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THE
COMMUNITY HEALTH PROBLEM
THE MACMILLAN COMPANY
imW TOKK . BOSTON • CHICAGO • DALLAS
ATLANTA • SAN FKANCISCO
MACMILLAN & CO., LufirsD
LONDON • BOMBAY • CALCUTTA
MKLBOUKNS
THS MACMILLAN CO. OF CANADA, Lm
ijiy
The Gonununity Health
Problem
By
ATHEL CAMPBELL BUENHAM, M.D.
HEALTH SEEVICE^ ATLANTIC DIVISIOIT, AMERICAN RED CROSS;
ATTENDING SURGEON^ VOLUNTEER HOSPITAL, NEW YORK
city; LIEUTENANT COLONEL, MEDICAL RESERVE
CORPS, U. S. army; fellow NEW YORK
ACADEMY OP MEDICINE
^t\o f orb
THE MACMILLAN COMPANY
1920
AU Rights Reserved
Copyright, 1920
By THE MACMILLAN COMPANY
Set up and electrotyped. Published October, 1020
PEEFACE
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.
TABLE OF CONTENTS
Preface
CHAPTEK I
The Health of the Community
CHAPTER II
Sickness as a Cause of Poverty 15
CHAPTER III
The Private Physician and Community Health. . . 33
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
CHAPTER XIII
Tuberculosis 115
CHAPTER XIV
Social Hygiene iisr its Relation- to Community
Health 122
CHAPTER XV
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
Eesponsibility 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
th€ child, nor hit parents, nor even his physician have ever
seen. The community recognizes its responsibility in the case
3
4 THE COMMUNITY HEALTH PKOBLEM
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
years 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 f^n-
erally disregarded. Not entirely so, because during recent
years many exhaustive 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 IMPORTANT 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 2.33
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, Merritta 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 the 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 published in the Journal of the American Medical Association
(April 10, 1920), states that according 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
nnderstanding 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 survey 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.
After making due allowance for those children who are crip-
pled or too iU 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.
EXAMINATION'S OP SCHOOL CHILDREN
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 PROBLEM
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 CHILDREN 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
15,692
1,214
2,511
161,686
63,925
33,475
29,756
25,168
10,203
35,225
4,578
742
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 :
Class 1.
Class 2.
Class 3.
Class 4.
treatment.
•Report of the Public Bealth Committee on Reconstmetlon. New
Xork State, Oct. 24. 1919.
Excellent — the child is well nourished.
Good — ^nutrition falls short of excellent.
The child requires supervision — ^borderline.
Nutrition seriously impaired — requires medical
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 CHILDEEN, 1918
City of New York
Public Parochial
Schools Schools Total
Class 1 35,606 5,37^ 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 wiU continue to
be neglected unless treatment is insisted upon by school
authorities or by welfare organizations.
COMMUNITY HEALTH SURVEYS
!A!mong adults there are few surveys which indicate
physical disability with 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
discover those 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 persons
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.
FRAMINGHAM HEALTH DEMONSTRATION
In the Framingham Community Health and Tuberculosis
Demonstration a careful health survey was made of the entire I
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 I
period of several days. I
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, Washington, 1919.
♦♦Armstrong, Donald B. : Framingham Monograph No. 4; Community
Bealtb Station, Framingham, Mass., November, 1918.
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 563
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
which 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
serious. 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, IT. 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
12 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 small 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 which 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 2 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 unable 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 he 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 Eramingham 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 sufficient hospital beds?
•In Dr. Armstrong's health census the number who said they wer*
eick represented 6.6 per cent, of the total surveyed.
U THE COMMUNITY HEALTH PKOBLEM
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
iUness but not suflBciently 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.
There 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 PROBLEM
munity there is always a certain number of crippled and
Biibnormal 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 employment
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 doUar 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":
*'I11 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,
SICKNESS 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 witli the following findings;
18 THE COMMUNITY HEALTH PROBLEM
YEARLY EXPENDITURES FOR SICKNESS
Washington, D. C, 1916
Income
Number
of
Families
Yearly
Expenditures
Under $600
Total
Whites
Colored....
Total
65
45
19
235
115
118
215
167
48
209
198
11
198
191
7
922
692
230
$12.01
$600-S900
12.83
10.03
20 84
S900-$1.200
Whites
Colored
Total
Whites
Colored.,..
Total
Whites
Colored....
Total
Whites
Colored....
Total
Whites
Colored
25.52
16.20
40.19
|1,200-$1,500
42.31
32.84
42.42
Oyer $1,500
43.16
28.95
58.71
Ayerage, all incomes —
69.57
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. When 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 Rockefeller 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 experiment, the number of calls made in the town of Ham-
•The ejcpendittires 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 COMMUNITY 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 schooF' 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 Bochefeller Fonndatlon for 1918. Fixb-
Ushed by the RockefeUer Foundation, New York, 1919.
SICKNESS AS A CAUSE OF POVERTY 21
The advocates of health insnrance, 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 Insurance of the American Medical Association: "As a result of
an investigation covering forty-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 38.3 per
cent, of the cases of those seeking aid. In New York City sickness or
deformity was present in two-thirds of the 3,000 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 1917 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. 2^1, Americaa Medical Afsociation, 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-
eary 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, William A. : Health and the State, London, 1917, p. 16^
PHYSICIAN AND COMMUNITY HEALTH 25
that it is impossible for any man to master the details of all
branches of the profession. The technic of surgery has become
so specialized that men spend years mastering the operative
technic 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 ejfforts are confined almost
entirely to the cure of illness. He has, as a rule, neither the
experience nor the time to practice preventive medicine.
Por 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
ihe private practice of medicine, except for its function ol
26 THE COMMUNITY HEALTH PEOBLEM
fumishmg 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
conmiunities, 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 Insurance : Ileport of the Special Committee of the American
Medical Association for 1919, p. 45.
PHYSICIAN AND COMMUNITY HEALTH 27
some 13,000 persons eeriously 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 1912-13 and covering approximately 10,000
persons, only 76 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 PKOBLEM
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 wTong." 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
i 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 charity 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
iiot, 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. Kecently 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
PHYSICIAN 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 community 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 remedy 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
already being expended. . . . Improved medical care must come from
more co-operative and less purely individualistic care from the medical
profession." (Report of Special Committee on Social Insurance, Ameri-
can Medical Association, 1919).
CHAPTER IV
HEALTH DEPARTMENTS AND COMMUNITY HEALTH
In the prevention of disease, much depends upon the public
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
Banitary 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 prevention and control of
Profeeeor Winslow, of Tale, has expressed this broader view
of public health in an address before the American Association
for the Advancement of Science.* "Public 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 medic^ and nursing service for the
early diagnosis and preventive treatment of disease, and the
* Winslow, C. E. A.: Tlie Untilled Fields of Public Health, Sclenct,
Jan. 9, 1920.
30
DEPARTMENTS AND COMMUNITY HEALTH 31
development of social machinery which will insure to every
individual in the community a standard of living adequate
for the maintenance of health/'
THE UNITED STATES PUBLIC HEALT]^ SEEVICE
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 1919 the commissioned personnel of the Public Health
Service consisted of a Surgeon-General and 217 medical offi-
cers of various grades. In addition there were 526 commis-
sioned 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
eoldiers, sailors and marines, made necessary as a result of
injuries or diseases incurred in service, was turned 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. Eural 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 Beport for 1919. U. S. Public Bealtb Service^ Wasliington, D. C
32 THE COMMUNITY HEALTH PEOBLEM
3. Prevention of the diseases of infancy and childhood : —
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 tuberculQsis 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-
mimity health problem. Like the Rockefeller Foundation the
PubHc 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 modem and scientific method of
health control.
iDEPAETMENTS AND COMMUNITY HEALTH 33
STATE HEALTH DEPARTMENTS
'■■ Public health, under the state system of government, is
largely a function of the State. Theoretically the Federal
health service has to do only with interstate health problems
and the 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 their 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
efficient 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 funds. 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 undertaken progressive measures for the state-
wide improvement of public health.
34 THE COMMUNITY HEALTH PROBLEM
LOCAL HEALTH DEPARTMENTS
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 forty-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.
DEPARTMENTS 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 OP PEE CAPITA APPRO PEIATIONS AND LOSSES*
Health Sickness Per Capita
City Appropriation Losses Annual Valtiation
Evanston $0.31 $12.82 $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: Economics of Health Administration.
American Journal of Public Health, February, 1920.
36 THE COMMUNITY HEALTH PEOBLEM
represent similar communities, yet Waukegan 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 ofiicer. 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 cany 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 Rockefeller 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, 1919.
DEPARTMENTS 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 known 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 nursing 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 68 130
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.
I
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 office 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 Red 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 Red 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 NUE8ING 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 Eeserve 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
work 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
42 THE COMMUNITY HEALTH PROBLEM
required not only nursing skill but an immense amount of
tact and social understanding. She 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
her a long way from the therapeutic principles she had learned
in the hospital.
THE RELATION OF THE VISITING NURSE 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 service 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-
*Gardntr, Mary Stwall: Public Health Nnrsing, p. 43, N«w Tork, lOlCk
PUBLIC HEALTH NUESING 43
sistently denied her the loyalty which they so rigorously
demanded for themselves/^
In 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 prescribe, 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 NURSINO
The anti-tuberculosis campaign required nurses of special
training and with a special knowledge 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 ^ven 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 that 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 NURSINa
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 NUKSING 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 PEOBLEM
employ a smaller number.* The need of a nurse for the care
of the sick and for the prevention of disease is not, however,
so 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
remarkable stimulus during the post-war period and promises
to spread rapidly.
SCHOOL NURSING
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 next
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.
•Ill states where coffipensatlon laws are In efffect, the InsTirance com-
panies recognize the value of a first aid station with a nurse in charge
and make a reduction in the insurance rates to employers adopting this
plan.
PUBLIC HEALTH NUKSING 47
In many schools there are classes in home hygiene and the
care of the sick, dietetics, and first aid, which are taught, in
part at least, by the school nurses.
OTHEE 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 NUESIITG 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 PROBLEM
in other localities bedside nursing has been placed under the
eame 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 the effort 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 NURSE 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 fuUest
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-
PUBLIC HEALTH NURSING 49
sionaUy 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 da/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 neighborhood 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
80 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 ia
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 PROBLEM
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 service 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
•Prom statistics furnished by the Henry Street Settlement.
PUBLIC HEALTH NUESING 51
intensive work it was felt tliat 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 52.5 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 Insur-
ance Company for its Industrial Policy holders. Report for 1918.
52 THE COMMUNITY HEALTH PROBLEM
INDUSTBIAL EXPERIENCE^ METROPOLITAN LIFE INSURANCE CO.
1911-1917
Deaths per 1,000
Age Period 1917
All ages 11.6
1 to 4 10.5
1 20.4
2 13,5
3 7.7
4 5.6.
5 to 9 3.4,
Per cent.
1911
Decline
12.5....
.... 7.2
12.8....
.... 18.0
25.2....
.... 19.1
16.6....
.... 18.7
9.3....
.... 17.2
6.6....
.... 15.2
2.7....
.... 3.7
2.7....
.... 3.7
4.7....
.... *2.1
7.3....
.... 9.6
9.5....
.... 11.6
13.7....
.... 9.5
19.8....
.... 1.0
36.0....
6
74.5....
.... *2.6
139.3....
*2.4
10 to 14 2.6
15 to 19 4.8
20 to 24 e,6
25 to 34 8.4
35 to 44 12.4
45 to 54 19.6
55 to 64 35.8
65 to 74 76.4
74 and over 142.6
•Per Cent, inciease 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.
EFFEbT 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 home. 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 vrithout 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 nurse
plays a major part in its execution.
CHAPTER yi
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 surveys, from vital statistics, and from com-
munity records, corresponds to the army officer^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 enthusiasm 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 worldng for better community
health. The disadvantage of private control is that there are
usually insufficient funds to reach more than a smaU 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 ot the community
56 THE COMMUlSriTY HEALTH PEOBLEM
rarely have sufficient broadness of vision and experience £o
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 that 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, used 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 the administration derives its
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.
PREVENTIOIT OP 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 scourge
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 EOR 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 wiU 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. SuflScient testimony is at
liand 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 diflficult 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 aifront 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 HEALTH i'KOBLEM
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, *T3o
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 conditions either in reference to physicians 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 thereby a certain amount of duplication of
effort. This is due largely to the personal equation, it being
regarded as the right and privilege 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
mous 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 be 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
60 THE COMMUNITY HEALTH PEOBLEM
injury to the heart. It 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 FOE 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 activities
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.
CAEE 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 acquaintancee.
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 oare. However, the
larger part of the totally disabled, especially the insane, should
be treated in institutions. The concentj-ation of various tjrpes
of chronic mental and physical disorders in a large institution
62 THE COMMUNITY HEALTH PEOBLEM
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. Most 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
some 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. FOE BETTER HEALTH 63
dent prevention is the prevention of industrial disease. If a
survey of industry clearly shows the prevalence o£ 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 deaths 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 period 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. Instruc-
64 THE COMMUNITY HEALTH PEOBLEM
tion of the child as to sex dangers and other measures to pre-
vent the spread of these diseases should not be neglected. It
is not the intention here to offer a solution of the 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 this 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 solutio* 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 that 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. The work of the Ford Com-
pany in taking an active interest in such patients and put-
ting them in employment commensurate with their physical
ability has already been mentioned. The experiment will bear
watching.
CAMPAIGN FOR BETTER HEALTH 65
HOSPITAL AND HOME CAKE
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 best conditions nine persons
aie cared for in the home to each one taken to a hospital.
Look through the homes of the poor and see if they receive
eyen 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 legislature^
of several states.
66 THE COMMUNITY HEALTH PROBLEM
Another question which 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. When 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
much territory and cccomplish few if any tangible results.
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 PROBLEM
laws. There was, it is true, the principle of liability for acci-i
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 lawyer who would finance the case
from his own pocket in the hope of a favorable verdict.
Naturally the legal fees were 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 be 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 69
WHAT COMPENSATION ACCOMPLISHED
At one stroke the compensation acts did much to abolish
these abuses. The difficulty 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 because 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 HEALTH PEOBLEM
lars, for this tends to prevent sufficient and adequate treat-
ment for the severe injuries. Unlimited treatment is apt to
lead to abuse of the privilege, but medical care for at
least two months 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 66-3/3 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.
Death 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 66-2/3 per cent, of the wage
at the time of death.
WOEKMEN'S COMPENSATION INSURANCE 71
EMPLOYMENTS INCLUDED
When the compensation laws were first introduced efforts
were concentrated upon what are known as the 'Tiazardous''
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.
ADMINISTEATION
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 modem social problems. As a rule, the
findings of the accident boards are final and cannot be
reviewed by the courts.
73 {THE COMMUNITY HEALTH PEOBLEM
INSURANCE CAEEIERS
Insnrance 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 ; Cab -
fomia, Connecticut, Massachusetts and Wisconsin.*
There can be no doubt that all industrial diseases should he
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.
WOKKMEN'S COMPENSATION INSURANCE 73
It seems hardly fair that his 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 doubt 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.
COMPENSATION 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 the 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 PEOBLEM
better medical care than lie 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 common, 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 INCREASED
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 employer 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.
CHAPTER 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.
Reasoning 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 PEOBLEM
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 Association 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 salary) 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 worker 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 aro
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
78 THE COMMUNITY HEALTH PEOBLEM
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. We 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. Practically, 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 compulsory insurance is objectionable. Yet we
COMPULSOEY HEALTH INSUEANCE 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 OP 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 COMMUNITY 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 hand
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 health
official the objection is less potent and under such conditions
many very able physicians might be induced to devote their
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 INSUEANCE 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 as
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 FUNCTION OF THE STATE
There can be no question as to the responsibility of the
(ommunity for the health of its citizens. While the extent of
(Jhis responsibility may be debatable the fact remains that,
82 THE COMMUNITY HEALTH PROBLEM
to a certain degree, the health of the individual is dependent
Tipon 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 less 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 wiU 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.
COMPULSOEY HEALTH INSURANCE 83
If state oflScials, 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 rt 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
INDUSTEIAL MEDICINE 85
slowed down production and caused a certain financial loss.
In large corporations it was 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 begun. Only compara-
tively few of the larger corporations have introduced what
may be considered a truly comprehensive tystem of health
protection.
86 THE COMMUNITY HEALTH PEOBLEM
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 efficient 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 acts
vary in the different states and in the various occupations.
In New York the rates for moderately hazardous occupations
INDUSTEIAL MEDICINE 87
run from five to twenty per cent, of the annual payroll. For
non-hazardous occupations the rates may be 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 number 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 PKOBLEM
PHYSICAL EXAMINATIONS
Physical examinations should be made of all applioants 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 who 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 b-e 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 actuallv placed in self-
supporting employment.
INDUSTRIAL MEDICHSTE 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 may 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 tbp. 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 PEOBLEM
become apparent to them that they not only secure free treat-
ment at the plant but that the treatment is, as a rule, at
least as good as that secured from private sources.
CONTRIBUTES TO WELFARE
Industrial medicine is today closely linked to industry. K ^
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 Ja
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 sickness
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 payment of the premium in a lump
sum calculated from the pay roll. This reduces the charges
for collection so that insurance of this t3rpe 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
employees of several years service. Sickness insurance with
a weekly benefit is usually written for a fijsed period of from
13 to 52 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.
CHAPTEE X
STATE MEDICINE
For years many clear thinkers have insisted that the com-
ing of a state 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 conmiunity 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 sa5'^s ^^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 cash' but also of sensitive flesh and blood. Health,
there cannot be the slightest doubt, is a vastly more funda-
mental and important matter than education, to say nothing
of such minor matters as the post ofiSce 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 cttempt which was made several years ago
to establish a Federal Department of Health 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 conditions 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 effects 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 looms
much larger than it does in the United States where 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 IIEDICINE 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 PEOBLEM
practitioner. In order to give his patient reasonably adequate
medical treatment according to modern 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 "fche 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 modern 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 change 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 IJnited States
Department of Health with a Secretary of Public Health.
This department would include the present IJnited 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 medical 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 PEOBLEM
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
etaff of most of the purely clerical duties.
PERSOITNEL
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
enthusiasm and co-operation of the physicians 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.
Th6 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 be 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 physicians 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 PEOBLEM
attention. State medicine is not an attempt to secure proper
treatment for the rich. It is intended primarily for the pre-
vention of disease and for the benefit of those who are unable
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 scientific 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 whether
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 Tipon
individual competition.
CHAPTER XI
HEALTH CENTERS
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 efficiency 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.
RED CROSS HEALTH CENTERS
After the war the American Red 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 PEOBLEM •
health centers scattered over the TJnited States.* In seven of
the cities there was more than one center, so that, in aU,
forty-nine communities were represented. This number is, no
doubt, very incomplete 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 centers, the Eed 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 clinics. 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
•Tobey, James A. : The Health Center Movement in the United States.
The Modern Hospital, March, 1920,
HEALTH CENTERS 101
not represent a fixed plan for the improvement of health but
varies considerably according to the 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 effort.*
In some cases the term ^^ealth 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 inhabitants. It constitutes 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 is
bringing together Important but hitherto independent health campaigns,
Buch as those for the prevention of tuberculosis, venereal diseases,
meptal dippnse.'?. industrial disensps, and above all the vitally necessary
modern effort for the conservation of child life. In turn, it offers new
Eossibilities of properly relating these volunteer activities to the official
ealth work of the city, county, state, and Federal authorities." (A. R. C
Circular 1000. September, 1910.)
102 THE COMMUNITY 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 commnnity 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 efficient
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 faU short of
accomplishing the maximum benefit for public health.**
INDUSTEIAL 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 plan which closely approaches this has been 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 CENTEKS 103
degree of development, 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 ; he
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; (e\ 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, unlilve some other health activi-
ties, are not largely theory with little or no practice. They are
104 THE COMMUNITY HEALTH PEOBLEM
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 which 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 with the community hospital and
patients discharged from hospitals may be kept under pro-
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 CEN-TEE
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 Jonrnal of Public Health, March, 1920.
HEALTH CENTEES 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 offers instruction in mater-
nity and child-welfare, thus reducing infant mortality. It
serves as a clearing house for all public health information,
thus effecting a closer co-operation among hospitals. It
divides the community into health districts, each with a defi-1
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 reduces-
loss of income caused by sickness; earning power rests
on health. (3) It decreases infant mortality. (4) It fostera
health education; one school 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 the home; a healthy
home produces a more efficient worker, a more contented cit-
izen. (10) Public health is purchasable; 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. This
movement had the endorsements of the State Charities Aid
Association and the State Commissioner of Health. The bill,
known as the Sage-Machold bill, proposed, in brief, a healtli
106 THE COMMUNITY HEALTH PEOBLEM
center in every commiinity 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 Eed 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 Eed Cross health program. This is to be
the mobilization of Eed 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 eflSciency in the public and volunteer activi-
ties in this field but offer a particular opportunity for effec-
tive Eed 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 Eed
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, April, 1920. This bill was introduced, but not acted
upon, during the 1920 session.
♦* American Red Cross Circular 1000, Sept. 29, 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 this case the Eed 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 Eed 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-wide organization of people who have come to-
gether for the purpose of finding some way to increase health,
happiness and the other good things of the earth, and of help-
ing to do away with poverty, misery, disease and preventable
death/'
The N"ational 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 th6
citizenship as a whole can participate directly in the control
of community affairs, while at the same time making con-
stant use of the highest technical skill available."
After some deliberation, the Mohawk-Brighton district 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 EXPEEIMENT 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 largely to
representatives of the people living in or employed in the dis-
trict, but the execution of the suggested solutions of the
health problems is referred to the Physicians Council, the
Nurses Council, and the Social Workers 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 specijBcally 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 assumption 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 ox 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
echooL 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 NUESIITG
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 employed. 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 staif, 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 Zo«: The Social Unit and Public Health Nursing,
Report of Social Unit Conference. National Social Unit Organ. New
York, 1919.
THE SOCIAL 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-Tuberculosis 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 33 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, chiefly examining children or
adults. Treatment at the center is given by these physicians
only in emergencies. When 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
113 THE COMMUNITY HEALTH PKOBLEM
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 welfare workers of the Social Unit, and in part by certain
other outside organizations.
The health service indicated certain gross 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-
standing of the relation of health to their own and their chil-
dren's welfare, was an important factor in securing prompt
action leading to the correction of sanitary defects.
THE SOCIAL UNIT EXPEEIMENT 113
■Among the citizens themselves the results have been 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 their 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
114 THE COMMUNITY HEALTH PROBLEM
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 Mayor of Cincinnati, recorded their desire
that the Social Unit should continue its work by a vote of
4434 to 130.
CHAPTER XIII
TUBERCULOSIS
Tuberculosis has been 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. When
we consider that tuberculosis 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.
DISTRIBUTION 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 significance except for
the fact that they point to the wide distribution of the causa-
115
116 THE COMMUNITY HEALTH PROBLEM
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 resistance 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 comer 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 problem 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 upun 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. Armstrong :*
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.
118 THE COMMUNITY HEALTH PEOBLEM
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 with 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 other diseases which, because
they imdermine the ge'neral 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 alL
THE DISCOVERY OF EVERY CASE
The most important phase of the tuberculosis problem lias
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. Donald B. Armstrong in Framing-
ham, Mass., a city of about 17,000 inhabitants, has been
TUBERCULOSIS 119
interesting as showing how many cases may be brought to
light by a careful medical survey. On January 1, 1917, there
were, according to the oJBficial 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 32
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 next 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,
•Armstrong. Donald B. : Tuberculosis Findings, Ftamiagliam Mono-
graph No. 5, March, 1919.
120 THE COMMUNITY HEALTH PROBLEM
as well as a social and medical problem. A certain percent-
age of the patients will be able to continue tlieir 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, under 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
f
The U. S. Public Health Service has 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 community health.
•Annual Report, 1919, U. S. PnbUc Health Service. Washington, O. 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 CONTROL 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 tjrphoid
•The spread of measles and smallpox 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 m 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. AU 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 fo 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 PKOBLEM
methods which were used in the 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 CAMPAIGN
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"
•Pierce, C. C: The Public Healtb Campaign against Ven»rtal Dlseastf,
Social Hygiene, October, 1919.
HYGIENE IN ITS KELATION TO HEALTH 125
3. "To control and prevent the spread of these diseases in
interstate traffic/'
In addition to interstate quarantine regulations wHch for-
bid interstate travel of persons infected with venereal dis-
ease except under a permit of the local health officer, a hill
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 minimum
requirements are, briefly, as follows:
(a) "Venereal diseases must be 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
From a medical viewpoint every case should have the oppor*
tunity of securing expert treatment at a moderate price.
126 THE COMMUNITY HEALTH PKOBLEM
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) Eecreation. 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 m ITS EELATION 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 furi;her discussion of this
question, especially in its social and economic aspects, the
reader is referred to the various publications of the Ameri-
can Social Hygiene Association,
CHAPTER XV
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 upon 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 of!
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
EEHABILITATION OF THE DISABLED 129
of society, that the tribes 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 nat
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 CEIPPLES FEOM INDUSTKIAL 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 movement 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 was
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 offices throughout 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 their 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 has 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
132 THE COMMUNITY HEALTH PEOBLEM
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 Eisk 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 author has discussed this phase of the subject more in detail
in an article entitled Rehabilitation in its Belation to the Physician,
Modern Medicine, February, 1920.
REHABILITATION OF THE DISABLED 133
If he compares unfavorably with the normal worker it is
necessary to give the man some form of training so that, by
his skiU, 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 either as major, minor or negligible. If there is a major
handicap, according to the Act, the man receives training
and an allowance for expenses varying 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 negligible 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
EEHABILITATION 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 training 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 effort. Many of
the diflBculties 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 argued
into accepting training. Such men succeed with a small
amount of help and guidance. 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 COMMUNITY HEALTH PROBLEM
est cases to deal with, the men being mentally unsettled and
not to be depended npon. 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, 1917. Discharged Oct. 7, 1919. Diagnosis: Old scar following
mastoid operation, left side. In hospital 9 months. Discharged from
hospital Oct. 7, 1919. Disability: Deafness left ear. Previous occu-
pation: Student, self supporting. Unable to continue course for lack of
funds. In this case the handicap is considered as 25 per cent. If ttiis
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, 1919. War Risk Bureau gives disability as 75 per
cent. Previous occupation — laborer. Examination shows multiple gun-
Bhot wounds completely healed. Complete blindness right eye, follow-
ing wound of temple. Deformity of right hand following G. S. W. la
nnable to use hand for finer movements but has strong grip and will bo
able to do heavy work. New occupation advised — vulcanizing. This man
will be 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, unable 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
suffering 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, mistakes 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 the Federal Board, are reprinted, by
permission, from an article by the author in Modern Medicine, Feb., 1920.
REHABILITATION OF THE DISABLED 137
BEHABILITATION 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
impossihle to outline its present status. What is true at the
time tkis is written may be changed 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
the 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 PEOBLEM
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 f ona of local community ef ort.
CHAPER XVI
ENDOWED HEALTH DEMONSTRATIONS*
Tlie 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 Eockefeller
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 were taken In part from the Annual
Reports of the Eockefeller Foundation. 1917 and 1918.
139
140 THE COMMUNITY HEALTH PROBLEM
war relief largely through the American Red Cross, and
the United War Work Fund of the Yonng 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 regular 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 work of the International Health Board,
and the researches of the Rockefeller Institute of Medical
Research.
THE ERENCH 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 conntry,
possibly because there are few national organizations whicB
can quickly inform each community what is being done in
every other.
ENDOWED HEALTH 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-
iteuses d'hygiene, were trained at the various dispensaries and
arrangements made to bring a group of physicians to the
United States to give them 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 Foundation 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 work to be carried on by local organizations
apparently is the general policy.
THE HEALTH CAMPAIGN m NORTH CAEOLINA
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 rtiral 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 PROBLEM
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 Eockefeller 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 typhoid 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 Rockefeller 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.
HOOKWORM INFECTION
For several years experiments have been conducted in an
effort to combat hookworm infection. This disease, widely
prevalent in our southern states, has been found to be of
almost worldwide occurrence. Hookworm disease exists wher-
ever the larvae of the worm find favorable soil conditions.
They 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 per cent, of all inhabitants
were found infected. Work done by H. 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 are 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 COMMUNITY HEALTH PEOBLEM
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 pnrge. 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 affliction.
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. f{
The survey indicated that probably two of every three
inhabitants of Jamaica have hookworm 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.
INAUGUEATION OF CONTEOL MEASURES
The survey is to be followed by a series of demonstrations
in control measures. The working arrangement provides that
•From the Appendix of the Report for 1918. Rockefeller Foundation.
New York.
ENDOWED HEALTH DEMONSTEATIONS 145
the Gk)vernmeiit 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 CONTEOL OP 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 the disease will
automatically stop. This has been known for many years and
yet there are literally thousands of communities which are
afficted with this disease and yet make no concerted effort to
be rid of it. It has remained for the Eockefeller Foundation
to demonstrate that it is cheaper to be rid of malaria than to
have it.
EXPEBIMENT AT CROSSET^ ARKANSAS, 1916*
The first of the tests was undertaken at Crosset, 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 ?s widely preva-
•Qnoted from the Report for IMS. >
146 THE COMMUNITY HEALTH PEOBLEM
lent as an endemic infection and, according to the estimate
of the local physicians, is responsible for about 60 per cent.
of all illness throughout the region. Within 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 eflBciency.
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 these mosquitoes.
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. TRe
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 large 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 direction. The same measures have been continued
under the supervision of a trained native lay inspector. The
following table shows the yearly results and the per capita
cost:
physicians' calls foe malaeia
Population 2129
1915 Calls (Compan/s records) 2500
1916 " " 741
1917 " " 200
1918 « « 7a
Eeduction for the three years, 97.1 per cent.
PEE 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 Eockefeller 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 Bed 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 Eockefeller Foundation. Some
are endowed and others secure their funds largely through
148 THE COMMUNITY HEALTH PKOBLEM
public subscriptions. They should all be looked upon as
merely auxiliary organizations and should in no case replace
public health activities or community health effort.
The American Eed 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 Eed Cross Bulletin,* 'T3y 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) Providing a public health nurse for
your coiomunity, 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 Eed 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 Red 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
chUdren in institutions. A publication department is main-
tained and many books and pamphlets on subjects dealing
with health and welfare are published.
The Kew 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
least, 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.
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 PubHc Schools, 1919.
Ayres, May; Williams, Jessb 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.
Byington, 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 Carbieua: The Hospital as a Social Agency in the
Community, 1918.
Dawson, Bertrand: The Nation's Welfare. The Future of tlfe
Medical Profession (Cavendish Lectures), 1918.
Devine, Edward T.: Disabled Soldiers and Sailors Pensions and
Training, 1919.
Dublin, Louis I. : Mortality Statistics of Insured Wage Earners and
Their Families. Experience of the MetropoUtan Life Insurance
Company, Industrial Department, 1911-16.
Everett, Ray H. : The cost of Venereal Disease to Industry, Jour, of
Industrial Hvgiene, September, 1920.
Faries, John Culbert: The Economic Consequences of Physical
DisabiUty, 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.
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.
REFERENCES
Harris, Garrard; and Billings, Frank: The Redemption of the
Disabled. A Study of Programs of Rehabilitation for the Disabled
of War and of Industry, 1919.
Hoffman, Frederick L. : Industrial Accidents in the United States
and Their Relative Frequency in Different Occupations, Prudential
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 Germany 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, Harry 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 of 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: Pubhc 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 Syphilis and Gonorrhoea, U. S.
Public 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 publishes a
monthly magazine and a series of bulletins on rehabilitation.
INDEX
Accidents, Prevention of 56, 62
Accidents, Industrial, and Liability Laws 67
Adults, Sick Rates 9
Administration of Compensation Laws 71
Alameda County Health Center 104
American Association of Labor Legislation 76
American Red Cross Health Centers 99
American Red Cross, Peace Time Program 148
Appropriations for Public Health 35
Bedside Nursing 43
Benefits, of Compensation Acts 70
Benefits, of Health Insurance 83
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 Health 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 Nursing 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 for 60
Crippled Employees of Ford Motor Company 60
Cripples, Civilian, Rehabilitation of 137
Cripples, Industrial 129
Death Benefits Under Compensation Laws 70
Defective Children in New York State 8
Demonstration, Framingham Health 10
Demonstration, Health 64
Departments, Health 30
Departments, Local HeaUli 34
Departments, State Health 33
Disabled, Rehabilitation of 61, 128
Disabled Soldiers, Case Histories 136
Disabled Soldiers, Rehabilitation 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 Workmen's Compensation 72
Draft Army, Percentage of Defects in 6
Draft, Disability Discovered by 4
Draft, Table, Disability Discovered by 5
Dumf erline 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 Health 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 Public Health Nursing 49
Ford Motor Company and Disabled Employees 60
Framingham, 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 78
Health Program of American Red Cross 148
Health Service in Social Unit Experiment 112
Health Study by Metropolitan Life Insurance Co 9
Henry Street Settlement 50
Home Care 65
INDEX
Hookworm Disease Combated by Eockefeller Founda-
tion 143
Hookworm Survey in Jamaica 144
Hospital Care 65
Hospitals and Health Centers 104
Hygiene, Social 122
Industrial Cripples 129
Industrial Diseases Under Compensation Laws 72
Industrial Health Centers 87, 102
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
Industry, Physical Examination in 88
Infancy, Disease of, in Public Health Service Program 32
Infant Welfare 63
Injury, Treatment of 58
Insurance Carriers for Proposed Health Insurance ... 77
Insurance Carriers for Workmen's Compensation In-
surance 72
Insurance, Compulsory Health 75
Insurance for Industrial Workers 90
Insurance, Health 21, 72
Insurance Nursing 61
Insurance, Workmen's Compensation 67
Institute for Crippled and Disabled Men 60, 130
International Health Board 143
Jamaica, Hookworm Survey in 144
Kensington Survey 17
Liabili^ Laws and Industrial Accidents 67
Life Insurance Nursing '51
Loss of Wages Due to Sickness 17
Major Handicap in Vocational Training 134
Major lUs 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 PKOBLEM
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 Visitmg 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 66
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 Health Nursing and Ked 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 f or . . . 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 52
Red Cross Health Centers 99
Red Cross Program for Health Centers 106
Red Cross Public Health Nursing 40
Rehabilitation 59
Rehabilitation of Civilian Cripples 137
Rehabilitation of Disabled Soldiers 61, 128
Rehabilitation, Origin of 130
Rockefeller Foundation 139
Rockefeller Foundation, Malarial Expenses in Arkansas 19
Rural Hygiene in Public Health Service Program 31
Russell Sage Foundation, Influence on Public Health. . 149
Safety Devices Increased by Compensation Laws 74
Sage-Machold Bill for Health Centers 105
Scale, Dumf erline 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 .... 32
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 Metropolitan Life Insurance Co.. 26
Sickness, Yearly Expenditures 18
Social Hygiene 64, 122
Social Hygiene, Medical Control 122
Social Hygiene, Military Control 123
Social Unit Experiment 108
Social Unit Experiment, Medical Care Ill ,
Social Unit Experiment, Tuberculosis Activities in.. Ill i
Social Unit Nursing I 110 j
Social Unit Plan u. 108 i
Social Unit Plan, Criticism of . . i 113 •
Soldiers, Disabled, Rehabilitation of 61 ^
Specialization in Public Health Nursing 43
State Health Departments 33
State Medical Service ...'..,.._. 95
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 6
Survey, Dutchess County 27
Survey, in Framingham, Mass 11
Survey, in Jamaica 144
Survey, Kensington 17
Surveys, Sickness 6
Totally Disabled, Care of 61
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 116
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