Biennial report of the North Carolina State Board of Health |
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H00111237 F .IIIINIIIHNIIUI lipiip ill 1 1 llllllllll llipillll I pilillll llllllll WHK I Y '. ": C i,;ND '''biennial 're PO. It) iBiBn^^m n NOK'fll CA IlilHitlilUIH Mvm id 1 A y n Ci)c Libcarp of t!;£ Unititmiv of Jl^ortb Carolina (EnDotoeD bp ^l^t SDialcctic ano P!)(lQnt!)ropic feiocirties WA 1 H?>G2b TWENTY-SECOND BIENNIAL REPORT OF THE NORTH CAROLINA STATE BOARD OF HEALTH JULY 1, 1926 - JUNE 30, 1928 Members of the State Board of Health 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, December 1, 1928. His Excellency, A. W. McLean, Governor of North Carolina. My Dear Sir:—Under authority of chapter 118, Ai'ticle 1, section 7050, Consolidated Statutes of North Carolina, I have the honor to submit the Biennial Report of the State Board of Health for the period July 1, 1926, to June 30, 1928. Very respectfully yours, Chas. O'H. Laughinghouse, Secretary and Treasurer. Public Health Work in North Carolina In the seventies Dr. Thomas Fanning Wood, of Wilmington, caught the vision of the possibilities of public health work to North Carolina. 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 inspiration, we shall never know. We do know 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 influence reached the people of the State in their General As-sembly of 1877, with the eff'ect that on February 12, 1877, the North Caro-lina State Board of Health was born. Ours was the twelfth State board of health to be established. Without treating the development of the newly-established board with that thoroughness that could be termed history, we think it enough to set down here in chronological order the principal events in the life and growth of the North Carolina State Board of Health. 1877. Board created. Consisted in the beginning of entire State Medical Society. Society acted through a committee. Annual appropri-ation, $100. 1878. First educational pamphlet issued. Subject, "Timely Aid for the Drowned and Suffocated." Annual appropriation, $100. 1879. The General Assembly reconstituted the Board of Health. Made it to consist of nine members: six appointed by the Governor, three elected by the State Medical Society. Term of office, five years. Dr. Thomas F. Wood elected fii-st Secretary of the Board, May 21. Other legislative provisions: (1) Chemical examination of water, and (2) organization of county boards of health, composed of all regular practicing physicians and, in addition, the mayor of the county town, the chairman of the board of county commissioners, and the county surveyor. Four educational pamphlets issued. Subjects: "Disinfection, Drainage, Drinking-water, and Disin-fectants;" "Sanitary Engineering;" "Methods of Performing Post-mortem Examinations;" "Limitation and Prevention of Diph-theria." Annual appropriation, $200. 1881. General Assembly passed a law requiring registration of vital statistics at annual tax listing; law ineffective. Annual appro-priation, $200. 1885. General Assembly made county boards of health more efficient; allowed printing privileges not to exceed $250 annually. Annual appropriation, $2,000. 1886. Bulletin made its appearance in April. Pamphlet on "Care Eyes and Ears," by Dr. Richard H. Lewis, printed and distributed. Subse-quent Legislature provided for extra edition of 10,000 copies for general distribution. Annual appropriation, $2,000. 1888. Yellow fever epidemic in Florida and refugees to Western North Carolina demonstrated value of a Board of Health to cope with situation. Annual appropriation, $2,000. 8 North Carolina Board of Health 1892. Dr. Thomas F. Wood, the Secretary of the Board, died August 22. Dr. Richard H. Lewis elected Secretary to succeed Dr. Thomas F. Wood, September 7. Annual appropriation, $2,000. 1893. Legislative provisions: (1) Laws improving the reporting of con-tagious diseases, (2) the protection of school children from epi-demics, (3) protecting the purity of public water supplies, and (4) regulation of common carriers. Legislature provided that Governor appoint five of the nine members of the Board of Health, that the State Medical Society elect four, and that the term of office of the members of the State Board of Health be reduced from five to two years. The $250 printing limit was removed. Pamphlet on quarantine and disinfection was prepared and re-printed by many of the State papers. Annual appropriation, $2,000. 1894. A number of public health conferences were arranged and held in difl!"erent towns of the State. Bulletin was increased from a mail-ing list of 800 to 1,200. Annual appropriation, $2,000. 1895. Dr. Albert Anderson and Dr. W. T. Pate were elected bacteriologists for the board. Annual appropriation, $2,000. 1896. Board passed a resolution requiring chemical and bacteriological examinations of municipal water supplies. Dr. Venable of Chapel Hill, undertook the chemical examination, and Drs. Anderson and Pate the bacteriological examination. Board also directed Mr. John C. Chase, the engineer member, to inspect all municipal water plants in the State. Annual appropriation, $2,000. 1897. General Assembly enacted law requiring county superintendents of health to be elected by county commissioners, and reduced term of ofi'ice to one year. Annual appropriation, $2,000. 1899. General Assembly improved the laws protecting public water sup-plies. Smallpox prevailed extensively in the State. Dr. Henry F. Long, and later, on Dr. Long's resignation. Dr. Joshua Tayloe were employed to travel over the State, consulting with and advising the local sanitary authorities as to proper means for protecting the public. Annual appropriation, $2,000. 1900. State Board of Agriculture, on request of State Board of Health, agreed to examine samples of water from public water supplies until Board of Health could provide its own examiner. Annual appropriation, $2,000. 1901. State Board of Embalmers, with representatives of State Board of Health, established. County health work placed in the hands of county sanitary committees composed of county commissioners and two physicians which commissioners elected to serve with them. Term of office of county superintendent of health made two years. Annual appropriation, $2,000. 1903. General Assembly enacted law permitting Board of Health to charge $5 for each analysis of a public water supply, this fee to be used in paying Department of Agriculture for services of examiner. Dr. C. W. Stiles, U. S. P. H. S., before the State Medical Society at Hot Springs, called attention to prevalence of hookworm dis- Twenty-second Biennial Report 9 ease in the South. Dr. J. L. Nicholson and Dr. W. S. Rankin, working under State Board of Health during fall of 1903 and spring of 1904, showed great prevalence of this disease in North Carolina. Annual appropriation, $2,000. 1904. A stenographer was employed. One hundred and twenty thousand pamphlets on tuberculosis were printed and distributed. There was a renewal and an extension of cooperative work between the Board of Health and the State press, a number of articles dealing with hygienic and sanitary subjects being furnished the papers and published in them. Annual appropriation, $2,000. 1905. General Assembly established State Laboratory of Hygiene; imposed water tax of $64 on all public water companies; voted $600 an-nually for support of Laboratory. Small appropriation made it necessary for the Department of Agriculture to continue to assist State Board of Health. Annual appropriation, $2,600. 1906. The North Carolina Association for the Study and Prevention of Tuberculosis was organized. Annual appropriation, $2,600. 1907. Two thousand dollars appropriated for the State Laboratory of Hygiene. Pasteur treatment provided. State Sanatorium for treatment of tuberculosis founded: $15,000 appropriated for permanent improvements and $5,000 for maintenance. A law re-quiring the separation of tuberculous prisoners from other pris-oners was enacted. Annual appropriation, $4,000. 1908. January 1, Dr. C. A. Shore became Director of State Laboratory of Hygiene. Annual appropriation, $4,000. 1909. General Assembly provided for (1) whole-time State Health Officer; (2) collection of vital statistics of towns having a population of 1,000 or over; (3) that all public water companies file plans and specifications of their plants with the State Board of Health, and that the State Board of Health pass necessary rules and regula-tions for the care of public watersheds and plants and furnish such rules and regulations and other advice to those having charge of public water supplies; (4) that counties provide free diphtheria antitoxin for county indigents, and (5) that the maintenance appropriation for the Sanatorium be increased from $5,000 to $7,500, and an additional $30,000 be granted for permanent im-provements. Dr. Richard H. Lewis resigned as Secretary of the Board, and Dr. W. S. Rankin was elected as his successor, begin-ning his official work July 1. Annual appropriation, $10,500. 1910. General effort to interest the people and State organizations in public health work. Bulletin increased from 3,500 edition to 10,500 edition. Addresses on public health work delivered to Con-ference of County Superintendents of Schools, State Federation of Women's Clubs, State Press Association, and Sanitary Sunday observed in April. Dr. John A. Ferrell elected, February, As-sistant Secretary for Hookworm Eradication; began work under State Board of Health and Rockefeller Sanitary Commission. First effort in the eradication of hookworm disease was to interest school teachers in the disease and through their assistance ex-amine and treat the children, and thereby reach the community. 10 North Carolina Board of Health Three bottled spring waters sold on the market examined, found polluted, and public attention called to the pollution. Annual appropriation, $10,500. 1911. Legislature established county boards of health to take the place of the county sanitary committees; county board of health com-posed of chairman board of county commissioners, county superin-tendent of schools, mayor of county town, and two physicians selected by the three county officials to serve with them. Legis-lature also abolished quarantine for smallpox and improved the quarantine laws. One thousand dollars annually appropriated to contract with antitoxin manufacturers for State supply of high-grade diphtheria antitoxin, with result that price of antitoxin was cut to one-fourth former price, saving the citizens of the State over $30,000 annually. Bulletin increased from 11,500 copies to 20,000 copies each edition; closer cooperation with press of State developed; regular weekly press articles prepared and sent to papers; increase in numbers of popular pamphlets for distribution. Hookworm work this year largely educational through the school forces and investigative through county dispensaries; thousands of children found infected and treated. Strong sentiment began to make itself felt for better health work by counties, four counties employing whole-time county health officers. Maintenance appro-priation for State Sanatorium increased to $12,500, with $20,000 voted for permanent improvements. Annual appropriation, $22,500. 1912. Bulletin increased to 40,000 edition; number of popular pamphlets dealing with different diseases increased; press work improved; educational work of Board along all lines amplified. Secretary of Board of Health called attention of conjoint meeting of State Medical Society and State Board of Health to the relative im-portance of health problems and the bearing of this subject upon the proper apportionment of health funds; instrumental in pass-ing a resolution to the effect that pellagra was an interstate prob-lem, not a State problem, and requesting the Federal Government to deal with pellagra as a Federal problem; resolution responsible, to considerable extent, for successful effort on part of Hon. John M. Faison's securing Congressional appropriation of $45,000 for the study of pellagra by the Federal Government. Hookworm work extended and county funds appropriated to supplement State and Rockefeller Foundation for this work. Annual appropriation, $22,500. 1913. General Assembly passed Model Vital Statistics Law with $10,000 appropriation for its enforcement. County superintendents of health changed to either county physician or county health officer. Educational efforts of Board continued and enlarged. Hookworm work along same line as year before increased in amount. Dr. John A. Ferrell resigned as Assistant Secretary to accept position with the central office of the Rockefeller Sanitary Commission in Washington, D. C. Dr. C. L. Pridgen succeeded Dr. Ferrell. The movement for improved county health work had by this time resulted in ten counties electing whole-time countv health officers. Twenty-second Biennial Report 11 The State Sanatorium for Treatment of Tuberculosis turned over by Extra Session of 1913 to the management of State Board of Health. Annual appropriation, $40,500. 1914. Preceding work of the Board continued. Board of Health took over management of Sanatorium; started out under many difficulties on account of the institution owing many debts and the appro-priation being limited. Hookworm work changed to community work directed to the installation of sanitary privies in all homes. Laboratory began to produce and distribute free anti-typhoid vac-cine. Dr. C. L. Pridgen resigned as Director Hookworm Eradi-cation, and Dr. W. P. Jacocks succeeded him. Annual appro-priation, $40,500. 1915. General Assembly makes State vital statistics law conform to National model by requiring burial permits in rural communities; enacts legislation permitting county commissioners and towns and cities to appropriate money for support of tuberculous citizens in State Sanatorium; provides $15,000 for purchase and building of antitoxin plant: appropriates $60,000 for payment of Sanatorium debts and new buildings and other improvements, and $25,000 annually for maintenance and $10,000 for extension anti-tubercu-losis work. Educational work greatly extended: Bulletin now 47,000; traveling public health exhibit shown at fairs and other assemblages; press work greatly developed through employment of journalist for whole time; stock lectures with lantern slides supplied public speakers in different parts of the State; com-munity soil pollution work under Dr. W. P. Jacocks stops in May, and Bureau of County Health Work with Dr. G. M. Cooper at its head, succeeds, beginning work in June. Considerable amount of work done for improvement of prison conditions. The unit system of county health work gets a good start: over 52,000 people given three complete vaccinations against typhoid fever, and medical inspection of schools put on in one county. Annual appropriation, $50,500. 1916. North Carolina was admitted to the Registration Area for deaths. To the educational agencies of the Board was added a self-sup-porting moving picture health show. Many saw this show during the year, and, seeing, believed in health work as never before. Bulletin had to be discontinued temporarily for lack of printing funds, but before discontinuance reached 51,000 edition. Co-operation with University in developing a plan and putting on a home post-graduate course in medicine, giving first course to 169 doctors. Put into operation an optional system of hotel inspec-tion, with grading and publishing scores. Continued unit system of county health work, giving three anti-typhoid injections to 48,000, making 100,000 immunized in summers of 1915 and 1916. Did complete medical inspection of five counties and with inspec-tion a large amount of educational work as to sanitary and hygienic living. Secured effort by Federal Children's Bureau to develop unit of child hygiene work, the Bureau using two em-ployees to work in Cumberland and Swain counties for about eight months. Laboratory of Hygiene buys land and erects its own 12 North Carolina Board of Health building. Sanatorium making a decided impression on the State. Annual appropriation, $55,500. 1917. The General Assembly passed the following important health legis-lation: Chapter 263, entitled "An act to prevent and control the occurrence of certain infectious diseases in North Carolina;" chapter 244, entitled "An act to provide for the physical ex-amination of the school children of the State at regular inter-vals;" chapter 276, entitled "An act for the cooperative and ef-fective development of rural sanitation;" chapter 257, entitled "An act to prevent blindness in infancy, designating certain powers and duties and otherwise providing for the enforcement of this act;" chapter 66, entitled "An act to provide for the sani-tary inspection and conduct of hotels and restaurants;" chapter 286, entitled "An act to regulate the treatment, handling and work of prisoners." Following the enactment of this legislation, administrative ma-chinery, consisting of a Bureau of Epidemiology under the direc-tion of Dr. A. McR. Crouch, a Bureau for the Medical Inspection of Schools under the direction of Dr. Geo. M. Cooper, and a Bureau for County Health Work, under the direction of Dr. B. E. Washburn, was established. Dr. Washburn, an officer of the Inter-national Health Board, was loaned to the State without cost and the International Health Board, in addition to furnishing Dr. Washburn, appropriated $15,000 annually for rural sanitation in accordance with the provisions of chapter 276. The United States Public Health Service in February, 1917, de-tailed Dr. K. E. Miller to study county health work in different sections of the country and to establish for demonstration pur-poses, in Edgecombe County, department of health on an economic basis easily within the financial reach of the average county. The State Laboratory of Hygiene moved into its own building January 15, 1917. The State was admitted to the registration area of the Union for births in January, 1917, the Bureau of the Census having found after investigation that our birth registration was 96 per cent complete. The special campaign against typhoid fever begun so satis-factorily in 1915, was continued. Free vaccination of the people, however, was interferred with by the difficulty in securing medical officers to do the work, the preparedness program of the Govern-ment having caused many physicians and nurses to enter the Army and Navy; nevertheless, a total of 30,000 citizens of the State were vaccinated as a direct result of the Board's activities, and many thousands of others were vaccinated by the physicians of the State as a result of the educational work of the Board directed to impressing the people with the value of vaccination as a means of prevention for typhoid fever. In December, 1917, life extension work as developed by the Life Extension Institute of New York, which consisted briefly of the free physical examination of interested citizens for the pur-pose of advising them as to their physical condition and needed Twenty-second Biennial Report 13 \ hygienic reform and medical treatment, was begun on a county basis. The funds necessary for this work were appropriated partly by the State and partly by the counties in which the life extension work was carried out. Dr. Amzi J. Ellington, who at the time was a resident physician in the New York City Hospital and who had during his residency in that institution studied the methods of the Life Extension Institute under Dr. Eugene Lyman Fisk, was employed and placed in charge of the work. Life ex-tension work was carried out in Vance, Alamance, Lenoir and Robeson counties, and resulted in the full physical examination of 4,000 citizens. This work was very favorably received, and the outlook for its continued development seemed excellent when, with the declaration of war and the call for physicians to enter the military service of the country, Dr. Ellington enlisted in the Medical Corps of the Army. For this reason, and for the further reason that it has been almost impossible to secure health officers during the past two years, the work was not resumed. The educational work of the State Board of Health consisted in the issuance of eight Bulletins, each monthly edition amount-ing to 45,000, and a daily newspaper health article. The Bureau continued its moving picture show exhibit and, in addition, pre-pared probably the best three-dimension educational exhibit in the United States. In 1917 the following exhibits were given: motion picture entertainments, 236; traveling public health ex-hibits, 32; special exhibits, 58; stereopticon entertainments, 3 — to a total of 95,000 people. Arrangements were made for the preparation of newspaper plate, which was sent to and extensively used by 202 papers having a total circulation of 303,000. A large part of this newspaper material was prepared by the well-known authority and publicist in matters of sanitary and hygienic edu-cation. Dr. W. A. Brady of Elmira, New York. The annual appropriation for the State Board of Health was $60,772.16. The annual appropriation for the State Laboratory of Hygiene was $12,500, and this, in addition to $9,087.22 in fees permitted under the laws of the State to be paid to the Laboratory for special work, provided the Laboratory with a total annual budget of $21,587.22. 1918. Much of the work this year was influenced by the war and had to do with preparedness. The State Health Officer visited Washing-ton, at the request of the Council of National Defense and as chairman of a committee of State Health Officers, on a number of occasions for conferences with respect to preparedness measures, provisions for the control of venereal diseases, arrange-ments for coordinating the control of infectious diseases in the civilian population with their control in cantonments, and to arrange, if possible, with the Public Health Service and the Surgeon-General of the Army for preserving the personnel of State health departments during the war. The State Health Officer also made a visit to the states of South Carolina, Georgia, Alabama and Florida for the Council of National Defense in order, 14 North Carolina Board of Health if possible, to interest the Governor, the State Board of Health, and the State Council of Defense in venereal disease control. Considerable time was given to assisting Major John W. Long, Medical Aide to the Governor, in the work of organizing the Medical Advisory Boards and in interesting physicians in enter-ing the medical service of the Army and Navy, and, later in the year, in inducing the physicians of the State to become members of the Volunteer Medical Service Corps. Pai'tly as a result of these activities, the Surgeon-General of the Army assigned Major Joseph J. Kinyoun to assist the State Board of Health in the control of communicable diseases, the Board being under no financial obligation for Major Kinyoun's assistance; and as a result of the successful termination of the activities of various interests looking to a more effective control of venereal diseases, the Kahn-Chamberlain Bill passed Congress, and made available to the State of North Carolina, and without condition $23,988.61 for venereal disease work. The Laboratory during this year began the distribution of a high grade of diphtheria antitoxin. The Bureau of Medical Inspection of Schools developed, and with a degree of success that we may say established, free dental clinics for the public schools of the State. The Bureau also de-veloped to a successful extent an arrangement in the form of adenoid and tonsil clubs for the practical and economic treatment of public school children suffering from these defects. The Bureau of Epidemiology employed two third-year medical students, equipped them with motorcycles, and put them into the field to investigate infringements of the quarantine law. Suf-ficient convictions were obtained to impress the medical profession with the determination of the State to enforce its health laws, and a fairly satisfactory compliance with the laws regarding the reporting of communicable diseases was brought about. The Bureau of Venereal Diseases, paid for by the Federal ap-propriation, was established in September under the directorship of Dr. James A. Keiger of Charlotte, N. C. Mr. Warren H. Booker, for the last seven years the efficient director of the Bureau of Engineering and Education, left in September for Red Cross work in France, the work of his bureau being continued, with the exception of the engineering work, by Mr. Ronald B. Wilson. As a result of Mr. Booker's leaving, cer-tain funds became available, and a Bureau of Infant Hygiene, under the directorship of Mrs. Kate Brew Vaughan, was organized late in 1918. Perhaps the most outstanding feature of the health work dur-ing the year 1918 was the epidemic of influenza. The epidemic began early in October and caused in October alone 6,056 deaths; in November 2,133 deaths; and in December 1,497 deaths, a total during the last three months of 9,686 deaths. The annual appropriation for the State Board of Health for 1918 was $73,210.38. Twenty-second Biennial Report 15 The annual appropriation for the State Laboratory of Hygiene was $12,500. The Laboratory, during this year, collected $8,532.48 in fees for special work, so that the total income of the Laboratory for this year was $21,032.48. 1919. The General Assembly passed the following important health legis-lation: Chapter 71, entitled "An act to prevent the spread of disease from insanitary privies;" chapter 192, entitled "An act to provide for the physical examination and treatment of the school children of the State at regular intervals;" chapter 206, entitled "An act for the prevention of venereal diseases;" chapter 213, entitled "An act to require the provision of adequate sanitary equipment for public schools;" chapter 214, entitled "An act to obtain reports of persons infected with venereal diseases;" chap-ter 215, entitled "An act for the repression of prostitution;" and chapter 288, entitled "An act to amend chapter 671, Public-Local Laws of 1913, relating to the injunction and abatement of certain nuisances." The Bureau of Engineering and Inspection was organized in April. The engineering work of the Board had been suspended with the resignation of Mr. Warren H. Booker in September, 1918, Mr. Booker having gone to France to engage in tuberculosis work under the direction of the Red Cross. Between September, 1918, and April, 1919, the engineering problems coming before the Board had been referred and very kindly and effectively taken care of by Col. J. L. Ludlow of Winston-Salem. Mr. H. E. Miller, an engineer and a graduate of the University of Michigan, was placed in charge of the new bureau, and his brother. Dr. K. E. Miller, of the United States Public Health Service, was detailed by the Service to assist him in the organization of his work. Mr. H. E. Miller and Dr. K. E. Miller spent the spring and sum-mer and a part of the fall in studying various types of privies, in preparing plans for the construction and maintenance of privies, and in preparing the necessary notices and literature to inform the people of the objects and requirements of the new privy law. On May 1st Dr. A. J. Warren, health officer of Rowan County, was appointed to and accepted the position of Assistant Secretary of the Board. On July 1st Mr. R. B. Wilson accepted the position of Director of Public Health Education. On August 1st Dr. A. McR. Crouch, Director of the Bureau of Epidemiology, i-esigned to accept a position with the city of Wil-mington. Dr. F. M. Register, whole-time health officer of North-ampton County, succeeded Dr. Crouch as director of the bureau. In September Dr. J. R. Gordon, Director of the Bureau of Vital Statistics since 1914, resigned on account of impaired health, and on October 1st the Bureau of Epidemiology and the Bureau of Vital Statistics were combined and placed under the direction of Dr. Register. In September Mrs. Kate Brew Vaughan, Director of the Bureau of Infant Hygiene, resigned. The bureau was reorganized under 16 North Carolina Board of Health an understanding with the American Red Cross and was enlarged to include, in addition to infant hygiene, the problem of public health nursing, the name of the bureau being changed to that of "Bureau of Public Health Nursing and Infant Hygiene." Under the agreement with the Red Cross this bureau was to have an available appropriation of $12,000 a year, half of which was to be furnished by the American Red Cross and half by the State Board of Health. The personnel of the bureau and its plan of work, under the agreement, was made contingent upon the ap-proval of both participating agencies, the American Red Cross and the State Board of Health. In December Miss Rose M. Ehren-feld took charge of the new bureau and began its organization and work. On October 1st Dr. Jas. A. Keiger, Director of the Bureau of Venereal Diseases, resigned and Dr. Millard Knowlton was ap-pointed to succeed him. The typhoid campaign carried on during the summer through previous years, was continued in the summer of 1919, using third-year medical students, furnished either with automobile or motor-cycle for getting about. Campaigns were carried out in the fol-lowing counties: Bertie, Cabarrus, Chatham, Chowan, Columbus, Craven, Hertford, Iredell, Johnston, Lincoln, Onslow, Pasquotank, Perquimans, Randolph, Richmond, Rockingham, Stanly, Union, Warren, Wayne. A total of 49,076 were given complete vacci-nations. The educational work of the Board consisted of the publication of a 48,000 monthly edition of the Bulletin, and the distribution of about 350,000 pieces of public health literature. The funds available during this fiscal year amounted to $198,- 549.14, of which $102,301.98 was from State appropriations and the remainder from outside sources. The appropriation for the State Laboratory of Hygiene for this year was $28,500; in addition to this, the Laboratory collected in fees for special work, for antitoxin, and in water taxes a total of $14,344.02, making a total of $42,844.02 available for work of Laboratory. 1920. During this year there was a Special Session of the General As-sembly, lasting twenty days and held in the latter part of August. This Special Session passed an act amending the vital statistics law,, making the fees for local registrars 50 cents instead of 25 cents for each certificate properly filed with the State Board of Health. On January 1st Dr. B. E. Washburn, who had had general direction of the cooperative county health work and who had rendered most acceptable service, was recalled by the Inter-national Health Board and detailed to take charge of their inter-ests in Jamaica. Dr. K. E. Miller, of the United States Public Health Service, who had been detailed in January, 1917, to or-ganize a model county health department in Edgecombe County and then, in 1919, to assist his brother, Mr. H. E. Miller, in organ-izing the work of the new Bureau of Engineering and Inspection, Twenty-second Biennial Report 17 to which was assigned the duty of enforcing the State-wide privy act, succeeded Dr. Washburn as Director of the Bureau of County Health Work. In January a cooperative effort with the United States Public Health Service and the International Health Board to demonstrate the possibilities and advantages of the eradication of malaria from certain towns and cities in the eastern part of the State was begun. The terms of cooperation were that the International Health Board and the State Board of Health were to pay one-half of the expenses of the local work and the town or city in which the work was done the other half, the Public Health Service furnishing, as its part, expert supervising personnel. The towns and cities chosen for this work were Goldsboro, Farmville, and Greenville, the budgets for each municipality being, respectively: Goldsboro, $13,670.98; Farmville, $5,000; and Greenville, $9,000, a total investment in this work of $27,670.98. Mr. A. W. Fuchs, Associate Sanitary Engineer, was detailed by the Service to have supervision of the v^^ork. In February Dr. A. J. Warren, Assistant Secretary of the State Board of Health, resigned his position in order to accept the appointment of city health officer of Charlotte, N. C. In the winter and spring of 1920, the North Carolina Land-owners' Association, under the progressive leadership of Mr. W. A. McGirt, of Wilmington, undertook a very extensive educational campaign against malaria, which was carried on through the pub-lic schools of thirty-eight counties in eastern North Carolina. A series of county and State prizes for the best essay on malaria by public school children were offered as an inducement to the school children to interest and inform themselves, and, indirectly, their parents, with regard to the importance of this disease. To make possible this work by the school children 75,000 malaria catechisms, prepared by Dr. H. R. Carter, of the United States Public Health Service, v/ere distributed through the public schools of the eastern part of the State to the school children. Thousands of essays were written, and it is reasonable to believe that the campaign was one of the most successful public health educational attempts yet undertaken. In June it was found advisable to separate the Bureau of Epi-demiology and the Bureau of Vital Statistics which had, on ac-count of the scarcity of health officers, been placed under the directorship of a single bureau chief. Dr. F. M. Register. Dr. Register was appointed Director of the Bureau of Vital Statistics and Dr. J. S. Mitchener was appointed Director of the Bureau of Epidemiology. In April the Interdepartmental Social Hygiene Board assigned to the State Board of Health several workers for making a study of vice conditions in North Carolina towns and cities and for taking such steps as were found expedient for decreasing prosti-tution. This group of workers was withdrawn in September, on account of differences developing between them and Dr. Knowlton, chief of the Bureau of Venereal Diseases, with the understanding 18 North Carolina Board of Health that another group of workers would be assigned to this work at a later date. In June arrangements were made with the United States Public Health Service and the American Social Hygiene Association for the development of an elaborate educational unit on sex hygiene and venereal diseases designed to reach rural meetings through the use of picture films and a portable truck. An outfit consist-ing of several lectures and a moving picture truck began work in Cumberland County in August, and from its very beginning met a most cordial reception and gave every promise of developing into one of the most useful agencies for dealing with the venereal disease problem. During the year the anti-typhoid vaccination campaign was con-tinued in Alamance, Bladen, Columbus, Duplin, Franklin, Gaston, Harnett and Mecklenburg counties. Cooperative campaigns, in which the counties furnished the working personnel, were also carried on in Anson, Johnston and Rutherford counties. A total of 29,435 citizens have been vaccinated against the disease, and this does not include Columbus County, in which the work was just beginning when this report was completed. The educational work of the State Board of Health during this year consisted of a 48,000 monthly edition of the State Board of Health Bulletin and the distribution of approximately 350,000 pieces of public health literature. The funds available during this fiscal year amounted to $342,- 284.33, of which $176,152.61 was State appropriation and the remainder from outside sources. The appropriation for the State Laboratory of Hygiene for this year was $25,000; in addition to this, the Laboratory collected in fees for special work, for antitoxin and in water taxes, a total of $13,698.89, making a total of $38,698.89 available for the work of the Laboratory. The above amount being insuff"icient, the Special Session of the Legislature authorized a loan of $15,000 to enable the work of the Laboratory to be carried on, making a total of $53,698.89 available for the work of the Laboratory during this year. 1921. The Legislature meeting early in January of this year was asked by the Board to amend the State law restricting the salary of the executive officer of the Board to $3,000 annually, so as to make the salary $5,000. Such an amendment was passed. A further request from the Board was that legislation be enacted removing the inspection tax of forty cents from privies coming under the supervision of the Board of Health. Such an amend-ment to the State-wide Privy Law was also enacted. A bill was introduced in this session of the General Assembly under the initiative of Hon. Emmet H. Bellamy requiring a physical ex-amination of all applicants for marriage and making issuance of license contingent upon the physical qualifications of the appli-cant. The State Board of Health approved and supported Mr. Bellamy's bill, realizing, as did the author of the bill, that the proposed legislation was but a step in the right direction and was, Twenty-second Biennial Report 19 therefore, rather loosely drawn and left many things to be de-sired. The bill finally passed in amended form as chapter 129, Public Laws of 1921. The general health of the State for 1921, as indicated in the vital statistical records for that year, published by the United States Bureau of the Census, was good, and there was an im-provement in reduced death rates for a number of diseases, as well as a reduction in the general death rate over previous years. Another general condition of State-wide importance with a vital bearing on the work of the Board of Health which had to be taken into account was a considerable amount of misunderstanding between respective groups of the medical profession and the Board of Health regarding matters of policy. Many physicians, men in good standing professionally and men with high civic ideals, seemed to feel that the Board of Health had no well-considered and reasonable objectives in the field of public health as it is related to that of private practice. This general condition was responsible for the Board of Health seeking and availing itself of opportunities to meet the profession, both in county, dis-trict and State societies, and to discuss with the profession what it conceived to be the proper relation between public health activities and professional practice. This subject was presented to and considered by the State Medical Society in its conjoint meeting with the State Board of Health at Pinehurst in April, 1921. See transactions Medical Society of the State of North Carolina, pages 472-506. As a result of these various conferences between representative men engaged in public health work and the profession, the general condition of misunderstanding and some little friction had disappeared to a large extent by the latter part of the year. Nevertheless, the results of contact between those engaged in social medicine and private practice were such as to encourage further conferences and efforts to bring about a fuller recognition of mutual interests on the part of the public and the profession, and the ultimate adoption of a program of relations which would be to the mutual advantage of both parties. Perhaps the most important change inaugurated in State health administration during this year was the adoption of a cost basis for standardizing and measuring the efficiency of public health work in those counties in which the State participated financially. This new principle is fully described in the State Board of Health Bulletin for January, 1922, and a further discussion of cost basis for public health work is unnecessary here except, perhaps, to say that it is apparently at least one of the first attempts to introduce the cost system of industry into government. The Bureau of Venereal Diseases, in charge of Dr. Millard Knowlton, established as a part of the war-time activities of the Board in cooperation with the Bureau of Venereal Diseases of the Federal Government, was combined with and made a part of the work of the Bureau of Epidemiology, under the general direc-tion of Dr. J. S. Mitchener. 20 North Carolina Board of Health Funds available for the year included: State appropriation, $275,000; miscellaneous receipts, $164,184.42; total, $439,184.42. 1922. In order to bring the records of this department into harmony with those of other State departments, in accordance with the act of the General Assembly of 1921, changing the fiscal year of the State so as to begin on July 1st each year, this report ends with June 30, 1922. It, therefore, covers a period of nineteen months; one full fiscal year from December 1, 1920, to November 30, 1921; seven months from December 1, 1921, to June 30, 1922. Effective February 1, the American Red Cross Society abrogated the agree-ment existing since 1919 by which it jointly financed with the Board of Health, the Bureau of Public Health Nursing and Infant Hygiene. This bureau was reorganized April 1 as the Bureau of Maternity and Infancy, for its maintenance the State receiving $27,259.66 annually from the United States Government in ac-cordance with the Sheppard-Towner Act for the promotion of the welfare of mothers and infants. Dr. K. P. B. Bonner of More-head City, was secured as the director of the reorganized Bureau, with Miss Rose M. Ehrenfeld as supervisor of nursing and Mrs. T. W. Bickett in charge of educational work. The funds available during this period, and their distribution, were seven-twelfths of the amounts set out under the tabulation for 1921. The appropriation for the State Laboratory of Hygiene for the nineteen months between December 1, 1920, and June 30, 1922, was $87,083.33; in addition to this, the Laboratory collected in fees for special work, for antitoxin, and in water taxes, a total of $30,872.51, making a total of $117,955.84 available for the work of the Laboratory. 1922-23. In order to further develop local responsibility for the protection and promotion of the public health, and to quicken local initiative, a policy of decentralization was adopted by the Board. To carry out this policy there were made several changes in the organi-zation of the Board's executive staff. The Bureau of County Health Work was discontinued. The Bureau of Epidemiology was combined with the Bureau of Vital Statistics. Dr. G. M. Cooper, director of the Bureau of Medical Inspection of Schools, was ap-pointed Assistant Secretary, and Dr. J. S. Mitchener, director of the Bureau of Epidemiology, was transferred to the Bureau of Medical Inspection of Schools. Dr. K. E. Miller, who for four years had been loaned to the Board by the United States Public Health Service, and had directed the work of the Bureau of County Health Work, was recalled for duty elsewhere. The State was divided into four districts with Dr. E. F. Long, Dr. H. A. Taylor, Dr. M. L. Ilsley, and Miss Rose M. Ehrenfeld as district directors. This plan of organization became effective in the early spring of 1923 and was continued through the calendar year. Six vacancies in the membership of the Board occurred during the year, four by expiration of term, and two by resignation. The terms of Dr. J. Howell Way of Waynesville, and Dr. A. J. Crowell of Charlotte, appointed by the Governor, expired, and Twenty-second Biennial Report 21 they were respectively appointed to succeed themselves. The terms of Dr. Charles O'H. Laughinghouse of Greenville, and Dr. Thomas E. Anderson of Statesville, elected by the State Medical Society, expired, and they w^ere respectively reelected. Mr. Charles E. Waddell of Asheville, appointed by the Governor in 1921, resigned and as his successor the Governor appointed Mr. James P. Stowe of Charlotte. Dr. F. R. Harris resigned to be-come health officer of Vance County, and to fill the unexpired term the Board elected Dr. D. A. Stanton of High Point. Dr. J. Howell Way was reelected president of the Board. The General Assembly of 1923 made provision for the constantly growing work of the Board, approving the budget as submitted and appropriating for the Board the sum of $425,000. Legislation enacted included an act to provide for the sanitary manufacture of bedding, to create an independent board of directors for the State Sanatorium, and to provide sanatorium facilities for tuber-culosis convicts. The important new development during the year was the begin-ning of malaria control work in certain counties of the coastal plain area of the State. Through the courtesy of the International Health Board a member of its field staff, Dr. H. A. Taylor, was loaned to the Board for the purpose of making preliminary sur-veys, and areas in Lenoir and Pamlico Counties were selected for investigation. The results showed Pamlico County to be suitable for the initial demonstration, and a unit for the investigation and control of malaria was organized with Dr. Taylor as the director, the budget being contributed forty per cent by the county, forty per cent by the State, and twenty per cent by the Inter-national Health Board. The progress of the work, and the results achieved, proved so satisfactory that in January, 1923, an addi-tional unit was organized in Beaufort Co"unty, and in May, Craven and Bladen Counties were added to the list. Detailed resumes of this work is given elsewhere in this report, but it should be stated here that the success of the intensive malaria control measures has been even greater than was anticipated. While specializing on malaria control measures, the county units have at the same time carried on a general program of public health work. The International Health Board has continued its cooper-ative aid in giving twenty per cent of the unit budget, and has continued the loan of Dr. Taylor, who has directed the work. In June the resignation of Dr. J. S. Mitchener as director of the Bureau of Medical Inspection of Schools was accepted, and Dr. Roy C. Mitchell, who had been engaged in special educational field work, was appointed to the vacancy. 1923-24. The Committee on Municipal Health Department Practice of the American Public Health Association requested the Secretary of the Board to become field director for the Committee in making a study of municipal health practices in the United States for the purpose of working out with and for the Committee a basis or set of principles on and through which city health departments could be given classification or grading, and further for giving 22 North Carolina Board of Health such additional time as might be needed in assisting such de-partments in improving their organization and provision for work. The request was brought before a special meeting of the Execu-tive Committee of the Board, and it directed the Secretary to take advantage of the opportunity offered to become acquainted intimately and broadly with health administration in the cities of the country, and at the same time continue to exercise general supervision of, and executive control over, the work of the Board. In January the Secretary established official headquarters in New York City for the work of the Committee, and the general organ-ization of the executive staff of the Board was continued with the Assistant Secretary, Dr. G. M. Cooper, as administrative or director. During the period of his absence the Secretary has kept in close touch with the work of the Board through frequent reports and a number of visits to the office for conferences with members of the staff. For the more efficient administration of the field activities of the Board the four districts into which the State has been divided the previous were consolidated into two, with Dr. E. F. Long and Dr. H. A. Taylor as Deputy State Health Officers, as directors, assisted respectively by Dr. C. N. Sisk, formerly health officer of Forsyth County, and Dr. George Collins, formerly health officer of Mecklenburg County. At the annual meeting for the Board in April further steps were taken towards making effective the policy of decentralization adopted the previous year. This' policy looks, in a broad way, to the diminishing of State personnel and the use of funds so made available for stimulating and paying county personnel, either whole or part time, to do work which formerly had been in all prob-ability incorporated and carried on by full-time personnel em-ployed by the Board. It was directed by the Board that all ma-chinery and resources of the Bureau of Maternity and Infancy and of the Bureau of Medical Inspection of schools be converted into county machinery and resources, either full-time or part-time, the transformation to be brought about gradually to become effective not later than January 1, 1925. During the year a plan for the more adequate sanitary control of public milk supplies in the State was formulated. The de-velopment of this important new undertaking was assigned to the Bureau of Engineering and Inspection. Mr. Malcolm Lewis, a graduate of Massachusetts Institute of Technology, and with about seven years of experience in public health work, was secured for this particular unit of work. As developed at the present time this service has been largely an advisory one, the various municipalities having at their command the aid of the Board in improving local milk supply conditions. The malaria control campaign in the coastal plain area was enlarged by the addition of organized units in Columbus, Bruns-wick and Hyde counties, making a total of seven counties in the State specializing on this plan of health work. The cooperative aid of the International Health Board was continued. Twenty-second Biennial Report 23 During the year Dr. Roy C. Mitchell, director of the Bureau of Medical Inspection of Schools, resigned. The work of the Bureau was continued under the supervision of the Assistant Secretary. Dr. M. L. Ilsley and Miss Rose M. Ehrenfeld, both district directors, resigned, and effective with the end of the fiscal year Dr. K. P. B. Bonner, director of the Bureau of Maternity and Infancy, resigned. The appropriation by the General Assembly was $275,000 and $300,000 respectively for the two years of the biennium. For the Laboratory of Hygiene the appropriation was $75,000 annually. 1924-25. During this year the work of the Board was directed by Dr. G. M. Cooper, serving as Acting Secretary. Dr. Rankin continued his work with the American Public Health Association. In June, 1925, Dr. Rankin resigned to accept the position of director of the hospital and orphanage divisions of the Duke Foundation. The system of district direction of county health work was dropped, district health officers resigning not being replaced. Dr. E. F. Long and Dr. C. N. Sisk were placed in charge of county health work, and upon the resignation of Dr. Long the responsi-bility for this work was left upon Dr. Sisk. Dr. K. P. B. Bonner resigned as Director of the Bureau of Maternity and Infancy, and Dr. H. A. Taylor was appointed to succeed him, with Dr. George Collins as assistant. On December 1 a division of Health Edu-cation was organized with Dr. M. L. Townsend in charge. 1925-26. Dr. Chas. O'H. Laughinghouse of Greenville, was elected Secre-tary to fill the unexpired term of Dr. W. S. Rankin, resigned, to take office October 1, 1926. Dr. M. L. Townsend resigned as Director of the Bureau of Health Education and Dr. G. M. Cooper succeeded him. 24 North Carolina Board of Health ORGANIZATION OF BOARD The work of the State Board of Health is administered by the State Health Officer and an executive staff, the members of which have definitely assigned duties. The Board consists of nine members, five appointed by the Governor and four elected by the State Medical Society. The terms are six years, and interlock. Not more than two of the Governor's appointees nor more than two elected by the Medical Society expire in any one year. The Board has certain legislation authority, having the power conferred upon it to adopt rules and regulations having the force and effect of law. The work of the Board is now divided into the following bureaux or divisions: Administration: Headed by the State Health Officer with general super-vision of the entire program of work. Laboratory: For diagnostic examination of various specimens, and of samples from public water supplies, and for manufacture and distribution of various vaccines and sera. Sanitary Engineering and Inspection: Enforce sanitary laws; supervise public water supplies and sewerage systems; investigate problems of stream pollution; supervise municipal milk sanitation; supervise shellfish sani-tation. Maternity and Infancy: Supervise maternal and infant hygiene nursing service; conduct prenatal educational service; midwife control. Medical Inspection of Schools: Through staff of nurses gives medical inspection of schools in one-third of the counties each year; conducts an-nually tonsil-adenoid corrective clinics; conducts dental clinics. Epidemiology: Enforces laws regarding communicable diseases; makes epidemiological investigations; conducts campaigns for immunization against typhoid fever, diphtheria, smallpox; makes malaria and mosquito surveys. Vital Statistics: Gathers through local registrars reports of births and deaths; tabulates and indexes certificates; keeps permanent file of all certificates. Health Education: Prepares educational literature, special pamphlets, edits monthly Health Bulletin, and conducts unit in visual education. Life Extension: Promotes periodic health examination for prevention of degenerative diseases; conducts special demonstration clinics for medical profession. County Health Work: Supervises and assists county health departments to which State contributes financiallv. Twenty-second Biennial Report 25 HEALTH—THE STATE'S GREATEST ASSET North Carolina rejoices today in the lowest death rate since the pioneer days of its first settlement. For the past year of 1927 a new low record was achieved, 11.3 per thousand of the population. This was under the rate for the United States' registration area which now includes approxi-mately 85 per cent of the population of the country. Again, it is demon-strated that North Carolina is not only a healthful State in which to live, but that it is in fact one of the most healthful of all the States in the Union. This has not always been true. Not so many years ago the State was hampered and its material progress checked by the prevalence of hook-worm disease and malaria. Smallpox was an ever-present menace, scar-ring and killing. The "Great White Plague" of tuberculosis each year claimed its thousands of victims. Typhoid fever was a constant summer scourge, killing and maiming. One out of every five of the babies born in the State died before reaching a first birthday. This condition was due to a number of causes. On account of its geo-graphical location, the State was especially susceptible to semi-tropical diseases, hookworm and malaria. Because of its predominant rural popu-lation, typhoid fever and other fecal-borne diseases, particularly the diar-rheal diseases of infants, largely alfected the public health. Unprotected public water supplies and general insanitary conditions throughout the State contributed to the high death rate. Today the picture is entirely changed. North Carolinians are a well and happy people, vigorous and able whether at work or play. Co-incident with the tremendous development during the years of the present century in agriculture and industries has been an improvement in general health conditions even more remarkable. Today it is true that no great number of our people are anaemic and weak from the effects of hookworm disease. That affliction is becoming rare in the State. Chills and fever and the sallow complexion of those chronically malarious now is so uncommon as to evoke comment, for ma-laria has been practically eradicated except from certain coastal sections as yet undrained or only partially developed agriculturally. Smallpox now kills less in a year than that comparatively new hazard to life, the auto-mobile, kills in a week. The annual death toll from tuberculosis has been cut more than half. Through sanitation and vaccination typhoid fever has been removed as a major factor affecting the public health. Simultaneously the infant death rate, following increased knowledge of sanitary living and the protection of public water and milk supplies, has been reduced more than one-half so that now instead of one out of each five of the babies born in the State dying during the first twelve months of life the ratio is one out of each thirteen. The vital statistics records for the State as compared with those of the Nation shows that North Carolina has made a markedly greater degree of improvement in the health of its people since 1900 than has its neighboring states, or the country as a whole. In 1900 the death rate for the entire registration area of the United States was 17.6 per thousand of the popu-lation. At that time North Carolina had no accurate records, but from 26 North Carolina Board of Health the most accurate data obtainable it is estimated that the death rate for the State was approximately 22.0 per thousand of the population. This extremely high death rate has been steadily pulled downward until last year it was 11.3 per thousand of the population as compared with 11.4 for the country as a whole. While the death rate for the Nation was falling 35 per cent, that of North Carolina dropped practically fifty per cent. This remarkable reduction in the death rate is the more noteworthy when considered in connection with the high birth rate. Last year there were 83,334 births in the State, a rate of 28.8 per thousand of the popu-lation. For the eighth consecutive year the State has maintained the highest birth rate in the United States. This means an addition annually to the population of a large group which is most susceptible to a number of fatal diseases. Tuberculosis, which holds a place throughout the world as one of the major causes of death, in 1927 claimed more than three thousand less vic-tims in this State than in 1910, just seventeen years previous. The total number of deaths from this cause last year was 2,769, giving the State a rate of 96.8 per hundred thousand of the population. This rate is con-siderably under that for the country as a whole and is lower than any other Southern State. This enviable record was made despite the fact that nearly five hundred deaths from tuberculosis were of non-residents of the State, patients at government or private sanatoria maintained in North Carolina because of its excellent climatic advantages. Sustaining the vital statistics records are the findings of the United States government in connection with medical examinations made of men called for military duty under the Selective Service Act. Figures are now available on the basis of more than two and one-half million men examined, of which number fifty thousand men were from North Carolina. This study gives a cross-section of the physical condition of the male population at an age when physical defects that may shorten life are beginning to ap-pear, and may be taken as a good picture of the general physical condition of the people. These statistics show that North Carolina averaged fewer rejections because of physical unfitness than the country as a whole, and on indi-vidual points ranked well above the average. As compared with the entire country there were in this State fewer defects per thousand, fewer defec-tive men per thousand, fewer mechanical defects, less hernia, less under-weight, fewer defects of the eyes, ears, throat, less organic heart disease, and less defective and deficient teeth. This State is today perhaps the best sanitated State in the Union, con-sidering its predominant rural population. For ten years it has had State laws requiring the sanitary disposal of human excreta. In this North Carolina was a pioneer, being the only State with such beneficial laws until in 1927 the legislature of Alabama gave that state legislation based upon that of North Carolina. Practically the entire urban population is now served with protected public water supplies and with water sewerage. The semi-urban and village and a large portion of the rural population is protected by a system of sanitary privies which are required to be con-structed and maintained sanitarily in accordance with plans and specifi-cations approved by the State Board of Health. Twenty-second Biennial Report . 27 Three factors have been primarily responsible for the changed health condition of our people, a change that in twenty-five years has brought the State from near the bottom to a point close to the top. First of all the State has been tremendously fortunate in having an alert and intelli-gent medical leadership, and with this has been a heartily cooperative profession. Such men as Wood, Lewis, Way, Rankin, have achieved na-tional and international reputations for their leadership in preventive medicine, and their labors for their fellowmen have been of inestimable value. Second, the newspapers of the State, day by day, week by week, have carried on an educational program for sanitation and hygienic living. Third, the General Assembly has consistently enacted needed legislation for the protection of the public health and biennially has provided adequate appropriations for the maintenance and development of public health measures. A natural sequence of the combination of these three factors has been the increasing realization of our people that health, like charity, begins at home. In Guilford County on June 1, 1911, was established the first county health department to be organized in the United States. Today North Carolina has 39 county health departments and six city health de-partments, serving more than one-half of the State's population. In this phase of development North Carolina has been exceeded only by the State of Ohio. For the protection and promotion of the public health the annual appro-priation by the General Assembly is $441,400.00, exclusive of appro-priations made for maintenance and permanent improvements at the State Sanatorium for the treatment of tuberculosis. This puts North Carolina in sixth place in the group of forty-eight States of the Union, the ranking states being Pennsylvania, New York, Illinois, Ohio, Massachusetts, North Carolina. The appropriations made by the counties and cities approximate $600,000.00 annually. This investment of money for the purpose of protecting and promoting the public health is probably the best paying one in direct dividends that is made by the State. The fact that the death rate in the past twenty-five years has been cut in half means a saving not only in lives, but in dollars and cents—a sum one hundred times greater than the amount which has been invested to achieve this result. In ajddition to the local county and city health departments, the State is served by a health department under the direction of a State Health Officer who devotes his time and energy to this one job. Divisions of this department, each under the direction of a trained expert, consist of a hygienic laboratory, vital statistics, epidemiology, county health work, medical inspection of schools, sanitary engineering and inspection, ma-ternity and infancy, health education, and life extension. The work of the State Board of Health may be briefly summarized by divisions as follows: (1) The State Laboratory of Hygiene annually makes 60,000 exam-inations to assist the physicians of the State in the diagnosis and treat-ment of their patients; periodically examines samples from all public water supplies; distributes 750,000 doses of typhoid vaccine for the prevention of typhoid fever; distributes 35,000 doses of pertussis vaccine for the pre-vention and treatment of whooping cough; manufactures and distributes 28 North Carolina Board of Health 225,000 doses of smallpox vaccine for the prevention of smallpox; dis-tributes 210,000 doses of toxin-antitoxin for the prevention of diphtheria and 1,500,000 units of antitoxin for the treatment of diphtheria; makes and distributes 1,800 Pasteur anti-rabic treatments, for the prevention of hydrophobia caused by the bites of mad dogs; distributes 5,000 packages of tetanus antitoxin for the prevention of this dread disease; distributes 125,000 ampoules of neo-arsphenamine for the treatment of syphilis; altogether, in water analysis, diagnostic examinations, and in sera and vaccines supplied, the laboratory performs a public service that at ordinary commercial rates would exceed $1,250,000.00 annually. (2) The division of vital statistics is charged with the vital bookkeeping of the State, an accounting in terms of life and death of the State's popu-lation. Its objective is to secure a permanent record of the more important facts concerning the birth and death of every citizen of the State, and from such records to prepare card indices and tabular classifications in such manner as to make readily available on inquiry the following information: (a) The total number of births occurring annually in the State; (b) the birth rate of the State, that is, the number of births per thousand of the population; (c) the birth rates by races, white and colored; (d) the number of illegitimate births; (e) the number of still-births attended by midwives; (f) the number of white births attended by physicians; (g) the number of white births attended by midwives; (h) the number of colored births attended by physicians; (i) the number of colored births attended by mid-wives; (j) all of the foregoing data as to births with respect to each county and city. These facts permit of comparisons of one part of the State with another, of the birth rate of the two races, and of the birth rate of this State with that of the other states and other countries. Such information is necessary in forming conclusions as to vital conditions in North Carolina and in the enactment of suitable legislation for dealing with these conditions. Last year there were 83,334 live births in the State, certificates for which were handled and classified. (a) The number of deaths occurring in the State annually; (b) the death rate, that is, the number of deaths per thousand of the population; (c) the number of deaths, by races, and the death rates by races; (d) the number of deaths among infants and young children as compared with the births, and the total deaths as compared with the total births, with net gain in population; (e) the total number of deaths by months and year from each of the 209 causes appearing in the International List of Causes of Death; (f) the number of deaths according to age and occupation; (g) the number of deaths according to age and the causes of death; (h) the number of "seasonal" deaths according to months; (i) all of the foregoing data classified according to county, town and city. This information is abso-lutely necessary to understand vital conditions in the State; to know where intensive health work is needed, against what causes of death health measures should be directed, and whether the work of local health depart-ments is associated with a decrease or no decrease in death rates. Last year 32,764 deaths occurred in the State, certificates for which were handled and classified. (3) Through its division of Epidemiology, the Board endeavors to con-trol the spread of contagious and infectious diseases. It supervises the Twenty-second Biennial Report 29 quarantine of approximately 50,000 such cases each year, supplying to each home where any of the contagious or infectious diseases occur, direc-tions for the care of the sick and other precautions necessary to prevent the spread of the disease; makes epidemiological investigations to ascer-tain the source of infection in such diseases as typhoid fever, diphtheria, etc., when such diseases appear in local epidemics; conducts with the assistance of local physicians mass vaccination campaigns for the pre-vention of typhoid and diphtheria, covering about 20 counties each year and securing about 40,000 typhoid vaccinations and 10,000 diphtheria vac-cinations; supervises a malaria control program in a number of eastern counties, and supervises a number of impounded water projects. (4) The 39 county health departments through the division of County Health Work are given supervision and advice, together with financial assistance. Assistance is supplied in planning and developing general and special units of local work, demonstrations, educational exhibits, clinics, laboratories, and the like, and assists in the organization of new county departments. (5) In the division of Medical Inspection of Schools, a field staff of eight nurses, eight dentists and one supervising dentist is maintained. An average of 90,000 school children are being examined by the nurses in those counties not having local health departments. The examinations are for the purpose of discovering the more common defects of childhood such as those of vision, hearing, throat, nose, teeth, skin or orthopoedic de-formities. Personal notes are sent to parents advising of such defects as may be found and urging that the child be given the indicated medical care in order that correction may be made. As a follow-up of this work, the Board conducts during the summer months clinics for operative treatment of children of school age suffering with diseased tonsils and adenoids. A special hospital unit sufficient to care for twenty-five patients is transported by truck. A hospital unit is maintained consisting of a physician to carefully examine the children and administer anaesthesia, eleven experienced nurses, and an orderly. The operating surgeon is a specialist secured on the recommendation of the local county board of health. About 2,000 children are now being treated each year in these summer clinics. An average of 36,000 school children are receiving dental treatment. This includes not only the cleaning of teeth, silver nitrate treatments or temporary fillings for decayed first teeth, but an average of 30,000 per-manent fillings each year, thereby saving that many permanent teeth, the greater portion of which would otherwise be lost. The school dentists doing this work are provided with portable outfits and conduct the dental clinics in the school buildings. A conservative estimate of the cost value of the work done in the tonsil and dental clinics each year is $500,000.00, an amount greater than the total appropriation made for all of the work of the Board. (6) The division of Sanitary Engineering and Inspection is charged with manifold duties all of which intimately affect the public health. Primarily this division supervises the construction and maintenance of all public water supply and sewerage systems. There are 238 public water supplies under supervision, representing an invested capital of $40,000,000 and an annual cost of operation of $3,750,000, serving 30 per cent of the 30 North Carolina Board of Health State's population. The operation of these plants is on the best modern scientific basis and in a manner capable of maintaining the full effective-ness in purification for which the plants were designed. The water supply plants of the State have been virtually built anew in the past ten years and the supervision and advice of the State Board of Health has been of inestimable value in safeguarding the municipalities against incompetent engineering service and inadequate provision for growth. It is noteworthy that all of this work has been handled by North Carolina engineers except a few of the minor improvements. This division is charged with the enforcement of the State sanitary privy law, the work being carried on by a force of ten sanitary inspectors. In addition to the sanitary privy work, supervising inspectors do hotel and cafe inspection and handle special investigations and complaints. One supervising inspector does jail and convict camp regulation, executing the duties assigned by law to both the State Board of Health and the State Department of Public Welfare. The milk sanitation division is assisting in the protection of milk sup-plies in 48 municipalities which have adopted the standard milk ordinance. This now includes about 80 per cent of the public milk supply of the State. The shellfish sanitation division has made a complete sanitary survey of the shellfish growing areas of the State, and supervision is maintained throughout the shipping season. North Carolina shellfish now are accepted in the markets of the country without question. Special engineering service is now available to the counties in the mat-ter of water supply and sewage disposal installation for consolidated schools. Through this service about 200 school sewage disposal projects are being handled each year, the total cost of the work involved in this supervision being $350,000.00. A special study of stream pollution is now being made, necessitated by the growing sewage and waste pollution. Engineering service, in a growing volume, is being supplied to State institutions. This work includes investigations to determine the needs of institutions in water supply and sewerage utilities for the advice of the Budget Commission in recommending appropriations, field surveys, prep-aration of plans, cost estimates and supervision of construction. (7) The division of Maternity and Infancy is primarily charged with the responsibility of reducing the infant and maternal death rate. It has the supervision of the 6,500 midwives of the State, and through special classes each year gives courses of instruction to 2,000 of these. Financial aid and supervision is given to twenty counties which have local maternity and infancy nurses. A correspondence course in prenatal care is maintained with an average of 10,000 expectant mothers. Twenty thousand babies are each year registered for whom special literature on infant care and diet is sent. The field nurses personally see 30,000 mothers and advise with them on the care of themselves and their babies. For the prevention of blindness, 8,000 packages of silver nitrate are distributed. (8) The division of Health Education consists of: (a) preparing copy for the monthly Health Bulletin, a publication of 32 pages with a circu-lation of 22,000, edited for the general public and containing timely articles on sanitation and personal hygiene. The publication is sent only to those Twenty-second Biennial Report 31 requesting it. This Bulletin has been rated by competent judges as the best of its class in the United States; (b) preparing special pamphlets on particular health subjects such as cancer, catarrh, care of babies, consti-pation, colds, care of the eyes, care of the teeth, hookworm disease, malaria, pellagra, tuberculosis, sanitary privies, venereal diseases, typhoid fever, diphtheria, smallpox and the various contagious and infectious diseases. Approximately 1,250,000 pieces of this special educational literature is dis-tributed annually; (c) the preparation of special articles on health sub-jects for the press of the State; (d) visual education through the means of a mobile motion picture unit in charge of an experienced operator, with showing primarily in the public schools of those counties having organized health departments, this unit being designed especially as aid to the local health officers. During the past year 13 counties were served, with 125 showings given to a total audience of 35,380. (9) The division of Life Extension was organized in January, 1928. This division was organized to meet a pressing public need, the action by the Board following resolutions by the President and Councillors of the State Medical Society urging the necessity of the work being undertaken. A study of the vital records of the State disclosed that whereas the death rate from the group of communicable diseases declined from 117.6 in 1917 to 35.4 in 1926, the death rate from degenerative diseases in the same ten-year period rose from 318.9 to 374.9. The total deaths from the degen-erative group in 1926 was 8,105, a fourth of all the deaths occurring in the State. Included in this group are heart disease, Bright's disease, and cancer, all of which particularly affect the citizenship in the age group of 40-60. The only way to combat the alarming increase in the deaths from these degenerative causes is to get those citizens aft'ected under competent medical care before the disease has reached an acute state. To detect these in their incipient and curable stage, it is necessary that thorough physical examinations be made periodically. The Life Extension division was or-ganized and is functioning with two objectives: (1) to acquaint those physicians residing in the rural sections of the State, and practicing with-out the aid of hospitals and laboratories, with the technique of making physical examinations of the apparently well; (2) to assist the medical profession in impressing upon the citizenship of the State the fact that through competent physical examinations these degenerative diseases may be discovered in their incipiency and alleviated or cured. Particularly affecting the coastal counties of the east have been two important undertakings, the field studies in malaria control measures and the survey of salt marsh mosquito infestation. While primarily both of these problems are local, in that they are confined to a comparatively limited area of the State, yet they materially affect the public health of the State as a whole and are an important factor in the agricultural and industrial development of the State. In 1925 the State Board of Health was able to interest the Rockefeller Foundation in malaria control measures to the extent that this Foundation established at Edenton a station for the intensive and thorough study and investigation of malaria control measures. The station is under the direc-tion of Dr. Mark F. Boyd who is assisted by a staff' of trained assistants. The study is still in progress and probably will not be concluded for several years yet. From this North Carolina will secure accurate data upon which 32 North Carolina Board of Health it may with confidence go forward towards the goal of complete eradication of malaria from the State. Second only to the malaria problem in the coastal section is that of the salt marsh mosquito infestation. There are fourteen counties affected, con-taining approximately 300,000 acres of salt marsh territory, this acreage being distributed as follows: Brunswick 17,000, New Hanover 8,500, Pender 6,300, Onslow 13,000, Carteret 80,000, Camden 8,000, Pasquotank 2,000, Perquimans 2,300, Chowan 9,800, Washington 14,600, Tyrrell 40,500, Hyde 25,500, Dare 53,000, Currituck 12,400. For the purpose of making a survey of the salt marsh areas of the South Atlantic and Gulf States, the Congress of the United States in 1926 appropriated the sum of $25,000 and the additional sum of $10,000 to con-tinue the survey through the fiscal year ending June 30, 1928. Under the auspices of the United States Public Health Service, with Dr. T. H. D. Griffits in charge, the survey was undertaken. Included in the survey was the investigation of various types of mosquito breeding areas in the salt marshes along the coast from Virginia to Key West, and from Key West to the Mexican border. This survey has already gathered incal-culably useful data with reference to the egg-laying and larval habits of solicitans mosquitoes; conditions which influence their breeding; distance and direction of their flights; and the influence upon them of tides, vege-tation, soils, salinity, natural enemies, climatological conditions and so on. In addition to this, extensive studies of the habits of these pests have been going on at Biloxi, Mississippi, Fort Pierce and Vero Beach, Florida, and Wilmington, North Carolina. The survey at Wilmington covered approximately all of the important breeding areas in New Hanover County, and in adjacent territories in Brunswick and Pender Counties. Information from this survey was of such valuable nature that it has put New Hanover County in position largely to decrease the mosquito infestation there. The necessary appropriation to continue this important work was left out of the regular appropriation bill introduced into the recent session of Congress. So necessary did its continuation appear that the State Health Off"icer, the Governor and a number of interested citizens urged upon the State's delegation in Congress that this appropriation item be restored. Largely due to the earnest and persistent efforts of Hon. Charles L. Aber-nethy, ably assisted by Hon. Lindsay Warren and other members of the delegation, an appropriation of $10,000 was secured. As a result prac-tically the entire remaining salt marsh area in North Carolina will be included in the survey, and the work upon this is now in progress. From it ways and means to control and prevent the breeding of solicitans mosquitoes, it is hoped will be developed. North Carolina moves forward, no longer a laggard handicapped by disease and poverty. An intelligent leadership has envisioned the fact that agricultural and industrial advancement depend upon a healthy citizen-ship, and through the General Assembly has provided the necessary funds for the protection and promotion of the public health. A medical leader-ship alert to the opportunity presented has carried on, under the direction of the State Board of Health, a continuously winning fight. Today North Carolina is one of the wonder states of the Union—progressive, prosperous, healthful. Twenty-second Biennial Report 33 BUREAU OF VITAL STATISTICS Report of Bureau of Vital Statistics for two years, July 1, 1926—June 30, 1928, inclusive. Since August, 1927, the Bureau of Vital Statistics and Epidemiology have been functioning as separate bureaus, with a director for each. OBJECTIVES The Bureau of Vital Statistics is more closely interlocked with other departments of the State Board of Health than any other department. The reason for all health work is based on vital statistics. The Bureau of Vital Statistics turns out an immense amount of work each year. One reason for this is because each month a definite amount comes into the office which must be taken care of. Then too vital statistics are becoming more useful as information accumulates from year to year. When the Bureau of Vital Statistics of the North Carolina State Board of Health was first created, there was no Bureau of Epidemiology, or Maternity and Infancy, no World War, no Veterans Bureau, no Compensa-tion Act, no School Age Law, no Welfare Department, few automobiles, and a smaller population. All of the above departments are making daily calls on the Bureau of Vital Statistics for information, or certified copies of birth and death certificates. The objective of the Bureau of Vital Statistics is to secure a permanent record of the more important facts concerning the birth and death of every citizen of the State of North Carolina, and from such records to prepare card indices and tabular classifications in such manner as to make readily available on inquiry the following information: 1. (a) The total number of births occurring annually in the State; (b) the birth rate of the State, that is, the number of births per thousand of the population; (c) the birth rates by races, white and colored; (d) the number of illegitimate births; (e) the number of stillbirths attended by midwives; (g) the number of white births attended by physicians; (h) the number of white births attended by midwives; (i) the number of colored births attended by physicians; (j) the number of colored births attended by midwives; (k) all of the foregoing data as to births with respect to each county and city. These facts permit of comparisons of one part of the State with another, of the birth rate of the two races, and of the birth rate of this State with that of the other states and other countries. Such information is necessary in forming conclusions as to vital conditions in North Carolina and in the enactment of suitable legislation for dealing with these conditions. 2. (a) The number of deaths occurring in the State of North Carolina annually; (b) the death rate, that is, the number of deaths per thousand of the population; (c) the number of deaths, by races, and the death rates by races in North Carolina; (d) the number of deaths among infants and young children as compared with the births, and the total deaths as com-pared with the total births, with net gain in population; (e) the total number of deaths by months and year from each of the 209 causes ap-pearing in the International List of Causes of Death; (f) the number of deaths according to age and to occupation; (g) the number of deaths according to age and the causes of death; (h) the number of "seasonal" deaths according to months; (i) all of the foregoing data classified ac- 34 North Carolina Board of Health cording to county, town and city. This information is absolutely necessary to understand vital conditions in the State; to know where health work is needed, against what causes of death health measures should be directed, and whether the work of health departments is associated with a decrease or no decrease in death rates. 3. Under one and two, information necessary for the public welfare and available under the operation of the vital statistics law has been briefly indicated. But the vital statistics law not only supplies information to legislatures, state and county commissioners, and other administrative bodies, which is necessary for framing conservation measures for human life, but it also records facts which may at any time become of great value to the individual. In matters of tracing ancestry, birth records are in-valuable; also in matters of proving age where the fact of age is in ques-tion, as for voting, as for the right to marry, as for the right to enter certain industries, as to entering school, as to liability for military service, etc. METHODS The Bureau of Vital Statistics secures the birth and death certificates for the births and deaths occurring in North Carolina through approxi-mately fourteen hundred and fifty local registrars, appointed by the chair-man of the boards of county commissioners for the various townships and by the mayors for the various incorporated towns and cities of the State. The duties and powers of the local registrars are defined in Consolidated Statutes, section 7113. The county pays the local registrars fifty cents for each birth and death certificate furnished by them to the off'ice of the State Registrar at Raleigh. The vital statistics law makes it the duty of the doctors and midwives in attendance on a birth to file a birth certificate with the local registrar of the district in which the birth occurs and makes the undertaker, or person acting as undertaker, responsible for the filing of the death certificate. The birth and death certificates filed with the local registrars of the State are sent to the Bureau of Vital Statistics on the fifth of the month succeeding the month in which the birth or death occurred. The certificates received in the office of the Bureau of Vital Statistics are examined carefully, and if incorrect or incomplete (as a large per cent of them are) effort is made to secure the information necessary to complete them. Every parent of a legitimate child whose birth is reported is sent a card advising them of the date of birth and whether or not name appears on the certificate. This gives the parent an opportunity to send in to the office the name of the child, in case it does not appear on the certificate, or to make such change in name or date of birth necessary to make certificate an accurate record of birth. The cer-tificates are then classified and tabulated according to county, townships, and registration districts, according to races, according to age at death, according to cause of death, according to death rates and birth rates, etc., in order to make readily available upon request the information mentioned under the heading of Objectives. ROUTINE WORK The routine work in the registration of births and deaths is indicated in the following table. This covers period from July 1, 1926, through June 30, 1928, inclusive. Twenty-second Biennial Report 35 BIENNIAL REPORT July, 1926—June, 1928 Letters and postals received *27,504 Casket dealers reports received 7,072 Supplementals received 3,346 Name cards received 11,240 Violation blanks received 51 Acceptance papers received - - 64 Report cards received from local registrars 24,154 Letters written 16,076 Form letters sent 49,224 Postal cards sent 137,257 Packages of supplies sent 11,301 Bulletins (transferred to another department) 108,304 Indexing: Cards made 254,296 Cards proofread 261,401 Cards assorted 242,262 Cards filed 221,054 Credit certificates sent local registrars 1,759 Certified copies made 5,754 Tables made 654 Cards punched and proofread 71,585 Cards furnished Dr. McCain giving information as to deaths from tuberculosis monthly 5,033 Epidemiology reports from death certificates 4,405 Transcripts made and proofread 240,157 Tabulation of births -..- 165,793 Number certificates made in triplicate 5,800 Lines miscellaneous typing 5,290 Certificates Received: Births 164,609 Deaths 68,333 Stillbirths 15,576 Total 248,518 Names checked on undertakers reports with death certificates .„.- 8,379 Local registrars visited 315 Doctors visited .. - 105 Undertakers and coffin dealers 105 Register of Deeds 20 Midwives 70 RESULTS OBTAINED Of course there is always a large per cent of routine work that is im-possible to put in a report of this kind, and without going into unnecessary detail, it may be said that the objective of this Bureau, as aforestated, has been reached, and that all of the information with its vital bearing upon the public health needs of the State and with the public health accomplish-ments of the State is readily and completely available. *This total does not include letters and postals received for Bureau of Epidemiology from July 1, 1926, to August, 1927. 36 North Carolina Board of Health BUREAU OF EPIDEMIOLOGY The Division of Epidemiology and Venereal Diseases, formally connected with the Bureau of Vital Statistics, was organized into a separate Bureau with a full-time Medical Director, July 1, 1927. OBJECTIVES To prevent and control the occurrence of infections and contagions with special reference to whooping cough, measles, diphtheria, scarlet fever, infantile paralysis, cerebro-spinal meningitis, chicken pox, septic sore throat, german measles, smallpox, typhoid fever, trachoma, malarial fevers, and venereal diseases. METHODS FOR OBJECTIVES For convenience of description, the methods employed by the Bureau in accomplishing its objectives may be divided into two main divisions or units, each having a dual responsibility in the enforcement of rules and regulations pertaining to the control of communicable diseases. Section I.—The County Unit A quarantine officer for each county and city having a separate health department in the State has been secured. He is the Bureau's representa-tive in the field, is required to execute oath of office, and is, therefore, designated as assistant collaborating epidemiologist, receiving compen-sation from their respective counties in accordance with the following provision: The said certification and the sum paid the quarantine officer by the county authority shall be in accordance with a system of fees determined by the North Carolina State Board of Health for each item of work in-volved in the duties of the quarantine officer: Provided, however, that the total annual payment for any county shall not be in excess of the sum stated for such county classified according to population as follows: Per Month Counties with a population less than 10,000 $15.00 Counties with a population of from 10,000 to 15,000 17.50 Counties with a population ctf from 15,000 to 25,000 -— -- 25.00 Counties with a population of from 25,000 to 40,000 35.00 Counties with a population of from 40,000 to 50,000____. 45.00 Counties with a population over 50,000 50.00 Duties of the Quarantine Officer The duties of the quarantine officer, acting as assistant collaborating epidemiologist are similar to a certain extent to those designated by the Board to the Bureau of Epidemiology and may be briefly outlined as follows : (a) To secure reports from parents, teachers, and physicians of all cases of communicable diseases. (b) To keep an accurate record in his office of all reports. (c) To transmit all reports daily to the Bureau of Epidemiology. (d) To supply the parent, guardian, or householder, when the disease is reported, with rules and regulations governing that person, with a placard to be posted on the house, and with a pamphlet descriptive of the disease, its dangers, cause, mode of infection, and methods of control. Twenty-second Biennial Report 37 (e) To inform the teachers in the community where the disease exists that the disease is present, and to supply them with rules and regu-lations governing the school while the disease is present, and with pamphlets descriptive of the disease, its dangers, cause, mode of in-fection, and methods of control, to be distributed through the children to the parents represented in the school. (f) To make the presence and locations of diseases known to the public by publishing notices in the county paper when the disease appears and how to prevent it. (g) To furnish householders forms to report diseases in their community which have not previously been reported. (h) To investigate all cases of suspected contagions which have not been reported, to determine the nature of the disease, (i) To enforce the laws, rules and regulations governing the control of communicable diseases, (j) To make monthly reports to the Bureau of Epidemiology of all the work, educational, administrative, or otherwise, done during the month. Section II.—Bureau of Epidemiology or State Unit In order for the reader to more easily comprehend the duties performed by this Bureau, consideration is given to the work under the following heads: (a) General Office Routine, (b) Special Immunization Campaigns for the Prevention of Typhoid Fever, (c) Special Immunization Campaigns for the Prevention of Diphtheria, (d) Investigations to determine the Pre-valence of Mosquitoes and to Institute Measures for the Control of Malarial Fevers. Office Routine The daily reports of the communicable diseases are recorded by the Bureau of Epidemiology by the counties in which they occur. These are permanent records of the Bureau, and they show the number, location, age distribution, increase or decrease in the number of cases of each disease from month to month and from year to year. Spot maps are kept, showing the daily occurrence of cases and monthly occurrence of deaths of smallpox, diphtheria, scarlet fever, and typhoid fever, and according to the sections of the State in which they occur, by counties, and townships, and whether the cases are urban or rural. Charts have been prepared showing the number of cases and deaths for the above four diseases for the years 1918 to 1927, inclusive. Weekly telegraphic and monthly written reports of all cases of infectious and contagious diseases reported are made to the Surgeon-General, United States Public Health Service, Washington, D. C. All report cards, blank forms, educational posters, placards and liter-ature on the reportable diseases, and all rules and regulations governing the control of the diseases are prepared and distributed to all assistant collaborating epidemiologists by the Bureau. During this biennial, 15,697 circular letters have been mailed by the department on subjects pertaining to the reporting and control of com-municable diseases. Weekly bulletins are issued by the Bureau showing the prevalence of typhoid fever, diphtheria, smallpox, scarlet fever, measles and whooping cough by counties. These bulletins are mailed to all assistant collaborating epidemiologists, members of the State Board of Health, and others inter-ested in the occurrence of these diseases in the State. The morbidity 38 North Carolina Board of Health statistics of all reportable diseases are checked against the mortality statistics in order to establish the efficiency of reporting. Special Immunization Campaigns for the Prevention of Typhoid Fever During the biennial, special immunization campaigns for the prevention of typhoid fever and diphtheria have been conducted in 37 counties. The campaigns are conducted in the following manner: The Bureau of Epidemiology circularizes the county and furnishes advertising materials to the county for the mailing list made up from the tax books. (The Bureau makes up mailing list from the records of births in the county, filed with the Bureau of Vital Statistics.) Physicians who participate in these campaigns are paid 8i/^ cents a single dose. Physicians make reports to the Bureau on forms supplied for the purpose. These are checked and certifications sent to the County Commissioners for payment. List of counties in which special campaigns for the prevention of typhoid and diphtheria together with the population immunized: No. Taking No. Taking Three Doses Three Doses County Typhoid Vaccine Toxin-Antito.vin 1. Alamance (1926) 5,868 1,047 2. Alexander (1927) 4,140 1,266 3. Burke (1928) 6,274 1,812 4. Caldwell (1927) 8,323 1,913 5. Camden (1927) 1,358 1 6. Caswell (1928) 3,446 1,933 7. Catawba (1926) 9,030 2,101 8. Chatham (1926) 2,444 89 9. Dare (1926) 902 478 10. Davie (1927) 3,934 1,314 11. Durham (1928) No Report* 12. Gates (1927) 2,006 444 13. Greene (1927) 8,705 2,642 14. Harnett (1927) 10,008 1,780 15. Hertford (1928) 3,549 715 16. Iredell (1928) 10,911 1,848 17. Lee (1928) 8,878 1,510 18. Lincoln (1926) 5,415 1,073 19. Madison (1927) No Report 20. Martin (1926) 4,540 1,513 21. Martin (1928) 4,282 1,654 22. Montgomery (1926) 181 44 23. Moore (1926) 5,186 723 24. Moore (1927) 244 25. Perquimans (1927) 3,208 295 26. Person (1926) 6,966 1,502 27. Randolph (1926) 5,984 1,940 28. Rockingham (1926) 3,233 422 29. 'Robeson (1928) No Report* 30. Scotland (1928) 3,921 1,016 31. Stanly (1927) No Report 32. Stokes (1928) 3,225 839 33. Surry (1928) No Report* 34. Warren (1927) 7,055 1,262 35. Washington (1927) 2,258 823 36. Wayne (1928) No Report* 37. Yadkin (1928) 7,487 2,160 Total 152,961 36,159 *Whole-time counties. Twenty-second Biennial Report 39 Total (11 counties—1926) 49,749 10,932 Total (11 counties—1927) 51,239 11,740 Total (9 counties—1928) ..51,973 13,487 Grand Total 152,961 36,159 Compiled Monthly Report of Part-Time County Quarantine Officers July 1, 1926, to June 30, 1928 Cases reported by householder.... — 7,992 Cases reported by health officers and nurses 10,290 Cases reported by physicians 35,090 Cases reported by teachers .— 3,329 Total number of cases reported 56,701 Homes placarded 41,736 Articles published 411 Teachers' certificates 5,838 Indictments 82 Total number cases reported by whole-time quarantine off. 112,050 Grand total cases reported by all 100 counties in State 168,751 Summary of Office Work Circular letters 15,697 Oaths of Office 23 Telegrams sent 128 Letters written—Individual — ._ 4,070 Multigraphed 4,759 Total all letters 24,526 VENEREAL DISEASE DIVISION Although since 1924 the distribution of medicinal remedies for the treat-ment of venereal diseases have been sent out by the State Laboratory of Hygiene, and since the Federal appropriation was discontinued, the Bureau has been unable to maintain public clinics for the treatment of indigent cases, nor has any extensive educational work been conducted. However, the Bureau receives a large number of letters requesting bulletins, pamph-lets and advice. These are carefully answered and whatever information requested sent. The purposes of this dissemination of information are as follows: (a) To stimulate the provision of facilities for proper treatment by estab-lishing clinics for persons infected with venereal disease who are unable to pay for treatment from private physicians. (b) Information concerning patients dangerous to the public health is referred to local health officers for investigation and action. (c) Instruction and advise is given to persons infected with venereal dis-ease concerning the necessity for proper treatment and continuing treatment until cured. (d) Tabulations are made from the data collected in an effort to gain knowledge of the prevalence of infection and the best methods of prevention. In gathering information concerning cases of venereal diseases dangerous to the public health, the Bureau has had recourse to the usual procedure of requiring physicians to report their cases and requiring druggists to report the sale of venereal disease remedies. These reports by physicians and druggists are required by Chapters 206 and 214, respectively. Public Laws of 1919. The system of reporting provided by law and the regulations adopted by the State Board of Health is designed especially to furnish usable infor- 40 North Carolina Board of Health mation concerning dangerous cases. For this reason physicians are re-quired to report names and addresses only when in their judgment the patients should be under the supervision of the health officer in order to protect the public health. When patients are considered trustworthy, physicians may report their cases by number without disclosure of identity. Reports that reach the office are so handled that information concerning cases that should be invesitgated is referred to the local health officer. Every effort is made to encourage reporting by physicians through courteous treatment rather than by harsh measures. In carrying out this policy a number of form letters have been drafted for use in the routine handling of venereal disease case reports. There has been reported to this office the following number of cases of venereal diseases by part-time quarantine officers: Gonorrhea 3,852 Syphilis 6,002 Chancroid 290 Balanitis 1 Total -._.. 10,145 Total number cases reported by whole-time quarantine off. 7,775 Grand total cases reported by all 100 counties in State 17,920 DIVISION FOR THE INVESTIGATION AND CONTROL OF MALARIAL FEVERS The work of the State Board of Health on Mosquito and Malaria Control through the division for this purpose, as a result of insistent demand, has increased four-fold in application during the last biennium. In addition to the work in the malarial zone of the State, which had previously absorbed the efforts of the division, three other variations were gone into, namely: 1. The study of impounded water and its effect upon the prevalence of mosquitoes and the incidence of malaria; 2. The investigation of situations which produce pestiferous mosquitoes; 3. The surveying of salt marsh areas conjointly with the U. S. Public Health Service. Of these issues, circumstances presented the questions surrounding the impounding of water as the paramount mosquito and malaria problem of the period. The damming of streams for developing hydro-electric power was in a stage of expansion. The effect upon health conditions had previ-ously led to long, bitter, and depressing ligitation and the issues by no means had been satisfactorily cleared. Adequate study of the situation necessitated application before and after building these projects, there-fore, a major portion of the division's time was given to it. Space in the report is allotted accordingly. The other issues, though probably having been more or less constant, were meeting with a continually decreasing de-gree of tolerance for they were proving more and more to be an obstacle in the courses which progress and development were taking. The original undertaking of the division in the malarial zone being already well-organized and in operation in the hands of county health units, is adequately covered in previous reports and therefore, not gone into here further than the aid offered in maintaining it and taking up the periodic problems which arose. Detail of the report is given in the order of the subjects named. Twenty-second Biennial Report 41 Studies on Impounded Waters Since the year 1904, attention has been focused upon the impounding of water for commercial purposes to an unprecedented degree. The elec-trical developments which have made practical the broadspread utilization of water power even to remote locations have created for the country assets which can be estimated only in hundreds of millions of dollars. North Carolina has had a large share in this harnessing and utilizing of a wasting natural resource. It now holds fourth place among the states in developed waterpower and second in developed horsepower as compared to population. In this State alone, fortunes have been spent in hydro-electric developments and upon the completion of developments projected or now under construction, the expenditures will have mounted fifty million more and the developed horsepower will be practically sixty per cent of that available in the State. While there is a limit to this resource to which the economic situation sooner or later will push development, it is far in the future and in the meantime there are due many changes in application, utilization, and demand which put the vista almost beyond conjecture. However, not only the tremendous asset of power from water impounding has presented itself, for as the ever-present thorn there is also a derogatory side which has claimed no small share of attention, which continues to loom as a tremendous liability and persists in engendering grave concern. The early impounders apparently were unaware of any health hazards contingent upon their projects. Available pond sites were dammed and filled, capacity for power being the interest. No concern was felt about the condition of the basins. Whole forests were flooded or partly inundated without a guess of evil days to come. Powerhouse wheels then spun busily on while malaria mosquitoes availed themselves of these newly-prepared and excellent breeding grounds. Thus, in connection with impounding for hydro-electric development, the malaria problem grew, and in the form of a lawsuit—Chattanooga & Tennessee River Power Company vs. Lawson — in the Tennessee courts, 1915, announced itself as a momentous issue. To the present, lawsuits tried and pending in the South have involved millions of dollars in addition to fees and costs. One power company at one time had six hundred suits pending against it, each for .$3,000.00, a total of $1,800,000.00. Together with the costs of war, North Carolina has been the battleground for sums commensurate with her position in the power field. The liability in health hazards and the uneasiness injected into the progress of a key industry cannot be estimated. There are sec-tions of the State for which progress awaits only until health conditions are brought up to standard. Also, there are instances in which industries have been turned away from the State because of the unavailability of suitable power. Another view of the situation is presented in our courts. Juries are called upon to settle claims for malaria damage. Malaria has existed before the present era of impounding, oftimes in the community in which the impounding is done. Defendants are not responsible for this. Plain-tives contend that impounders have created or intensified these conditions. Conclusive facts often have been wanting. The dilemma of a jury left to settle the issue upon evidence which is largely a matter of greatly-diff'ering opinion is obvious. Neither the jeopardizing of health through impre- 42 North Carolina Board of Health cautions or lack of foresight nor the persecution of those in a position to make available our natural resources can be condoned. The availability of more definite information regarding the mosquito and malaria condition in a locality both before and after impounding would greatly facilitate the clearing up of difficulties. More preferable, however, than the settling of controversies would be the elimination of their causes. This bespeaks the need of knowledge which will go further toward the elimination of health detriments in the maintenance of power ponds. Much has been done already. No more ponds are found rising in uncleared forests. Old ponds have been cleared, and the practice of keeping all of them clean and of discouraging mosquito breeding is general. However, amidst a condition of uncertainty there has arisen a desire for more knowledge in handling mosquito and malaria con-ditions, better and surer methods of control, and some level of conduct and understanding which will reduce health hazards to a minimum, com-mand the approval of fair-minded people, and better put the hydro-electric industry upon the road of progress with the good-will of all concerned. In these problems and controversies the State has a responsibility, an obligation, a stake for loss or gain. It is true that a state best promotes its interests by fostering industries and even truer is this in the safe-guarding of the health of its people. Solving the problems outlined is progress in promoting such interests. Purpose of Studies Industries naturally follow in the wake of power development and can thrive only in proportion as the power interests prosper. Power growth has come more and more to center around water developments and like-wise has the malaria problem centered. The work and development of the U. S. Public Health Service gave hydro-electric projects their living chance. This was excellent headway, but there is yet much to be done in carrying on that work. While the present knowledge is generally appli-cable and makes possible the contingent interests, each project has an individual equation upon which much of its prosperity may depend and which to know is highly desirable. As with railroads and other organi-zations in whose welfare malaria has been discovered to play a part, im-pounders may desire to gain the asset accruing to the improving of health conditions and the gaining of good-will among those whom they may benefit, but this is not incumbent upon them. However, all are concerned in knowing that conditions, if not improved, remain at least unchanged. This is another call for facts resultant of which there has arisen an urgent need for the study of mosquito and malaria conditions in connection with North Carolina industries. Power officials are deeply concerned with it, and in addition to maintaining their own forces for control work on ponds already in use, they are much interested in work carried on by the State. These problems in the State were given cognizance and a program insti-tuted with the following purposes in view: to further determine the effect, on mosquito and malaria propagation from damming water-courses, to determine the variation in species breeding because of changing from flow-ing streams—the natural haunts in the South of Anopheles Punctipennis — to sluggish streams and ponds—the natural breeding places of Anopheles Quadrimaculatus, the principal carriers of malaria; to ascertain and perma- Twenty-second Biennial Report 43 nently record conditions surrounding impounded water projects before and after impounding; to work toward the future elimination as far as possible of the mosquito and malaria problem. A brief consideration of breeding habits and the effect of surroundings and changes may give something of the outlook of the undertaking. Differential Breeding The breeding habits of the different species of mosquitoes are an im-portant consideration in the impounding of water, and is the factor that threatened to bring to grief the first water-power projects in the South. While the whole mosquito family is given with variable adaptability, each species has a marked preference for waters of particular characteristics. This is so pronounced that the type to be found in different situations can be forecast with fair accuracy. Preference with most species is for natural instead of artificial collections of water. However, when both are present this may often mean a greater extent of breeding in the natural, than in the artificial ones, rather than all breeding in one and none in the other. In all cases quiet and protection are essential for propagation. Absence of trash, weeds, grass, or other obstructions, or the presence of wave and ripple action are strong deterrents to production. Of the Anopheles, the Quadrimaculatus, or principal malaria carriers, breed in ponds, lakes, pools, lagoons and estuaries, sluggish streams and tubs and cans. Marine growth, floatage, and moderate stagnancy only add to their comfort. Organic acids such as tannic, any kind of filth as excreta or waste, or contaminations of a chemical nature tend to discourage them. Appreciable quantities of any of these will stop their breeding altogether. Anopheles Crucians tend to begin breeding where Quadrimaculatus leave off. The inclusion of minerals such as found in brackish water, or swamp and bog water containing tannic acid proves attractive to them. These attributes with a nature akin to Quadrimaculatus for peaceful water, tend to locate this group in lowlands and flat country. They therefoi'e may be on the scene in malaria epidemics. Punctipennis is the free-water active stream group of the Anopheles. They are to be found harbored along running streams, springs, branches, and not infrequently in springs. They are more adaptable to both temper-ature and environment changes than the other species, upon necessity will resort to various departures from their choice of waters, and therefore, are the more widely distributed. It is hilly country with pronounced fall that affords the best impounding sites. Any kind of condition may exist on a small scale in such an area, but in whole it is one of springs and briskly moving water-courses, and therefore, the haunts of Punctipennis. Though this species can be infected with malaria it has not been proved infective in nature and disease carry-ing has not been generally charged to them. When such an area as they inhabit is impounded and the flowing water replaced by relatively still water, they may tend to lose interest and wane in their breeding while Quadrimaculatus thus favored will begin intensified activities which, if not controlled, soon will reach unhealthful proportions. Even though the adaptability of the Punctipennis may continue them in unabated numbers, it can be dependably relied upon that, left to their own volition, Quad-rimaculatus will be added to the mosquito population evolving from such 44 North Carolina Board of Health changes. Thus, from the nature of the insects, the hazard of malaria is incurred upon impounding. Other factors of prime importance in the control of mosquitoes in im-pounded waters are sanctuary and natural enemies. To utilize a location for breeding, mosquitoes must find in it more than favorable water con-ditions. Sanctuary from agitating elements and enemies are essential. If an otherwise favorable body of water is free of trash, floatage, and vegeta-tion, and is open to wind and wave action, mosquito larvae do not thrive in it. The mosquito realm in all three stages is inflicted with numerous pre-dacious enemies—fish, birds, insects, parasites, plants, reptiles, and even their own cannabalism. It is possible to utilize these natural enemies in the control of mosquitoes. One of them, a small surface minnow—Gam-busia Affinis—has been used extensively in ponds. However, conditions must be suitable to their abilities and habits or the purpose is defeated. Any material such as growth or trash and floatage will offer mosquito larvae sanctuary and bar access to the minnows. In addition to these considerations there are other factors such as geology, topography, and climate which exert direct influence on a mos-quito situation and off'er extended avenues of study. In the work on im-pounded water, these were gone into extensively, however, any compre-hensive treatment of the subject is too extensive for space here. Methods and Procedure Studies of impounded water projects were carried on in the form of sur-veys. A feature of the work was cooperation between the State Board of Health and county health organizations in whose territory the work was carried on. The general data collected was histories of past occurrences of malaria, present malaria both by history and by taking blood tests, and general premises conditions which pertain to mosquito favorability. These constitute an index to the prevalence of malaria, past and present. Also a general mosquito survey of the territory is made with a view of de-termining the kind and prevalence of mosquitoes. This finds service in correlation with existing malaria conditions as well as showing potenti-alities and also as a basis for future comparison. The territory of immediate interest for study is that within a one mile range of the territory of impounding, this being considered the probable extent of effect from a breeding area. When such an area has been laid out, workers proceeded from house to house. The purpose was explained and then through a series of questions, blanks arranged for the desired information were filled out. In addition blood smears were taken as fol-lows: The tip of a little finger was thoroughly cleaned with alcohol, and while being gripped to cause congestion, was quickly punctured with a needle. The first drop of blood was wiped away, the second drop was picked up with an end edge of a clean slide, placed on the face of a second slide near one end, allowed a moment to spread across their widths, and with the first slide held at 45 degrees to the face of the second, was quickly smeared along two-thirds of this surface. Such a smear dries very rapidly. The serial number of the person being examined is then written with lead pencil directly into the smear. Slides were then returned to container for safe-keeping. Daily they were brought into the office, wrapped in tissue paper, and filed to await examination. Twenty-second Biennial Report 45 Completing the blood smear work was as follows: Wright's stain, secured already prepared, was used for staining. The method given for preparation and use was—"Stock solutions; dissolve two-tenths grain dry slain in 120 cc of acetone-free methyl alcohol, store in a light-proof bottle. For staining, filter 20 cc stock solution, dilute with 5 cc acetone-free methyl alcohol. With slide lying flat apply small amount of stain with medicine dropper, let remain for one and one-half minutes, add distilled water, allow to stand for three or four minutes; rinse with distilled water and permit drying." Slides are then ready for examination. Examinations were made on a movable stage microscope, oil immersion. Detail of identification will not be gone into here. After twenty minutes of careful scrutiny, unless findings were otherwise, smears were passed up as negative. Results were then duly recorded. Mosquito Conditions In surveying for mosquito conditions in areas as large as those involved in the present day impounding project, the application must be shaped in a manner to best secure the desired results and still be within range of practicability according to personnel available for it. The method in gen-eral is to size up the territory carefully, spot a maximum number of pro-ducing areas, choose from these the apparently more significant, in quantity within range of practicable application, and then visit them by regular schedule, seeking out the desired breeding and prevalence date and record-ing in collective forms. The date thus compiled constitutes a permanent record in cross-section of the areas under surveillance. Good maps are very useful and time-saving in planning and getting the work under way. In following the plan laid out, field notes are compiled carrying data of apparent value. Such mosquitoes and larvae as are taken are labeled and reserved to later be identified and results entered on the records started in the field. Thus is gradually compiled a continuous portrayal of tran-spirations through a season. Field equipment is simple, consisting of insect-catching apparatus and containers for storing until catches are identified. Identification is done both microscopically while the insects are in the larvae stage and by maturing and identifying adults. Recording is a highly essential feature and demands careful attention, for the permanent value of the work rests thereon. Studies on impounded waters were made on three projects: The High Rock Project of the Tallassee Power Company, Davidson, Davie and Rowan counties; Lake Lure, Rutherford county, and the Norwood project of the Carolina Power & Light Company, Stanly and Montgomery counties. The data collected on these projects is within itself of quantity sufficient to form a volume. Only collective results in outline are given here. The High Rock Project The High Rock Project, under construction at the time of this report, is one of the twenty major hydro-electric power developments producing from 500 to 93,000 horsepower per unit, wholly or partly within North Carolina and is one of the five in the State promoted by the Tallassee Power Com-pany. To the 216,000 horsepower now being developed by the company in the State, this project is planned to add 45,000, which, by contract stipulating delivery of current by the first of 1928, is consigned wholesale 46 North Carolina Board of Health o to the Southern Power Company which will market it for industrial or general use locally or broadspread as the demand may arise. The project is located on a twenty-three mile section of the Yadkin river, occupying an area from the dam and powerhouse site at High Rock Mountain eighteen miles east of Salisbury; along the territory of the com-mon border of Davidson and Rowan counties, upstream, northwest, touch-ing Davie county on two sides by branching into the South Yadkin river for eight miles. Figures given for the lake and dam are as follows: dam, 59 feet high, 1,200 feet long; lake 19,000 acres or 20.7 square miles in area, 300-mile shore line, to back water 23 miles. The mosquito surveys on this project were carried on through two sea-sons— 1926 and 1927. The history and blood work was terminated in the first year. Work of this type on a large project is volumnous and in many respects subject to the difficulties that go with the organizing of temporary forces of limited personnel for such work. Due cognizance is taken of this and results evaluated accordingly. Malaria in the High Rock Territory History and blood indices disclose that for the period embraced by the 1926 survey in the High Rock territory, malaria as compared to districts in which the disease becomes a major problem, was not a feature of public health importance. The infections as shown by histories was 1.789<', by blood smears, 3.50%. It is well, however, for those interested in malaria and malaria control to remember that the problem is a constantly shifting and fluctuating one and that it is practically impossible to secure a picture of the disease at rest, nor is it expected that the parasitic or history indices will remain the same for long periods of time. Sectional differences, in view of the disease and toleration for it, will have influence. Also, the experience gained in one community may be entirely contradicted by that from another of similar type. Mosquitoes in the High Rock Territory The outcome of the mosquito survey in the High Rock territory amply meets any normal expectation that may have been held for it. Both Culex and Anopheles existed in proportion as they were aff"orded sanctuary and favorable conditions. Culex were generally prevalent in limited quantities throughout the terri-tory, with exaggeration in sections when afforded fitting encouragement such as conditions of water contamination by rubbish, waste, or sewage. This was given expression in the increase in prevalence during dry seasons. Punctipennis existed in by far the greatest quantities, v/hich marks the section as majorly Punctipennis grounds. This measures up to original appearances, that at large the section topographically was fitted best to the production of this type of mosquito. Quadrimaculatus existed in limited quantities and were fairly well dis-tributed under general conditions throughout the territory. They appear prominently where efforts were confined to territory of the type most suited to them. This again supports original indications, that while the territory was by nature majorly of Punctipennis producing proclivities, it also would be subject to local Quadrimaculatus production
Object Description
Description
Title | Biennial report of the North Carolina State Board of Health |
Other Title | Report of the North Carolina State Board of Health. |
Creator | North Carolina. State Board of Health. |
Date | 1926; 1927; 1928 |
Subjects |
North Carolina. State Board of Health--Statistics--Periodicals Public health--North Carolina--Statistics--Periodicals Public Health--North Carolina |
Place | North Carolina, United States |
Time Period | (1900-1929) North Carolina's industrial revolution and World War One |
Description | Report covers two calendar years (13th-18th); (19th) covers Dec. 1, 1920-June 30, 1922; thence each covers July 1-June 30 years.; Printer: 13th (1909/10)-18th (1919/20) by Edwards & Broughton; 19th (1921/22)-20th (1923/24) by Bynum; 21st (1925/26)-<44th (1970/72)> unnamed. |
Publisher | Raleigh :The Board,1911- |
Agency-Current | North Carolina Department of Health and Human Services |
Rights | State Document see http://digital.ncdcr.gov/u?/p249901coll22,63754 |
Physical Characteristics | v. ;24 cm. |
Collection | Health Sciences Library, University of North Carolina at Chapel Hill |
Type | text |
Language | English |
Format | Reports |
Digital Characteristics-A | 9,573 KB; 170 p. |
Series | Biennial report of the North Carolina State Board of Health |
Digital Collection |
Ensuring Democracy through Digital Access, a North Carolina LSTA-funded grant project North Carolina Digital State Documents Collection N.C. Public Health Collection |
Digital Format | application/pdf |
Related Items | Printer: 13th (1909/10)-18th (1919/20) by Edwards & Broughton; 19th (1921/22)-20th (1923/24) by Bynum; 21st (1925/26)-<44th (1970/72)> unnamed. |
Title Replaces | North Carolina. Board of Health../1 |
Audience | All |
Pres File Name-M | pubs_edp_biennialreportboardofhealth19261928.pdf |
Pres Local File Path-M | \Preservation_content\StatePubs\pubs_edp\images_master\ |
Full Text | H00111237 F .IIIINIIIHNIIUI lipiip ill 1 1 llllllllll llipillll I pilillll llllllll WHK I Y '. ": C i,;ND '''biennial 're PO. It) iBiBn^^m n NOK'fll CA IlilHitlilUIH Mvm id 1 A y n Ci)c Libcarp of t!;£ Unititmiv of Jl^ortb Carolina (EnDotoeD bp ^l^t SDialcctic ano P!)(lQnt!)ropic feiocirties WA 1 H?>G2b TWENTY-SECOND BIENNIAL REPORT OF THE NORTH CAROLINA STATE BOARD OF HEALTH JULY 1, 1926 - JUNE 30, 1928 Members of the State Board of Health 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, December 1, 1928. His Excellency, A. W. McLean, Governor of North Carolina. My Dear Sir:—Under authority of chapter 118, Ai'ticle 1, section 7050, Consolidated Statutes of North Carolina, I have the honor to submit the Biennial Report of the State Board of Health for the period July 1, 1926, to June 30, 1928. Very respectfully yours, Chas. O'H. Laughinghouse, Secretary and Treasurer. Public Health Work in North Carolina In the seventies Dr. Thomas Fanning Wood, of Wilmington, caught the vision of the possibilities of public health work to North Carolina. 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 inspiration, we shall never know. We do know 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 influence reached the people of the State in their General As-sembly of 1877, with the eff'ect that on February 12, 1877, the North Caro-lina State Board of Health was born. Ours was the twelfth State board of health to be established. Without treating the development of the newly-established board with that thoroughness that could be termed history, we think it enough to set down here in chronological order the principal events in the life and growth of the North Carolina State Board of Health. 1877. Board created. Consisted in the beginning of entire State Medical Society. Society acted through a committee. Annual appropri-ation, $100. 1878. First educational pamphlet issued. Subject, "Timely Aid for the Drowned and Suffocated." Annual appropriation, $100. 1879. The General Assembly reconstituted the Board of Health. Made it to consist of nine members: six appointed by the Governor, three elected by the State Medical Society. Term of office, five years. Dr. Thomas F. Wood elected fii-st Secretary of the Board, May 21. Other legislative provisions: (1) Chemical examination of water, and (2) organization of county boards of health, composed of all regular practicing physicians and, in addition, the mayor of the county town, the chairman of the board of county commissioners, and the county surveyor. Four educational pamphlets issued. Subjects: "Disinfection, Drainage, Drinking-water, and Disin-fectants;" "Sanitary Engineering;" "Methods of Performing Post-mortem Examinations;" "Limitation and Prevention of Diph-theria." Annual appropriation, $200. 1881. General Assembly passed a law requiring registration of vital statistics at annual tax listing; law ineffective. Annual appro-priation, $200. 1885. General Assembly made county boards of health more efficient; allowed printing privileges not to exceed $250 annually. Annual appropriation, $2,000. 1886. Bulletin made its appearance in April. Pamphlet on "Care Eyes and Ears," by Dr. Richard H. Lewis, printed and distributed. Subse-quent Legislature provided for extra edition of 10,000 copies for general distribution. Annual appropriation, $2,000. 1888. Yellow fever epidemic in Florida and refugees to Western North Carolina demonstrated value of a Board of Health to cope with situation. Annual appropriation, $2,000. 8 North Carolina Board of Health 1892. Dr. Thomas F. Wood, the Secretary of the Board, died August 22. Dr. Richard H. Lewis elected Secretary to succeed Dr. Thomas F. Wood, September 7. Annual appropriation, $2,000. 1893. Legislative provisions: (1) Laws improving the reporting of con-tagious diseases, (2) the protection of school children from epi-demics, (3) protecting the purity of public water supplies, and (4) regulation of common carriers. Legislature provided that Governor appoint five of the nine members of the Board of Health, that the State Medical Society elect four, and that the term of office of the members of the State Board of Health be reduced from five to two years. The $250 printing limit was removed. Pamphlet on quarantine and disinfection was prepared and re-printed by many of the State papers. Annual appropriation, $2,000. 1894. A number of public health conferences were arranged and held in difl!"erent towns of the State. Bulletin was increased from a mail-ing list of 800 to 1,200. Annual appropriation, $2,000. 1895. Dr. Albert Anderson and Dr. W. T. Pate were elected bacteriologists for the board. Annual appropriation, $2,000. 1896. Board passed a resolution requiring chemical and bacteriological examinations of municipal water supplies. Dr. Venable of Chapel Hill, undertook the chemical examination, and Drs. Anderson and Pate the bacteriological examination. Board also directed Mr. John C. Chase, the engineer member, to inspect all municipal water plants in the State. Annual appropriation, $2,000. 1897. General Assembly enacted law requiring county superintendents of health to be elected by county commissioners, and reduced term of ofi'ice to one year. Annual appropriation, $2,000. 1899. General Assembly improved the laws protecting public water sup-plies. Smallpox prevailed extensively in the State. Dr. Henry F. Long, and later, on Dr. Long's resignation. Dr. Joshua Tayloe were employed to travel over the State, consulting with and advising the local sanitary authorities as to proper means for protecting the public. Annual appropriation, $2,000. 1900. State Board of Agriculture, on request of State Board of Health, agreed to examine samples of water from public water supplies until Board of Health could provide its own examiner. Annual appropriation, $2,000. 1901. State Board of Embalmers, with representatives of State Board of Health, established. County health work placed in the hands of county sanitary committees composed of county commissioners and two physicians which commissioners elected to serve with them. Term of office of county superintendent of health made two years. Annual appropriation, $2,000. 1903. General Assembly enacted law permitting Board of Health to charge $5 for each analysis of a public water supply, this fee to be used in paying Department of Agriculture for services of examiner. Dr. C. W. Stiles, U. S. P. H. S., before the State Medical Society at Hot Springs, called attention to prevalence of hookworm dis- Twenty-second Biennial Report 9 ease in the South. Dr. J. L. Nicholson and Dr. W. S. Rankin, working under State Board of Health during fall of 1903 and spring of 1904, showed great prevalence of this disease in North Carolina. Annual appropriation, $2,000. 1904. A stenographer was employed. One hundred and twenty thousand pamphlets on tuberculosis were printed and distributed. There was a renewal and an extension of cooperative work between the Board of Health and the State press, a number of articles dealing with hygienic and sanitary subjects being furnished the papers and published in them. Annual appropriation, $2,000. 1905. General Assembly established State Laboratory of Hygiene; imposed water tax of $64 on all public water companies; voted $600 an-nually for support of Laboratory. Small appropriation made it necessary for the Department of Agriculture to continue to assist State Board of Health. Annual appropriation, $2,600. 1906. The North Carolina Association for the Study and Prevention of Tuberculosis was organized. Annual appropriation, $2,600. 1907. Two thousand dollars appropriated for the State Laboratory of Hygiene. Pasteur treatment provided. State Sanatorium for treatment of tuberculosis founded: $15,000 appropriated for permanent improvements and $5,000 for maintenance. A law re-quiring the separation of tuberculous prisoners from other pris-oners was enacted. Annual appropriation, $4,000. 1908. January 1, Dr. C. A. Shore became Director of State Laboratory of Hygiene. Annual appropriation, $4,000. 1909. General Assembly provided for (1) whole-time State Health Officer; (2) collection of vital statistics of towns having a population of 1,000 or over; (3) that all public water companies file plans and specifications of their plants with the State Board of Health, and that the State Board of Health pass necessary rules and regula-tions for the care of public watersheds and plants and furnish such rules and regulations and other advice to those having charge of public water supplies; (4) that counties provide free diphtheria antitoxin for county indigents, and (5) that the maintenance appropriation for the Sanatorium be increased from $5,000 to $7,500, and an additional $30,000 be granted for permanent im-provements. Dr. Richard H. Lewis resigned as Secretary of the Board, and Dr. W. S. Rankin was elected as his successor, begin-ning his official work July 1. Annual appropriation, $10,500. 1910. General effort to interest the people and State organizations in public health work. Bulletin increased from 3,500 edition to 10,500 edition. Addresses on public health work delivered to Con-ference of County Superintendents of Schools, State Federation of Women's Clubs, State Press Association, and Sanitary Sunday observed in April. Dr. John A. Ferrell elected, February, As-sistant Secretary for Hookworm Eradication; began work under State Board of Health and Rockefeller Sanitary Commission. First effort in the eradication of hookworm disease was to interest school teachers in the disease and through their assistance ex-amine and treat the children, and thereby reach the community. 10 North Carolina Board of Health Three bottled spring waters sold on the market examined, found polluted, and public attention called to the pollution. Annual appropriation, $10,500. 1911. Legislature established county boards of health to take the place of the county sanitary committees; county board of health com-posed of chairman board of county commissioners, county superin-tendent of schools, mayor of county town, and two physicians selected by the three county officials to serve with them. Legis-lature also abolished quarantine for smallpox and improved the quarantine laws. One thousand dollars annually appropriated to contract with antitoxin manufacturers for State supply of high-grade diphtheria antitoxin, with result that price of antitoxin was cut to one-fourth former price, saving the citizens of the State over $30,000 annually. Bulletin increased from 11,500 copies to 20,000 copies each edition; closer cooperation with press of State developed; regular weekly press articles prepared and sent to papers; increase in numbers of popular pamphlets for distribution. Hookworm work this year largely educational through the school forces and investigative through county dispensaries; thousands of children found infected and treated. Strong sentiment began to make itself felt for better health work by counties, four counties employing whole-time county health officers. Maintenance appro-priation for State Sanatorium increased to $12,500, with $20,000 voted for permanent improvements. Annual appropriation, $22,500. 1912. Bulletin increased to 40,000 edition; number of popular pamphlets dealing with different diseases increased; press work improved; educational work of Board along all lines amplified. Secretary of Board of Health called attention of conjoint meeting of State Medical Society and State Board of Health to the relative im-portance of health problems and the bearing of this subject upon the proper apportionment of health funds; instrumental in pass-ing a resolution to the effect that pellagra was an interstate prob-lem, not a State problem, and requesting the Federal Government to deal with pellagra as a Federal problem; resolution responsible, to considerable extent, for successful effort on part of Hon. John M. Faison's securing Congressional appropriation of $45,000 for the study of pellagra by the Federal Government. Hookworm work extended and county funds appropriated to supplement State and Rockefeller Foundation for this work. Annual appropriation, $22,500. 1913. General Assembly passed Model Vital Statistics Law with $10,000 appropriation for its enforcement. County superintendents of health changed to either county physician or county health officer. Educational efforts of Board continued and enlarged. Hookworm work along same line as year before increased in amount. Dr. John A. Ferrell resigned as Assistant Secretary to accept position with the central office of the Rockefeller Sanitary Commission in Washington, D. C. Dr. C. L. Pridgen succeeded Dr. Ferrell. The movement for improved county health work had by this time resulted in ten counties electing whole-time countv health officers. Twenty-second Biennial Report 11 The State Sanatorium for Treatment of Tuberculosis turned over by Extra Session of 1913 to the management of State Board of Health. Annual appropriation, $40,500. 1914. Preceding work of the Board continued. Board of Health took over management of Sanatorium; started out under many difficulties on account of the institution owing many debts and the appro-priation being limited. Hookworm work changed to community work directed to the installation of sanitary privies in all homes. Laboratory began to produce and distribute free anti-typhoid vac-cine. Dr. C. L. Pridgen resigned as Director Hookworm Eradi-cation, and Dr. W. P. Jacocks succeeded him. Annual appro-priation, $40,500. 1915. General Assembly makes State vital statistics law conform to National model by requiring burial permits in rural communities; enacts legislation permitting county commissioners and towns and cities to appropriate money for support of tuberculous citizens in State Sanatorium; provides $15,000 for purchase and building of antitoxin plant: appropriates $60,000 for payment of Sanatorium debts and new buildings and other improvements, and $25,000 annually for maintenance and $10,000 for extension anti-tubercu-losis work. Educational work greatly extended: Bulletin now 47,000; traveling public health exhibit shown at fairs and other assemblages; press work greatly developed through employment of journalist for whole time; stock lectures with lantern slides supplied public speakers in different parts of the State; com-munity soil pollution work under Dr. W. P. Jacocks stops in May, and Bureau of County Health Work with Dr. G. M. Cooper at its head, succeeds, beginning work in June. Considerable amount of work done for improvement of prison conditions. The unit system of county health work gets a good start: over 52,000 people given three complete vaccinations against typhoid fever, and medical inspection of schools put on in one county. Annual appropriation, $50,500. 1916. North Carolina was admitted to the Registration Area for deaths. To the educational agencies of the Board was added a self-sup-porting moving picture health show. Many saw this show during the year, and, seeing, believed in health work as never before. Bulletin had to be discontinued temporarily for lack of printing funds, but before discontinuance reached 51,000 edition. Co-operation with University in developing a plan and putting on a home post-graduate course in medicine, giving first course to 169 doctors. Put into operation an optional system of hotel inspec-tion, with grading and publishing scores. Continued unit system of county health work, giving three anti-typhoid injections to 48,000, making 100,000 immunized in summers of 1915 and 1916. Did complete medical inspection of five counties and with inspec-tion a large amount of educational work as to sanitary and hygienic living. Secured effort by Federal Children's Bureau to develop unit of child hygiene work, the Bureau using two em-ployees to work in Cumberland and Swain counties for about eight months. Laboratory of Hygiene buys land and erects its own 12 North Carolina Board of Health building. Sanatorium making a decided impression on the State. Annual appropriation, $55,500. 1917. The General Assembly passed the following important health legis-lation: Chapter 263, entitled "An act to prevent and control the occurrence of certain infectious diseases in North Carolina;" chapter 244, entitled "An act to provide for the physical ex-amination of the school children of the State at regular inter-vals;" chapter 276, entitled "An act for the cooperative and ef-fective development of rural sanitation;" chapter 257, entitled "An act to prevent blindness in infancy, designating certain powers and duties and otherwise providing for the enforcement of this act;" chapter 66, entitled "An act to provide for the sani-tary inspection and conduct of hotels and restaurants;" chapter 286, entitled "An act to regulate the treatment, handling and work of prisoners." Following the enactment of this legislation, administrative ma-chinery, consisting of a Bureau of Epidemiology under the direc-tion of Dr. A. McR. Crouch, a Bureau for the Medical Inspection of Schools under the direction of Dr. Geo. M. Cooper, and a Bureau for County Health Work, under the direction of Dr. B. E. Washburn, was established. Dr. Washburn, an officer of the Inter-national Health Board, was loaned to the State without cost and the International Health Board, in addition to furnishing Dr. Washburn, appropriated $15,000 annually for rural sanitation in accordance with the provisions of chapter 276. The United States Public Health Service in February, 1917, de-tailed Dr. K. E. Miller to study county health work in different sections of the country and to establish for demonstration pur-poses, in Edgecombe County, department of health on an economic basis easily within the financial reach of the average county. The State Laboratory of Hygiene moved into its own building January 15, 1917. The State was admitted to the registration area of the Union for births in January, 1917, the Bureau of the Census having found after investigation that our birth registration was 96 per cent complete. The special campaign against typhoid fever begun so satis-factorily in 1915, was continued. Free vaccination of the people, however, was interferred with by the difficulty in securing medical officers to do the work, the preparedness program of the Govern-ment having caused many physicians and nurses to enter the Army and Navy; nevertheless, a total of 30,000 citizens of the State were vaccinated as a direct result of the Board's activities, and many thousands of others were vaccinated by the physicians of the State as a result of the educational work of the Board directed to impressing the people with the value of vaccination as a means of prevention for typhoid fever. In December, 1917, life extension work as developed by the Life Extension Institute of New York, which consisted briefly of the free physical examination of interested citizens for the pur-pose of advising them as to their physical condition and needed Twenty-second Biennial Report 13 \ hygienic reform and medical treatment, was begun on a county basis. The funds necessary for this work were appropriated partly by the State and partly by the counties in which the life extension work was carried out. Dr. Amzi J. Ellington, who at the time was a resident physician in the New York City Hospital and who had during his residency in that institution studied the methods of the Life Extension Institute under Dr. Eugene Lyman Fisk, was employed and placed in charge of the work. Life ex-tension work was carried out in Vance, Alamance, Lenoir and Robeson counties, and resulted in the full physical examination of 4,000 citizens. This work was very favorably received, and the outlook for its continued development seemed excellent when, with the declaration of war and the call for physicians to enter the military service of the country, Dr. Ellington enlisted in the Medical Corps of the Army. For this reason, and for the further reason that it has been almost impossible to secure health officers during the past two years, the work was not resumed. The educational work of the State Board of Health consisted in the issuance of eight Bulletins, each monthly edition amount-ing to 45,000, and a daily newspaper health article. The Bureau continued its moving picture show exhibit and, in addition, pre-pared probably the best three-dimension educational exhibit in the United States. In 1917 the following exhibits were given: motion picture entertainments, 236; traveling public health ex-hibits, 32; special exhibits, 58; stereopticon entertainments, 3 — to a total of 95,000 people. Arrangements were made for the preparation of newspaper plate, which was sent to and extensively used by 202 papers having a total circulation of 303,000. A large part of this newspaper material was prepared by the well-known authority and publicist in matters of sanitary and hygienic edu-cation. Dr. W. A. Brady of Elmira, New York. The annual appropriation for the State Board of Health was $60,772.16. The annual appropriation for the State Laboratory of Hygiene was $12,500, and this, in addition to $9,087.22 in fees permitted under the laws of the State to be paid to the Laboratory for special work, provided the Laboratory with a total annual budget of $21,587.22. 1918. Much of the work this year was influenced by the war and had to do with preparedness. The State Health Officer visited Washing-ton, at the request of the Council of National Defense and as chairman of a committee of State Health Officers, on a number of occasions for conferences with respect to preparedness measures, provisions for the control of venereal diseases, arrange-ments for coordinating the control of infectious diseases in the civilian population with their control in cantonments, and to arrange, if possible, with the Public Health Service and the Surgeon-General of the Army for preserving the personnel of State health departments during the war. The State Health Officer also made a visit to the states of South Carolina, Georgia, Alabama and Florida for the Council of National Defense in order, 14 North Carolina Board of Health if possible, to interest the Governor, the State Board of Health, and the State Council of Defense in venereal disease control. Considerable time was given to assisting Major John W. Long, Medical Aide to the Governor, in the work of organizing the Medical Advisory Boards and in interesting physicians in enter-ing the medical service of the Army and Navy, and, later in the year, in inducing the physicians of the State to become members of the Volunteer Medical Service Corps. Pai'tly as a result of these activities, the Surgeon-General of the Army assigned Major Joseph J. Kinyoun to assist the State Board of Health in the control of communicable diseases, the Board being under no financial obligation for Major Kinyoun's assistance; and as a result of the successful termination of the activities of various interests looking to a more effective control of venereal diseases, the Kahn-Chamberlain Bill passed Congress, and made available to the State of North Carolina, and without condition $23,988.61 for venereal disease work. The Laboratory during this year began the distribution of a high grade of diphtheria antitoxin. The Bureau of Medical Inspection of Schools developed, and with a degree of success that we may say established, free dental clinics for the public schools of the State. The Bureau also de-veloped to a successful extent an arrangement in the form of adenoid and tonsil clubs for the practical and economic treatment of public school children suffering from these defects. The Bureau of Epidemiology employed two third-year medical students, equipped them with motorcycles, and put them into the field to investigate infringements of the quarantine law. Suf-ficient convictions were obtained to impress the medical profession with the determination of the State to enforce its health laws, and a fairly satisfactory compliance with the laws regarding the reporting of communicable diseases was brought about. The Bureau of Venereal Diseases, paid for by the Federal ap-propriation, was established in September under the directorship of Dr. James A. Keiger of Charlotte, N. C. Mr. Warren H. Booker, for the last seven years the efficient director of the Bureau of Engineering and Education, left in September for Red Cross work in France, the work of his bureau being continued, with the exception of the engineering work, by Mr. Ronald B. Wilson. As a result of Mr. Booker's leaving, cer-tain funds became available, and a Bureau of Infant Hygiene, under the directorship of Mrs. Kate Brew Vaughan, was organized late in 1918. Perhaps the most outstanding feature of the health work dur-ing the year 1918 was the epidemic of influenza. The epidemic began early in October and caused in October alone 6,056 deaths; in November 2,133 deaths; and in December 1,497 deaths, a total during the last three months of 9,686 deaths. The annual appropriation for the State Board of Health for 1918 was $73,210.38. Twenty-second Biennial Report 15 The annual appropriation for the State Laboratory of Hygiene was $12,500. The Laboratory, during this year, collected $8,532.48 in fees for special work, so that the total income of the Laboratory for this year was $21,032.48. 1919. The General Assembly passed the following important health legis-lation: Chapter 71, entitled "An act to prevent the spread of disease from insanitary privies;" chapter 192, entitled "An act to provide for the physical examination and treatment of the school children of the State at regular intervals;" chapter 206, entitled "An act for the prevention of venereal diseases;" chapter 213, entitled "An act to require the provision of adequate sanitary equipment for public schools;" chapter 214, entitled "An act to obtain reports of persons infected with venereal diseases;" chap-ter 215, entitled "An act for the repression of prostitution;" and chapter 288, entitled "An act to amend chapter 671, Public-Local Laws of 1913, relating to the injunction and abatement of certain nuisances." The Bureau of Engineering and Inspection was organized in April. The engineering work of the Board had been suspended with the resignation of Mr. Warren H. Booker in September, 1918, Mr. Booker having gone to France to engage in tuberculosis work under the direction of the Red Cross. Between September, 1918, and April, 1919, the engineering problems coming before the Board had been referred and very kindly and effectively taken care of by Col. J. L. Ludlow of Winston-Salem. Mr. H. E. Miller, an engineer and a graduate of the University of Michigan, was placed in charge of the new bureau, and his brother. Dr. K. E. Miller, of the United States Public Health Service, was detailed by the Service to assist him in the organization of his work. Mr. H. E. Miller and Dr. K. E. Miller spent the spring and sum-mer and a part of the fall in studying various types of privies, in preparing plans for the construction and maintenance of privies, and in preparing the necessary notices and literature to inform the people of the objects and requirements of the new privy law. On May 1st Dr. A. J. Warren, health officer of Rowan County, was appointed to and accepted the position of Assistant Secretary of the Board. On July 1st Mr. R. B. Wilson accepted the position of Director of Public Health Education. On August 1st Dr. A. McR. Crouch, Director of the Bureau of Epidemiology, i-esigned to accept a position with the city of Wil-mington. Dr. F. M. Register, whole-time health officer of North-ampton County, succeeded Dr. Crouch as director of the bureau. In September Dr. J. R. Gordon, Director of the Bureau of Vital Statistics since 1914, resigned on account of impaired health, and on October 1st the Bureau of Epidemiology and the Bureau of Vital Statistics were combined and placed under the direction of Dr. Register. In September Mrs. Kate Brew Vaughan, Director of the Bureau of Infant Hygiene, resigned. The bureau was reorganized under 16 North Carolina Board of Health an understanding with the American Red Cross and was enlarged to include, in addition to infant hygiene, the problem of public health nursing, the name of the bureau being changed to that of "Bureau of Public Health Nursing and Infant Hygiene." Under the agreement with the Red Cross this bureau was to have an available appropriation of $12,000 a year, half of which was to be furnished by the American Red Cross and half by the State Board of Health. The personnel of the bureau and its plan of work, under the agreement, was made contingent upon the ap-proval of both participating agencies, the American Red Cross and the State Board of Health. In December Miss Rose M. Ehren-feld took charge of the new bureau and began its organization and work. On October 1st Dr. Jas. A. Keiger, Director of the Bureau of Venereal Diseases, resigned and Dr. Millard Knowlton was ap-pointed to succeed him. The typhoid campaign carried on during the summer through previous years, was continued in the summer of 1919, using third-year medical students, furnished either with automobile or motor-cycle for getting about. Campaigns were carried out in the fol-lowing counties: Bertie, Cabarrus, Chatham, Chowan, Columbus, Craven, Hertford, Iredell, Johnston, Lincoln, Onslow, Pasquotank, Perquimans, Randolph, Richmond, Rockingham, Stanly, Union, Warren, Wayne. A total of 49,076 were given complete vacci-nations. The educational work of the Board consisted of the publication of a 48,000 monthly edition of the Bulletin, and the distribution of about 350,000 pieces of public health literature. The funds available during this fiscal year amounted to $198,- 549.14, of which $102,301.98 was from State appropriations and the remainder from outside sources. The appropriation for the State Laboratory of Hygiene for this year was $28,500; in addition to this, the Laboratory collected in fees for special work, for antitoxin, and in water taxes a total of $14,344.02, making a total of $42,844.02 available for work of Laboratory. 1920. During this year there was a Special Session of the General As-sembly, lasting twenty days and held in the latter part of August. This Special Session passed an act amending the vital statistics law,, making the fees for local registrars 50 cents instead of 25 cents for each certificate properly filed with the State Board of Health. On January 1st Dr. B. E. Washburn, who had had general direction of the cooperative county health work and who had rendered most acceptable service, was recalled by the Inter-national Health Board and detailed to take charge of their inter-ests in Jamaica. Dr. K. E. Miller, of the United States Public Health Service, who had been detailed in January, 1917, to or-ganize a model county health department in Edgecombe County and then, in 1919, to assist his brother, Mr. H. E. Miller, in organ-izing the work of the new Bureau of Engineering and Inspection, Twenty-second Biennial Report 17 to which was assigned the duty of enforcing the State-wide privy act, succeeded Dr. Washburn as Director of the Bureau of County Health Work. In January a cooperative effort with the United States Public Health Service and the International Health Board to demonstrate the possibilities and advantages of the eradication of malaria from certain towns and cities in the eastern part of the State was begun. The terms of cooperation were that the International Health Board and the State Board of Health were to pay one-half of the expenses of the local work and the town or city in which the work was done the other half, the Public Health Service furnishing, as its part, expert supervising personnel. The towns and cities chosen for this work were Goldsboro, Farmville, and Greenville, the budgets for each municipality being, respectively: Goldsboro, $13,670.98; Farmville, $5,000; and Greenville, $9,000, a total investment in this work of $27,670.98. Mr. A. W. Fuchs, Associate Sanitary Engineer, was detailed by the Service to have supervision of the v^^ork. In February Dr. A. J. Warren, Assistant Secretary of the State Board of Health, resigned his position in order to accept the appointment of city health officer of Charlotte, N. C. In the winter and spring of 1920, the North Carolina Land-owners' Association, under the progressive leadership of Mr. W. A. McGirt, of Wilmington, undertook a very extensive educational campaign against malaria, which was carried on through the pub-lic schools of thirty-eight counties in eastern North Carolina. A series of county and State prizes for the best essay on malaria by public school children were offered as an inducement to the school children to interest and inform themselves, and, indirectly, their parents, with regard to the importance of this disease. To make possible this work by the school children 75,000 malaria catechisms, prepared by Dr. H. R. Carter, of the United States Public Health Service, v/ere distributed through the public schools of the eastern part of the State to the school children. Thousands of essays were written, and it is reasonable to believe that the campaign was one of the most successful public health educational attempts yet undertaken. In June it was found advisable to separate the Bureau of Epi-demiology and the Bureau of Vital Statistics which had, on ac-count of the scarcity of health officers, been placed under the directorship of a single bureau chief. Dr. F. M. Register. Dr. Register was appointed Director of the Bureau of Vital Statistics and Dr. J. S. Mitchener was appointed Director of the Bureau of Epidemiology. In April the Interdepartmental Social Hygiene Board assigned to the State Board of Health several workers for making a study of vice conditions in North Carolina towns and cities and for taking such steps as were found expedient for decreasing prosti-tution. This group of workers was withdrawn in September, on account of differences developing between them and Dr. Knowlton, chief of the Bureau of Venereal Diseases, with the understanding 18 North Carolina Board of Health that another group of workers would be assigned to this work at a later date. In June arrangements were made with the United States Public Health Service and the American Social Hygiene Association for the development of an elaborate educational unit on sex hygiene and venereal diseases designed to reach rural meetings through the use of picture films and a portable truck. An outfit consist-ing of several lectures and a moving picture truck began work in Cumberland County in August, and from its very beginning met a most cordial reception and gave every promise of developing into one of the most useful agencies for dealing with the venereal disease problem. During the year the anti-typhoid vaccination campaign was con-tinued in Alamance, Bladen, Columbus, Duplin, Franklin, Gaston, Harnett and Mecklenburg counties. Cooperative campaigns, in which the counties furnished the working personnel, were also carried on in Anson, Johnston and Rutherford counties. A total of 29,435 citizens have been vaccinated against the disease, and this does not include Columbus County, in which the work was just beginning when this report was completed. The educational work of the State Board of Health during this year consisted of a 48,000 monthly edition of the State Board of Health Bulletin and the distribution of approximately 350,000 pieces of public health literature. The funds available during this fiscal year amounted to $342,- 284.33, of which $176,152.61 was State appropriation and the remainder from outside sources. The appropriation for the State Laboratory of Hygiene for this year was $25,000; in addition to this, the Laboratory collected in fees for special work, for antitoxin and in water taxes, a total of $13,698.89, making a total of $38,698.89 available for the work of the Laboratory. The above amount being insuff"icient, the Special Session of the Legislature authorized a loan of $15,000 to enable the work of the Laboratory to be carried on, making a total of $53,698.89 available for the work of the Laboratory during this year. 1921. The Legislature meeting early in January of this year was asked by the Board to amend the State law restricting the salary of the executive officer of the Board to $3,000 annually, so as to make the salary $5,000. Such an amendment was passed. A further request from the Board was that legislation be enacted removing the inspection tax of forty cents from privies coming under the supervision of the Board of Health. Such an amend-ment to the State-wide Privy Law was also enacted. A bill was introduced in this session of the General Assembly under the initiative of Hon. Emmet H. Bellamy requiring a physical ex-amination of all applicants for marriage and making issuance of license contingent upon the physical qualifications of the appli-cant. The State Board of Health approved and supported Mr. Bellamy's bill, realizing, as did the author of the bill, that the proposed legislation was but a step in the right direction and was, Twenty-second Biennial Report 19 therefore, rather loosely drawn and left many things to be de-sired. The bill finally passed in amended form as chapter 129, Public Laws of 1921. The general health of the State for 1921, as indicated in the vital statistical records for that year, published by the United States Bureau of the Census, was good, and there was an im-provement in reduced death rates for a number of diseases, as well as a reduction in the general death rate over previous years. Another general condition of State-wide importance with a vital bearing on the work of the Board of Health which had to be taken into account was a considerable amount of misunderstanding between respective groups of the medical profession and the Board of Health regarding matters of policy. Many physicians, men in good standing professionally and men with high civic ideals, seemed to feel that the Board of Health had no well-considered and reasonable objectives in the field of public health as it is related to that of private practice. This general condition was responsible for the Board of Health seeking and availing itself of opportunities to meet the profession, both in county, dis-trict and State societies, and to discuss with the profession what it conceived to be the proper relation between public health activities and professional practice. This subject was presented to and considered by the State Medical Society in its conjoint meeting with the State Board of Health at Pinehurst in April, 1921. See transactions Medical Society of the State of North Carolina, pages 472-506. As a result of these various conferences between representative men engaged in public health work and the profession, the general condition of misunderstanding and some little friction had disappeared to a large extent by the latter part of the year. Nevertheless, the results of contact between those engaged in social medicine and private practice were such as to encourage further conferences and efforts to bring about a fuller recognition of mutual interests on the part of the public and the profession, and the ultimate adoption of a program of relations which would be to the mutual advantage of both parties. Perhaps the most important change inaugurated in State health administration during this year was the adoption of a cost basis for standardizing and measuring the efficiency of public health work in those counties in which the State participated financially. This new principle is fully described in the State Board of Health Bulletin for January, 1922, and a further discussion of cost basis for public health work is unnecessary here except, perhaps, to say that it is apparently at least one of the first attempts to introduce the cost system of industry into government. The Bureau of Venereal Diseases, in charge of Dr. Millard Knowlton, established as a part of the war-time activities of the Board in cooperation with the Bureau of Venereal Diseases of the Federal Government, was combined with and made a part of the work of the Bureau of Epidemiology, under the general direc-tion of Dr. J. S. Mitchener. 20 North Carolina Board of Health Funds available for the year included: State appropriation, $275,000; miscellaneous receipts, $164,184.42; total, $439,184.42. 1922. In order to bring the records of this department into harmony with those of other State departments, in accordance with the act of the General Assembly of 1921, changing the fiscal year of the State so as to begin on July 1st each year, this report ends with June 30, 1922. It, therefore, covers a period of nineteen months; one full fiscal year from December 1, 1920, to November 30, 1921; seven months from December 1, 1921, to June 30, 1922. Effective February 1, the American Red Cross Society abrogated the agree-ment existing since 1919 by which it jointly financed with the Board of Health, the Bureau of Public Health Nursing and Infant Hygiene. This bureau was reorganized April 1 as the Bureau of Maternity and Infancy, for its maintenance the State receiving $27,259.66 annually from the United States Government in ac-cordance with the Sheppard-Towner Act for the promotion of the welfare of mothers and infants. Dr. K. P. B. Bonner of More-head City, was secured as the director of the reorganized Bureau, with Miss Rose M. Ehrenfeld as supervisor of nursing and Mrs. T. W. Bickett in charge of educational work. The funds available during this period, and their distribution, were seven-twelfths of the amounts set out under the tabulation for 1921. The appropriation for the State Laboratory of Hygiene for the nineteen months between December 1, 1920, and June 30, 1922, was $87,083.33; in addition to this, the Laboratory collected in fees for special work, for antitoxin, and in water taxes, a total of $30,872.51, making a total of $117,955.84 available for the work of the Laboratory. 1922-23. In order to further develop local responsibility for the protection and promotion of the public health, and to quicken local initiative, a policy of decentralization was adopted by the Board. To carry out this policy there were made several changes in the organi-zation of the Board's executive staff. The Bureau of County Health Work was discontinued. The Bureau of Epidemiology was combined with the Bureau of Vital Statistics. Dr. G. M. Cooper, director of the Bureau of Medical Inspection of Schools, was ap-pointed Assistant Secretary, and Dr. J. S. Mitchener, director of the Bureau of Epidemiology, was transferred to the Bureau of Medical Inspection of Schools. Dr. K. E. Miller, who for four years had been loaned to the Board by the United States Public Health Service, and had directed the work of the Bureau of County Health Work, was recalled for duty elsewhere. The State was divided into four districts with Dr. E. F. Long, Dr. H. A. Taylor, Dr. M. L. Ilsley, and Miss Rose M. Ehrenfeld as district directors. This plan of organization became effective in the early spring of 1923 and was continued through the calendar year. Six vacancies in the membership of the Board occurred during the year, four by expiration of term, and two by resignation. The terms of Dr. J. Howell Way of Waynesville, and Dr. A. J. Crowell of Charlotte, appointed by the Governor, expired, and Twenty-second Biennial Report 21 they were respectively appointed to succeed themselves. The terms of Dr. Charles O'H. Laughinghouse of Greenville, and Dr. Thomas E. Anderson of Statesville, elected by the State Medical Society, expired, and they w^ere respectively reelected. Mr. Charles E. Waddell of Asheville, appointed by the Governor in 1921, resigned and as his successor the Governor appointed Mr. James P. Stowe of Charlotte. Dr. F. R. Harris resigned to be-come health officer of Vance County, and to fill the unexpired term the Board elected Dr. D. A. Stanton of High Point. Dr. J. Howell Way was reelected president of the Board. The General Assembly of 1923 made provision for the constantly growing work of the Board, approving the budget as submitted and appropriating for the Board the sum of $425,000. Legislation enacted included an act to provide for the sanitary manufacture of bedding, to create an independent board of directors for the State Sanatorium, and to provide sanatorium facilities for tuber-culosis convicts. The important new development during the year was the begin-ning of malaria control work in certain counties of the coastal plain area of the State. Through the courtesy of the International Health Board a member of its field staff, Dr. H. A. Taylor, was loaned to the Board for the purpose of making preliminary sur-veys, and areas in Lenoir and Pamlico Counties were selected for investigation. The results showed Pamlico County to be suitable for the initial demonstration, and a unit for the investigation and control of malaria was organized with Dr. Taylor as the director, the budget being contributed forty per cent by the county, forty per cent by the State, and twenty per cent by the Inter-national Health Board. The progress of the work, and the results achieved, proved so satisfactory that in January, 1923, an addi-tional unit was organized in Beaufort Co"unty, and in May, Craven and Bladen Counties were added to the list. Detailed resumes of this work is given elsewhere in this report, but it should be stated here that the success of the intensive malaria control measures has been even greater than was anticipated. While specializing on malaria control measures, the county units have at the same time carried on a general program of public health work. The International Health Board has continued its cooper-ative aid in giving twenty per cent of the unit budget, and has continued the loan of Dr. Taylor, who has directed the work. In June the resignation of Dr. J. S. Mitchener as director of the Bureau of Medical Inspection of Schools was accepted, and Dr. Roy C. Mitchell, who had been engaged in special educational field work, was appointed to the vacancy. 1923-24. The Committee on Municipal Health Department Practice of the American Public Health Association requested the Secretary of the Board to become field director for the Committee in making a study of municipal health practices in the United States for the purpose of working out with and for the Committee a basis or set of principles on and through which city health departments could be given classification or grading, and further for giving 22 North Carolina Board of Health such additional time as might be needed in assisting such de-partments in improving their organization and provision for work. The request was brought before a special meeting of the Execu-tive Committee of the Board, and it directed the Secretary to take advantage of the opportunity offered to become acquainted intimately and broadly with health administration in the cities of the country, and at the same time continue to exercise general supervision of, and executive control over, the work of the Board. In January the Secretary established official headquarters in New York City for the work of the Committee, and the general organ-ization of the executive staff of the Board was continued with the Assistant Secretary, Dr. G. M. Cooper, as administrative or director. During the period of his absence the Secretary has kept in close touch with the work of the Board through frequent reports and a number of visits to the office for conferences with members of the staff. For the more efficient administration of the field activities of the Board the four districts into which the State has been divided the previous were consolidated into two, with Dr. E. F. Long and Dr. H. A. Taylor as Deputy State Health Officers, as directors, assisted respectively by Dr. C. N. Sisk, formerly health officer of Forsyth County, and Dr. George Collins, formerly health officer of Mecklenburg County. At the annual meeting for the Board in April further steps were taken towards making effective the policy of decentralization adopted the previous year. This' policy looks, in a broad way, to the diminishing of State personnel and the use of funds so made available for stimulating and paying county personnel, either whole or part time, to do work which formerly had been in all prob-ability incorporated and carried on by full-time personnel em-ployed by the Board. It was directed by the Board that all ma-chinery and resources of the Bureau of Maternity and Infancy and of the Bureau of Medical Inspection of schools be converted into county machinery and resources, either full-time or part-time, the transformation to be brought about gradually to become effective not later than January 1, 1925. During the year a plan for the more adequate sanitary control of public milk supplies in the State was formulated. The de-velopment of this important new undertaking was assigned to the Bureau of Engineering and Inspection. Mr. Malcolm Lewis, a graduate of Massachusetts Institute of Technology, and with about seven years of experience in public health work, was secured for this particular unit of work. As developed at the present time this service has been largely an advisory one, the various municipalities having at their command the aid of the Board in improving local milk supply conditions. The malaria control campaign in the coastal plain area was enlarged by the addition of organized units in Columbus, Bruns-wick and Hyde counties, making a total of seven counties in the State specializing on this plan of health work. The cooperative aid of the International Health Board was continued. Twenty-second Biennial Report 23 During the year Dr. Roy C. Mitchell, director of the Bureau of Medical Inspection of Schools, resigned. The work of the Bureau was continued under the supervision of the Assistant Secretary. Dr. M. L. Ilsley and Miss Rose M. Ehrenfeld, both district directors, resigned, and effective with the end of the fiscal year Dr. K. P. B. Bonner, director of the Bureau of Maternity and Infancy, resigned. The appropriation by the General Assembly was $275,000 and $300,000 respectively for the two years of the biennium. For the Laboratory of Hygiene the appropriation was $75,000 annually. 1924-25. During this year the work of the Board was directed by Dr. G. M. Cooper, serving as Acting Secretary. Dr. Rankin continued his work with the American Public Health Association. In June, 1925, Dr. Rankin resigned to accept the position of director of the hospital and orphanage divisions of the Duke Foundation. The system of district direction of county health work was dropped, district health officers resigning not being replaced. Dr. E. F. Long and Dr. C. N. Sisk were placed in charge of county health work, and upon the resignation of Dr. Long the responsi-bility for this work was left upon Dr. Sisk. Dr. K. P. B. Bonner resigned as Director of the Bureau of Maternity and Infancy, and Dr. H. A. Taylor was appointed to succeed him, with Dr. George Collins as assistant. On December 1 a division of Health Edu-cation was organized with Dr. M. L. Townsend in charge. 1925-26. Dr. Chas. O'H. Laughinghouse of Greenville, was elected Secre-tary to fill the unexpired term of Dr. W. S. Rankin, resigned, to take office October 1, 1926. Dr. M. L. Townsend resigned as Director of the Bureau of Health Education and Dr. G. M. Cooper succeeded him. 24 North Carolina Board of Health ORGANIZATION OF BOARD The work of the State Board of Health is administered by the State Health Officer and an executive staff, the members of which have definitely assigned duties. The Board consists of nine members, five appointed by the Governor and four elected by the State Medical Society. The terms are six years, and interlock. Not more than two of the Governor's appointees nor more than two elected by the Medical Society expire in any one year. The Board has certain legislation authority, having the power conferred upon it to adopt rules and regulations having the force and effect of law. The work of the Board is now divided into the following bureaux or divisions: Administration: Headed by the State Health Officer with general super-vision of the entire program of work. Laboratory: For diagnostic examination of various specimens, and of samples from public water supplies, and for manufacture and distribution of various vaccines and sera. Sanitary Engineering and Inspection: Enforce sanitary laws; supervise public water supplies and sewerage systems; investigate problems of stream pollution; supervise municipal milk sanitation; supervise shellfish sani-tation. Maternity and Infancy: Supervise maternal and infant hygiene nursing service; conduct prenatal educational service; midwife control. Medical Inspection of Schools: Through staff of nurses gives medical inspection of schools in one-third of the counties each year; conducts an-nually tonsil-adenoid corrective clinics; conducts dental clinics. Epidemiology: Enforces laws regarding communicable diseases; makes epidemiological investigations; conducts campaigns for immunization against typhoid fever, diphtheria, smallpox; makes malaria and mosquito surveys. Vital Statistics: Gathers through local registrars reports of births and deaths; tabulates and indexes certificates; keeps permanent file of all certificates. Health Education: Prepares educational literature, special pamphlets, edits monthly Health Bulletin, and conducts unit in visual education. Life Extension: Promotes periodic health examination for prevention of degenerative diseases; conducts special demonstration clinics for medical profession. County Health Work: Supervises and assists county health departments to which State contributes financiallv. Twenty-second Biennial Report 25 HEALTH—THE STATE'S GREATEST ASSET North Carolina rejoices today in the lowest death rate since the pioneer days of its first settlement. For the past year of 1927 a new low record was achieved, 11.3 per thousand of the population. This was under the rate for the United States' registration area which now includes approxi-mately 85 per cent of the population of the country. Again, it is demon-strated that North Carolina is not only a healthful State in which to live, but that it is in fact one of the most healthful of all the States in the Union. This has not always been true. Not so many years ago the State was hampered and its material progress checked by the prevalence of hook-worm disease and malaria. Smallpox was an ever-present menace, scar-ring and killing. The "Great White Plague" of tuberculosis each year claimed its thousands of victims. Typhoid fever was a constant summer scourge, killing and maiming. One out of every five of the babies born in the State died before reaching a first birthday. This condition was due to a number of causes. On account of its geo-graphical location, the State was especially susceptible to semi-tropical diseases, hookworm and malaria. Because of its predominant rural popu-lation, typhoid fever and other fecal-borne diseases, particularly the diar-rheal diseases of infants, largely alfected the public health. Unprotected public water supplies and general insanitary conditions throughout the State contributed to the high death rate. Today the picture is entirely changed. North Carolinians are a well and happy people, vigorous and able whether at work or play. Co-incident with the tremendous development during the years of the present century in agriculture and industries has been an improvement in general health conditions even more remarkable. Today it is true that no great number of our people are anaemic and weak from the effects of hookworm disease. That affliction is becoming rare in the State. Chills and fever and the sallow complexion of those chronically malarious now is so uncommon as to evoke comment, for ma-laria has been practically eradicated except from certain coastal sections as yet undrained or only partially developed agriculturally. Smallpox now kills less in a year than that comparatively new hazard to life, the auto-mobile, kills in a week. The annual death toll from tuberculosis has been cut more than half. Through sanitation and vaccination typhoid fever has been removed as a major factor affecting the public health. Simultaneously the infant death rate, following increased knowledge of sanitary living and the protection of public water and milk supplies, has been reduced more than one-half so that now instead of one out of each five of the babies born in the State dying during the first twelve months of life the ratio is one out of each thirteen. The vital statistics records for the State as compared with those of the Nation shows that North Carolina has made a markedly greater degree of improvement in the health of its people since 1900 than has its neighboring states, or the country as a whole. In 1900 the death rate for the entire registration area of the United States was 17.6 per thousand of the popu-lation. At that time North Carolina had no accurate records, but from 26 North Carolina Board of Health the most accurate data obtainable it is estimated that the death rate for the State was approximately 22.0 per thousand of the population. This extremely high death rate has been steadily pulled downward until last year it was 11.3 per thousand of the population as compared with 11.4 for the country as a whole. While the death rate for the Nation was falling 35 per cent, that of North Carolina dropped practically fifty per cent. This remarkable reduction in the death rate is the more noteworthy when considered in connection with the high birth rate. Last year there were 83,334 births in the State, a rate of 28.8 per thousand of the popu-lation. For the eighth consecutive year the State has maintained the highest birth rate in the United States. This means an addition annually to the population of a large group which is most susceptible to a number of fatal diseases. Tuberculosis, which holds a place throughout the world as one of the major causes of death, in 1927 claimed more than three thousand less vic-tims in this State than in 1910, just seventeen years previous. The total number of deaths from this cause last year was 2,769, giving the State a rate of 96.8 per hundred thousand of the population. This rate is con-siderably under that for the country as a whole and is lower than any other Southern State. This enviable record was made despite the fact that nearly five hundred deaths from tuberculosis were of non-residents of the State, patients at government or private sanatoria maintained in North Carolina because of its excellent climatic advantages. Sustaining the vital statistics records are the findings of the United States government in connection with medical examinations made of men called for military duty under the Selective Service Act. Figures are now available on the basis of more than two and one-half million men examined, of which number fifty thousand men were from North Carolina. This study gives a cross-section of the physical condition of the male population at an age when physical defects that may shorten life are beginning to ap-pear, and may be taken as a good picture of the general physical condition of the people. These statistics show that North Carolina averaged fewer rejections because of physical unfitness than the country as a whole, and on indi-vidual points ranked well above the average. As compared with the entire country there were in this State fewer defects per thousand, fewer defec-tive men per thousand, fewer mechanical defects, less hernia, less under-weight, fewer defects of the eyes, ears, throat, less organic heart disease, and less defective and deficient teeth. This State is today perhaps the best sanitated State in the Union, con-sidering its predominant rural population. For ten years it has had State laws requiring the sanitary disposal of human excreta. In this North Carolina was a pioneer, being the only State with such beneficial laws until in 1927 the legislature of Alabama gave that state legislation based upon that of North Carolina. Practically the entire urban population is now served with protected public water supplies and with water sewerage. The semi-urban and village and a large portion of the rural population is protected by a system of sanitary privies which are required to be con-structed and maintained sanitarily in accordance with plans and specifi-cations approved by the State Board of Health. Twenty-second Biennial Report . 27 Three factors have been primarily responsible for the changed health condition of our people, a change that in twenty-five years has brought the State from near the bottom to a point close to the top. First of all the State has been tremendously fortunate in having an alert and intelli-gent medical leadership, and with this has been a heartily cooperative profession. Such men as Wood, Lewis, Way, Rankin, have achieved na-tional and international reputations for their leadership in preventive medicine, and their labors for their fellowmen have been of inestimable value. Second, the newspapers of the State, day by day, week by week, have carried on an educational program for sanitation and hygienic living. Third, the General Assembly has consistently enacted needed legislation for the protection of the public health and biennially has provided adequate appropriations for the maintenance and development of public health measures. A natural sequence of the combination of these three factors has been the increasing realization of our people that health, like charity, begins at home. In Guilford County on June 1, 1911, was established the first county health department to be organized in the United States. Today North Carolina has 39 county health departments and six city health de-partments, serving more than one-half of the State's population. In this phase of development North Carolina has been exceeded only by the State of Ohio. For the protection and promotion of the public health the annual appro-priation by the General Assembly is $441,400.00, exclusive of appro-priations made for maintenance and permanent improvements at the State Sanatorium for the treatment of tuberculosis. This puts North Carolina in sixth place in the group of forty-eight States of the Union, the ranking states being Pennsylvania, New York, Illinois, Ohio, Massachusetts, North Carolina. The appropriations made by the counties and cities approximate $600,000.00 annually. This investment of money for the purpose of protecting and promoting the public health is probably the best paying one in direct dividends that is made by the State. The fact that the death rate in the past twenty-five years has been cut in half means a saving not only in lives, but in dollars and cents—a sum one hundred times greater than the amount which has been invested to achieve this result. In ajddition to the local county and city health departments, the State is served by a health department under the direction of a State Health Officer who devotes his time and energy to this one job. Divisions of this department, each under the direction of a trained expert, consist of a hygienic laboratory, vital statistics, epidemiology, county health work, medical inspection of schools, sanitary engineering and inspection, ma-ternity and infancy, health education, and life extension. The work of the State Board of Health may be briefly summarized by divisions as follows: (1) The State Laboratory of Hygiene annually makes 60,000 exam-inations to assist the physicians of the State in the diagnosis and treat-ment of their patients; periodically examines samples from all public water supplies; distributes 750,000 doses of typhoid vaccine for the prevention of typhoid fever; distributes 35,000 doses of pertussis vaccine for the pre-vention and treatment of whooping cough; manufactures and distributes 28 North Carolina Board of Health 225,000 doses of smallpox vaccine for the prevention of smallpox; dis-tributes 210,000 doses of toxin-antitoxin for the prevention of diphtheria and 1,500,000 units of antitoxin for the treatment of diphtheria; makes and distributes 1,800 Pasteur anti-rabic treatments, for the prevention of hydrophobia caused by the bites of mad dogs; distributes 5,000 packages of tetanus antitoxin for the prevention of this dread disease; distributes 125,000 ampoules of neo-arsphenamine for the treatment of syphilis; altogether, in water analysis, diagnostic examinations, and in sera and vaccines supplied, the laboratory performs a public service that at ordinary commercial rates would exceed $1,250,000.00 annually. (2) The division of vital statistics is charged with the vital bookkeeping of the State, an accounting in terms of life and death of the State's popu-lation. Its objective is to secure a permanent record of the more important facts concerning the birth and death of every citizen of the State, and from such records to prepare card indices and tabular classifications in such manner as to make readily available on inquiry the following information: (a) The total number of births occurring annually in the State; (b) the birth rate of the State, that is, the number of births per thousand of the population; (c) the birth rates by races, white and colored; (d) the number of illegitimate births; (e) the number of still-births attended by midwives; (f) the number of white births attended by physicians; (g) the number of white births attended by midwives; (h) the number of colored births attended by physicians; (i) the number of colored births attended by mid-wives; (j) all of the foregoing data as to births with respect to each county and city. These facts permit of comparisons of one part of the State with another, of the birth rate of the two races, and of the birth rate of this State with that of the other states and other countries. Such information is necessary in forming conclusions as to vital conditions in North Carolina and in the enactment of suitable legislation for dealing with these conditions. Last year there were 83,334 live births in the State, certificates for which were handled and classified. (a) The number of deaths occurring in the State annually; (b) the death rate, that is, the number of deaths per thousand of the population; (c) the number of deaths, by races, and the death rates by races; (d) the number of deaths among infants and young children as compared with the births, and the total deaths as compared with the total births, with net gain in population; (e) the total number of deaths by months and year from each of the 209 causes appearing in the International List of Causes of Death; (f) the number of deaths according to age and occupation; (g) the number of deaths according to age and the causes of death; (h) the number of "seasonal" deaths according to months; (i) all of the foregoing data classified according to county, town and city. This information is abso-lutely necessary to understand vital conditions in the State; to know where intensive health work is needed, against what causes of death health measures should be directed, and whether the work of local health depart-ments is associated with a decrease or no decrease in death rates. Last year 32,764 deaths occurred in the State, certificates for which were handled and classified. (3) Through its division of Epidemiology, the Board endeavors to con-trol the spread of contagious and infectious diseases. It supervises the Twenty-second Biennial Report 29 quarantine of approximately 50,000 such cases each year, supplying to each home where any of the contagious or infectious diseases occur, direc-tions for the care of the sick and other precautions necessary to prevent the spread of the disease; makes epidemiological investigations to ascer-tain the source of infection in such diseases as typhoid fever, diphtheria, etc., when such diseases appear in local epidemics; conducts with the assistance of local physicians mass vaccination campaigns for the pre-vention of typhoid and diphtheria, covering about 20 counties each year and securing about 40,000 typhoid vaccinations and 10,000 diphtheria vac-cinations; supervises a malaria control program in a number of eastern counties, and supervises a number of impounded water projects. (4) The 39 county health departments through the division of County Health Work are given supervision and advice, together with financial assistance. Assistance is supplied in planning and developing general and special units of local work, demonstrations, educational exhibits, clinics, laboratories, and the like, and assists in the organization of new county departments. (5) In the division of Medical Inspection of Schools, a field staff of eight nurses, eight dentists and one supervising dentist is maintained. An average of 90,000 school children are being examined by the nurses in those counties not having local health departments. The examinations are for the purpose of discovering the more common defects of childhood such as those of vision, hearing, throat, nose, teeth, skin or orthopoedic de-formities. Personal notes are sent to parents advising of such defects as may be found and urging that the child be given the indicated medical care in order that correction may be made. As a follow-up of this work, the Board conducts during the summer months clinics for operative treatment of children of school age suffering with diseased tonsils and adenoids. A special hospital unit sufficient to care for twenty-five patients is transported by truck. A hospital unit is maintained consisting of a physician to carefully examine the children and administer anaesthesia, eleven experienced nurses, and an orderly. The operating surgeon is a specialist secured on the recommendation of the local county board of health. About 2,000 children are now being treated each year in these summer clinics. An average of 36,000 school children are receiving dental treatment. This includes not only the cleaning of teeth, silver nitrate treatments or temporary fillings for decayed first teeth, but an average of 30,000 per-manent fillings each year, thereby saving that many permanent teeth, the greater portion of which would otherwise be lost. The school dentists doing this work are provided with portable outfits and conduct the dental clinics in the school buildings. A conservative estimate of the cost value of the work done in the tonsil and dental clinics each year is $500,000.00, an amount greater than the total appropriation made for all of the work of the Board. (6) The division of Sanitary Engineering and Inspection is charged with manifold duties all of which intimately affect the public health. Primarily this division supervises the construction and maintenance of all public water supply and sewerage systems. There are 238 public water supplies under supervision, representing an invested capital of $40,000,000 and an annual cost of operation of $3,750,000, serving 30 per cent of the 30 North Carolina Board of Health State's population. The operation of these plants is on the best modern scientific basis and in a manner capable of maintaining the full effective-ness in purification for which the plants were designed. The water supply plants of the State have been virtually built anew in the past ten years and the supervision and advice of the State Board of Health has been of inestimable value in safeguarding the municipalities against incompetent engineering service and inadequate provision for growth. It is noteworthy that all of this work has been handled by North Carolina engineers except a few of the minor improvements. This division is charged with the enforcement of the State sanitary privy law, the work being carried on by a force of ten sanitary inspectors. In addition to the sanitary privy work, supervising inspectors do hotel and cafe inspection and handle special investigations and complaints. One supervising inspector does jail and convict camp regulation, executing the duties assigned by law to both the State Board of Health and the State Department of Public Welfare. The milk sanitation division is assisting in the protection of milk sup-plies in 48 municipalities which have adopted the standard milk ordinance. This now includes about 80 per cent of the public milk supply of the State. The shellfish sanitation division has made a complete sanitary survey of the shellfish growing areas of the State, and supervision is maintained throughout the shipping season. North Carolina shellfish now are accepted in the markets of the country without question. Special engineering service is now available to the counties in the mat-ter of water supply and sewage disposal installation for consolidated schools. Through this service about 200 school sewage disposal projects are being handled each year, the total cost of the work involved in this supervision being $350,000.00. A special study of stream pollution is now being made, necessitated by the growing sewage and waste pollution. Engineering service, in a growing volume, is being supplied to State institutions. This work includes investigations to determine the needs of institutions in water supply and sewerage utilities for the advice of the Budget Commission in recommending appropriations, field surveys, prep-aration of plans, cost estimates and supervision of construction. (7) The division of Maternity and Infancy is primarily charged with the responsibility of reducing the infant and maternal death rate. It has the supervision of the 6,500 midwives of the State, and through special classes each year gives courses of instruction to 2,000 of these. Financial aid and supervision is given to twenty counties which have local maternity and infancy nurses. A correspondence course in prenatal care is maintained with an average of 10,000 expectant mothers. Twenty thousand babies are each year registered for whom special literature on infant care and diet is sent. The field nurses personally see 30,000 mothers and advise with them on the care of themselves and their babies. For the prevention of blindness, 8,000 packages of silver nitrate are distributed. (8) The division of Health Education consists of: (a) preparing copy for the monthly Health Bulletin, a publication of 32 pages with a circu-lation of 22,000, edited for the general public and containing timely articles on sanitation and personal hygiene. The publication is sent only to those Twenty-second Biennial Report 31 requesting it. This Bulletin has been rated by competent judges as the best of its class in the United States; (b) preparing special pamphlets on particular health subjects such as cancer, catarrh, care of babies, consti-pation, colds, care of the eyes, care of the teeth, hookworm disease, malaria, pellagra, tuberculosis, sanitary privies, venereal diseases, typhoid fever, diphtheria, smallpox and the various contagious and infectious diseases. Approximately 1,250,000 pieces of this special educational literature is dis-tributed annually; (c) the preparation of special articles on health sub-jects for the press of the State; (d) visual education through the means of a mobile motion picture unit in charge of an experienced operator, with showing primarily in the public schools of those counties having organized health departments, this unit being designed especially as aid to the local health officers. During the past year 13 counties were served, with 125 showings given to a total audience of 35,380. (9) The division of Life Extension was organized in January, 1928. This division was organized to meet a pressing public need, the action by the Board following resolutions by the President and Councillors of the State Medical Society urging the necessity of the work being undertaken. A study of the vital records of the State disclosed that whereas the death rate from the group of communicable diseases declined from 117.6 in 1917 to 35.4 in 1926, the death rate from degenerative diseases in the same ten-year period rose from 318.9 to 374.9. The total deaths from the degen-erative group in 1926 was 8,105, a fourth of all the deaths occurring in the State. Included in this group are heart disease, Bright's disease, and cancer, all of which particularly affect the citizenship in the age group of 40-60. The only way to combat the alarming increase in the deaths from these degenerative causes is to get those citizens aft'ected under competent medical care before the disease has reached an acute state. To detect these in their incipient and curable stage, it is necessary that thorough physical examinations be made periodically. The Life Extension division was or-ganized and is functioning with two objectives: (1) to acquaint those physicians residing in the rural sections of the State, and practicing with-out the aid of hospitals and laboratories, with the technique of making physical examinations of the apparently well; (2) to assist the medical profession in impressing upon the citizenship of the State the fact that through competent physical examinations these degenerative diseases may be discovered in their incipiency and alleviated or cured. Particularly affecting the coastal counties of the east have been two important undertakings, the field studies in malaria control measures and the survey of salt marsh mosquito infestation. While primarily both of these problems are local, in that they are confined to a comparatively limited area of the State, yet they materially affect the public health of the State as a whole and are an important factor in the agricultural and industrial development of the State. In 1925 the State Board of Health was able to interest the Rockefeller Foundation in malaria control measures to the extent that this Foundation established at Edenton a station for the intensive and thorough study and investigation of malaria control measures. The station is under the direc-tion of Dr. Mark F. Boyd who is assisted by a staff' of trained assistants. The study is still in progress and probably will not be concluded for several years yet. From this North Carolina will secure accurate data upon which 32 North Carolina Board of Health it may with confidence go forward towards the goal of complete eradication of malaria from the State. Second only to the malaria problem in the coastal section is that of the salt marsh mosquito infestation. There are fourteen counties affected, con-taining approximately 300,000 acres of salt marsh territory, this acreage being distributed as follows: Brunswick 17,000, New Hanover 8,500, Pender 6,300, Onslow 13,000, Carteret 80,000, Camden 8,000, Pasquotank 2,000, Perquimans 2,300, Chowan 9,800, Washington 14,600, Tyrrell 40,500, Hyde 25,500, Dare 53,000, Currituck 12,400. For the purpose of making a survey of the salt marsh areas of the South Atlantic and Gulf States, the Congress of the United States in 1926 appropriated the sum of $25,000 and the additional sum of $10,000 to con-tinue the survey through the fiscal year ending June 30, 1928. Under the auspices of the United States Public Health Service, with Dr. T. H. D. Griffits in charge, the survey was undertaken. Included in the survey was the investigation of various types of mosquito breeding areas in the salt marshes along the coast from Virginia to Key West, and from Key West to the Mexican border. This survey has already gathered incal-culably useful data with reference to the egg-laying and larval habits of solicitans mosquitoes; conditions which influence their breeding; distance and direction of their flights; and the influence upon them of tides, vege-tation, soils, salinity, natural enemies, climatological conditions and so on. In addition to this, extensive studies of the habits of these pests have been going on at Biloxi, Mississippi, Fort Pierce and Vero Beach, Florida, and Wilmington, North Carolina. The survey at Wilmington covered approximately all of the important breeding areas in New Hanover County, and in adjacent territories in Brunswick and Pender Counties. Information from this survey was of such valuable nature that it has put New Hanover County in position largely to decrease the mosquito infestation there. The necessary appropriation to continue this important work was left out of the regular appropriation bill introduced into the recent session of Congress. So necessary did its continuation appear that the State Health Off"icer, the Governor and a number of interested citizens urged upon the State's delegation in Congress that this appropriation item be restored. Largely due to the earnest and persistent efforts of Hon. Charles L. Aber-nethy, ably assisted by Hon. Lindsay Warren and other members of the delegation, an appropriation of $10,000 was secured. As a result prac-tically the entire remaining salt marsh area in North Carolina will be included in the survey, and the work upon this is now in progress. From it ways and means to control and prevent the breeding of solicitans mosquitoes, it is hoped will be developed. North Carolina moves forward, no longer a laggard handicapped by disease and poverty. An intelligent leadership has envisioned the fact that agricultural and industrial advancement depend upon a healthy citizen-ship, and through the General Assembly has provided the necessary funds for the protection and promotion of the public health. A medical leader-ship alert to the opportunity presented has carried on, under the direction of the State Board of Health, a continuously winning fight. Today North Carolina is one of the wonder states of the Union—progressive, prosperous, healthful. Twenty-second Biennial Report 33 BUREAU OF VITAL STATISTICS Report of Bureau of Vital Statistics for two years, July 1, 1926—June 30, 1928, inclusive. Since August, 1927, the Bureau of Vital Statistics and Epidemiology have been functioning as separate bureaus, with a director for each. OBJECTIVES The Bureau of Vital Statistics is more closely interlocked with other departments of the State Board of Health than any other department. The reason for all health work is based on vital statistics. The Bureau of Vital Statistics turns out an immense amount of work each year. One reason for this is because each month a definite amount comes into the office which must be taken care of. Then too vital statistics are becoming more useful as information accumulates from year to year. When the Bureau of Vital Statistics of the North Carolina State Board of Health was first created, there was no Bureau of Epidemiology, or Maternity and Infancy, no World War, no Veterans Bureau, no Compensa-tion Act, no School Age Law, no Welfare Department, few automobiles, and a smaller population. All of the above departments are making daily calls on the Bureau of Vital Statistics for information, or certified copies of birth and death certificates. The objective of the Bureau of Vital Statistics is to secure a permanent record of the more important facts concerning the birth and death of every citizen of the State of North Carolina, and from such records to prepare card indices and tabular classifications in such manner as to make readily available on inquiry the following information: 1. (a) The total number of births occurring annually in the State; (b) the birth rate of the State, that is, the number of births per thousand of the population; (c) the birth rates by races, white and colored; (d) the number of illegitimate births; (e) the number of stillbirths attended by midwives; (g) the number of white births attended by physicians; (h) the number of white births attended by midwives; (i) the number of colored births attended by physicians; (j) the number of colored births attended by midwives; (k) all of the foregoing data as to births with respect to each county and city. These facts permit of comparisons of one part of the State with another, of the birth rate of the two races, and of the birth rate of this State with that of the other states and other countries. Such information is necessary in forming conclusions as to vital conditions in North Carolina and in the enactment of suitable legislation for dealing with these conditions. 2. (a) The number of deaths occurring in the State of North Carolina annually; (b) the death rate, that is, the number of deaths per thousand of the population; (c) the number of deaths, by races, and the death rates by races in North Carolina; (d) the number of deaths among infants and young children as compared with the births, and the total deaths as com-pared with the total births, with net gain in population; (e) the total number of deaths by months and year from each of the 209 causes ap-pearing in the International List of Causes of Death; (f) the number of deaths according to age and to occupation; (g) the number of deaths according to age and the causes of death; (h) the number of "seasonal" deaths according to months; (i) all of the foregoing data classified ac- 34 North Carolina Board of Health cording to county, town and city. This information is absolutely necessary to understand vital conditions in the State; to know where health work is needed, against what causes of death health measures should be directed, and whether the work of health departments is associated with a decrease or no decrease in death rates. 3. Under one and two, information necessary for the public welfare and available under the operation of the vital statistics law has been briefly indicated. But the vital statistics law not only supplies information to legislatures, state and county commissioners, and other administrative bodies, which is necessary for framing conservation measures for human life, but it also records facts which may at any time become of great value to the individual. In matters of tracing ancestry, birth records are in-valuable; also in matters of proving age where the fact of age is in ques-tion, as for voting, as for the right to marry, as for the right to enter certain industries, as to entering school, as to liability for military service, etc. METHODS The Bureau of Vital Statistics secures the birth and death certificates for the births and deaths occurring in North Carolina through approxi-mately fourteen hundred and fifty local registrars, appointed by the chair-man of the boards of county commissioners for the various townships and by the mayors for the various incorporated towns and cities of the State. The duties and powers of the local registrars are defined in Consolidated Statutes, section 7113. The county pays the local registrars fifty cents for each birth and death certificate furnished by them to the off'ice of the State Registrar at Raleigh. The vital statistics law makes it the duty of the doctors and midwives in attendance on a birth to file a birth certificate with the local registrar of the district in which the birth occurs and makes the undertaker, or person acting as undertaker, responsible for the filing of the death certificate. The birth and death certificates filed with the local registrars of the State are sent to the Bureau of Vital Statistics on the fifth of the month succeeding the month in which the birth or death occurred. The certificates received in the office of the Bureau of Vital Statistics are examined carefully, and if incorrect or incomplete (as a large per cent of them are) effort is made to secure the information necessary to complete them. Every parent of a legitimate child whose birth is reported is sent a card advising them of the date of birth and whether or not name appears on the certificate. This gives the parent an opportunity to send in to the office the name of the child, in case it does not appear on the certificate, or to make such change in name or date of birth necessary to make certificate an accurate record of birth. The cer-tificates are then classified and tabulated according to county, townships, and registration districts, according to races, according to age at death, according to cause of death, according to death rates and birth rates, etc., in order to make readily available upon request the information mentioned under the heading of Objectives. ROUTINE WORK The routine work in the registration of births and deaths is indicated in the following table. This covers period from July 1, 1926, through June 30, 1928, inclusive. Twenty-second Biennial Report 35 BIENNIAL REPORT July, 1926—June, 1928 Letters and postals received *27,504 Casket dealers reports received 7,072 Supplementals received 3,346 Name cards received 11,240 Violation blanks received 51 Acceptance papers received - - 64 Report cards received from local registrars 24,154 Letters written 16,076 Form letters sent 49,224 Postal cards sent 137,257 Packages of supplies sent 11,301 Bulletins (transferred to another department) 108,304 Indexing: Cards made 254,296 Cards proofread 261,401 Cards assorted 242,262 Cards filed 221,054 Credit certificates sent local registrars 1,759 Certified copies made 5,754 Tables made 654 Cards punched and proofread 71,585 Cards furnished Dr. McCain giving information as to deaths from tuberculosis monthly 5,033 Epidemiology reports from death certificates 4,405 Transcripts made and proofread 240,157 Tabulation of births -..- 165,793 Number certificates made in triplicate 5,800 Lines miscellaneous typing 5,290 Certificates Received: Births 164,609 Deaths 68,333 Stillbirths 15,576 Total 248,518 Names checked on undertakers reports with death certificates .„.- 8,379 Local registrars visited 315 Doctors visited .. - 105 Undertakers and coffin dealers 105 Register of Deeds 20 Midwives 70 RESULTS OBTAINED Of course there is always a large per cent of routine work that is im-possible to put in a report of this kind, and without going into unnecessary detail, it may be said that the objective of this Bureau, as aforestated, has been reached, and that all of the information with its vital bearing upon the public health needs of the State and with the public health accomplish-ments of the State is readily and completely available. *This total does not include letters and postals received for Bureau of Epidemiology from July 1, 1926, to August, 1927. 36 North Carolina Board of Health BUREAU OF EPIDEMIOLOGY The Division of Epidemiology and Venereal Diseases, formally connected with the Bureau of Vital Statistics, was organized into a separate Bureau with a full-time Medical Director, July 1, 1927. OBJECTIVES To prevent and control the occurrence of infections and contagions with special reference to whooping cough, measles, diphtheria, scarlet fever, infantile paralysis, cerebro-spinal meningitis, chicken pox, septic sore throat, german measles, smallpox, typhoid fever, trachoma, malarial fevers, and venereal diseases. METHODS FOR OBJECTIVES For convenience of description, the methods employed by the Bureau in accomplishing its objectives may be divided into two main divisions or units, each having a dual responsibility in the enforcement of rules and regulations pertaining to the control of communicable diseases. Section I.—The County Unit A quarantine officer for each county and city having a separate health department in the State has been secured. He is the Bureau's representa-tive in the field, is required to execute oath of office, and is, therefore, designated as assistant collaborating epidemiologist, receiving compen-sation from their respective counties in accordance with the following provision: The said certification and the sum paid the quarantine officer by the county authority shall be in accordance with a system of fees determined by the North Carolina State Board of Health for each item of work in-volved in the duties of the quarantine officer: Provided, however, that the total annual payment for any county shall not be in excess of the sum stated for such county classified according to population as follows: Per Month Counties with a population less than 10,000 $15.00 Counties with a population of from 10,000 to 15,000 17.50 Counties with a population ctf from 15,000 to 25,000 -— -- 25.00 Counties with a population of from 25,000 to 40,000 35.00 Counties with a population of from 40,000 to 50,000____. 45.00 Counties with a population over 50,000 50.00 Duties of the Quarantine Officer The duties of the quarantine officer, acting as assistant collaborating epidemiologist are similar to a certain extent to those designated by the Board to the Bureau of Epidemiology and may be briefly outlined as follows : (a) To secure reports from parents, teachers, and physicians of all cases of communicable diseases. (b) To keep an accurate record in his office of all reports. (c) To transmit all reports daily to the Bureau of Epidemiology. (d) To supply the parent, guardian, or householder, when the disease is reported, with rules and regulations governing that person, with a placard to be posted on the house, and with a pamphlet descriptive of the disease, its dangers, cause, mode of infection, and methods of control. Twenty-second Biennial Report 37 (e) To inform the teachers in the community where the disease exists that the disease is present, and to supply them with rules and regu-lations governing the school while the disease is present, and with pamphlets descriptive of the disease, its dangers, cause, mode of in-fection, and methods of control, to be distributed through the children to the parents represented in the school. (f) To make the presence and locations of diseases known to the public by publishing notices in the county paper when the disease appears and how to prevent it. (g) To furnish householders forms to report diseases in their community which have not previously been reported. (h) To investigate all cases of suspected contagions which have not been reported, to determine the nature of the disease, (i) To enforce the laws, rules and regulations governing the control of communicable diseases, (j) To make monthly reports to the Bureau of Epidemiology of all the work, educational, administrative, or otherwise, done during the month. Section II.—Bureau of Epidemiology or State Unit In order for the reader to more easily comprehend the duties performed by this Bureau, consideration is given to the work under the following heads: (a) General Office Routine, (b) Special Immunization Campaigns for the Prevention of Typhoid Fever, (c) Special Immunization Campaigns for the Prevention of Diphtheria, (d) Investigations to determine the Pre-valence of Mosquitoes and to Institute Measures for the Control of Malarial Fevers. Office Routine The daily reports of the communicable diseases are recorded by the Bureau of Epidemiology by the counties in which they occur. These are permanent records of the Bureau, and they show the number, location, age distribution, increase or decrease in the number of cases of each disease from month to month and from year to year. Spot maps are kept, showing the daily occurrence of cases and monthly occurrence of deaths of smallpox, diphtheria, scarlet fever, and typhoid fever, and according to the sections of the State in which they occur, by counties, and townships, and whether the cases are urban or rural. Charts have been prepared showing the number of cases and deaths for the above four diseases for the years 1918 to 1927, inclusive. Weekly telegraphic and monthly written reports of all cases of infectious and contagious diseases reported are made to the Surgeon-General, United States Public Health Service, Washington, D. C. All report cards, blank forms, educational posters, placards and liter-ature on the reportable diseases, and all rules and regulations governing the control of the diseases are prepared and distributed to all assistant collaborating epidemiologists by the Bureau. During this biennial, 15,697 circular letters have been mailed by the department on subjects pertaining to the reporting and control of com-municable diseases. Weekly bulletins are issued by the Bureau showing the prevalence of typhoid fever, diphtheria, smallpox, scarlet fever, measles and whooping cough by counties. These bulletins are mailed to all assistant collaborating epidemiologists, members of the State Board of Health, and others inter-ested in the occurrence of these diseases in the State. The morbidity 38 North Carolina Board of Health statistics of all reportable diseases are checked against the mortality statistics in order to establish the efficiency of reporting. Special Immunization Campaigns for the Prevention of Typhoid Fever During the biennial, special immunization campaigns for the prevention of typhoid fever and diphtheria have been conducted in 37 counties. The campaigns are conducted in the following manner: The Bureau of Epidemiology circularizes the county and furnishes advertising materials to the county for the mailing list made up from the tax books. (The Bureau makes up mailing list from the records of births in the county, filed with the Bureau of Vital Statistics.) Physicians who participate in these campaigns are paid 8i/^ cents a single dose. Physicians make reports to the Bureau on forms supplied for the purpose. These are checked and certifications sent to the County Commissioners for payment. List of counties in which special campaigns for the prevention of typhoid and diphtheria together with the population immunized: No. Taking No. Taking Three Doses Three Doses County Typhoid Vaccine Toxin-Antito.vin 1. Alamance (1926) 5,868 1,047 2. Alexander (1927) 4,140 1,266 3. Burke (1928) 6,274 1,812 4. Caldwell (1927) 8,323 1,913 5. Camden (1927) 1,358 1 6. Caswell (1928) 3,446 1,933 7. Catawba (1926) 9,030 2,101 8. Chatham (1926) 2,444 89 9. Dare (1926) 902 478 10. Davie (1927) 3,934 1,314 11. Durham (1928) No Report* 12. Gates (1927) 2,006 444 13. Greene (1927) 8,705 2,642 14. Harnett (1927) 10,008 1,780 15. Hertford (1928) 3,549 715 16. Iredell (1928) 10,911 1,848 17. Lee (1928) 8,878 1,510 18. Lincoln (1926) 5,415 1,073 19. Madison (1927) No Report 20. Martin (1926) 4,540 1,513 21. Martin (1928) 4,282 1,654 22. Montgomery (1926) 181 44 23. Moore (1926) 5,186 723 24. Moore (1927) 244 25. Perquimans (1927) 3,208 295 26. Person (1926) 6,966 1,502 27. Randolph (1926) 5,984 1,940 28. Rockingham (1926) 3,233 422 29. 'Robeson (1928) No Report* 30. Scotland (1928) 3,921 1,016 31. Stanly (1927) No Report 32. Stokes (1928) 3,225 839 33. Surry (1928) No Report* 34. Warren (1927) 7,055 1,262 35. Washington (1927) 2,258 823 36. Wayne (1928) No Report* 37. Yadkin (1928) 7,487 2,160 Total 152,961 36,159 *Whole-time counties. Twenty-second Biennial Report 39 Total (11 counties—1926) 49,749 10,932 Total (11 counties—1927) 51,239 11,740 Total (9 counties—1928) ..51,973 13,487 Grand Total 152,961 36,159 Compiled Monthly Report of Part-Time County Quarantine Officers July 1, 1926, to June 30, 1928 Cases reported by householder.... — 7,992 Cases reported by health officers and nurses 10,290 Cases reported by physicians 35,090 Cases reported by teachers .— 3,329 Total number of cases reported 56,701 Homes placarded 41,736 Articles published 411 Teachers' certificates 5,838 Indictments 82 Total number cases reported by whole-time quarantine off. 112,050 Grand total cases reported by all 100 counties in State 168,751 Summary of Office Work Circular letters 15,697 Oaths of Office 23 Telegrams sent 128 Letters written—Individual — ._ 4,070 Multigraphed 4,759 Total all letters 24,526 VENEREAL DISEASE DIVISION Although since 1924 the distribution of medicinal remedies for the treat-ment of venereal diseases have been sent out by the State Laboratory of Hygiene, and since the Federal appropriation was discontinued, the Bureau has been unable to maintain public clinics for the treatment of indigent cases, nor has any extensive educational work been conducted. However, the Bureau receives a large number of letters requesting bulletins, pamph-lets and advice. These are carefully answered and whatever information requested sent. The purposes of this dissemination of information are as follows: (a) To stimulate the provision of facilities for proper treatment by estab-lishing clinics for persons infected with venereal disease who are unable to pay for treatment from private physicians. (b) Information concerning patients dangerous to the public health is referred to local health officers for investigation and action. (c) Instruction and advise is given to persons infected with venereal dis-ease concerning the necessity for proper treatment and continuing treatment until cured. (d) Tabulations are made from the data collected in an effort to gain knowledge of the prevalence of infection and the best methods of prevention. In gathering information concerning cases of venereal diseases dangerous to the public health, the Bureau has had recourse to the usual procedure of requiring physicians to report their cases and requiring druggists to report the sale of venereal disease remedies. These reports by physicians and druggists are required by Chapters 206 and 214, respectively. Public Laws of 1919. The system of reporting provided by law and the regulations adopted by the State Board of Health is designed especially to furnish usable infor- 40 North Carolina Board of Health mation concerning dangerous cases. For this reason physicians are re-quired to report names and addresses only when in their judgment the patients should be under the supervision of the health officer in order to protect the public health. When patients are considered trustworthy, physicians may report their cases by number without disclosure of identity. Reports that reach the office are so handled that information concerning cases that should be invesitgated is referred to the local health officer. Every effort is made to encourage reporting by physicians through courteous treatment rather than by harsh measures. In carrying out this policy a number of form letters have been drafted for use in the routine handling of venereal disease case reports. There has been reported to this office the following number of cases of venereal diseases by part-time quarantine officers: Gonorrhea 3,852 Syphilis 6,002 Chancroid 290 Balanitis 1 Total -._.. 10,145 Total number cases reported by whole-time quarantine off. 7,775 Grand total cases reported by all 100 counties in State 17,920 DIVISION FOR THE INVESTIGATION AND CONTROL OF MALARIAL FEVERS The work of the State Board of Health on Mosquito and Malaria Control through the division for this purpose, as a result of insistent demand, has increased four-fold in application during the last biennium. In addition to the work in the malarial zone of the State, which had previously absorbed the efforts of the division, three other variations were gone into, namely: 1. The study of impounded water and its effect upon the prevalence of mosquitoes and the incidence of malaria; 2. The investigation of situations which produce pestiferous mosquitoes; 3. The surveying of salt marsh areas conjointly with the U. S. Public Health Service. Of these issues, circumstances presented the questions surrounding the impounding of water as the paramount mosquito and malaria problem of the period. The damming of streams for developing hydro-electric power was in a stage of expansion. The effect upon health conditions had previ-ously led to long, bitter, and depressing ligitation and the issues by no means had been satisfactorily cleared. Adequate study of the situation necessitated application before and after building these projects, there-fore, a major portion of the division's time was given to it. Space in the report is allotted accordingly. The other issues, though probably having been more or less constant, were meeting with a continually decreasing de-gree of tolerance for they were proving more and more to be an obstacle in the courses which progress and development were taking. The original undertaking of the division in the malarial zone being already well-organized and in operation in the hands of county health units, is adequately covered in previous reports and therefore, not gone into here further than the aid offered in maintaining it and taking up the periodic problems which arose. Detail of the report is given in the order of the subjects named. Twenty-second Biennial Report 41 Studies on Impounded Waters Since the year 1904, attention has been focused upon the impounding of water for commercial purposes to an unprecedented degree. The elec-trical developments which have made practical the broadspread utilization of water power even to remote locations have created for the country assets which can be estimated only in hundreds of millions of dollars. North Carolina has had a large share in this harnessing and utilizing of a wasting natural resource. It now holds fourth place among the states in developed waterpower and second in developed horsepower as compared to population. In this State alone, fortunes have been spent in hydro-electric developments and upon the completion of developments projected or now under construction, the expenditures will have mounted fifty million more and the developed horsepower will be practically sixty per cent of that available in the State. While there is a limit to this resource to which the economic situation sooner or later will push development, it is far in the future and in the meantime there are due many changes in application, utilization, and demand which put the vista almost beyond conjecture. However, not only the tremendous asset of power from water impounding has presented itself, for as the ever-present thorn there is also a derogatory side which has claimed no small share of attention, which continues to loom as a tremendous liability and persists in engendering grave concern. The early impounders apparently were unaware of any health hazards contingent upon their projects. Available pond sites were dammed and filled, capacity for power being the interest. No concern was felt about the condition of the basins. Whole forests were flooded or partly inundated without a guess of evil days to come. Powerhouse wheels then spun busily on while malaria mosquitoes availed themselves of these newly-prepared and excellent breeding grounds. Thus, in connection with impounding for hydro-electric development, the malaria problem grew, and in the form of a lawsuit—Chattanooga & Tennessee River Power Company vs. Lawson — in the Tennessee courts, 1915, announced itself as a momentous issue. To the present, lawsuits tried and pending in the South have involved millions of dollars in addition to fees and costs. One power company at one time had six hundred suits pending against it, each for .$3,000.00, a total of $1,800,000.00. Together with the costs of war, North Carolina has been the battleground for sums commensurate with her position in the power field. The liability in health hazards and the uneasiness injected into the progress of a key industry cannot be estimated. There are sec-tions of the State for which progress awaits only until health conditions are brought up to standard. Also, there are instances in which industries have been turned away from the State because of the unavailability of suitable power. Another view of the situation is presented in our courts. Juries are called upon to settle claims for malaria damage. Malaria has existed before the present era of impounding, oftimes in the community in which the impounding is done. Defendants are not responsible for this. Plain-tives contend that impounders have created or intensified these conditions. Conclusive facts often have been wanting. The dilemma of a jury left to settle the issue upon evidence which is largely a matter of greatly-diff'ering opinion is obvious. Neither the jeopardizing of health through impre- 42 North Carolina Board of Health cautions or lack of foresight nor the persecution of those in a position to make available our natural resources can be condoned. The availability of more definite information regarding the mosquito and malaria condition in a locality both before and after impounding would greatly facilitate the clearing up of difficulties. More preferable, however, than the settling of controversies would be the elimination of their causes. This bespeaks the need of knowledge which will go further toward the elimination of health detriments in the maintenance of power ponds. Much has been done already. No more ponds are found rising in uncleared forests. Old ponds have been cleared, and the practice of keeping all of them clean and of discouraging mosquito breeding is general. However, amidst a condition of uncertainty there has arisen a desire for more knowledge in handling mosquito and malaria con-ditions, better and surer methods of control, and some level of conduct and understanding which will reduce health hazards to a minimum, com-mand the approval of fair-minded people, and better put the hydro-electric industry upon the road of progress with the good-will of all concerned. In these problems and controversies the State has a responsibility, an obligation, a stake for loss or gain. It is true that a state best promotes its interests by fostering industries and even truer is this in the safe-guarding of the health of its people. Solving the problems outlined is progress in promoting such interests. Purpose of Studies Industries naturally follow in the wake of power development and can thrive only in proportion as the power interests prosper. Power growth has come more and more to center around water developments and like-wise has the malaria problem centered. The work and development of the U. S. Public Health Service gave hydro-electric projects their living chance. This was excellent headway, but there is yet much to be done in carrying on that work. While the present knowledge is generally appli-cable and makes possible the contingent interests, each project has an individual equation upon which much of its prosperity may depend and which to know is highly desirable. As with railroads and other organi-zations in whose welfare malaria has been discovered to play a part, im-pounders may desire to gain the asset accruing to the improving of health conditions and the gaining of good-will among those whom they may benefit, but this is not incumbent upon them. However, all are concerned in knowing that conditions, if not improved, remain at least unchanged. This is another call for facts resultant of which there has arisen an urgent need for the study of mosquito and malaria conditions in connection with North Carolina industries. Power officials are deeply concerned with it, and in addition to maintaining their own forces for control work on ponds already in use, they are much interested in work carried on by the State. These problems in the State were given cognizance and a program insti-tuted with the following purposes in view: to further determine the effect, on mosquito and malaria propagation from damming water-courses, to determine the variation in species breeding because of changing from flow-ing streams—the natural haunts in the South of Anopheles Punctipennis — to sluggish streams and ponds—the natural breeding places of Anopheles Quadrimaculatus, the principal carriers of malaria; to ascertain and perma- Twenty-second Biennial Report 43 nently record conditions surrounding impounded water projects before and after impounding; to work toward the future elimination as far as possible of the mosquito and malaria problem. A brief consideration of breeding habits and the effect of surroundings and changes may give something of the outlook of the undertaking. Differential Breeding The breeding habits of the different species of mosquitoes are an im-portant consideration in the impounding of water, and is the factor that threatened to bring to grief the first water-power projects in the South. While the whole mosquito family is given with variable adaptability, each species has a marked preference for waters of particular characteristics. This is so pronounced that the type to be found in different situations can be forecast with fair accuracy. Preference with most species is for natural instead of artificial collections of water. However, when both are present this may often mean a greater extent of breeding in the natural, than in the artificial ones, rather than all breeding in one and none in the other. In all cases quiet and protection are essential for propagation. Absence of trash, weeds, grass, or other obstructions, or the presence of wave and ripple action are strong deterrents to production. Of the Anopheles, the Quadrimaculatus, or principal malaria carriers, breed in ponds, lakes, pools, lagoons and estuaries, sluggish streams and tubs and cans. Marine growth, floatage, and moderate stagnancy only add to their comfort. Organic acids such as tannic, any kind of filth as excreta or waste, or contaminations of a chemical nature tend to discourage them. Appreciable quantities of any of these will stop their breeding altogether. Anopheles Crucians tend to begin breeding where Quadrimaculatus leave off. The inclusion of minerals such as found in brackish water, or swamp and bog water containing tannic acid proves attractive to them. These attributes with a nature akin to Quadrimaculatus for peaceful water, tend to locate this group in lowlands and flat country. They therefoi'e may be on the scene in malaria epidemics. Punctipennis is the free-water active stream group of the Anopheles. They are to be found harbored along running streams, springs, branches, and not infrequently in springs. They are more adaptable to both temper-ature and environment changes than the other species, upon necessity will resort to various departures from their choice of waters, and therefore, are the more widely distributed. It is hilly country with pronounced fall that affords the best impounding sites. Any kind of condition may exist on a small scale in such an area, but in whole it is one of springs and briskly moving water-courses, and therefore, the haunts of Punctipennis. Though this species can be infected with malaria it has not been proved infective in nature and disease carry-ing has not been generally charged to them. When such an area as they inhabit is impounded and the flowing water replaced by relatively still water, they may tend to lose interest and wane in their breeding while Quadrimaculatus thus favored will begin intensified activities which, if not controlled, soon will reach unhealthful proportions. Even though the adaptability of the Punctipennis may continue them in unabated numbers, it can be dependably relied upon that, left to their own volition, Quad-rimaculatus will be added to the mosquito population evolving from such 44 North Carolina Board of Health changes. Thus, from the nature of the insects, the hazard of malaria is incurred upon impounding. Other factors of prime importance in the control of mosquitoes in im-pounded waters are sanctuary and natural enemies. To utilize a location for breeding, mosquitoes must find in it more than favorable water con-ditions. Sanctuary from agitating elements and enemies are essential. If an otherwise favorable body of water is free of trash, floatage, and vegeta-tion, and is open to wind and wave action, mosquito larvae do not thrive in it. The mosquito realm in all three stages is inflicted with numerous pre-dacious enemies—fish, birds, insects, parasites, plants, reptiles, and even their own cannabalism. It is possible to utilize these natural enemies in the control of mosquitoes. One of them, a small surface minnow—Gam-busia Affinis—has been used extensively in ponds. However, conditions must be suitable to their abilities and habits or the purpose is defeated. Any material such as growth or trash and floatage will offer mosquito larvae sanctuary and bar access to the minnows. In addition to these considerations there are other factors such as geology, topography, and climate which exert direct influence on a mos-quito situation and off'er extended avenues of study. In the work on im-pounded water, these were gone into extensively, however, any compre-hensive treatment of the subject is too extensive for space here. Methods and Procedure Studies of impounded water projects were carried on in the form of sur-veys. A feature of the work was cooperation between the State Board of Health and county health organizations in whose territory the work was carried on. The general data collected was histories of past occurrences of malaria, present malaria both by history and by taking blood tests, and general premises conditions which pertain to mosquito favorability. These constitute an index to the prevalence of malaria, past and present. Also a general mosquito survey of the territory is made with a view of de-termining the kind and prevalence of mosquitoes. This finds service in correlation with existing malaria conditions as well as showing potenti-alities and also as a basis for future comparison. The territory of immediate interest for study is that within a one mile range of the territory of impounding, this being considered the probable extent of effect from a breeding area. When such an area has been laid out, workers proceeded from house to house. The purpose was explained and then through a series of questions, blanks arranged for the desired information were filled out. In addition blood smears were taken as fol-lows: The tip of a little finger was thoroughly cleaned with alcohol, and while being gripped to cause congestion, was quickly punctured with a needle. The first drop of blood was wiped away, the second drop was picked up with an end edge of a clean slide, placed on the face of a second slide near one end, allowed a moment to spread across their widths, and with the first slide held at 45 degrees to the face of the second, was quickly smeared along two-thirds of this surface. Such a smear dries very rapidly. The serial number of the person being examined is then written with lead pencil directly into the smear. Slides were then returned to container for safe-keeping. Daily they were brought into the office, wrapped in tissue paper, and filed to await examination. Twenty-second Biennial Report 45 Completing the blood smear work was as follows: Wright's stain, secured already prepared, was used for staining. The method given for preparation and use was—"Stock solutions; dissolve two-tenths grain dry slain in 120 cc of acetone-free methyl alcohol, store in a light-proof bottle. For staining, filter 20 cc stock solution, dilute with 5 cc acetone-free methyl alcohol. With slide lying flat apply small amount of stain with medicine dropper, let remain for one and one-half minutes, add distilled water, allow to stand for three or four minutes; rinse with distilled water and permit drying." Slides are then ready for examination. Examinations were made on a movable stage microscope, oil immersion. Detail of identification will not be gone into here. After twenty minutes of careful scrutiny, unless findings were otherwise, smears were passed up as negative. Results were then duly recorded. Mosquito Conditions In surveying for mosquito conditions in areas as large as those involved in the present day impounding project, the application must be shaped in a manner to best secure the desired results and still be within range of practicability according to personnel available for it. The method in gen-eral is to size up the territory carefully, spot a maximum number of pro-ducing areas, choose from these the apparently more significant, in quantity within range of practicable application, and then visit them by regular schedule, seeking out the desired breeding and prevalence date and record-ing in collective forms. The date thus compiled constitutes a permanent record in cross-section of the areas under surveillance. Good maps are very useful and time-saving in planning and getting the work under way. In following the plan laid out, field notes are compiled carrying data of apparent value. Such mosquitoes and larvae as are taken are labeled and reserved to later be identified and results entered on the records started in the field. Thus is gradually compiled a continuous portrayal of tran-spirations through a season. Field equipment is simple, consisting of insect-catching apparatus and containers for storing until catches are identified. Identification is done both microscopically while the insects are in the larvae stage and by maturing and identifying adults. Recording is a highly essential feature and demands careful attention, for the permanent value of the work rests thereon. Studies on impounded waters were made on three projects: The High Rock Project of the Tallassee Power Company, Davidson, Davie and Rowan counties; Lake Lure, Rutherford county, and the Norwood project of the Carolina Power & Light Company, Stanly and Montgomery counties. The data collected on these projects is within itself of quantity sufficient to form a volume. Only collective results in outline are given here. The High Rock Project The High Rock Project, under construction at the time of this report, is one of the twenty major hydro-electric power developments producing from 500 to 93,000 horsepower per unit, wholly or partly within North Carolina and is one of the five in the State promoted by the Tallassee Power Com-pany. To the 216,000 horsepower now being developed by the company in the State, this project is planned to add 45,000, which, by contract stipulating delivery of current by the first of 1928, is consigned wholesale 46 North Carolina Board of Health o to the Southern Power Company which will market it for industrial or general use locally or broadspread as the demand may arise. The project is located on a twenty-three mile section of the Yadkin river, occupying an area from the dam and powerhouse site at High Rock Mountain eighteen miles east of Salisbury; along the territory of the com-mon border of Davidson and Rowan counties, upstream, northwest, touch-ing Davie county on two sides by branching into the South Yadkin river for eight miles. Figures given for the lake and dam are as follows: dam, 59 feet high, 1,200 feet long; lake 19,000 acres or 20.7 square miles in area, 300-mile shore line, to back water 23 miles. The mosquito surveys on this project were carried on through two sea-sons— 1926 and 1927. The history and blood work was terminated in the first year. Work of this type on a large project is volumnous and in many respects subject to the difficulties that go with the organizing of temporary forces of limited personnel for such work. Due cognizance is taken of this and results evaluated accordingly. Malaria in the High Rock Territory History and blood indices disclose that for the period embraced by the 1926 survey in the High Rock territory, malaria as compared to districts in which the disease becomes a major problem, was not a feature of public health importance. The infections as shown by histories was 1.789<', by blood smears, 3.50%. It is well, however, for those interested in malaria and malaria control to remember that the problem is a constantly shifting and fluctuating one and that it is practically impossible to secure a picture of the disease at rest, nor is it expected that the parasitic or history indices will remain the same for long periods of time. Sectional differences, in view of the disease and toleration for it, will have influence. Also, the experience gained in one community may be entirely contradicted by that from another of similar type. Mosquitoes in the High Rock Territory The outcome of the mosquito survey in the High Rock territory amply meets any normal expectation that may have been held for it. Both Culex and Anopheles existed in proportion as they were aff"orded sanctuary and favorable conditions. Culex were generally prevalent in limited quantities throughout the terri-tory, with exaggeration in sections when afforded fitting encouragement such as conditions of water contamination by rubbish, waste, or sewage. This was given expression in the increase in prevalence during dry seasons. Punctipennis existed in by far the greatest quantities, v/hich marks the section as majorly Punctipennis grounds. This measures up to original appearances, that at large the section topographically was fitted best to the production of this type of mosquito. Quadrimaculatus existed in limited quantities and were fairly well dis-tributed under general conditions throughout the territory. They appear prominently where efforts were confined to territory of the type most suited to them. This again supports original indications, that while the territory was by nature majorly of Punctipennis producing proclivities, it also would be subject to local Quadrimaculatus production |