Biennial report of the North Carolina State Board of Health

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TWENTY-THIRD BIENNIAL REPORT
OF THE
NORTH CAROLINA
STATE BOARD OF HEALTH
JULY 1, 1928-JUNE 30, 1930
Members of the State Board of Health
i
Elected by the North Carolina Medical Society
Cyrus Thompson, M. D.
Term Expires 1931
D. A. Stanton, M. D.
Term Expires 1931
L. E. McDaniel, M. D.
Term Expires 1935
Thomas E. Anderson, M. D.
Term Expires 1935
Appointed by the Governor
John B. Wright, M. D.
Term Expires 1931
E. J. Tucker, D. D. S.
Term Expires 1931
James P. Stowe, Ph.G.
Term Expires 1933
Chas. C. Orr, M. D.
Term Expires 1935
A. J. Crowell, M. D.
Term Expires 1935
Letter of Transmittal
Raleigh, N. C.
November 15, 1930.
His Excellency, O. Max Gardner,
Governor of North Carolina.
My Dear Sir:—Under authority of chapter 118, Article 1, Section
7050, Consolidated Statutes of North Carolina, I have to submit to you
for transmission to the General Assembly the Biennial Report of the
State Board of Health for the period July 1, 1928, to June 30, 1930.
Very truly yours,
H. A. Taylor, M.D.,
Acting Secretary.
Table of Contents
Page
The State Board of Health ___ L_ 7
A Symposium on Public Health Education 13
The Relationship of Education to Public Healths 14
The Relationship of Public Health to Higher Education 19
The Influence of Public Health and Education Upon the Improve-ment
of the Human Race 24
The Social and Economic Aspects of Human Ailments and Public
Health 29
Bureau of County Health Work 35
The Bureau of Sanitary Engineering and Inspection 46
Bureau of Epidemiology 107
Bureau of Health Education 116
Bureau of Maternity and Infancy 154
Bureau of Medical Inspection of Schools 160
Bureau of Vital Statistics 169
State Laboratory of Hygiene 172
Cancer Control Program 175
Rehabilitation Orthopedic Clinics 180
Minutes of Meetings of the Board and the Executive Committee 183
N C. STATE BOARD
O RGAN I ZAT I O N
OF H E A LT H
& ACT I V I T I E S
Ht
THE STATE BOARD OF HEALTH
ORGANIZATION
North Carolina was the twelfth State in the Union to recognize govern-mental
responsibility for the protection and promotion of the public health
of its people, and to create a governmental agency specifically charged with
the duty of meeting that responsibility.
In the seventies Dr. Thomas Fanning Wood, of Wilmington, caught the
vision of the possibilities of public health work to the State. How fully
he grasped the far-reaching consequences of his idea, how clearly he saw
the ever-growing hosts of lives saved as a result of his vision and inspira-tion,
cannot be known. It is true, however, that the vision never left him,
and that under its sway he worked, through the Medical Journal which he
edited and through the North Carolina State Medical Society, until his in-fluence
reached the people of the State in their General Assembly of 1877,
with the effect that on February 12, 1877, legislation was ratified creating
the North Carolina State Board of Health.
Under this legislative enactment the Board in the beginning consisted
of the entire membership of the State Medical Society. There was an
annual appropriation of $100.00. The State Medical Society undertook to
discharge the duties imposed upon it through a committee.
Two years of practical experience proved that such an organization
would not meet the public needs, and in 1879 the General Assembly recon-stituted
the Board, setting up a membership of nine, six appointed by the
Governor and three elected by the State Medical Society, the term of office
being five years. From time to time since there have been revisions and
amendments, but basically the organization plan of the State Board of
Health has remained unchanged during these fifty-one years of its life.
The present organization of the Board, as shown diagrammatically in
the accompanying chart, consists of nine members, five of whom are ap-pointed
by the Governor and four of whom are elected by the Medical
Society of the State of North Carolina. The plan of organization includes
two important administrative principles the wisdom of which has been
tested and proved through the years of practical experience: (1) Stability
of organization and permanency of policies; (2) Partnership of the State
and the medical profession in the conservation of human life.
The stability of the organization of the Board of Health depends funda-mentally
upon the Board's freedom from political tinkering. The divorce-ment
of the State Board of Health from politics depends largely upon the
manner of selecting the members of the Board. Sudden and marked
changes in the personnel of the Board's membership under the present
plan of organization are impossible: First, because the members of the
Board of Health are appointed for terms of six years and the terms of
service of the individual members expire, not in the same year, but in
different years. The appointment of new members of the Board is, there-fore,
gradual and not sudden. Second, the membersship of the Board of
Health is selected by two parties: one, the Governor, and the other, the
State Medical Society. It is far less likely that two parties naming a
Board would be dominated by political considerations than where one party
8 North Carolina State Board of Health
names the Board. This division of the appointive and elective power and
this provision for the gradual exercise of that power by two parties guaran-tees
the State Board of Health against the sudden changes of personnel
and policy associated with a purely political organization. The State Board
of Health is stable. Its individual members come and go, but as an or-ganized
body it stays.
This stability of organization is the responsible factor for the perman-ency
of policies adopted by the Board. Political boards elected or appointed
for two years or four years are naturally inclined to adopt two and four-year
policies, to attempt to make the best showing possible during the
short term of their official life. The administrative thoughts and plans
are largely defined by the time limitations of their administration. This
is not true of a self-perpetuating body such as the State Board of Health;
that, as legally constituted, has no limits to its life.
The second administrative principle included in the organization of the
State Board of Health is the recognition by the State of the fundamental
relation of the medical profession to the work of disease prevention. The
State recognizes: (1) the debt of society to that profession by which nearly
all of the experimentation and discovery on which disease prevention is
based, with the exception of the work of Pasteur, was contributed; (2) the
interest of organized medicine in the conservation of human life and the
peculiar ability of organized medicine to advise the State as to the methods
of prevention; (3) the necessity of securing from the medical profession,
first, information in regard to the occurrence of deaths and their causes,
and the appearance of epidemics.
EXECUTIVE STAFF
The work of the State Board of Health is large and varied, and is,
therefore, apportioned among a number of bureaus, or special divisions,
each directed by an administrative head chosen for his special training and
ability, and is charged with responsibility for developing and administer-ing
specific phases of public health work. The present organization set-up
follows
:
Administration: Headed by the State Health Officer with general super-vision
of the entire public health program.
The executive officer is the Secretary of the Board, who is, by statute,
State Health Officer. He is elected by the Board for a term of six years.
The duties of the office require that this official should be a man with
technical training and experience, and, therefore, should be selected on
account of his technical rather than of his political qualifications. It is,
therefore, right that he should be selected by a specially qualified committee,
that is, the State Board of Health, and not be elected in a general election,
as would be the case if the office were a political one. The six-year term
of office is in accordance with the idea of permanency of policies. The
law requires that the Secretary, and State Health Officer, shall be a
registered physician in the State, and that he shall not engage in private
practice, but shall devote his time and energy to the work of the Board.
The correlation of the work of the several bureaus, to insure a har-monious
and efficient administration of the work of the Board, is through
the supervision and direction of the executive officer of the Board. The
Twenty-third Biennial Report 9
division of the executive staff into special bureaus has the advantage of
giving individualism to the work of each bureau and thereby creating a
laudable pride and a healthy rivalry among the various bureau directors.
While each bureau is separate and independent of other bureaus, the work
of the entire executive staff is coordinated, the work of the Board being
given compactness by the relation of the bureaus to one another through
the executive officer of the Board. The administrative heads of the several
bureaus, or directors, are selected by the executive officer of the Board,
their terms of service being dependent only upon their success or failure in
discharging their duties.
There are naturally many problems and duties which cannot be assigned
to any of the special bureaus, which by their nature must be under the
immediate direction of the executive officer. These may be briefly stated
as follows: (1) to assume primary responsibility for the enforcement of
the more important State health laws; (2) to consider and determine,
with the advice and consent of the Board, what should be the more im-portant
public health policies of the State; (3) to secure the needed legis-lation
that will make possible the adoption of desirable health policies;
(4) to supervise and assist in the execution of established policies.
The enforement of law rests, in a general way and broadly, upon the
judicial machinery of the State. On the other hand, it is not only the
privilege but the duty of any citizen to see that the violation of any
law is brought to the attention of the courts and dealt with. The more
thorough understanding of the purposes and the character of the public
health laws and the keener appreciation of their importance imposes in
a special way upon the executive officer of the State Board of Health the
duty of seeing that these particular laws are fully complied with.
The duty of considering and formulating for the action of the Board
what should be the more important public health policies of the State
rests largely with the executive officer of the Board on account of its
primary and general responsibility for the development of an effective pro-gram
of human conservation.
After the Board has considered and definitely decided upon a course of
action it becomes the duty of the executive officer to bring to the attention
of the people generally the need of the course of action approvd by the
Board, and to so inform, interest, and appeal to the public, and reflexively
and directly to the General Assembly as to secure legislative approval and
provision for the public health policies which have been adopted by the
State Board of Health.
The efficiency of any agency is conditioned largely upon the personnel
who are employed in its activities. The responsibility of finding and secur-ing
persons properly qualified by native endowments, training and experi-ence
to direct the special bureaus, or divisions, entrusted with carrying
out the established policies of the Board rests almost entirely upon the
executive officer.
As has been heretofore pointed out, the organization of the work of
the Board embraces a number of special bureaus which are held respon-sible
for some definite State health policy, and which are so organized as
to be independent of each other. Naturally, these bureaus and divisions
in the character of their work are closely related and some means of co-
10 North Carolina State Board of Health
ordinating their activities is necessary. This means the executive officer
supplies.
The majority of the calls by letter or person upon the Board for service
can be and are referred to the special bureau of the Board concerned
directly with the sort of service called for in the letter or by the visitor.
However, there are a number of calls upon the Board for services that
are general in character, or not provided for by some special agency. These
services necessarily have to be supplied by the executive officer.
The duty of receiving, disbursing and accounting for public moneys
made available through appropriations by the General Assembly, and
secured from other sources, in accordance with directions of the Budget
Bureau, is a duty that rests primarily upon the executive officer because
of his primary and general responsibility for the interests as a whole of
the Board.
The methods of work followed depend largely upon the character of
the duties which the executive officer seeks to discharge. For this reason
it is well in the discussion of methods to relate them to the special duties
of the executive officer as above set forth.
Investigations as to the violation of the more important health laws of
the State, and the initiating of prosecutions where violations are found, are
carried out largely as a part of the special activities of the Bureau of
Vital Statistics, Epidemiology, and Sanitary Engineering and Inspection.
The responsibility falls upon the executive officer to see that these bureaus
fearlessly and without discrimination enforce the important laws entrusted
to their execution. The larger work of the executive officer in law enforce-ment,
however, concerns itself with bringing to public attention the prin-cipal
State health laws and the needs of their careful observance, and
in this way building up a public sentiment favorable to the observance of
public health laws and sympathetic with the judicial machinery in im-posing
penalties upon those who violate them.
In determining the public health policies for the State it is necessary:
(a) that the executive officer secure information through special and
regular reports on the vital statistics of the State, and in this way to
be fully cognizant at all times of the vital conditions of the State as
shown by the State's birth rate, the State's general death rate, the State's
special death rates for certain diseases, the State's death rates by coun-ties,
by races, and by seasons; (b) that he secure information, through
public health literature, books and periodicals, as to the more recent de-velopments
and discoveries in public health work; (c) that then by keep-ing
in touch through conferences with other State health officers and
Federal health officers, he be thoroughly conversant with the methods
and accomplishments of other State departments of health, and that he
be alert to those larger interstate movements, especially those related
to action by the Federal Government, in order that whenever and wher-ever
possible these larger movements may be influenced to the advantage
of this State.
To secure the necessary measures and appropriations for the develop-ment
of the State health policies the people are informed, through bulle-tins,
the newspapers, exhibits, addresses, as to vital conditions and as
to necessary measures and appropriations for favorably influencing the
vitality and physical efficiency of North Carolina people. In this way
Twenty-third Biennial Report 11
the effort is made to develop a favorable public sentiment for the de-velopment
of the more important public health policies. The executive
officer further seeks to find and interest certain individuals, qualified by-heart
and head and position, for influencing, introducing, and support-ing
in the General Assembly needed legislation.
To find and secure, within budgetary limitations, a personnel for the
bureau, division or agency of the Board that is to be relied upon for
carrying into successful execution some special and important public
health policy calls for an acquaintance with those who are in touch
with men qualified for such positions, and a judgment of men on the
part of the executive officer. This judgment of men by which an ad-ministrative
officer selects his assistants is, of course, basic in the success
or failure of an administration.
In giving assistance to members of the executive staff charged with
carrying out certain public health policies the executive officer attempts
to keep in close touch with the work of each bureau or division through
regular monthly reports, special reports, and conferences from time to
time.
The general work of the Board is a matter largely of correspondence
and conference. The correspondence is extensive both in volume and
variety, and personal callers at the offices of the Board require a con-siderable
time devoted to conferences.
The book-keeping for all the bureaus is done in the executive office
by a system approved by the State Auditor and the Budget Bureau, and
all purchases are made through one purchasing agent.
For the biennium the budget for each of the two years approved
by the General Assembly of 1929 was as follows:
Administration $ 29,745
County Health Work 123,415
Sanitary Engineering and Inspection 75,720
Epidemiology 10,490
Health Education , 11,410
Life Extension 11,600
Maternity and Infancy 50,580
Medical Inspection of Schools 69,780
Vital Statistics 29,630
Laboratory of Hygiene 97,650
Printing 20,900
Orthopedic Clinics 5,000
Total $535,920
Less Estimated Receipts 44,450
Net Appropriation $491,470
Inasmuch as the work of the several special bureaus and divisions
are treated in detail in subsequent pages of this biennial report, their
functions are here briefly summarized:
County Health Work. Promote the development of adequate public
health service in the various counties; supervise and assist organized
county units to better serve their communities.
12 North Carolina State Board of Health
Sanitary Engineering and Inspection. Enforce sanitary laws; super-vise
public water supplies and sewerage systems; investigate problems
of stream pollution; supervise municipal milk sanitation; supervise shell-fish
sanitation; make malaria and mosquito surveys.
Epidemiology. Enforce laws regarding communicable diseases; make
epidemiological investigations; conduct campaigns for immunization
against typhoid fever, diphtheria, and smallpox.
Health Education. Prepare and distribute educational literature, in-cluding
the monthly Health Bulletin; conduct mobile unit in visual edu-cation.
Life Extension. Promote periodic health examinations for prevention
of degenerative diseases such as those of the heart and kidneys and
cancer; conduct special demonstration clinics for the medical profession.
Maternity and Infancy. Supervise maternal and infant hygiene nur-sing
service; conduct prenatal educational service; control midwife
practice.
Medical Inspection of Schools. Through staff of nurses render in-spection
services in public schools; conduct tonsil and adenoid clinics and
dental clinics for corrective treatment.
Vital Statistics. Gather through local registrars reports of births
and deaths; tabulate and index certificates; keep permanent file of all
certificates.
Laboratory of Hygiene. Make diagnostic examinations of various speci-mens;
make bacteriological and chemical analyses of samples from public
water supplies; manufacture and distribute various vaccines and sera.
Orthopedic Clinics. Conduct clinics for the correction of orthopedic
defects in children.
A Symposium
on
Public Health Education
Papers presented before the Section of Public Health
and Education of the Medical Society of the State of
North Carolina, meeting at Pinehurst, April 29, 1930.
14 North Carolina State Board of Health
THE RELATIONSHIP OF EDUCATION TO
PUBLIC HEALTH
A. T. Allen, LL. D., Raleigh
State Superintendent of Public Instruction
Ladies and Gentlemen, perhaps it is not seemly for a school man to
talk on a health program before a distinguished group of physicians.
However incongruous it may seem, I am glad to have the opportunity.
I hope we shall get on fine together.
Before starting on the little which I have to say, I should like to
pay my respects to the medical profession. No one can adequately state
the debt which the world owes to the physician. In his efforts to
alleviate suffering and to postpone death, he has been successful to an
amazing extent. The profession and practice of medicine rests upon
a scientific basis as fully as any human anterprise can. With unceasing
effort the doctor pursues the facts; with uncanny wisdom he relates
them to life. He respects the facts which come out of the laboratory.
On his part there is no hesitation when fact and opinion come into
conflict. He is constantly on the trail of some elusive and hidden secret.
If, at the end of a long journey, he makes a discovery which might
enrich him if he capitalized it for his own benefit, he generously dedi-cates
it to the service of humanity. Moreover, his attitudes are largely
altruistic; his interest in the welfare of people tends to make him un-selfish.
His allegiance to a professional code of ethics, his belief in
high standards of training, and his impatience with sham mark him
for distinction.
I am called upon to speak briefly of the relation between health
and education. In trying to trace this relationship, I shall have in
mind mainly the institution of public education and the enterprise known
as public health. Why do we support education at the expense of the
public? What promise does it hold? How does it affect life and the
relations of men? Why do we spend tax money to try to keep people
well? Do these two public undertakings conflict or harmonize with each
other? Let us examine each of them briefly. The sustaining motive
of public education has many phases. It has an economic phase because
we believe it will make men more productive; it has a political phase,
because we believe an educated citizenship will run a better govern-ment;
it has a strong moral motive because we believe education will
help men to behave in a seemly manner and improve their chances of
living together in peace. The State in promoting public education is
not actuated by motives of philanthropy and charity. It is trying to
provide for the economic independence of its citizens—an independence
which is to be finally won by the efforts of the individual. The State
does not levy tribute on its citizens and spend the proceeds on the schools
out of the spirit which prompted the widow to throw her mite into
the box, however commendable her action may have been. The State
acts under the influence of self-interest and the hope of perpetuation.
If the State is to prosper and become great, it must be sustained by the
intelligence, the moral stamina and the political sagacity of its citizens.
Twenty-third Biennial Report 15
There is no philanthropy or altruism in such an attitude. History is
full of instances in which one person has died for another; a mother
for her child; a father for his son; a man for his friend. Greater love
hath no man than this. John D. Rockefeller, out of his love for humanity,
may give his millions for the benefit of people whom he will never see.
When the State invests in the public school or in public health it is
looking for substantial benefits to itself, although such benefits may come
indirectly. It expects them through the cumulative results of individual
improvement.
I conceive of the public school as an effort to enable every child
born under our flag to do four things well: (a) To become an individual
in his own name and right. He wants to be separate and distinct and
different from every other individual. He does not desire to be merely
one of a group, or a specimen of a kind, but an entity which has value
within itself, capable of growth and expansion, and endowed with the
power to unfold from within. Such an individual is steadfast and not
pliant or subseiwient. He will not change his outlook, as does the
weather cock, with every puff of wind. (b) To become a self-determin-ing
individual. If in this he succeeds, he will be able to carry his own
economic load, to sustain his own moral rectitude and vote his own
ticket. The old apprentice system put the individual in a groove from
which he could not escape, except by almost superhuman effort. If one
lives in a groove, he will go straight. There will be no turn-ing
to right or left. There will be no expansion. There is no
chance to exercise judgment or choice. He is no wiser at sixty
than at twenty. The high school sets the youth on a plane of
opportunity. On that level he is free from many restrictions. There
is a wide range of choice. Within the limits of his ability, he can
determine for himself the direction his life will take. On that level
he can free himself from economic slavery and win gloriously his
spiritual freedom and political independence, (c) To become a coopera-tive
individual. Cooperation implies a degree of equality among the co-operating
agents. A group of individuals, each with the power of self-determination,
can meet on this level. If there is not a degree of equality
among these people there can be no cooperation. The relationship will
be that of king and subject; of lord and serf; of master and slave.
Without this equality which goes along with individual self determina-tion,
society becomes stratified and one group sits astride the neck of
another. In America we are looking toward a different kind of civili-zation,
one predicated upon the Declaration of Independence, and we
have set up the public school to sustain it. (d) To become a participat-ing
individual. Democracy means participation. Our whole government
fabric rests upon that basis. Every citizen has his part. The State
expects him to become capable of playing that part well. This, in brief,
is what the school is for. This is what Thomas Jefferson and Horace
Mann said it would do for a free people. This is the philosophy which
has pushed it forward and caused the American people to pour out their
money in almost unlimited millions. In practice, however, the expected
results do not always materialize. Health work has come gradually into
the schools. More than fifty years ago, physiology became a part of the
course of study under the influence of Thomas Huxley. Then the dis-
16 North Carolina State Board of Health
coveries of Pasteur startled the world. On the basis of this new knowl-edge,
the sciences of hygiene and sanitation were developed. Under
pressure from Professor Sedgewick, of the Massachusetts Institute of
Technology, their study became a part of the work of the school. The
philosophy behind these movements suggested that the health of the
people would be greatly benefited by the mere knowledge of these subjects.
They doubtless did much good, but knowledge of itself does not affect
behavior.
For a hundred years teachers tried to reach the exceptional child
through better teaching devices. After they had learned to do the best
teaching known, there was still a large percentage of children who did
not respond, who did not change their demeanor, and who were still
an actual menace to the school and a potential one to society. Then the
physicians were called in. Medical inspection of school children was
introduced. The whole country was shocked at the tabulations of the
results. Great numbers of children suffering from remediable physical
defects were found in every school. After a few years of study, the
ratio of the several kinds of defects could be predicted with reasonable
accuracy. Perhaps even more shocking to the public mind were the
revelations made by the physical condition of the men drafted for the
world war. With these facts before them, the American people set out
to meet the situation in a vigorous manner. Here was a great and new
problem for the school and for society at large. The answer was the
establishment of larger and more effective departments of health, the
employment of school physicians and nurses and the institution of school
health programs. In North Carolina we spend on an average about
thirty dollars per year for each school child. If for any reason that
child fails of promotion, the thirty dollars is lost, when measured in
terms of intellectual or moral development. There are many thousand
children in this State who fail of promotion annually on account of
their physical condition. They not only fail to learn but oftentimes are
most troublesome in their conduct. In place of moving towards better
citizenship, they become a possible menace to society. How can they
work when their bodies are tortured or their minds clouded? A filling
in a tooth, a pair of glasses, or an operation on his throat often trans-forms
an obstreperous, backward child into a tractable student, and
enables him to make a grade a year. Why spend thirty dollars a year
trying to teach a child who is laboring under a physical handicap,
when a little medical attention will possible remake him?
The motive behind a public health program might be stated as a
three-fold one: 1. economic—to make more productive citizens; 2. moral
—
to make citizens who can live at peace with themselves and their
neighbors; 3. civic—to make every citizen a sustaining member of society
and not a dependent one. It is claimed that the people of America lose
annually $1,200,000,000 on account of illness. Public health work is
intended to reduce that loss. A health program in connection with the
school might be stated in outlines as follows: 1. health instruction; 2. for-mation
of health habits; 3. control of communicable diseases; 4. pro-vision
of a hygienic school situation; and 5. health service. Each of
these main divisions can be listed under many appropriate heads. Health
instruction and the formation of health habits belong peculiarly to the
Twenty-third Biennial Report 17
teacher. Of course, the scientist must tell us what to teach, but we
think we can give the instruction better than the scientist himself.
Health instruction is of little value unless the knowledge is translated
into habitual conduct. The teacher working with both the parent and the
child, is the only person who can deal successfully with it. Through
the daily cleanliness examinations she brings about the habits of wash-ing
hands and brushing teeth. Through the socialized school lunch they
form better eating and play habits. She can also supervise the efforts
to improve posture with correctional exercises, make the rest periods
most productive of good and improve the eating habits of undernourished
children. This can only be done by persons in daily contact with the
children. In the matter of immunization, the physician plays the lead-ing
part and the teacher a secondary one only. While the teacher
after some preliminary training can do something in testing the eyes
and ears, every child should have a thorough medical examination by
a competent physician at least once every year. The most difficult part
of the whole health program is to secure the correction of the defects
after they have been discovered and tabulated. One way is to notify
the parent of the trouble and make an estimate of what the work will
be worth. The parent then takes the child to a physician for treat-ment.
In many cases, the parent is either too poor or too hardened
in his ways to give attention to the matter. In such cases the whole
thing comes to a stop. The dental and health clinics for school children
have done worlds of good already. I am wondering if the follow-up
work will not more and more result in dental clinics in which the teeth
of the smaller children are treated. This will not interfere with dentists
in private practice, but will bring them in the long run more practice;
because the children find out what it all means. In the same way
certain other simple operations might be performed by some surgeon
employed by the State. There should, of course, be left an option with
the parents as to what physician will do the work or whether the work
will be done at all. If the State stands ready to do it without expense
to the parent, many more parents, in my opinion, will have it attended
to in private practice.
The schools have one justifiable complaint against the public health
service. It is inclined to consider too little the value of a child's time
in school. We wait until school opens and then begin feverishly to vac-cinate.
For two or three weeks the school is in confusion and is
operated under great difficulty. Children with sore arms are irritable
and cross. Many of them remain out of school. The spirit of the school
is broken down and it is hard to re-establish. Furthermore, school hours
are usually selected for medical examinations. Children are excluded
from the public schools on account of contagious diseases, but the Sun-day
schools and churches go ahead. I am unable to see why a child
would not catch influenza at moving picture shows as readily as in
school. Schools are in session only six hours of the twenty-four, and
for only 160 days out of the 365. Every day and every hour of that
time should be devoted to the school's own program of activities. If
remedial and immunization work could "be carried on at hours and on
days when the schools are not in session, much loss of time and un-necessary
confusion could be avoided. If the schools are to do the work
18 North Carolina State Board of Health
which has been assigned them, they will need every bit of the allotted
time.
The most promising and sensible development bearing on the health
of school children is, from the standpoint of the school, the pre-school
clinic. If all the children could receive the necessary medical attention
during the first six years of their lives and before they start to school,
they would, in my opinion, be much better off. I know it would greatly
improve the school situation. This is now being done, to a considerable
extent, in many communities. I hope it will continue until much of the
work now being done during the school session will be attended to before
the opening of school. The pre-school clinic rests upon the idea that
a child shall have had all the apparent and necessary medical attention
before he starts to school. Every bit of remedial and immunization
work which is done before the child enters school greatly facilitates the
whole program. If the health service could find some way to combat
contagious diseases without so much loss of time from school another
great advance would be made, and it would be entitled to the unstinted
thanks of the schools as well of the taxpayers themselves.
Teachers, of course, do not understand all of the fine points of a
physician's code of ethics. We are not concerned with the methods
which shall be used to bring relief to the school children. Whether it is
done by physicians in private practice or by the health service itself is
not a question for us to determine. We know, however, that it must
be done if the schools are to function efficiently. Every school child
has the same right to the proper medical attention that he has to an
open schoolhouse door. Even if the ability of the child to his school work
were not affected by the medical service, it would still be worth all it
costs in the happiness of the individual and in the prospect of a finer
attitude on his part toward the world about him. These two public
agencies must work in the closest cooperation because each is dependent
in many ways upon the other. Unless you manage to keep the children
well, we can not teach them effectively. On the other hand, unless
they are taught well you will have no vehicle through which you can
spread your philosophy of public health. The more intelligent your
community is, the easier it is for you to keep it well. How far can
you get with a health program in a community in which all the people
are ignorant? Health and education naturally grow together, other-wise
they atrophy separately. The two enterprises rest upon the same
philosophy of public service, and have the same general objectives in
the advancement of civilization. For my part, I pledge you that the
schools will do their best to meet you half way in every effort to im-prove
the physical well-being of the childhood of this country. Through
such a joint program we can visualize a civilization in which there will
be fewer dependents, and in which a larger percentage will be able not
only each to carry his own load, but also to bear his proportion of the
joint load which failure and misfortune place upon every community.
Twenty-third Biennial Report 19
THE RELATIONSHIP OF PUBLIC HEALTH
TO HIGHER EDUCATION
E. C. Brooks, LL. D., Raleigh
President, State College of Agriculture and Engineering
Mr. President, Ladies and Gentlemen, it appeals to my vanity, when
I think that I am qualified to become a member of this Society. And
this gives me an opportunity to outline to you to some extent my train-ing
in order to prove to you what I have just said. When I was superin-tendent
of a city school system, discipline came under my supervision. I
learned to operate adroitly on the whole body, and succeeded admirably,
so they said! When I became connected with Trinity College as head
of the Department of Teacher Training, it was very interesting to me
to observe mental differences, and joy sometimes would come when I
could observe the appearance of intelligence, and I learned the value
of the clinic. When I became State superintendent of Public Instruction
it was a part of my work to relate the profession to business, and I
have some understanding of the meaning of fees. But I think the best
training that I have received and which qualifies me best to become a
member of this body, has come to me since I became the chief executive
of a large educational institution; for I have learned to use the gentle
art of mental suggestion in such an adroit way that when I am non-committal
it's difficult for those interested to understand whether that
attitude is due to lack of comprehension or to ignorance.
I have taken some liberties with my subject and shall discuss it
rather from the standpoint of the relation of higher education to public
health, than as you have it stated in the program. I know that in
every discussion of public health, our minds naturally turn to a con-sideration
of the greatest good to the greatest number. And that is
right. But I have chosen this afternoon to emphasize, rather, the
individual.
I received some months ago a little volume called the Story of a
Pine Tree a Thousand Years Old. I shall give you the outlines of that
story, which will serve as a parallel to my theme. It was born, according
to the story, in 856 and was taken down in 1903—when the march of
progress demanded its removal. Scientists desired to make a study of
it, and they proposed to take it apart, layer by layer, in order to learn
its life history. At the age of twenty it received some injury, probably
due to a snowstorm, that gave it curvature of the spine; but it over-came
that, and for a hundred years it experienced a rich growth; then
came years of hunger and famine, and the layers were so thin that the
scientists could hardly detect the growth. At the age of 140 it was in-jured
by a falling tree, and in its side was stuck a limb, that started
decay; but for nearly two hundred years it had rich growth again.
Then violent storms attacked it, tore away its branches and apparently
stunted its growth for the time being; insects and other disease pro-ducers
entered its body. Afterward life came back in its fullness, and
the disease or the attack was covered up, and nothing of these save
the scars seem to have remained.
20 North Carolina State Board of Health
At the age of 630, arrowheads were driven into its base. This
tallies with history, for they appeared when the Cliff Dwellers came
to the southern Rocky Mountains. The Spaniards came, thirty years
later; bullets testify to this, also the marks of an axe on its side; for
civilized man is the only one that applies the axe in such destructive
manner to a growing tree. In 1804, droughts appeared; our history
shows that this period is one of the great droughts throughout the
country. This was followed by earthquakes in 1812. You may recall
that it was about that period that the Creeks had their great uprising
in Tennessee and throughout the south, and General Jackson was
called into play, and there made history. They were excited to this
revolt by this great earthquake, the signs of which appear in the old
pine tree. In 1859 some one had blazed on its side long marks indi-cating
a blazed trail, and that is about the time the southern route was
opened from the east to the gold diggings of California. In 1903 it was
taken down.
The remarkable fact is, not that it was attacked by disease or by
its natural enemies or by storms: the remarkable thing is that life
came back, and when it was taken down the cellular life was as rich
and as strong as it was at the age of twenty. Another remarkable
fact is, that in the same soil and in the same climate and in the same
area, countless thousands of trees were born and died. They did not
have the vitality to renew themselves as they were attacked by their
common enemies. And this, ladies and gentlemen, is the parallel of
my theme. Not that disease appears, but that life returns is the
phenomenon that attracts the admiration of the world!
I shall take an individual and parallel the tree, and ask you, in
your imagination to let's take him apart, layer by layer, as we have
done the old pine tree. I am taking a man eighty years of age, who
is in full possesssion of his faculties, whose mind is alert, and whose
body is still remaking life for itself. In my imagination, I find that in
childhood it was attacked by infantile diseases, good health seemed to
disappear, and poor growth and lean years came to the infant. Then
life rushed back, and in the early years and in adolescence it grew
normally, and the rings' show rich growth. In later adolescence we
find it shaken by some kind of internal disturbance that we can't un-derstand;
it may have been religion, or social antagonisms that wrenched
asunder the relationship between mind and body; and there were a
number of years of lean growth and decay set in. Then life came
back again, covered up the scars that were left as a result of the
attack by internal storms or by outward enemies. In middle life, be-tween
forty and fifty, we find evidences that decay set in, and dissolu-tion
was threatened, due perhaps to business or profession, or to domestic
or anti-social conditions, or perhaps to some physical defect. We can't
tell whether the beginning was mental or physical. But life rushed back
again, and for a period of thirty years there was coordination and
harmony and rich life. Was the cause mental or physical? There the
parallel breaks down between the man and the old pine tree! What
was the secret of the constant return of life?
That is the riddle of the Sphinx; and it's the most modern question
of today. How much of our time is spent on the causes of disease?
Twenty-third Biennial Report 21
I am concerned as I stand before you, not so much with the disease,
because countless thousands are attacked by the same disease and go
down before they reach the average ago of fifty-eight; but what causes
life to return in its fullness and to build the cellular life, such that
I can stand before you today, apparently, Mr. President, in full pos-session
of my faculties.
John Locke said it 250 years ago, "A sound mind in a sound body,
is a short but full, description of a happy state in this world." There
is nothing new for us to add to that. The question comes back to us,
how to produce the sound mind in the sound body and create a harmony
that will give us perpetual life, even if we have to suspend in this
world and continue in the next. Higher education, ladies and gentle-men,
is concerned more and more with the sound mind in a sound body,
which means the harmony of body and mind; not the two at war. Mental
disease is, in higher education, not receiving sufficient attention. Mental
and physical tests today, though so imperfect that they can not be
followed altogether, are in the right direction. And a wonderful advance
has come as a result.
Higher education sometimes neglects the individual, but its tendency
is to make a study of the whole individual. Sometimes its results have
been fallacious. More than a hundred years, with the rise of modern
public education, higher education gave sanction to the theory that the
more the intellect in the little child is stimulated the more advantage
will he have. As a result of that theory, we had the rise of the infant
school, and little children entered school at the age of one and two
years and memorized the subject matter of adults. And each country
held up as a prize its precocious child. In Norway, it was said that a
two-year-old child could recite the history of every crowned head of
Europe, several chapters of the New Testament, and a chronology of the
world. In France, they set forward one precocious child who could sur-pass
the child of Norway; then in Hartford, Connecticut, we had a prize
baby exhibited. The fad ran for twenty years. Then higher education
began to discuss the results, and after tabulating the effects over the
twenty-year period it was learned that precocity might be a disease
more dangerous than curvature of the spine. Most of those brought
forward died early or were confined in homes for defectives. Hence,
the old folk story, that a child may be so smart that it will hardly
reach the age of maturity.
Froebel, one of the greatest philosophers that higher education gave
to elementary education, spoke of the divinity, within, and the harmony
of body and soul, and taught that it could be perfected and developed
by the right kind of plays and games, and hence we have the kinder-garten.
Following that we have had a rise of physical education in our
higher institutions, which even today is in its infancy, but augurs well
for the future.
I wish to give you a little of the results of some of our experiments
at State College as a result of the establishment of our department
of physical education. Every student entering is required to stand a
physical examination, when his condition is charted and indexed, and
at the end of the year we compare this chart with his scholastic
record. In the meantime we notify his parents if he has certain physical
22 North Carolina State Board of Health
defects that should be corrected. We have had to drop this year around
a hundred students because of a lack of scholarship attainments. A
little more than 80 per cent of those that were dropped from college
had diseased tonsils. And we are raising this question today if we
shall not require all freshmen entering who have diseased tonsils to have
them removed before we shall permit them to enter college, thus placing
the same emphasis on that disease that we place on typhoid and small-pox.
The second defect is malnutrition, the third is curvature of the
spine, and a lack of coordination of body and limbs.
We haven't collected sufficient information to give anything like
scientific results from the study that we are making; it will probably
take five or ten years more to classify this material and reduce it to
some kind of formula. But it seems to be evident that athletic train-ing
is becoming too severe, especially for the immature boy in college
or in high school. We shall be interested to follow these data, to see
after the student has left be none the the worse, or perhaps better, as
a result.
Higher education is becoming more and more interested in the diet
of the people. We are studying today vitamine contents, and are mak-ing
tests in laboratories all over the country. There is practically noth-ing
new in it except the scientific application. Long before the classic
age of Greece, vegetables, it is said, came into use largely because of
the medicinal properties which they contained; cabbage was used as a
remedy for drunkenness, asparagus for disgestion, beets for the blood,
cucumbers for their healing qualities, and garlic was used to arouse
the valor of warriors, it being rationed out just before the action.
Parsley gave the brain agreeable sensation, onions were tonic, hyssop
purified the blood, thyme was antidote for serpents' bites, ginger was
good for scurvy, and asafetida was the chief seasoning quality. Evidently
tastes, as well as styles, have changed! That brings us then, if we
are to study diet, to the study of the relation of soil and climate
to health.
Julian S. Huxley, in the current Atlantic Monthly, discusses the re-lation
of the chemistry of the soil to health. This article contains some
very interesting suggestions. In many parts of the world animals have
a tendency to eat bones and carcasses of other animals because the soil
is deficient in phosphorus and so are the plants in that area, hence
dwarfed animals are the results. In New Zealand the missing element
is iron. Animals suffer there from anemia, because the plants do not
contain this element in sufficient quantities. In parts of the United
States and Canada, and in many other parts of the world a lack of
iodine causes a disease of the thyroid. Pellagra is on the increase in
the south, due to an improper diet.
Health may turn on the kind of pastures we maintain. The grass
on which the animal feeds, the milk that goes to the children, and
the meat that goes on the table, may be deficient in the proper element
—
although the Chambers of Commerce may advertise that a certain terri-tory
is rich in a given vitamine content. It may be necessary to consider
the kind of pastures we should have before the Live at Home campaign
can operate successfully with cotton and corn and tobacco as competitors.
Twenty-third Biennial Report 23
Our diet is changing; less meat and bread, more vegetables and milk
products and poultry products are being used. But is the soil capable
of producing or supplying the vitamine elements that the food is supposed
to possess? Because it is the right kind of vegetable is no guarantee that
the vegetable contains the vitamine contents even when the soil possesses
it. A people or clan may pass away through a change of diet.
In conclusion, let me summarize as follows: Higher education if it is
to make its rightful contribution to health, must be concerned through
research and experimentation, as well as by instruction, with mental and
physical defects, and the relation of the two. The teacher and the
physician must form better cooperative relationships. Second, physical
education and relation of health to intellectual progress is just coming
under the microscope, we may say, for a study, and in years to come
we may be able to understand something of the mental in its relation
to the physical, and how one affects the other. Third, the relation of
diet to agriculture, the relation of health to industry, the relation of
the moral consciousness of people to a harmonious life of all of its
citizens are vital topics in a scheme of higher education.
24 North Carolina State Board of Health
THE INFLUENCE OF PUBLIC HEALTH AND
EDUCATION UPON THE IMPROVEMENT
OF THE HUMAN RACE
William Louis Poteat, LL. D., Wake Forest
President Emeritus of Wake Forest College.
Just as individual cells unite to form a tissue, and tissues an organ,
and organs a system of organs, and systems of organs an organism, so
we may think of individual persons uniting in a family line and lines in
strains, with a certain pigmentation, stature and physiognomy, and strains
in types, and types in races, and races, with progressive differentiation
in isolation, issuing in species. There is as yet but one species of man.
It is not probable that there will be others; for the forces which have
molded man into the primary races—White, Yellow-Brown, and Black,
with their daughter races—appear to have about expended themselves.
Variations will continue to arise, but no new sets of external conditions
are left unoccupied to favor and consolidate them. The isolation which
protected incipient variations against being dragged back into the an-cestral
type is isolation no more. The applications of science are level-ling
barriers, facilitating communication, and multiplying contacts, so
reversing the conditions which favored racial differentiation. Even now
you can drive no wedge into this human complex and split it into abso-lutely
distinct units. High authorities declare that the races which
we now recognize are unstable, mixed, and merge more or less with
other racial groups. They are freely miscible, and the assumed sterility,
weakness of offspring, and ultimate extinction of mixed bloods must be
dismissed as wanting scientific support.
Accordingly, the stage seems to be set for another drama, as long
as Bernard Shaw's Back to Methuselah, wherein the common origin of
the races of man will reassert its stabilizing power, and as the genera-tions
pass reduce diversities as slowly as they evolved, and eventually
draw back the far-wandered children into a common type again.
One thing is clear and sure. The human stock is plastic. Like the
whirling clay under the pressure of the potter's hand, it may be molded
into forms of strength and beauty express and admirable, noble in reason,
infinite in faculty, in action like an angel, in apprehension like a god;
or into forms of weakness and distortion: of the same lump of clay, a
vessel made unto honor and another unto dishonor. Another thing is
clear and sure. The clay is variable in quality and temper. It is quite
vain to insist that the only differences among the races are differences
of opportunity and training. The brain of the belated groups is not
of equal potentiality with the brain of the groups which have made the
modern world. While diversities of racial physique are not of species
value, some biologists hold that diversities of mental constitution are
pronounced enough to warrant classifying them as distinct "mental
species." And since the brain is the master tissue and mind the domi-nant
organ of man, his excellency lies back of his brow, and the peril
of degeneracy is there also.
Twenty-third Biennial Report 25
Now, our topic requires us to consider the forces which play upon
this plastic and responsive stuff of human kind, with especial reference
to its improvement. In the ancient mythology the three Fates, who were
daughters of Necessity, determined the destiny of men. In modern bi-ology
the three Fates become three Factors, which may be conveniently
thought of as the three sides of the triangle of Life. They are Environ-ment,
Training, and Heredity. To you these are familiar conceptions, but
for the sake of a point of view it may be of service to take a moment
to recall them.
Environment means the total situation into which one is born. It
includes life's physical surroundings of climate, food, shelter; also the
climate of opinion and sentiment, the intellectual and moral standards,
social conventions—all the forces which play upon life from without.
Training as here used covers all our activities, our work, our play, our
intercourse. For our deeds determine us and our fellowships educate us.
Even formal education is not so much reception as awakening. The
contacts malevolent or gracious which we establish with our contem-poraries
or with our predecessors surviving in books awaken and draw
us out. It is the active effort in response which constitutes education.
And character conceived as the end of education is the sum of our
organized responses.
Heredity is the third factor which determines the individual life.
It is a process and a relationship by which offspring tend to resemble
their parents; it is resemblance based on descent. It supplies the sub-stance
of life, the material upon which the other factors operate. It
ordains our inborn gifts and capacities, our limitations, weaknesses,
defects. It sets the boundaries beyond which no favoring external con-ditions,
no intelligence or assiduity of training, no passion of ambition
is ever able to transport us. And I remind you that environment and
training affect only the existing generation, but heredity affects all suc-ceeding
generations. As another says, wooden legs are not inherited, but
wooden heads are. Environment, training, heredity,—these three, but the
greatest of these is heredity.
Suffer a word of caution here. Do not think of these factors as
sharply distinct and independent; much less as contestants in making
or marring the human stock. Environment and training cooperate with
heredity in producing any feature or characteristic of the organism. No
characteristic is determined exclusively by the environment, and none ex-clusively
by heredity. In the efficient organism it is essential to have
the right materials, and these are supplied by heredity. But it is equally
essential that these materials "should interact properly with each other
and with other things; and the way they interact and what they pro-duce
depends on the conditions" (Jennings). Add to these complex inter-actions
the eight or ten chemical regulators, the internal secretions, which
control growth and development, and you face an amazingly intricate
and baffling problem of analysis. You will lose not a little of the as-surance
inspired by the marvelous discoveries of some fifteen years ago.
Permit me now to ask your attention to a curious fact. There ap-pears
to have been little improvement of the human stock within the
historic period. It is Sir Francis Galton's judgment that two centuries
of Athenian history (B. C. 500 to B. C. 300) made a larger contribu-
26 North Carolina State Board of Health
tion of men of genius than any two subsequent centuries. English as he
was, he said that the Athenian race of that time was as superior to the
present English race as the English race is superior to the present Afri-can
race. Certainly men of Athens eighty generations back of us set
standards in philosophy, art, letters, and statesmanship which are the
despair of all the later time! Professor Conklin of Princeton has no
doubt that human evolution has halted either temporarily or permanently.
The human brain, which is the highest structure of the evolutionary
series, has not increased in size since the time of the Cro-Magnon race,
20,000 years ago. The prevalence of nervous disorders indicates that
the nervous system is less harmonious and efficient than formerly, or
that it is losing its power of adaptation to changed conditions. Witness,
further, the increasing percentage of defect.
In striking contrast with this apparently stationary biological inherit-ance,
not to say racial deterioration, the social inheritance of the race
has extended enormously in complexity and range. Man's world of
activities, apparatus, body of knowledge, laws, institutions, has developed
faster than man's capacities. A grave problem emerges just there. We
have the machine, the weapon, but lack the wisdom and conscience to
put them to right uses. We are not unlike our New Guinea contempora-ries
of the Neolithic age set down of a sudden on Broadway.
What is the explanation of this anomaly? I offer some considera-tions.
In the first place, during all the lapsing centuries the emphasis has
been strong upon environment and training, slight or nil upon heredity.
The difference between the old world and the new relates to environ-ment
and training. Civilization itself connotes the improvement of these
two external factors. We have forgotten the type of manhood and wo-manhood
to which alone the significance of any civilization is due. When
they showed the eminent historian Renan through the brilliant corridors
of the Paris exposition and pressed him for his impression, he said, "I
have been thinking how many exquisite things there are that we can
do without."
And then—you must allow me to say it—one of the invincible ob-stacles
to race improvement is doctors. It is true, according to Pliny,
that Rome got on without them for six hundred years, but that ease-ment
was local and transient. You see, in cases of weak or degenerate
stock the doctoring has been palliative, not remedial and preventive. Of
course, care and relief are as noble as necessary, but they are costly and
superficial as compared with the effort to forestall. Doctors and nurses
and hospitals, at once the token and crown of civilized life, have intercepted
the action of the law of natural selection, which under primitive or barbaric
conditions would have eliminated weak and degenerate stocks. You receive
the weaklings and skillfully nurse them up to maturity, when by the neglect
and ignorance of society they are allowed to multiply their kind endlessly.
Beside this pollution of our best blood, which is our most precious
possession, it has been spilt by the hogshead to fertilize crops in silly
and criminal wars.
Again, there has been a conspiracy of silence on this fundamental
matter by all the agencies of enlightenment—the home, the school, the
press, the church. For the most part it has been curtly dismissed as
Twenty-third Biennial Report 27
"not nice," as a fad in vulgarity. The superstition that a certain per-centage
of disease and defect registers the decree of Providence has
been influential. The canker and tragedy of the social evil has been
condoned as "necessary," humanity rots at the root, and we acquiesce.
It is further said in justification of this silence that there is peril in
bringing the phenomena of sex into the focus of attention. Better let
sleeping dogs lie. Moreover, the attitude of reticence and mystery in
regard to the physical basis and connotations of love refines it to a
spiritual attraction and decorates it with the embroideries of sentiment
and romance. To open out its evolutionary history and its hereditary
issue can only degrade it and turn a herd of swine into life's holy
of holies.
Now at length, however, this conspiracy of silence is broken. The
Lambeth Conference of Anglican bishops declared in 1920 that the
time for such a policy on such matters was gone. A discreet book for
the guidance of young people held up as obscene the last month in a
Massachusetts court has been released as legitimate. Public health
agencies have at last found their voices, and their bulletins of informa-tion
will exert their most important influence, not in showing people
how to destroy wiggletails and to feed babies, but in educating them
about babies with a better heritage. We have seen the peril of feeble-mindedness
and insanity multiplying under the cloak of silence. Nearly
two million of our people need institutional care. One-half of these
defectives owe their defects to heredity and unrestrained will reproduce
their defects in geometric ratio. Five million of us are unable to master
the primary grades of the public school. Twenty million are capable
of only superintended labor. This scrub stock and the progressive
degeneracy of the race which it prophesies presented a social emergency
before which no social convention could stand. And the dogs were found
not to be asleep. Innocence was already violated by an underground
system of education—by means of ignorant nurses, the gossip of un-clean
and misinformed companions, quacks, patent medicine venders, sex
books, and personal adventures.
Allow one other consideration. While the size of the American family
has been declining since the eighteenth century, enough babies are now
born for our increasing native population. The insistent question is,
"Born, but in what homes?" The upper grades of capacity are not main-taining
themselves; the lower show an amazing fertility. The graduates
of Harvard have .7 of a child on the average; of Vassar .5. A feeble-minded
couple has an average of 7 children. At this rate, two hundred
years hence a thousand Harvard graduates will have fifty descendants,
but a thousand Roumanian laborers of Boston will have one hundred
thousand. Recent biological opinion appears to favor general birth con-trol
as the only effective corrective of this menacing differential birth rate.
It remains to ask what is to be done for the improvement of the
race. The answer is easily made, but its practical application is thronged
with difficulties. It is a common place of practical biology today to
control heredity for the improvement of the stock of animals and plants.
This has been done by selective breeding. The question is whether a
like care and method would work in the case of man. There is now
no doubt among men who have right to an opinion on the matter that
28 North Carolina State Board of Health
while man walks at the head of the animal procession, he belongs
to it, and that the processes and laws of heredity observed in the
lower orders of file are operative in him.
Some persons like Gilbert Chesterton and Bernard Shaw, and some
newspapers make merry with the science of eugenics because they do
not take the trouble to inform themselves. It is not free love, or trial
marriage; it is not killing off weaklings, not breeding people like pigs
and poultry. It has no program. It is merely the study and guidance
of the agencies within human control which will improve or impair the
inborn qualities of future generations. Positive eugenics seeks to pro-mote
the increase of the best stocks; negative eugenics seeks to promote
the decrease of the worst stocks. With all our lately acquired knowl-edge,
I do not think we are ready to undertake selective mating of the
fittest for race improvement. Beyond question we are ready for restric-tive
mating to eliminate the obviously unfit. Care for the feeble-minded,
the insane, the epileptic, the inebriate, the congenital defective of any
type, the victim of chronic contagious disease, care for them with in-telligence
and humanity, but deny them, in one way or another, rigor-ously
and inexorably, the opportunity of perpetuating and multiplying
their kind to the inevitable deterioration of the race.
Twenty-third Biennial Report 29
THE SOCIAL AND ECONOMIC ASPECTS OF HUMAN
AILMENTS AND PUBLIC HEALTH
Chas. O'Hagan Laughinghouse, M. D., Raleigh
Secretary, State Board of Health
Mr. Chairman, Ladies and Gentlemen, the social aspects of human
illness and public health embrace more or less all the satisfactions
and dissatisfactions of human life. Human illness enters so constantly
into the thread of events which make up individual and collective life,
that for lack of time we will forego further allusion to the social aspects
of our subject. The economic aspects of human illness and public health
cannot in my judgment be more intelligently portrayed than by: (a)
ai-riving at the economic value of men en masse; (b) indicating the cost
of disease; (c) presenting the salvage which can come to society through
the practice of disease prevention and through the promulgation of public
health activities. The social aspects of the subject will compel the ad-mission
that life and health have a higher value than money, in that
they give value to all things else. Life and health are ends in them-selves—
the conservation of both needs no justification. One cannot,
however, make clear the economic phase of human illness except by the
presentation of the subject on a financial basis. As gruesome as it is
admitted to be, I shall attempt through the portrayal of the work of
other men to discuss at least one narrow aspect of life, namely, the
actual cost of maintenance on the basis of dollars and cents. Having
done this, I will undertake to show the potential productive value of
human beings themselves at only three periods of life, and, lastly, it is
my purpose to give you a glimpse of the economic salvage that has
come to the world through the practice of disease prevention and public
health.
We Americans habitually emphasize the importance of our national
wealth in terms of real property, machinery, manufactured products, na-tural
resources, and so on. So centered have we been upon this, that
we have seemingly forgotten that human life is the nation's greatest
asset. We have not quite appreciated the economic value of human
beings and their health. Of course, when earnings cease and expenses
mount because of illness, individuals affected thereby give concern to
the individual problem. When the bread winner of a family is removed
through accident or disease and the family has to become self-supporting,
the individual family and perhaps the individual community, comes to
know the individual economic loss which has been sustained by the
family and community. But in viewing our human resources as a whole,
we have not yet come to appreciate the economic features contained in
saving human beings from disease; nor have we come to the full under-standing
of what a profitable investment, nationally speaking, life con-servation
is. In other words, what does it cost to bring up a child to the
age of eighteen, or to the age when the child comes to be self-supporting?
What are the future earnings of that child after he is weaned from his
family and from the paternalism of the State?
30 North Carolina State Board of Health
A cross section of the average wage-earning families in America
shows that the cost of rearing a child to the age of self-support includ-ing
food, shelter, clothing, education and so on is $7,238. If we include
the interest on the capital, and if we make allowance for the children
who do not survive the age of eighteen, the amount is increased to more
than $10,000. This does not include the money value of the mother's
care, although we recognize that the working mother makes a real
financial contribution to the family's maintenance. Child-rearing is an
industry in which capital is invested by parents and the State, which
capital is destined to produce future returns not to the family so much
as to the State itself. Therefore, child-rearing has come to be the
State's chief concern. Normal, healthy adults not only produce a market
for the State and Nation's products, but in addition they produce vastly
more than they consume and in their production add to the taxable
values in the way of real property, tangible and intangible in the com-munities
where they live. It has been computed that the value of the
future earnings of a normal individual at the age of eighteen on through
life is well in excess of $41,000 and the expenditures essential to the
necessities of existence for that individual are less than $13,000. So
that the economic worth to the community of a well adjusted human
machine at the age of eighteen is well in excess of $29,000. This applies
to the wage earner whose income is estimated to be $2,500 a year. The
maximum value of this particular human machine in this particular
wage-earning class is reached at about the age of twenty-five and is in
excess of $3,200. His earnings decline as the years advance, until at
the age of seventy they cease. A child born in this class of society is
worth to the State $9,333. It costs money to raise this child to the
age of self-support, but when the child begins to work, it produces more
than it consumes. The sixty million productive males in the United
States have a future net earning capacity of more than a trillion dollars.
Now there are more than 8,500,000 gainfully occupied women in the
United States, which, when added, makes the additional sum of five
hundred billion dollars, so that the total human assets, if audited and
valued from a standpoint of future earning capacity, will bring the
tremendous and staggering sum of one trillion, five hundred billion
dollars. In 1922 our national wealth in material assets was three hun-dred
twenty-one billions of dollars. So, if our calculations are correct,
our human capital exceeds our inanimate wealth by about five to one.
Having obtained an idea of the actual value to the United States of
its human machines, let's see what we are losing because of sickness.
According to Frankel and Dublin the average individual spends one-fortieth
of his time in bed because of incapacitating illness. The average
worker loses 2 per cent of his time, a fraction more than seven days a
year, because of incapacitating illness. One-fortieth of the population
is constantly ill to the extent of being bedridden. Extensive and reliable
studies indicate that where one is incapacitated, there are at least two
physically impaired to the extent of from 10 to 50 percent of their
efficiency, which is to say that for every thousand people, there are
fifty who suffer from prevalent and chronic diseases, which completely
incapacitate them for a small part of their duration. For example,
tuberculosis, cancer, heart disease, vascular disease, chronic indigestion,
Twenty-third Biennial Report 31
gallstones, kidney stones, hernias, unrepaired injuries following child
birth, and so on. The annual expense to the people of the United States
for medical service, if itemized and totaled, would read about as
follows
:
150,000 physicians, @ $3,000 per annum ..... $ 450,000,000
140,000 private duty nurses, @ $1,500 per annum 210,000,000
150,000 practical nurses, @ $1,000 per annum ... „ 150,000,000
100,000 attendants, @ $1,000 per annum ,- 100,000,000
50,000 dentists, @ $3,000 per annum 150,000,000
7,000 hospitals, with a total of 860,000 beds _ 750,000,000
Druggists for medicines 700,000,000
25,000 healers, chiropractors, osteopaths, christian scientists,
etc., @ $2,000 per annum _ 50,000,000
Grand total $2,560,000,000
The people of the United States, it will be noted, are paying for the
treatment of disease not less than $2,500,000,000 a year, or ($2,500,-
000,000^120,000,000 population) $20.83 per capita, or approximately $100
per family. The average wage-earner's family, according to studies con-ducted
by the U. S. Bureau of Labor statistics, pays $60.39 a year for
medical services. The average farmer's family, according to studies con-ducted
by the U. S. Department of Agriculture, pays $61.60 a year for
medical services. The average family represented in the clerical per-sonnel
employed by a large insurance company pays $80.00 a year for
medical services. In addition to the expense for medical services im-posed
by disease, there is an estimated annual loss to the people of the
United States of $2,000,000,000, as a result of decreased wage-earning
capacity. And there is a still further loss of permanently interrupted
wage-earning capacity through postponable deaths, estimated to be
$6,000,000,000, making a total annual cost of disease to the people of this
country $2,500,000,000 for medical services, plus $2,000,000,000 loss in
wage-earning capacity, plus $6,000,000,000 death losses—a total of $10,-
000,000,000 a year. The total annual income of the United States is
about $90,000,000,000. Any service which costs as much as medical care
and which is so absolutely essential to both individual and national
prosperity and happiness, raises at once the question of the ability
of the people to pay for it. The income of the people of the United
States, according to Leo Wolman, quoted in The Survey for June 15,
1927, was as follows:
6% of families, annual income in excess of $2,900
909c of families, annual income under 2,000
67 r/r of families, annual income under 1,450
As staggering as these figures are, they do not cover the total cost,
to-wit, the sickness causing premature death, the sickness removing in-dividuals
in their prime when they have tremendous productive value.
Now let us come to the economic value of preventive medicine and public
health. Practically one-third of the deaths that occur every year are
preventable. The great bulk of preventable deaths are in infancy and
childhood. More than 120,000 babies died from preventable diseases
32 North Carolina State Board of Health
last year. There is no reason for this except the indifference of in-dividuals
who control the community in which these children live.
Mothers will save their babies if given a chance. Would that the
physicians of the country could make the legislatures in their own
particular communities understand that babies have a dollar-and-cents
value of more than $9,000 if they are boys and $4,000 if they are girls,
and that capital lost throughout the country from infant deaths alone,
which could be prevented, is more than seven hundred and fifty million
dollars. Every year more than 30,000 young men and women between
twenty-five and twenty-nine years of age die from entirely preventable
causes and their capital value, having in mind their net future earn-ings,
is more than seven hundred and fifty million dollars. Havinp due
regard for the value of human life at each age period, it has ^ >>
mated that the total capital value of lives which can be savet .able
through the application of preventive medicine and public health
United States is well over ten billions of dollars. New let's bring x.
problem home. Every year in North Carolina there are in round numbers
6,500 deaths of infants under one year of age—half of them are males,
half females. In the death of the males we lost last year 3,250 times
$9,333; in the death of the females 3,250 times $4,666, which in the
aggregate is a loss to the State of $45,496,750 caused by the death of
infants under one year of age last year. We find in North Carolina
the number of deaths of males at the age of eighteen is 125, and the
average number of deaths of females at the age of eighteen is 125. A
male at the age of eighteen has a future earning capacity of $30,000; a
female a future earning capacity of $15,000. One hundred and twenty-five
times $30,000 is $3,750,000; a hundred and twenty-five times $15,000
is $1,875,000—which gives us a total of $5,625,000, combined net future
earnings. The average number of males dying in North Carolina at the
age of 25 is 250; females dying at the age of 25 also 250. Multiply 250
by 32,000 and we have $8,000,000. Then multiply 250 by 16,000 and we
have $4,000,000. This totals $12,000,00. Now add the loss from deaths
of one year of age $45,496,750, the loss from deaths of 18 years of age
$5,625,000, and the loss from deaths of 25 years of age $12,000,000, and
we have $63,121,750. One-third of these deaths are preventable. The
State actually lost last year by death in only these three age groups
$21,040,583 plus. The average family spends yearly $80 on sickness.
We have aproximately 600,000 families in North Carolina. This multi-plied
by $80 amounts to $48,000,000. Two per cent of our population is
sick all the time, which means that 60,000 people in North Carolina are
sick 365 days in a year. To care for this sickness it takes in North Caro-lina
two thousand physicians at an average of $3,500; 700 dentists at an
average of $3,500 a year; 1,000 nurses at an average of $1,500 a year;
600 nurses doing private duty; 5,000 midwives; 800 orderlies; stenogra-phers;
assistants in hospitals and offices of private physicians; druggists;
drugs and sick room supplies; patent medicines; osteopaths; chiro-practors;
christian scientists; faith healers; neuropaths and so on, and
so on. And to this we will add the loss of time of the sick people and
their families and we can easily see that sickness costs this State more
than $50,000,000 a year.
Twenty-third Biennial Report 33
Lastly, we come to the salvage to society through the practice of pre-ventive
medicine and the promulgation of public health. We have
conquered epidemics of serious import with the exception of influenza.
In 1875 the death rate was 28.3 per thousand; in 1925 it was 11.5; and
in 1880 the average life span was about 40 years; it is now nearer 56
years. In 1901 a baby born in the United States registration area might
expect to live 49.24 years: this expectation of life has been extended to
57.74 years. The diseases which have been most reduced are those which
affect infants and young children. Infant mortality has been cut 60
per cent in the past twenty years. In the past, nearly 25 per cent of
the babies did not survive the first year, only about 7 per cent die today,
and two-thirds of this 7 percent will be prevented in the near future.
In the death rate from typhoid fever was thirty-six per 100,000
-tration area. This disease is now not far from extinction.
-a is on the point of being wiped out. In 1900 it had a death
m 43.3 per 100,000. In 1926 this death rate was reduced to 7.5.
The most striking demonstration of the effectiveness of public health work
is the experience of the Metropolitan Life Insurance Company: 17 years
ago, it instituted a program of health education and nursing service
for its working class policy holders. It has expended over $20,000,000
in this line of work, and in 17 years it has decreased its mortality rate
more than 30 per cent. The accumulative saving to this one company in
mortality between 1911 and 1925 has totaled the amazing sum of
$43,000,000. During this period of their demonstration the death rate
from tuberculosis among the industrial policy holders has been reduced
to 56 per cent; the typhoid fever reduction is 80 per cent; the com-municable
disease of childhood reduction is 55.5 per cent; the reduction
from diphtheria alone being 62 per cent. In every important condition
the death rate has declined among the industrial policy holders twice
as fast as it has declined in the general population. The expectation
of life has among these industrial policy holders increased by nine years,
since 1911. Whereas the corresponding increase in the general popu-lation
has been about five years. Health work when properly undertaken
and adequately financed pays by every test of this business organization.
The efforts of preventive medicine directed to the prevention of typhoid
fever in North Carolina has saved the State $215,000,000 since 1914. In
1914 North Carolina had 3,260 deaths from tuberculosis; in 1928 it had
2,244 deaths from tuberculosis. If the same death rate from tuberculosis
in 1914 had continued through 1928 we would have had 14,224 deaths
from tuberculosis which we did not have, which means a saving in the
net earnings of males and females at the age of 18 of $309,401,000.
North Carolina is spending today less than forty cents per capita
in preventive medicine and more than $15.00 per capita on cost of sick-ness
alone, one-third of which sickness is preventable. In 1920 there
were 603,683 males twenty-one years and over in this State; 607,044
females twenty-one years and over. According to the estimates
above mentioned we would have $20.00 earning capacity apiece for the
males and $10.00 earning capacity apiece for the females; and
according to this, the total worth of man power in North Carolina
ten year ago, our last census was taken, Would reach the gigantic figure
of $18,144,300,000; while the material wealth in 1920 was only $4,543,-
34 North Carolina State Board of Health
110,000. The achievements in the field of public health have completely
changed the surroundings of the average citizen in the United States.
They no longer live in dread of plague, cholera, yellow fever, virulent
smallpox, typhoid fever and a host of other horrors. Did time permit,
we could with profit look back into the days when plague, pestilence
and famine were rife in the world. We have but to go back to 1914
as far as North Carolina is concerned, when the population of the State
was less than 2,000,000, and find where we had 839 deaths from typhoid
fever, the disease giving a death rate of 35.8, while in 1928 we had 185
deaths with a death rate of only 6.3. If the rate of 1914 had continued
up to 1928 inclusive we would have had 10,000 deaths from typhoid
fever which we did not have. Figuring these deaths at net future earn-ings
of $29,000 for males and $14,500 for females, we would produce
the enormous sum of $214,368,000 saved the State from one piece of
work alone, namely, the prevention of typhoid. Take tuberculosis: North
Carolina had in 1914, 3,260 deaths from this disease. In 1928 we had
2,240 deaths from tuberculosis—the saving of 1,016 people and their
potential earnings last year. If the same rate had continued during the
14 years from 1914 to 1928, we would have had 14,224 deaths that we
did not have—a saving to the State in the net future earnings of males
and females of $309,401,000. The elimination of accidents would add
more than a year to the average expectation of life. A goodly propor-tion
from heart disease are preventable, which prevention would add
appreciably to the span of life. The same may be said of arteriosclerosis,
and cancer.
If we were but willing to utilize and if we would but finance ways
and means to put preventive medicine into actual practice, we could
easily raise the expectation of life from 58 to 65 years. We are confronted
with a real situation. We know how great is the value of human life.
We know the surrent losses from sickness and death. We have
the knowledge and resources necessary for the control of dis-ease.
Obviously, if we are governed by knowledge we will im-mediately
undertake to more consistently and meticulously avail
oui'selves of the advantages of disease prevention. Today public health
work is really in its infancy, the public is coming to see and know
that less than fifty cents per capita represent the total expenditure for
public health, while more than fifteen dollars per capita represents the
money spent for medical service, which money is directed to the allevia-tion
of disease and not to its prevention. The prevention of disease
is a purchasable thing. Money invested in the business will bring un-told
dividends. Not only in dollars, but in happiness and in the joy
of living.
Twenty-third Biennial Report 35
BUREAU OF COUNTY HEALTH WORK
Rural county health work in the United States, in the sense that
the term is now used, had a rather belated beginning. There are some
conflicting claims as to the date and location of the first full-time county
health department. Jefferson County, Ky., claims to have initiated this
service in 1908. This view, however, rests upon very vague and uncon-vincing
evidence, which in some respects tends to disprove rather than
support the claim. Although the need for full-time county health de-partments
was stressed many times prior to 1911, the only tenable con-clusion
was that can be drawn from the records thus far presented
is that the first definite efforts of an official nature that were made in
the direction of establishing a full-time county health department took
place in that year. North Carolina enjoys, we believe, the distinction of
having established the first full-time county health department on July
1st, 1911. During the same year, under the inspiration of Surgeon L. L.
Lumsden, U. S. Public Health Service, the health officer of Yakima
County, Washington, was appointed full-time medical director.
Other independent organizations followed these early beginnings.
Progress was, however, very uncertain up to 1917, when state financial
cooperation was introduced in North Carolina. From the beginning
of this cooperative arrangement, it became apparent that a vitalizing
principle had been discovered. The first financial cooperation was
formed on a three year basis in which the county, during the first year,
assumed 50 % of the entire expenditure and the State Board of Health
and International Health Board each supplied 25%. This financial as-sistance
was on a descending scale and during the second year, the
rates were 60%, 20 </, and 20% respectively; and during the third year—
75%, 12y2
f/f and 12%% respectively. At the close of the three-year
period it was contemplated that financial cooperation from agencies other
than those of the county would cease.
Before the end of the contemplated three-year period it became
evident that the principle of financial cooperation and assistance was a
policy of the State Board of Health to be continued indefinitely. With
reference to the influence of this financial cooperation, it seems certain
that the present development in county health departments would have
been delayed for many years without the aid of financial cooperation
from sources other than the county. Before the event of financial co-operation,
there was a lack of system and uniformity and misdirected
effort on the part of county health officials.
While the investment of state funds in local health work entitles the
state to a voice in the management of the local project, this right is
exercised in North Carolina with caution and in an advisory capacity
only. Cooperation rendered by the state does not mean domination. The
zeal for local self-government, though perhaps sleeping, is not dead. To
do violence to this principle will call forth a righteous indignation that
may well be dangerous or even disasterous. In the second place, if the
State Board of Health assumes power or authority it is accepting an
equal measure of responsibility which may prove at times to be most
embarrassing. Although the State Board of Health offers a county help
K
HW
H
DO
O
» CO
38 North Carolina State Board of Health
and not dictation, it does not hold itself aloof from the management of
local affairs. On the contrary, experience has shown the wisdom, under
the cooperative system, of delegating the selection of health officials and
the formulation of the program of work to the State Board of Health.
In so doing, the State Board of Health acts only as the county's agent,
and performs such functions as privileges and not as obligations. Thus,
in this manner, directional influence is accomplished, but the authority
and burden of responsibility is placed upon the local community.
During the period July 1, 1928, to June 30, 1930, the State Board of
Health cooperated with forty-three full-time county health departments,
thirty-eight of whom were under the direct supervision of a medical
director and five conducting public health nursing service only. The
preceding table gives a list of the organized county health departments
in the state together with the date of organization, the personnel em-ployed,
the total annual budget and the amounts appropriated by co-operating
agencies. (See Table No. 1, p. 36.)
The following table shows the combined work accomplished in the
forty-three counties for the period July 1, 1928, to December 31, 1929,
together with the cost equivalent earned:
i. communicable disease control
1. Contagious Diseases:
Quarantine by Mail
Measles
ig_j
Pertussis
.
1,375
Scarlet Fever 555
Diphtheria
j 347
Smallpox _ 73
Chickenpox 344
Typhoid . 143
Paratyphoid j
Septic Sore Throat _, 32
Poliomyelitis g
Cerebro-spinal Meningitis 9
Rubella _ 53
Pellagra 105
Total Number 4 451
Cost Equivalent $2,225.50
Quarantine by Visits
Measles 973
Pertussis 6 956
Scarlet Fever 2 204
Diphtheria 3 014
Smallpox . 357
Chickenpox 3 286
Typhoid 734
Paratyphoid 1
Septic Sore Throat. 61
Poliomyelitis 39
Rubella 544
Cerebro-spinal Meningitis ..
_
39
B. Dysentery... 144
Typhus Fever 2
Pellagra 30
Diphtheria Carriers 8
Return visits 8 804
Total visits 42
Total Number 27,248
Cost Equivalent $40,872.00
Twenty-third Biennial Report 39
40 North Carolina State Board of Health
hi. medical and laboratory services
Medical
Twenty-third Biennial Report
v. food control
41
1. Inspections:
Dairy —
Abattoir
Hotel, restaurant, market -
2. Examinations and Tests of Animals:
Ante mortem (when temperatures are taken)
Post mortem, viscera attached. —
Cows tuberculin tested by veterinarian employed by health
department 11,019.00
VI. MISCELLANEOUS
1. Conferences, Health Officer:
Office conference by health officer -
Official group (including meeting of Board of Health and
County Commissioners)
2. Convictions, Violation of health laws
VII. TRANSPORTATION
1. Mileage (Official Business):
Car miles. ---
Health officer-miles
Nurse-miles..
Sanitary inspector-miles
Totals
1,692,661
637,149
748,632
356,961
169,266.10
31,857.45
22,458.96
10,708.83
$1,388,357.84
42 North Carolina State Board of Health
On January 1st, 1930, the State Board of Health adopted a plan
of the American Public Health Association for reporting activities of
rural health departments. The following tabular summary gives the
accomplishments of the forty-three full-time departments for the period
January 1, 1930, to June 30, 1930.
Communicable Disease Control
Item 1. Reportable Diseases:
Cerebrospinal Meningitis-
Chancroid
Diphtheria
Gonorrhea
Measles.
Poliomyelitis
Scarlet Fever
Smallpox. ..
Syphilis.
Tuberculosis
Typhoid Fever
Whooping Cough
Others
Cases Reported
Twenty-third Biennial Report 43
Item 6. Tuberculosis Control:
Number
Nurses visits to cases or contacts 3,882
Nurses visits to post sanatoria cases - 689
Visits to physicians or clinics for diagnosis or treatment 10,395
New cases registered with physicians or clinics for diagnosis or treatment 7,240
New Cases hospitalized: Incipient 99
Advanced 176
Under 15 years of age 359
Patient days in hospital 42,784
Children completing 6 weeks: Open air class room.. 3,122
Prevent oria 19
HEALTH OF THE CHILD
Item 7. Prenatal:
Number
New prenatal cases visited by nurse 2,421
Nurses visits to prenatal cases 3,326
Prenatal visits to physicians 1,187
Cases delivered in hospital ' 343
Midlives instructed and registered. __ 1,275
Item 8 Infant:
Number
Nurse visits to infants under one year 12,926
Visits to infants under 1 year to physicians.. ^ 2,279
Visits infants under 1 year to nurses conference 900
Item 9. Pre-School Child:
Number
Nurses visits to children ages 1-5 years 9,668
Visits children ages 1-5 years to medical conference 11,763
Visits children ages 1-5 years to nurses conference 3,983
Item 10. School Child:
Number
Number school children same grade weighed: First 17,051
Second 11. 853
Number schools notification of weight sent to parents: First 7,176
Second 1,949
Number underweights weighed: Every 2 weeks 7.000
Every 4 weeks 18,615
School children examined by physician --. 46.494
Hours spent in examination by physician 5,134
Number schools in which physician examined children. 1,183
Number parents present at time of examination — 5,397
School children, vision, hearing and measurements made by teacher or nurse 73,084
School < hildren inspected by physician or nurse 87.569
School children having teeth filled 18,867
S.hool children having teeth extracted^ 16,694
ol children having teeth cleaned 23.041
School children having glasses fitted 687
School children having tonsil and adenoid operations 2,469
School children having orthopedic defects corrected 176
School children with heart or lung defects placed under physician.. 972
Nurses visits in behalf of grade school children 14,839
-
I ool children visiting nurses conference 3,663
Number parents present at nurses conference 1,605
ool buildings inspected once per year - 908
44 North Carolina State Board of Health
sanitation
Item 11.
Number
Sanitary inspections and reinspections 106,956
Food handlers examined 3,250
Dairy cows tuberculin tested 8,804
Dairy farms inspected 4,022
Rural water supplies improved 191
Rural privies built or improved 6,471
Urban privies built or improved- 7,005
Sewer connections 1, 420
LABORATORY
Item 12.
Number
Examination for diphtheria 1,230
Examination for typhoid 305
Examination for tuberculosis 521
Examination for syphilis 6,688
Examination for gonorrhea 418
Examination of -milk samples 4,551
Examination of water samples: Public supplies 2,934
Rural-semi-public 950
Examination, others 3,823
POPULAR HEALTH INSTRUCTION
Item 13.
Number
Number health pamphlets, placards, etc., distributed 123,214
Articles on Health published in newspapers. 1.189
Lectures or talks on Health 3.874
Showing of motion pictures on Health 3.301
Special demonstrations to promote Health work 1,055
COUNTY PHYSICIAN REPORT
Number
Examination, prisoners 7,498
Examination for marriage 1,51.3
Examination, teachers 245
Examination, child for industry 1,238
Examination by court order 292
Examination for admission to institution 657
Examination for lunacy 531
Examination, post mortem 153
Visits to jail.- --- 2,657
Visits to convict camp 1,465
Visits to county home ___ 2,241
Visits to County T. B. Hospital 766
Completed anti-rabic treatments _. 93
Treatment, hookworm _,. _ _
_
381
Since the organization of the first full-time county health department
in Guilford County, North Carolina, there has been a steady growth in
development until the end of 1929 when it was found that 1,883,047 of
the State's 2,975,000 population was under full-time health protection,
which gives a percentage of 63.3%.
Twenty-third Biennial Report 45
The accompanying graph illustrates the development of the county-health
units in the State.
46 North Carolina State Board of Health
THE BUREAU OF SANITARY ENGINEERING
AND INSPECTION
The activities of this bureau embrace all of the non-medical activi-ties
of the State Board of Health. The community or area, usually the
municipality, rather than the individual is the object of attention. The
work of the Bureau is directed toward the improvement of the sanitary
environment, for the prevention of spread of contagious diseases and the
elimination of conditions that indirectly exercise a deleterious influence
upon the health of the people. The measures employed in the conduct of
these activities involve practical sanitation, engineering, chemistry and
biology directed along the lines of—(a) Practical application of recognized
principles of sanitation and public health engineering in the establish-ment
of safeguard to the health of the community and the State, and
(b) Scientific investigations to furnish information upon which to base
and execute sound, safe and progressive policies consistent with wise
public economy.
This biennium marks the completion of a decade of activity of this
bureau, which was created by the General Assembly of 1919, under the
present directorship, and an attempt will be made to present in this
report a brief review of the development and accomplishments of the
division for the ten-year period. Starting in the spring of 1919 with one
man, engaged in the execution of a single project, the Bureau has ex-perienced
a healthy growth until this year the total personnel in its
service numbered thirty-two, engaged in twenty-two distinct activities.
Although this expansion may appear rapid, it has not been sporadic. No
activity has been assumed for the sake of mere expansion or without
careful consideration of its public health significance and the ability of
the organization successfully to carry it into execution. New enter-prises
have been undertaken one at a time and each well established
before a new one was launched. It has been the policy of the bureau
in instituting new activities to select specially trained personnel for the
particular project and concentrate every effort upon it until it was
a "going concern," and then, by training the other members of the
organization in that line of work, consolidate the new work as far as
possible with the other duties of the general personnel. This plan
offers the advantages that—(a) the department is not entirely depend-ent
upon one individual to handle one particular phase of work, as it
would be with a corps of specialists, (b) the service rendered is much
greater and more prompt, (c) travel expense is reduced to a minimum,
and (d) the personnel of the bureau is given much broader training, ex-perience
and perspective, which deepens their appreciation of public
health problems, affords more professional development and increases
their usefulness.
The policy of the bureau has been progressive and far sighted, its
measures preventive rather than remedial. There has been an apprecia-tion
of the problems of sanitation before these problems became acute,
and preventive measures applied in time have forestalled the develop-ment
of conditions that would be extremely difficult, if not impossible,
Twenty-third Biennial Report 47
to remedy. An example of this foresight is afforded in the stream
sanitation program. With the rapidly increasing population and in-dustrial
development of the State it was foreseen that without a full
understanding of the situation and adequate control measures the pollu-tion
of North Carolina streams would attain such proportions that ex-tremely
foul and dangerous conditions would prevail, with no hope of
applying economically practicable remedial measures that would return
these streams even approximately to their former natural condition. So,
several years ago, before the problem became acute, an intensive pro-gram
of stream sanitation was begun, and later continued in coopera-tion
with the Department of Conservation and Development, involving
complete hydrological, physical, chemical and biological studies of the
various river systems, investigations of the quantities and characteris-tics
of all the sewage and industrial wastes entering the streams, deter-mination
of suitable methods of treatment for such wastes and the ap-plication
of these findings in the enforcement of a program of wastes
treatment that will insure the maintenance of safe and decent stream
conditions. Thus North Carolina has been able to avoid the deplorable
situation that exists in most of the densely populated and highly in-dustrialized
states by applying the effective ounce of prevention rather
than relying upon the uncertain pound of cure.
The foregoing example is representative of the policy governing all
the enterpi*ises of the bureau. Moreover, in the development of the or-ganization
every effort has been made to assume new activities in the
order of their public health importance, and to coordinate them with
existing activities in such a way that they would be of mutual assist-ance,
capable of exercise by the general personnel of the division with
a consequent economy of administration.
During the first years of the bureau's work, attention was centered
principally upon educational measures for the promotion of community
interest in essential sanitary improvements, such as excreta disposal,
water supply, sewerage and milk sanitation, upon the enforcement of
State laws and regulations relating to these matters, and the applica-tion
of accepted principles and standards. With these fundamental en-terprises
well established and functioning smoothly on a routine basis,
and with the rapid muncipal and industrial development of the State,
much attention has been directed in thev later years to extensive and
highly specialized scientific investigations in the sanitary chemistry and
biology of water purification, sewage and industrial wastes treatment
and stream pollution to afford basic information on which to found
policies and direct activities in dealing with the present and future
problems of sanitation in a rapidly growing commonwealth.
•ACTIVITIES OF BUREAU
The various functions of the bureau are administered through the
following three divisions, comprising twenty-two distinct activities, manned
by specially trained pex-sonnel. Included in parentheses after each activity
is the date of institution of active field work.
48 North Carolina State Board of Health
I—Sanitary Inspection Division
1. Enforcement of State Sanitary Privy Law (1919)
2. School sanitation (1919)
3. State institution sanitation (1921)
4. Hotel and restaurant sanitation (1921)
5. Jail and convict camp regulation (1925)
6. Bedding sanitation (1929)
7. Summer and tourist camp sanitation (1928)
8. Barber shop sanitation (1929)
9. Roadside sanitation (1930)
II—Sanitary Engineering Division
1. Public water supply control (1921)
2. Certification of interstate carrier water supplies to U. S. Public
Health Service (1921)
3. Public sewage disposal control (1921)
4. School water supply and sewage engineering service (1925)
5. Stream pollution surveys (1926)
6. Industrial wastes investigations (1926)
7. Central sewage and industrial wastes laboratory service (1926)
8. State institution water supply and sewerage engineering service
(1927)
9. Mineral water analyses for N. C. Dept. Conservation and Develop-ment
(1928)
10. Chemical and bacteriological examination of public water supplies
(April 1,—July 1, 1929)
11. Mosquito and malaria control (1929)
III—Food Sanitation Division
1. Milk Sanitation (1924)
2. Shellfish sanitation (1925)
ORGANIZATION OF BUREAU
The accompanying chart is designed to show in a general way the
organization of the bureau, the duties of the personnel and the inter-relationships
of the various activities. A more detailed account of the
functioning of the organization will be given later in this report.
Twenty-third Biennial Report 49
oigAfliZAno/i-or the e>vr£av of tmrnwopG amd l7i6PEcrion
liOXTH CAROLl/tA 6TATE bOA1$ Of HEALTH
Chief E/ioi/iEEn
Administration
PRI/ICIEAL
A&516TAHT
£^TQUUtR.
Public Vater Supply
Public Sewge Disposal
crtream Sanitation
Sevage <uxi Indcis-tnal
wastes Inves-tigations
3 &TE/10GRAPH&R.- CLERKS
decreterial and
Stenographic Service
Assistant
E/iqi/ifcER
Office Engineer
Correspondence
l!e_viev> of Plan*
Library.
School Engineering
3 DISTRICT
E/KliTEEB§
SAmMy Chemist
Public Water Supply
Sevafce And Indus-trial
waste* Disposal
Field Investigations
Certification In-terstate
Carrier
Water &upply__
ASSlSTA/iT
SjlQlflEfcH
Institutional
Engineering
E &A/iITARY
Chemists
URORATOgyAooT
/Mocta] Water
Analyses
Sevage, Indus-trial
wastes and
Stream Analyses
JU/1IOJL
Etioi/ieee.
LAtoiiftroiYAsgr.
8pecial Industri-al
Wastes Inves-tigations
AasiSTA/iT
E/1QI/IESR.
Mosquito and
Malaria Control
AS6I6TA/1T
E/Kil/lEEB.
Milk and Sbellfisb
Sanitation
Sbellfisb Control
Chief
6A/trrAKy
INSPECTOR
Priyy,Jail and
Convict Camp,
Hotel and Cafe,
Milk, School, In-stitution
, Tour-ist
and Summer
Camp, bedding,
barber Sbop,and.
Roadside Sanitation
4 District
5A/llTARy
Inspectors
Privy, Jail and
Convict Camp,
Hotel and Care,
Milk .School, In
stitution .Tour-ist
and Summer
Camp, bedding,
barber Sbop.and
^adside Sanitation
8 SA/llTARy
INSPECTORS,
Privy, School Tour-ist
and Summer
Camp,and Road-side
Sanitation
50 North Carolina State Board of Health
I—SANITARY INSPECTION DIVISION
1—ENFORCEMENT OF STATE SANITARY PRIVY LAW
Objective: The purpose in this activity is the prevention of spread of
infectious diseases that are caused by the insanitary disposal of
human excreta.
Methods: In 1917 the legislature appropriated $15,000 to be used as
a supplement to funds available from the Federal Government and
public health foundations, on a 1 to 3 basis, for the purpose of stimulat-ing
rural sanitation, but provided that none of this fund should be
expended except as a supplement to funds given by outside sources. The
General Assembly of 1919 enacted legislation, considered bold at the
time, providing that no person shall maintain or use a residence, lo-cated
within three hundred yards of another residence, that is not pro-vided
with sewerage or with a sanitary privy complying in construction
and maintenance with the requirements of the State Board of Health,
and authorizing the Board to enforce this act. This statewide sani-tary
privy law was the first of its kind in the country, and remained
the only one until the last two years when two other States, guided
by North Carolina's successful experience, enacted similar legislation.
For the past eleven years this bureau has been engaged with the rigid
enforcement of this statute, involving more than 650,000 inspections of
privies. This is accomplished through a force of sanitary inspectors,
the present organization consisting of a chief inspector, four district
supervising inspectors and eight inspectors. The chief inspector, in
addition to supervising the activities of the division, is charged with the
inspection of jails and convict camps, hotels, cafes, schools, State insti-tutions,
milk supplies, tourist and summer camps, bedding manufactur-ing
and selling establishments, barber shops, and roadside stations in
a definite district of the State. He is employed jointly with the State
Department of Public Welfare, and devotes about one-half of his time
to the prison, jail and convict camp work of that department. The
four district supervising inspectors are responsible for all of the sani-tation
activities mentioned above in their respective districts, and main-tain
close supervision over the work of the sanitary inspection in their
districts. The eight sanitary inspectors are charged with the inspection,
construction and maintenance of Sanitary Privies, the sanitation of
schools, tourist and summer camps and roadside establishments and the
investigation of special complaints in their area. The county is the unit
of work in sanitary inspection. When an inspector is detailed to a
county, he remains there until all privies, schools, camps and wayside
stations which come within the scope of the law and regulations, are
sanitated. He is then transferred to another county. Where local health
departments exist, the inspectors work in close cooperation with those
organization. The inspectors distribute sanitation literature, inspect
privies, cite defects of privy construction and maintenance, advise and
show property owners and tenants how to remedy these defects, issue
notices for compliance with the law, and where unable to secure com-pliance
with reasonable effort within the time limit of the official notice
they prosecute the violator in the magistrate's court. They secure the
Twenty-third Biennial Report 51
adoption of local ordinances requiring connection to the public sewerage
system where available, encourage municipalities in the extension of their
sewers to outlying districts, and assist the local sanitary officials in the
enforcement of sewer connections. They stimulate the installation of
new public water supplies and sewerage systems, and, wherever such
improvements are seriously considered or undertaken, concessions are
granted in the enforcement of the privy law pending the completion of
the work, in order that money may not be needlessly spent for privies
soon to be abandoned. The policy governing this activity is one of co-operation
and service. Inspectors maintain the attitude of assisting
the violator rather than compelling compliance with any law or regu-lation,
and invoke the law only in obstinate cases where reason and per-suasion
are of no avail. The rapid decrease in prosecutions during the
decade attests the wisdom of this policy of education of the public.
In addition to the building and maintenance of sanitary privies, the
inspection force has devoted much attention in recent years to the sanita-tion
of country schools, dairies, hotels and cafes and to investigations
of typhoid in rural communities and mill villages. Much time has been
given to local health departments for cooperative activities and for in-struction
of their sanitary inspection personnel in the methods and stand-ards
of this department. In several localities county-wide programs of
sanitation have been carried out in conjunction with local health or-ganizations.
For the past three years the sanitary inspectors have obtained and
tabulated information for each home served by the excreta disposal
facilities inspected to indicate the names of owner and occupant of the
property, whether the home is inside or outside of the corporate limits
of municipalities, the type of privy or sewage disposal employed, the
procedure by which improvements were effected, the unused depths
of pit in the earth pit type of privies, the items found defective in privy
maintenance, the number of persons in the home, the number having
typhoid vaccinations within three years, the number of cases and deaths
from typhoid in the last three years and the type and protection of the
water supply used by the family. From such a sanitation census, which
will shortly cover the entire state and include upwards of 200,000 homes,
very valuable basic information can be obtained upon the life of privy
buildings and pits and their defects in design, upon the sources of
typhoid infection, whether from insanitary excreta disposal or from
improperly protected water supplies, and upon the relative merits of
sanitation and immunization as preventive measures in controlling
typhoid.
Epidemiological and vital statistic records of typhoid cases and
deaths have been studied with reference to the foci of their occurrence
and correlated with the sanitary protection afforded in the urban, in-corporated
and rural communities. Since the sanitary privy law does
not apply to strictly rural sections of the State on the theory that
isolation itself is a most effective means of preventing the spread of
intestinal diseases, these comparisons of morbidity and mortality rates
are very illuminating and convincing arguments for sanitation.
52 North Carolina State Board of Health
Results: The items listed below represent the principle accomplish-ments
in this activity of privy sanitation. So far as available records
permit, the figures indicate the results obtained during each biennium
of the eleven years of the bureau's work under the present administra-tion:
Items For biennium ending June 30
1920 1922 1924 1926 1928 1930
Privies inspected 63,107 151,796 154,600 73.592 80,517 60,308
Sewer connections made 5,268 6,107 6,442 2,077
Septic tanks constructed .__ 132 842 854 921
Privies condemned in sewer areas _ ., 2.073 1,450
Prosecutions under privy law 1,500 834 1,382 989 672 285
Investigations of special complaints ___ 528 153 27
It will be noticed that in the last few years there has been a con-siderable
decrease in the number of privy inspections and sewer con-nections.
A number of causes are responsible for this, among which the
most important are: the assumption of new bureau activities, which
will be discussed later, employing the inspection personnel in their ex-ecution;
typhoid fever investigations in rural communities; sanitation
of dairy water supplies and sewage disposal facilities in connection with
the enforcement of the U. S. P. H. S. Standard Milk Ordinance in sixty-five
towns of the State; county-wide programs of sanitation in coopera-tion
with county health departments; more intensive rural school sani-tation;
the collection and reporting of detailed sanitation and typhoid
history data for each home sanitated; the training and assistance given
to the inspection personnel of local health departments; the depressed
economic situation which has caused more householders to undertake
their own privy construction and necessitated individual supervision of
the work by the inspectors; reduction in number of sanitary inspectors
engaged in privy law enforcement due to insufficient funds; and the
misunderstanding on the part of the public of the former mass-pro-duction
methods of privy construction where trained carpenters often
followed the inspectors in their work. Especially has this last factor de-terred
the rapidity of privy building. As a result of unfounded sus-picions
of collusion between inspectors and itinerant, the bureau issued
strict orders three years ago directing inspectors to prevent and dis-courage
workmen as far as possible, from following them from place to
place. This order has made it necessary to train an inexperienced man
in the construction of practically every privy and to give every job
detailed attention. The net result has been to lower the standard of
construction, to increase the unit cost and to impair the efficiency of the
inspection force to a very great extent.
Typhoid History and Water Supply Survey of Homes Sanitated
by Inspection Division
During the past three years the sanitary inspectors, in addition to
their other duties, have obtained complete typhoid histories at all homes
which have been sanitated by approved privies in that period, have
collected information regarding the maintenance of privies previously
built, such as rates of filling of earth pits under different conditions of
soil and usage and development of defects in construction, and secured
Twenty-third Biennial Report 53
full data on the types of water supply used in these homes. It is
believed that such information, covering so large a part of the semi-rural
population of the State will be very valuable to health agencies
in affording an indication of the relative merits of sanitation and im-munization
in the control of typhoid fever incidence, in indicating the
useful life of sanitary privies of the type analyzed in North Carolina
and their weak points in construction and maintenance, and in estimat-ing
the importance of private water supply protection in the control of
typhoid transmission.
The data on family typhoid history and water supply which have
been collected in the counties in which the sanitation work has been
completed and reports filed during the three-year period are given in
the following table
:
Counties in which sanitation program completed 58
Number of homes sanitated 50,578
Population of homes sanitated 199,822
Typhoid History
Number vaccinated in last 3 years 36,313
Number cases typhoid in last 3 years 1,260
Number deaths from typhoid in last 3 years 62
Water Supply
Homes served by open well 15,552
Homes served by well with pump 18,685
Homes served by municipal water supply 14,942
Homes served by spring 1,181
Homes served by cistern 218
It is noteworthy that, in spite of educational measures and intensive
typhoid vaccination campaigns, only 18 per cent of the people living in
the semi-urban homes included in this representative survey have availed
themselves of the protection afforded by vaccine. This indicates that
sanitation of environment must be depended upon to safeguard four out
of every five of these persons. The number of vaccinations reported in
this survey is of course not absolutely accurate, but probably indicates
a greater vaccination ratio than actually exists because it is found that
unless questioned closely the average person that has been vaccinated for
smallpox or anything else will at first answer in the affirmative as to
typhoid vaccination. Typhoid incidence is obviously still far too high.
This condition is due to a variety of causes,—lack of immunization, in-sanitary
disposal of excrement, unprotected water supplies,—and con-stitutes
an insistent demand for improved sanitation. Almost one-third
of the homes surveyed obtained water from open and unprotected wells
and springs, and in general the privies were old and in a bad state of
maintenance, due to long intervals that must elapse between sanitation
surveys because of the limited force of inspectors.
When more complete data are secured, it is hoped to find some very
interesting correlations between typhoid incidence and vaccination, water
supply and privy maintenance.
54 North Carolina State Board of Health
Typhoid Morbidity Rates
From the case reports of the Bureau of Epidemiology the following
table has been prepared showing the typhoid morbidity rates for the
State for the past three years. The cases have been segregated accord-ing
to race and place of residence, and the typhoid rates expressed in
cases per 100,000 population:
Typhoid Morbidity Rates
Typhoid Cases per 100,000 Population
Incorporated
Year General* White Colored Places Rnralj-
1927 _ 44.0 39.0 56.0 47.1 42.5
1928 .. 36.4 31.2 49.2 42.4 33.8
1929 .... .. 29.3 24.6 41.0 32.3 28.0
From these figures it is seen that in each classification typhoid fever
is declining at a most encouraging rate. In this three-year period the
general State rate has been diminished by 33.3 percent, the general white
rate by 37 percent, the general colored rate by 26.8 percent, the rate for
all incorporated places by 31.5 percent, and the rate for rural communi-ties
by 34 percent. But a noteworthy and important public health fact
is revealed by comparison of the rates for the white and colored races.
While the case rate for white population is only 24.6, the corresponding
rate for negroes is 41.0, or 67 percent higher than for whites. This
difference is undoubtedly due to the difference in living conditions, and
mainly to the inferior sanitation of negro homes and environment, but
it is a condition which should, and can, be greatly improved by the con-tinuance
of strict sanitary measures. In fact, in this population group
typhoid control measures other than sanitation avail little.
The typhoid rate for incorporated towns and cities remains somewhat
above the State average, while the rural rate is slightly below. This
differential is expected, due to the greater opportunity for dissemination
of the disease in densely populated communities. Before the day of
State-wide privy sanitation of these populous areas, public water supply
and sewage disposal improvement, the differential was tremendously
greater. Moreover, privy sanitation in cities, towns and villages has had
the effect of reducing the rural rate,—directly by including in its scope
all rural areas within one mile of community centers or from town and
city limits, and indirectly by removing foci of typhoid infection from the
populous districts where rural typhoid formerly had its principal source.
Furthermore, more than half the total number of privies sanitated are
located outside the corporate limits of any city or incorporated place, in
rural areas, surrounding municipalities, in mill villages and other unin-corporated
places.
It should be noted also that in the "urban" communities there are
usually one or more hospitals and that all deaths occurring in these
hospitals are charged to the community in which the hospital is located
regardless of the origin of the case. This tends to show a higher
"urban" death rate than actually exists.
* "General" rates are for entire State, regardless of race or residence.
t "Rural" refers to population living outside of incorporated places.
Twenty-third Biennial Report 55
Typhoid Mortality Rates
From the official records of typhiod deaths filed with the Bureau of
Vital Statistics the following table has been prepared showing the
typhoid mortality rates for the past thirteen years. The deaths have
been classified into several divisions according to race and residence and
the rates expressed in deaths per 100,000 population. Computations were
made on the basis of U. S. Census reports and estimates of population.
56 North Carolina State Board of Health
result. Hardly less significant can be the results achieved through the
improvement and protection of public water, milk and food supplies. It
is safe to say that preventive public health measures directed toward
the sanitation of environment are of paramount importance.
It has been previously noted that typhoid morbidity rates for negroes
are greatly in excess of those for whites. From the mortality figures
above an even greater difference is observed between the typhoid death
rates for the two races. For the State as a whole the negro rate is 3.3
times the white rate; for urban populations it is more than twice as
great; and for rural communities it is 3.9 times as great. Typhoid
seems to be a much more virulent disease in the case of negroes than
it is with white people as the following tabulation for the past three
years period indicates:
Percentage Typhoid Cases Resulting in Deaths
Year General White Colored
1927 19.2 14.7 22.9
1928 17.3 13.4 23.4
1929 18.8 13.3 26.9
Mean 18.4 13.8 24.4
Much has been accomplished in ridding the State of the scourage of
typhoid and other intestinal diseases, but much remains to be done. The
negro typhoid problem is one of many which effective sanitation can
solve. The general typhoid rate is yet too high. Urban rates can be
greatly decreased by continued and concentrated effort, and the time has
arrived when general public health protection demands that State-wide
sanitation measures be extended to all rural districts. A lapse in vigil-ance
will result in the loss of results already achieved and a return of
the death rates of former years. By effective and complete sanitation
typhoid fever may become an unknown disease, banished from the country
as have been cholera and yellow fever.
2—SCHOOL SANITATION
Objective: By the general sanitation of school buildings and surround-ings
and the provision of safe water supplies and sewage disposal facili-ties
every effort is made to protect school children, teachers and their
families from infectious diseases, to inculcate in them an appreciation
of the principles and practices of sanitation, to be employed in their
homes and carried with them into life, and to emphasize the indirect
beneficent effects on health and happiness of cleanliness of body and
environment.
Methods: The General Assembly of 1919 enacted legislation requiring
the provision of adequate sanitary equipment for the public schools of
the State. Field work was actively undertaken during the same year
and carried on conjointly with the administration of the State-wide sani-tary
privy law. The sanitary facilities of the schools were found to be
in a deplorable condition generally, especially so in the country districts,
where, in most cases, no provisions other than those afforded by Nature
herself, had been made for lending privacy or disposing of excremental
matter. Water was usually carried from a spring located below the
school grounds or drawn by a rope and bucket from an open well.
Twenty-third Biennial Report 57
School buildings were remote and small, poorly lighted, heated and venti-lated,
and, with their surroundings, filthily kept. With the phenomenal
improvement in educational facilities in the last few years have come
hundreds of large consolidated schools with mo