National Organization for Public Health Nursing. ... 39 

National Social Unit Organization 108 

Negligible Handicap in Vocational Training 134 

New York City, Examination of School Children .... 9 
New York City, Mal-nutrition in School Children ... 8 
New York State, Physical Condition of School Chil- 
dren 8 

North Carolina Health Campaign 141 

Nursing, Community 48 

Nursing Industrial 45 

Nursing in Public Health Work 52 

Nursing, Insurance 51 

Nursing, Public Health 38 

Nursing, School 46 

Nursing Service for Industrial Workers 89 

Organization for Public Health Nursing 39 

Organization, Social Unit 100 

Percentage of Defects in Draft Army 6 

Physical Examination in Industry 88 

Physician, Private in Community Health Work 23 

Physician, Relation of Visiting Nurse and 42 

Physicians and Vocational Training 132 

Physicians, Attitude of Toward Health Insurance 79 

Physician's Calls Influenced by Malarial Control 146 

Physicians, Under State Medicine 97 



INDEX 

Poverty and Sickness 15 

Premiums of Health Insurance 78 

Pre-natal Care 63 

Prevention of Accidents 56 

Prevention of Disease 56 

Private Practice and State Medicine 93 

Public Attitude Toward Health Insurance 81 

Public Health, A Function of the State 81 

Public Health Nursing 38 

Public Healtli Nursing and Eed Cross 40 

Public Health Nursing, Fees for 49 

Public Health Nursing, Growth of 39 

Public Health Nursing in Social Unit 110 

Public Health Nursing for Tuberculosis 44 

Public Health Nursing, National Organization for... 39 

Public Health Nursing, Specialization in 43 

Public Health Nursing, Training for 40 

Public Health Service 31 

Public Health Service Campaign Against Sex Diseases 124 

Public Health and Visiting Nursing 53 

Eed Cross Health Centers 99 

Eed Cross Program for Health Centers 106 

Eed Cross Public Health Nursing 40 

Eehabilitation 59 

Eehabilitation of Civilian Cripples 137 

Eehabilitation of Disabled Soldiers 61, 128 

Eehabilitation, Origin of 130 

Eockefeller Foundation 139 

Eockefeller Foundation, Malarial Expenses in Arkansas 19 

Eural Hygiene in Public Health Service Program 31 

Eussell Sage Foundation, Influence on Public Health. . 149 

Safety Devices Increased by Compensation Laws 74 

Sage-Machold Bill for Health Centers 105 

Scale, Dumferline 8 

School Children, Examinations of 7 

School Children, Physical Condition in New York 

State 8 

School Nursing 46 

Service, Health 9 

Sewage Disposal, Public Health Service Program 33 

Sex Diseases, Control of 123 



THE COMMUNITY HEALTH PROBLEM 

Sex Diseases, Public Health Service Campaign Against 124 

Sex Diseases, Treatment of 125 

Sick, Percentage in Community 12 

Sick Rates for Adults 9 

Sickness As a Cause of Wage Loss 17 

Sickness, Expenditure for 17 

Sickness, Responsibility for 3 

Sickness Surveys 6 

Sickness Survey, by j\Ietropolitan Life Insurance Co.. 26 

Sickness, Yearly Expenditures 18 

Social Hygiene C4, 122 

Social Hygiene, Medical Control 122 

Social Hygiene, Military Control 123 

Social Unit Experiment 108 

Social Unit Experiment, ]\Iedical Care Ill, 

Social Unit Experiment, Tuberculosis Activities in.. Ill' 

Social Unit Nursing 110 

Social Unit Plan 108 ; 

Social Unit Plan, Criticism of 113 

Soldiers, Disabled, Rehabilitation of 61 

Specialization in Public Health Nursing 43 

State Health Departments 33 

State Medical Service , . . • ^^ 

State Medicine 92 

State Medicine and Private Practice 93 

State, Public Health a Function of 81 

Study of Mal-nutrition 8 

Surgeon General's Report of Draft Defects 5 

Survey, Dutchess County 27 

Survey, in Pramingham, Mass 11 

Survey, in Jamaica 144 

Survey, Kensington I'' 

Survevs, Sickness ^ 

Totally Disabled, Care of <>1 

Training, Vocational 130 

Treatment of Disease 58 

Treatment of Injury 58 

Tubercle Bacilli, Distribution of 115 

Tuberculosis 115 

Tuberculosis Activities in Social Unit Ill 

Tuberculosis, Control of H^ 



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