Biennial report of the North Carolina State Board of Health

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SEVENTEENTH BIENNIAL REPORT
OF THE
NORTH CAROLINA STATE
BOARD OF HEALTH
1917-1918
I '
RALEIGH
Edwards & Broughton Printing Co.
State Printers
1919
TABLE OF CONTENTS
PAGE
Members of the State Board of Health , 3
Letter of Transmittal 5
Preface 6
Health Work in the State of North Carolina for the Biennial Period
1917-1918 7
What the Board of Health is doing with its money 12
Present Organization of the North Carolina State Board of Health 19
Work of the Executive Office 21
Bureau of Education 25
Bureau of County Health Work 27
Bureau of Medical Inspection of Schools 36
State Laboratory of Hygiene 39
Bureau of Epidemiology 41
Bureau of Vital Statistics 47
Bureau of Infant Hygiene 51
Bureau of Venereal Diseases 54
Recommendations of the North Carolina State Board of Health to the
General Assembly of 1919 55
The First Recommendation 55
The Second Recommendation 59
The Third Recommendation 60
The Fourth Recommendation 63
General Financial Report 69
Financial Report, Laboratory of Hygiene 70
Fund Balance Sheet 71
Appropriations, Earnings, and Expenditures 72
Financial Report. Bureau of County Health Work 80
Disbursements by Counties 81
Members of the State Board of Health
^
i
Elected by the North Carolina Medical Society:
Thomas E. Anderson, M.D., Statesville.
Term expires 1923.
Charles O'H. Laughinghouse, M.D., Greenville.
Term expires 1923.
F. R. Harris, M.D., Henderson.
Term expires 1919.
Cyrus Thompson, M.D., Jacksonville.
Term expires 1919.
Appointed by the Governor:
J. L. Ludlow, C.E., Winston-Salem.
Term expires 1921.
J. Howell Way, M.D., Waynesville.
Term expires 1923.
Richard H. Lewis, M.D., LL.D., Raleigh.
Term expires 1919.
Edward J. Wood, M.D., Wilmington.
Term expires 1919.
E. C. Register, M.D., Charlotte.
Term expires 1923.
LETTER OF TRANSMITTAL
Raleigh, 'N. C, January 1, 1919.
His Excellency, T, W. Bickett,
Governor of North Carolina.
My dear Sir :—Under authority of section 3, chapter 62, Public Laws
of 1911, as amended by the General Assembly of 1913, I have the honor
to submit the Biennial Report of the State Board of Health for the
years 1917 and 1918.
Very respectfully yours,
W. S. Rankin,
Secretary and Treasurer.
PREFACE
The same principles hare influenced the preparation of this biennial
report as governed the j^reparation of our last report; therefore, the
preface of the report of 1915-1916 is altogether pertinent to this one,
and we trust we may be pardoned for the repetition
:
"It is our intention to smash precedent in the size and substance of
biennial reports. The large size of the average biennial report appears
to rest on the hope of impressing those to whom it is addressed (not the
few who read it) vdih the size rather than with the contents of the re-port.
The size alone of most of these reports precludes their being read
by busy people; and it makes little difference whether the other class
does or does not read them. There is a story of a young reporter who
was directed by a large i^ew York paper to report a certain lynching
of unusual public interest. The young reporter wired his paper to hold
three columns for his story. The editor wired the reporter to confine
himself to one column. The young reporter, in the atmosphere of the
lynching, could see only the importance of the lynching, and wired back
to the paper that it was impossible to restrict his story to a single column.
The business manager telegraphed, 'Description whole creation covered
in Genesis one. Read it.'
"With this idea of brevity, and ^\dth the hope of reaching busy people,
we have sought the avoidance (1) of matter that can be obtained easily
from other publications, and (2) of matter consisting largely of details
and statistics that is of little general interest and that can be more con-veniently
supplied to those interested in the form of supplementary re-ports.
For example, the State public health laws, the itemized statement
of the bookkeeper, and the vital statistics of the State have been ex-cluded
from the report. Any or all of this matter may be obtained in
separate form by request of the State Board of Health.
"The arrangement of this report is by fairly independent subdivisions,
so that it is possible for one to read and understand any part of the re-port
without reading the whole report."
Health Work in the State of North Carolina
for the Biennial Period 1917-1918
HISTORICAL
DEVELOPMENT OF PtBLIC HEALTH WORK IN NORTH CAROLINA
In the biennial report of 1915-1916, pages 10 to 15, inclusive, we attempted
to epitomize by years the development of public health work in North Caro-lina.
If it were not for the high cost of paper and printing at this time, we
should repeat that part of our last report, adding the principal developments
in the health work of the State for the years 1917 and 1918. Under the pres-ent
circumstances, however, we shall restrict the record to the principal
developments in the health work of the State for the last two years, referring
the reader who may be interested in securing the complete record to the
previous biennial report. •
1917. The General Assembly of North Carolina passed the following important
health legislation: Chapter 263, entitled "An act to prevent and
control the occurrence of certain infectious diseases in North Caro-lina";
chapter 244, entitled "An act to provide for the physical
examination of the school children of the State at regular intervals";
chapter 276, entitled "An act for the cooperative and effective devel-opment
of rural sanitation"; chapter 257. entitled "An act to pre-vent
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 sanitary 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, the administrative
machinery, consisting of a bureau of epidemiology under the. direc-tion
of Dr. A. ]\IcR. 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 International 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 pro-visions
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 sec-tions
of the country and to establish for demonstration purposes, in
Edgecombe County, an efficient 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.
NOBTH CaROLIXA BoARD OF HeALTH
The State was admitted to the registration area of the Union
January. 1917, the Bureau of the Census having found after investi-gation
that our birth registration was 96 per cent complete.
The special campaign against typhoid fever, begun so satisfac-torily
in 1915. was continued. Free vaccination of the people, how-ever,
was interfered with by the difficulty in securing medical officers
to do the vaccination, the preparedness program of the Government
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 im-press
the public with the value of vaccination as a means of pre-vention
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 purpose
of advising them as to their physical condition and needed hy-gienic
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 put in charge of this work. Life extension work was
carried out in Vance. Alamance, Lenoir, and Robeson counties, and
resulted in the full physical examinations of 4,000 citizens. This
work was very favorably received, and the outlook for its con-tinued
development seemed excellent when, with the declaration
of the war and the call for physicians to enter the military service
of the country. Dr. Ellington felt compelled to enter 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 amounting to
45,000, and a daily newspaper health article. The Bureau continued
its moving picture show exhibit and, in addition, prepared probably
the best three-dimension educational exhibit in the United States.
In 1917, the following exhibits were given: motion picture enter-tainments,
236; traveling public health exhibits, 32; special ex-hibits,
58; stereopticon entertainments, 3—^to a total of 95,000 peo-ple.
Arrangements were made for the preparation of newspaper
plate, which was sent to and extensively used by 202 papers having
a total subscription list of 303,000. A large part of this newspaper
material was prepared hy the well-known authority and publicist
in matters of sanitary and hygienic education. Dr. W. A. Brady of
Elmira, New York.
Sevknteenth Biennial Repokt 9
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 per-mitted
under the laws of the State to be paid to the Laboratory
of Hygiene for special work, provide 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 Washington,
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, arrrangements 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, if possible, to interest the Governor, the
State Board of Health, and the State Council of Defense in venereal
disease control.
Considerable tinT.e w'as 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 entering the medi-cal
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.
Partly as a result of these activities, the Surgeon General of the
army assigned ]\Iajor 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 for the 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. This Bureau also de-veloped
to a successful extent an arrangement in the form of ade-noid
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
10 XoRTH Carolina Board of Health
field to investigate infringements of the quarantine law. Sufficient
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 for Venereal Diseases, paid for by the Federal appro-priation,
was established in September under the directorship of
Dr. James A. Keiger, of Charlotte, X. 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. Wil-son.
As a result of Mr. Booker's leaving, certain funds became
available, and a Bureau of Infant Hygiene, under the directorship
of Mrs. Kate Brew Vaughn, was organized late in 1918.
Perhaps the most outstanding feature of the health work during
the year 1918 was the epidemic of influenza. The epidemic began
early in October and caused in October alone 6,056 deaths; in No-vember
2,133 deaths; and in December, 1.497 deaths, a total during
the last three months of 9,686 deaths. A fuller report of the work
in handling this epidemic is found on pages 15 and 23 of this report.
The annual appropriation for the. State Board of Health for 1918
was $73,210.38.
The annual appropriation for the State Laboratory of Hygiene was
$12,500. The Laboratory, during 1918, collected $8,532.48 in fees for
special work, so that the total income of the Laboratory for this
year was $21,032.48.
In addition to the regular appropriation, as above given, the Laboratory
of Hygiene has received, in accordance with the original act, fees for ex-amination
of pathological specimens submitted by physicians; also a tax on
all water companies of $64 annually for the examination of monthly samples
of water, and, since 1907, a small amount for administering the Pasteur
treatment to persons bitten by rabid animals. Receipts from these sources
began to come in in 1905. The annual receipts from these sources for the
various years have been as shown in the following table:
1905 $ 3,425.27
1906 3,425.27
1907 4,887.97
1908 4,887.97
1909 5.196.54
1910 5,196.54
1911 6.271.39
1912 6.271.39
1913 6,118.94
1914 6.118.94
1915 8.541.72
1916 8.541.72
1917 8,809.85
1918 8.809.85
Seventeenth Biennial Report 11
RE\^NUE BASIS STATE BOARD OF HEALTH SINCE ESTABLISHMENT.
Year
WHAT THE BOAKI) OF HEALTH IS HOIXi WITH ITS 3I0NEY
The following was prepared for and is taken from the North Carolina
Manual for the year 1919:
We assume that the people of North Carolina are interested particularly
in two things with respect to the work of the State Bo^d of Health: (1)
What the Board spends; (2) wihat the Board gets for the expenditure. This
statement, therefore, will deal, in as brief a manner as is consistent with
clearness, with the debit and credit side of the State's account with public
health.
Just one additional introductory statement needs to be made—a statement
in no sense intended as an apology, but as simple justice to the Board of
Health. The work of the State Board of Health, during the last biennium.
has been seriously interfered with by two things: (1) the war; (2) the
epidemic of influenza. The war called for a mobilization of medical men
and health officers. The State Board of Health lost a number of its officers
to the military service of the country, and it was not only impossible to
replace our losses, but impossible to secure health officers for extensions in
the health work that would have been made but for the war. The epidemic
of influenza necessitated the cessation of much public health work for the
reason that public health forces were concentrated on the epidemic.
EXPENSES OF THE STATE FOR PUBLIC HEALTH
During the biennial period of 1917-1918, the average annual income of the
State Board of Health, including the Laboratory but not the Sanatorium, has
been $88,301.12.
DIVIDENDS ox INVESTMENTS IN PUBLIC HEALTH
Item 1.—The State Laboratory of Hygiene has examined annually for the
last two years 8,652 microsopic specimens, which would have cost the peo-ple
and the physicians of this State, if examined in other laboratories, a
minimum of $1..50 per specimen, or a total of $12,978. This $12,978 is one
dividend that is paid on the State's investment of $88,301.12 in he health
of her people.
Itevti 2.—The State Laboratory of Hygiene has examined annually for the
last two years 2,100 samples of drinking water. These analyses, if made by
other laboratories would have cost the State $5 apiece, or a total of $10,500
This $10,500 is a second dividend paid on the State's investment of $88,-
301.12 in the health of her people.
Item 3.—The State Laboratory of Hygiene has treated annually for the
last two years 336 citizens of North Carolina who had been bitten by rabid
animals. It would have cost these citizens a minimum of $15,000 to have
secured this treatment outside the State. This $15,000, then, may be re-garded
as a third dividend paid on the State's investment of $88,301.12 in
the health of her people.
Item -'/.—The State Laboratory of Hygiene has distributed annually for the
last two years 248,876 doses of typhoid vaccine. 7,896 doses of whooping
cough vaccine, and 29,580 doses of smallpox vaccine, which vaccines, if pur-chased
at the ordinary retail price, would have cost a minimum of $100,000.
This $100,000 is, then, a fourth dividend paid on the State's investment of
$88,301.12 in the health of her people.
Seventeenth Biennial Report 13
Item J.—The State Laboratory of Hygiene has distributed annually for the
last two years 2,412 doses, or 12,060,000 units, of diphtheria antitoxin. The
antitoxin, distributed free of cost to the people in 1918, at the old retail price
would have cost $12,060. The antitoxin distributed in 1917, at about one-fourth
the previous retail price of antitoxin, saved our people an additional
$9,000, making a total saving on diphtheria antitoxin of $21,000 for the last
two j'ears. or an annual saving of at least $10,000. But this by no means
represents the total amount saved under this item to the citizens of North
Carolina. Commercial manufacturers of antitoxin, in order to sell their
product at all in North Carolina in competition with the State's free anti-toxin,
have had to cut their original price to one-third of what it was. The
people are now paying only one-third of what they otherwise would have to
pay for the antitoxin of private manufacturers. The arrangement of the
State Board of Health for supplying antitoxin to the people of North Caro-lina
saves our State not less than $20,000 a year. This $20,000 is, then, a
fifth dividend paid on the State's investment of $88,301.12 in public health.
Item 6.—The State Board of Health has interested the International Health
Board and the United States Public Health Service in opportunities for suc-cessful
public health work in North Carolina to the extent of obtaining from
these agencies, during the past two years, a total appropriation of $43,-
720.96. In addition to this direct appropriation, we have secured from the
above agencies the loan of health officials for work in North Carolina, with-out
cost to the State, whose combined salaries during the time of their work
in this State has amounted ta over $16,000. In short, we have been instru-mental
in securing from outside sources, without cost to the State, during
the last two years, $60,000 worth of health work.
Item 7.—A silver nitrate solution has been supplied to all the physicians
and midwives of the State, with instructions as to the law requiring the ap
plication of this solution to the eyes of all new-born children for the pre-vention
of gonorrheal ophthalmia, or blindness in the new-born.
There occurs in North Carolina annually about 100 cases of gonorrheal
ophthalmia, or blindness in the new-born—a form of blindness that is pre-vented
in 98 per cent of the births, where it otherwise would occur, by the
use of the silver nitrate solution; in other words, there are 12 V^ cases of
this preventable blindness for every 10,000 births. The State Epidemiologist
believes that he is conservative in assuming that in at least half of the
births occurring in the State. 40,000 births, the law requiring the applica-tion
of silver nitrate is complied with. If this estimate is correct and if
the prophylactic is 98 per cent efl^cient in preventing blindness. 49 cases of
blindness are prevented each year through this law. Let us assume, how-ever,
that less than half of this amount of blindness is prevented—20 cases.
It costs the State of North Carolina $185 a year per blind child to give it an
education with the hope of making it self-supporting. It requires at least
ten years at the Blind Institution for the child to receive this education.
This would make a total cost to the State for educating the blind child, as
an effort to make it self-supporting, ten times $185, or $1,850; for twenty
blind children this would be $37,000. While estimates of the amount saved
by this law will vary with the individual viewpoint, it will be admitted by
all that this law is saving the State each year many thousands of dollars,
and saving some of the State's citizens a loss that is incalculable.
14 ISToRTii Carolina Board of Health
Item S.—The Board of Health was successful in securing the appointment
of all the officers—State and county—concerned with quarantine work in
North Cai'olina to the position of collaborating epidemiologist of the Fed-eral
Government. While the Federal Government pays these officials only
$1 per year in accordance with an Act of Congress, the position of an official
in the Federal Government permits the State and county quarantine officers
to use the franking privilege which saves to the State and the counties not
less than $5,000 a year postage.
Item 9.—Several years ago the State Board of Health was responsible for
a change in the management of outbreaks of smallpox. The change effected
was shifting the responsibility of protecting the unvaccinated (the only
susceptibles) from the community to the unvaccinated individual. In mak-ing
this change, the State Board of Health did away with a system of small-pox
quarantine and isolation which, according to reports from counties for
the year preceding the change in the method of control, was costing the State
$66,000. Smallpox is one of the least significant factors in the State's death
rate. As a result of the change in the method of control, there has been,
apparently, no increase in either cases or deaths. It appears, therefore, that
the Board of Health, through this policy of making the individual responsible
for his susceptibility to smallpox instead of his .community, is saving the
State annually something like $50,000.
Item 10.—In 1914, for the first time in the history of the State, deaths from
all causes were accurately recorded. In that year there were 839 deaths
from typhoid fever; in 1915, 744; in 1916, 700; in 1917, 628, and in 1918. 502.
There were saved, therefore, 839 less 628, or. 211 lives from typhoid fever
during the year 1917. There were saved 839 less 502, or 337 lives during the
year 1918, or. during the two years, there have been saved 548 lives from
typhoid fever.
The fatality from typhoid fever is 10 per cent; that is, 100 cases of the
disease cause 10 deaths. A decrease of 548 deaths, therefore, was neces-sarily
associated with the prevention of 5,480 cases of the disease. Taking
the estimates of the value of the average life at the average age at death
from typhoid fever, made by political economists of national reputation and
based upon the life expectancy and earning capacity, the 548 lives saved
were worth $4,000 each, a total of $2,192,000 of vital conservation.
The prevention of 5,480 cases of typhoid fever associated with this saving
of 548 lives also has a money equivalent. The average case of typhoid fever
lasts six weeks. The cost of treating an average case of typhoid fever, esti-mating
the amount paid physicians, druggists, and nurses, and losses of
salary or per diem on account of sickness, may be conservatively estimated
at $100 a case (usually estimated at $200 each case), which amounts to a
total of $548,000 saved from sickness.
In this item it appears, therefore, that through the work of typhoid pre-vention
as organized, directed, and carried on by the Board, and through
the Board's previous efforts there is a vital saving to the State of No.'th
Carolina estimated at $2,740,000.
. Itevi 11.—The State law which requires that all plans and specifications
for waterworks and sewerage systems shall be submitted to and approved by
the State Board of Health, before being accepted by the municipalities for
which the plans and specifications are designed, safeguards our towns and
cities against the work of cheap engineers and contractors. To illustrate: A
Seventeenth Biennial Report 15
town in this State, before this law went into operation, let a contract for the
installation of a public water supply. The water supply was found dan-gerous
on account of its location and had to be moved. The location of the
water supply, had it been passed upon by the State Board of Health, would
never have been approved. To change the location of the supply cost the town
somewhere between $10,000 and $1.5,000. Many such losses have been saved
the municipalities of the State by this law which requires that all plans and
specifications for water supplies and sewerage systems be examined and ap-proved
by the engineers of the State Board of Health before being accepted
by the towns and cities for which they are intended.
Item 12.—The State Board of Health, in its direction of the management
of the influenza epidemic, believes and claims that when the epidemic has
passed and the records are available, comparisons with the other states will
show that the influenza cases and deaths per thousand population in North
Carolina compare favorably with the incidence of the disease elsewhere, and
that in attaining these results the cost of handling the epidemic to this State
was small, comparatively speaking. In the work of medical relief, sixty-four
communities were served with seventy emergency doctors and sixty-one
emergency nurses at a total cost to the State of $1,266.37. We claim now,
leaving the verification of the claim to the future, that in this work we
saved many thousands of dollars to the State of North Carolina.
Item 13.—Over 160,000 school children have been given a preliminary physi-cal
examination by school teachers in accordance with instructions and un-der
the direction of the State Board of Health. About 48,700 of these school
children have been given a second or complete physical examination by
physicians and specially trained nurses in accordance with instructions and
under the direction of the State Board of Health. It is oflficially recorded
that 10,670 of these school children have been treated. As a result of the
above examinations and treatments, thousands of other school children of
which we have no record have received much needed and proper treatment.
Item, 14.—During the first full year, 1918. of its existence, the Bureau of
Epidemiology of the State Board of Health prescribed the method and super-vised
the quarantine of 29,785 cases of communicable diseases. As a further
precaution against the unnecessary spread of communicable diseases, the
teachers, pupils, and patrons of 3,598 public schools were notified, through a
well-developed system, of the existence of communicable diseases in the
school community, of the dangers of the disease, its methods of spread, and
the means for its control. In this way. many thousands of cases of con-tagions
that would have occurred otherwise, causing many deaths, have been
prevented.
Item 1-).—Probably the most important, certainly the most fundamental,
health law that any State may enact is a vital statistics law. The vital sta-tistics
law of North Carolina requires the State to secure, and permanently
preserve in a fire-proof vault, a complete record of the two principal events
in the life of each citizen—the birth and the death of the citizen. The State
holds that not one of its citizens is so humble that his coming and his going
should not be taken official note of. An annual average of 77,000 births and
34.000 deaths are registered, card indexed and classified by race, sex, age,
county, township, town or city, and by cause of death.
For the individual, these records mean that each child may be enabled
to keep track of its ancestors—father, mother, grandparents, great grand-
16 XoRTH Carolina Board of Health
parents, collateral kin. Each individual will be enabled to prove his or
her age in the courts, his or her right to suffrage, the right to marriage,
the right to insurance, the right to enter various industries, the right to
inheritance, etc.
For the State, this law means that the number of deaths per thousand of
the population occurring in North Carolina, or in any county or township,
or town or city of the State, shall be known; it means that the number of
births per thousand of the population in the State, in the counties, in any
part or subdivision of the State, shall be known; that by comparing such
figures with similar figures from the other states of the Union, the people
of this State, the people of other states and of the world, may know, not
guess, what health conditions in North Carolina are.
Best of all. this law has shown and caused to be published on the au-thority
of the United States Government the fact that the State of North
Carolina is one of the healthiest in the Union. This is the meaning of our
death rate of 13.0 per thousand of the population per year, and our birth
rate of 31.9 per thousand of the population per year as compared with the
average death rate of 13.9 and birth rate of 24.8 of the registration states of
the Union for the same year—the last year for which the figures are
available.
Item 16.—A continuous and extensive educational campaign has been
waged against unhygienic and insanitary conditions in the homes and com-munities
of the State. This has been carried on in the following manner:
The Health Bulletin has been mailed to an average of 48,000 people monthly;
specially prepared leaflets, pamphlets and placards have been distributed
upon request to an extent exceeding 30,000 monthly; daily articles have been
supplied to the newspapers of the State for publication, these having been
used in publications having a circulation in excess of 1,125,000; a total of
12,816 letters have been written; motion pictures featuring health subjects in
an entertaining manner have been witnessed by approximately .58,298 peo-ple;
approximately 19,971 people have witnessed illustrated health lectures;
approximately 52,285- people have witnessed special health exhibits. The
value of the results attained by these efforts is something that cannot be
estimated in dollars and cents. The value of any educational movement is
an intangible quantity. The Bible, the work of the ministers and the
churches, the school system, the press, all are vital agencies upon which no
exact value can be placed, but of such tremendous importance that no
sane person would argue for the suppression of any. In like manner the
educational work along health lines cannot be valued exactly. It has car-ried
information and instruction to the people of the State, reaching di-rectly
at least one-half of the population. "Line upon line, precept upon
precept," the prevention of disease has been preached, and the deaths from
preventable diseases have been materially reduced.
Item n.—The State Board of Health, by its educational activities, has
fostered, strengthened, and directed an interest on the part of the counties
in local health work so that today North Carolina has sixteen counties, em-bracing
a total population of 687,634, or 28V2 per cent of the population of
the State, under whole-time county health officers. No State in the Union
has developed its county health work to a like extent.
Sevexteexth Biennial Report 17
Item IS.—In nine of the sixteen counties referred to in item 17, the State
Board of Health has had direction of the county health work for a period of
fourteen months, and in that time the amount of work accomp]is]ied is in-dicated
in the following tabulation:
1. 969 public health meetings were held with a total attendance of
87.450.
2. 815 health articles were published in the county papers.
3. 7.364 homes constructed sanitary privies.
4. 20,834 people were examined for hookworm disease, and 3,928 were
treated.
5. 479 schools were visited by health officers.
6. 38,969 school children were examined by the teachers working under
the direction of the health officers.
7. 12.699 school children were examined by the health officers, these chil-dren
being referred by the teachers.
8. 6.171 defective children were treated.
9. 1,528 adults were given physical examinations by the health officers.
10. 37.234 people were vaccinated against typhoid fever.
11. 6.450 people were vaccinated against smallpox.
12. 4.356 cases of infectious diseases were quarantined.
Item 19.—The executive office of the State Board of Health rendered con-siderable
assistance, possibly amounting altogether to two months full-timo
service, to the Council of National Defense, the Surgeon General of the Army.
and the Medical Aide to the Governor in the preparedness program of the
country.
Item 20.—To indicate the general business handled by the State Board of
Health, the official correspondence, during the last two years, has amounted
to a receipt of 92,550 letters and 104,120 replies. This is equivalent to a
daily correspondence of 126 letters received, and 142 replies. This does not
include the preparation and mailing of 110,704 multigraph letters.
18 XoRTH Carolina Board of Health
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^§.^ i^Sv^ <\, ^ \ N ^
PRESENT ORGANIZATION OF THE NORTH CAROLINA STATE
BOARD OF HEALTH
The North Carolina State Board of Health consists of the Board proper
and the executive staff.
TJie Board of Health, as indicated diagramatically on page 18, consists of
nine members, five of whom ai'e appointed by the Governor and four of whom
are elected by the North Carolina State Medical Society. The organization
of this body embodies two important administrative principles: (1) stability
of organization and permanency of policies; (2) partnership of State and
the medical profession in the conservation of human life.
The stability of the organization of the Board of Health depends funda-mentally
upon the Board's freedom from political tinkering. The divorce-ment
of the State Board of Health from politics depends largely upon the
manner of selecting the members of the Board. Sudden and marked changes
in the personnel of the Board under the present plan of organization are
impossible: First, because the members of the Board of Health are ap-pointed
for terms of six years and their terms of service expire, not in the
same year, but in different years. The appointment of new members of the
Board is, therefore, gradual and not sudden. Second, the Board of Health
is selected by two parties: one, the Governor, and the other, the State Medi-cal
Society. It is far less likely that two parties naming a Board would be
dominated by political considerations than where one party names the Board.
This division of the appointive and elective power and this provision for the
slow and gradual exercise of that power by two parties guarantee the State
Board of Health against the sudden changes of personnel and policy asso-ciated
with a purely political organization. The Board of Health is stable;
its members come and go, but as an organized body it stays.
This stability of organization is the responsible factor for the permanency
of policies adopted by the Board. Political boards elected or appointed for
two years or four years are naturally inclined to adopt two- and four-year
policies, to attempt to make the best showing possible during the short term
of their official life. Their administrative thoughts and plans are largely
defined by the time limitations of their administration. This is not true
of self-perpetuating bodies such as the Board of Health, that, as legally con-stituted,
has no limit to its life.
The second administrative principle embodied in the organization of the
State Board of Health is the recognition by the State of the fundamental rela-tion
of the medical profession to the work of prevention. The State recog-nizes
(1) the debt of society to that profession by which nearly all of the
experimentation and discovery on which disease prevention is based, with
the exception of the work of Pasteur, was contributed; (2) the interest of
organized medicine in the conservation of human life and the peculiar abil-ity
of organized medicine to advise the State as to the methods of preven-tion;
and (3) the necessity of securing trom the medical profession first
information in regard to the occurrence of deaths and their causes, and the
appearances of epidemics.
The executive staff of the State Board of Health may be divided into the
executive office and the various bureaus or special divisions.
The Executive Office.—The executive officer of the State Board of Health
should be a man with technical training and experience, and, therefore.
20 I^ORTH Carolina Board of Health
should be selected on account of his technical rather than his political quali-fications.
It is, therefore, right that the Secretary of the State Board of
Health, or the executive officer, should be selected by a specially qualified
committee, that is, the State Board of Health, and not elected in a general
election, as would be the case if the office were a political one. The six-year
term of office for which the Secretary is elected is. in accordance with the
idea of permanency of policies. The work of the executive office is detailed
elsewhere.
The Bureaus or Special Divisions of the Executive Staff.-—The work of the
State Board of Health is large and varied, and is, therefore, apportioned
among eight bureaus. These bureaus are each directed by an officer with
special talent and training. The different bureaus and their more important
problems are fully and clearly indicated in the diagram on page 18.
The Correlation of the Work, of the Board.—This is also clearly indicated
in the diagram on page 18. The division of the executive sitaff into special
bureaus has the advantage of giving individualism to the work of each
bureau and thereby creating a laudable pride and a healthy rivalry among
the various bureaus engaged in the general work of the Board. While each
bureau is separate and independent of other bureaus, as indicated in the
diagram, the work of the entire executive staff is coordinated—the work of
the Board being given compactness by the relation of the bureaus to one
another through the executive office of the Board.
IVORK OF THE EXECUTIVE OFFICE
Character of Work
OBJECTIVES
The objectives of the executive office are: To determine what should be
the public health policies of the State; to secure the adoption of desirable
health policies by the State Government, and to supervise and to assist in
their execution. More fully and analytically stated, the objectives of the
executive office are:
(1) To determine what are the more important state health policies of
the State of North Carolina, and in what order they should be developed.
(2) To arrange for and, when possible, to secure, by appropriate educa-tional
methods and legislative recommendations, the necessary measures and
appropriations for the successful development of the more important State
health policies.
(3) To find and employ persons properly qualified by native endowments,
training, and experience, to man and direct bureaus or divisions under the
State Board of Health for the successful development of the more important
plans of the Hoard.
(4) To give such direction, supervision, and assistance to the bureaus or
divisions entrusted with the execution of State health policies as they may
need.
(5) To deal with all matters of official interest that may come to the
attention of the State Board of Health that are not referable to some bureau
or division entrusted with carrying out some special public health work.
(6) To receive, disburse, and account for the funds available for the work
of the State Board of Health.
METHODS
The methods of work adopted depend entirely upon the objectives sought.
Therefore, in discussing the methods of the work of the executive office, we
shall discuss them in connection with each of the aforementioned objectives.
Methods for Objective 1.—In determining the public health policies of the
State, it is necessary (a) that the executive office secure information through
special and regular reports on the vital statistics of the State, and in this
way be fully cognizant at all times of the vital conditions of the State as
shown by the State's birth rate, the State's general death rate, the State's
special death rates for certain diseases, the death rates in the State by
counties, by races, and by seasons; (6) that the executive office secure infor-mation,
through public health literature, books, and periodicals, as to the
more recent developments and discoveries in public health work; (c) that
the executive off.ce. by keeping in touch through conferences with other
State health officers and Federal health officers, be thoroughly conversant
with the methods and accomplishments of other State departments of health,
and that the executive office be alert to those larger interstate movements,
especially those related to action by the central government, in order that
whenever and wherever possible those larger movements may be influenced
to the advantage of the State.
For Objective 2.—To secure the necessary measures and appropriations for
the development of the State health policies, the following methods are pur-sued:
(a) The people of the State are informed, through bulletins, exhibits,
22 jSTorth Carolina Board of Health
the press, and public addresses, as to vital conditions and as to necessary
measures and appropriations for favorably influencing the vitality and phy-sical
efl!iciency of North Carolina people. In this way the executive office
seeks to develop a favorable public sentiment for the development of its more
important public health policies; (6) The executive office seeks to find and
to interest certain individuals qualified by heart and head and position, for
influencing, introducing, and supporting needed legislation.
For Objective 3.—To find and secure, with the available means, a personnel
for the bureau, division, or agency of the Board that may be relied upon
for carrying into successful execution some special and important public
health policy, calls for (1) an acquaintance with those who are in touch
with men qualified for such positions, and (2) a judgment of men. This
judgment of men by which an administrative oflScer selects his assistants
is. of course, basic in the success or failure of an administration.
Fo7- Ohjective '/.—In giving assistance to members of the executive staff
charged with carrying out certain special health policies, the executive oflSce
attempts to keep in touch with the work of each division or agency through
regular monthly reports, special reports, and conferences from time to time.
Consideration for the right amount of assistance—not too much and not too
little—is regarded as important. Too much supervision tends to smother
individually, to stifle the pride of accomplishment, to break down the self-confidence
of an agency; while, on the other hand, too little supervision not
infrequently results in a useless expenditure of funds.
For Objective 5.—In taking care of the general business of the Board which
is not referable to special bureaus, the executive oflice uses much of its time
in correspondence or in conferences. Perhaps 60 per cent of the time of the
executive office is spent in this way. The total correspondence of the execu-tive
office is shown on this page. In addition to this correspondence, from 12
to 20 per cent of the time of the executive officer is consumed in official con-ferences
with callers. This would leave about 25 or 30 per cent of the time
of the executive office to be devoted to the other objectives.
For Objective 6.—The bookkeeping of the executive office is entrusted to
a thoroughly reliable, careful, and bonded clerk, whose system of account-ing
has been devised by an expert accountant and whose work is audited
at regular intervals.
ROUTIXE WORK
Letters received 6.971
Magazines and bulletins received and reviewed (1918) ^ . . 711
Letters written : Individual 7. .537
^Tultigraph 22.099
Total 29,546
Articles written: Newspaper (words) ; 750
Bulletin (words) 20. .300
Official publication (words) 41,150
Other publication (words) 33,825
Forms and placards prepared 14
Addresses delivered : Number 23
Total audience 1,900
Inspections: State institutions (1917) ^
Countv institutions (1917) 16
Hotels (1917) 4
Epidemics: Conferences with local authorities (1917) 14
Supervision of (1917) 1
Jail reports received and examined (1918) 284
Convict camp reports received and examined (1918) 191
Seventeenth Biennial Eeport 23
Telegrams received o05
Telegrams sent 810
Vouchers issued 3,813
Receipts issued 411
Financial reports prepared 93
Days out of office on official business 165
Percentage of work not embraced in above statement 30
Important items not included in above statement: Conferences, Medical De-fense
Work, Legislation, Influenza Work.
M0>THLY AVERAGE
Letters received 290
Magazines and bulletins received and reviev/ed 59
Letters written: Individual 314
IMultigraph 917
Total 1.231
Articles written: Newspaper (words) ' 31
Bulletin (words) 845
Official publication (words) 1,714
Other publication (words) 1.409
Forms and placards prepared 1
Addresses delivered : Number 1
Total audience , 79
Inspections: State institutions
County institutions 1
Hotels
Epidemics : Conferences with local authorities 1
Super\ision of
Jail reports received and examined 23
Convict camp reports received and examined 15
Telegrams received 21
Telegrams sent 33
Vouchers issued 158
Receipts issued 17
Financial reports prepared 3
Days out of office on official business 6
Percentage of work not embraced in above statement 22
RESULTS OBTAINED
Result 1.—The executive office planned, established, and gave much time
to the successful development of the work of five new bureaus. The executive
office, therefore, shares the credit of the work accomplished by these bureaus.
The bureaus established during the last two years are: (a) A Bureau of
Epidemiology (complete report of work on pages 41 to 46, inclusive), which
concerns itself with enforcing the State laws that prescribe methods of quar-antine
for the prevention of communicable diseases; (6) A Bureau for Medical
Inspection of School Children (complete report of work on pages 35 to 37, in-clusive),
which concerns itself with arranging for and supervising the physi-cal
examination of public school children, and providing and securing proper
treatment for as large a number of the school children that are found to
need medical treatment as is possible w'ith the means at the disposal of the
Bureau; (c) A Bureau of Infant Hygiene (complete report of work on pages
51 to 53, inclusive), which concerns itself mainly with the great and un-necessary
loss of life under five years of age—11,749 deaths out of a total of
34,000 deaths at all ages for the State each year, and more than one-third of
the total deaths—with the aim of lessening this vital loss by special educa-tional
measures and by demonstrating to the local governments of the State
the value of public health nurses for educating and assistin.p: the mothers of
2-i XoRTH Carolina Board of Health
the State in the care of their children; {(I) A Bureau of County Health Work
(complete report of work on pages 26 to 34, inclusive), which concerns it-self
with the proper development of model county health departments and
with the supervision of nine such county health departments now in opera-tion;
(e) A Bureau of Venereal Diseases (complete report of work on page
54), which concerns itself with the treatment and the rendering noninfectious
of persons having venereal diseases, with suppressing prostitution, and with
educating the public to the advantages of sex hygiene and the dangers of
unchastity.
Result 2.—The State Board of Health has interested the International
Health Board and the United States Public Health Service in opportunities
for successful public health work in North Carolina to the extent of obtaining
from these agencies, during the past two years, a total appropriation of
$43,720.96. In addition to this direct appropriation, we have secured from
the above agencies the loan of health officials for work in North Carolina,
without cost to the State, whose combined salaries during the time of their
work in this State have amounted to over $16,000. In short, we have been
instrumental in securing from outside sources, without cost to the State,
during the last two years. $60,000 worth of health work.
Result 3.—The executive office rendered considerable assistance to the
Council of National Defense and to the office of the Surgeon General in the
preparedness program of the country. This assistance consisted in making
a number of trips to Washington for conferences, and at one time in making
a ten-day trip for the Council of National Defense to the States of South
Carolina, Georgia, Alabama and Florida for conferring with th-e Governors,
the State Health Officers, and the Chairman of the State Councils of Defense
of those States with respect to sanitary defense measures. We also gave
much time and assistance to the Council of National Defense in the organi-zation
of the Volunteer Medical Service Corps, the aim of which was the
mobilization of the medical profession on the basis of a signed agreement
by each physician who is a member of the corps, leaving to the Council of
National Defense the disposition of his services during the war. Still fur-ther
work on the preparedness program of the country was assistance ren-dered
to Major J. W. Long. Medical Aide to the Governor, in the organiza-tion
of the Medical Advisory Boards.
Result .'f.—The executive office formulated, after conference with State
officials, local agencies and authorities, the measures directed to the regu-lation
of the influenza epidemic and to the medical relief work. In the work
of medical relief, we were instrumental in serving sixty-four communities,
having sent seventy emergency doctors and sixty-one nurses at a total ex-pense
to the State of approximately $1,266.37. This report is being made be-fore
the epidemic has subsided and before figures are available showing
case rates and death rates in other states, and the cost of handling the
epidemic to other states, but we feel safe in asserting now that when these
figures are available, the case rates and death rates in this State will com-pare
favorably with those in other states, and we believe that comparison
of the cost of handling the epidemic will show a saving of many thousands
of dollars to the State of North Carolina.
Result .').—The executive office has handled an official correspondence dur-ing
the last two years amounting to a receipt of 6,971 letters and 7,537 re-plies.
This does not include the preparation and mailing of 22,009 multi-graph
letters.
WORK OF THE BUREAU OF EDUCATION
Character of AVork
OBJECTIVES
The Bureau of Education is conducted for the following specific purposes:
(a) To appoint out and endeavor to change those habits and customs
which interfere with the highest physical and mental development of the
individual and the State.
(&) To prevent epidemics of communicable diseases by giving warning of
their occurrence, and by giving information with regard to the methods of
control and prevention.
(c) To interest the people of the State in individual and community health
work in order that home and community hygiene and sanitation may be im-proved,
and health instead of disease made "catching."
METHODS
The methods of attaining these purposes are as follows:
(1) The Health Bulletin has been published monthly, dealing informa-tively
with subjects of hygiene and sanitation. It is mailed free upon re-quest
to any citizen of the State. The average monthly circulation is 48,000
copies.
(2) Special pamphlets and placards, dealing in a thorough manner with
specific diseases and conditions, have been prepared. These are mailed upon
request free to citizens of the State. The average number distributed
monthly has exceeded 30,000.
(3) A press service has been maintained through which daily articles,
varying in length from two to five hundred words, have been sent to all the
newspapers of the State. These consist of: articles having a news value but
little value in the teaching of hygiene and sanitation; articles having both
a news value and which teach hygiene and sanitation; articles which teach
hygiene and sanitation, but with little or no new^s value. In addition
specially prepared articles on hygiene and sanitation have been prepared in
plate form for distribution to 102 weekly newspapers of the State. The
newspapers of the State have cooperated most heartily by making extended
use of this press service.
(4) Stock lectures have been prepared, together with lantern slides to
illustrate them, these being furnished to civic organizations interested in
promoting community health. Lanterns, slides, and lectures have been so
arranged as to be easily available, and have been largely utilized.
(o) Traveling exhibits, covering many subjects of hygiene and sanitation,
have been prepared which through models and charts give a graphic pre-sentation
of the subject. These have been furnished to local organizations
in the same manner as the illustrated lectures. In addition an elaborate
exhibit has been prepared for the fairs of the State, the exhibit being given
by a trained demonstrator.
(6) Motion pictures, featuring health subjects in an entertaining manner,
have been used by means of a special traveling motion picture outfit which
began the service in March. 1916. Through this method a number of people
have been reached who could not be reached through other methods.
26 XoKTH C'aholina Board of Health
KOUTINE WORK
The details of the work are indicated in the following summary:
Newspapers and magazines received and reviewed 13,660
Letters and postals received 19.530
Letters written : Individual 6,701
Multigraph 6.115
Total 12,816
Articles written: Newspapers
Health Bulletin
Official Pamphlets
Other publications
Total words 419,723
Motion picture entertainments given 264
Total audience witnessing same, approximately 58,298
Addresses delivered 11
Total audience present, approximately 1,861
Stock lectures given 167
Total audience present, approximately 19,971
Traveling public health exhibits given 39
Number seeing exhibits, approximately 52,285
Special exhibits given 58
Monthly Health Bulletins mailed 696,500
Pamphlets, leaflets, and placards distributed 743,398
Articles prepared for newspaper plates (words) 23,100
Number plates sent to newspapers 920
EESULTS OBTAINED
Through the means of personal correspondence, the monthly Health Bul-letin,
special pamphlets and placards, addresses, lectures, special traveling
exhibits, and the newspapers of the State approximately one half of the en-tire
population of North Carolina has been reached directly with a message
of health. The value of this is something that cannot be estimated in dollars
and cents.
The value of any educational movement is an intangible thing the worth of
which we realize, but which we cannot reduce to terms of money. The Bible,
the work of the ministers and the churches, the school system, the press, all
these are educational agencies of tremendous importance. So vital are they,
in fact, that no sane person would for a moment argue for the suppression
of any one. Yet it is not possible to say what any one of these agencies is
worth to North Carolina in sums of money.
So it is with the educational health work conducted by this Bureau. It
has carried information and instruction to the people of the State with re-gard
to hygiene and sanitation. It has shown how communicable diseases
may be avoided; how epidemics may be controlled and prevented. It has
waged warfare against those insanitary conditions which produce typhoid
fever and the allied diarrheal diseases. It has carried a message of hope to
the tubercular and has been the instrument of saving many from untimely
death by pointing out the way to restored health. "Line upon line, precept
upon precept," the prevention of disease has been preached, and the deaths
from preventable causes have been materially reduced in the State.
REPORT OF THE BUREAU OF COUNTY HEALTH WORK
(July 1, 1917, to November 30, 1918)
Character of Work
The Bureau of County Health Work of the North Carolina State Board of
Health is the agency through which the State extends cooperation to the
counties in organizing and maintaining permanent county health depart-ments.
The Bureau was organized July 1, 1917, and is supported by funds
provided by the General Assembly and by the International Health Board.
OBJECTIVES
The object of the work of the Bureau is to defnonstrate the best methods
of performing County Health Work.
The work of each county health department organized and conducted by
the Bureau of County Health Work is to present the health problems of the
county, together with the best means of solution, to the people in a definite
and comprehensive manner, and by a plan designed to reach directly and
educate each home. This plan comprises lectures and demonstrations, news-paper
articles and letters, and home visits with the aim of having the people
apply in their homes the latest discoveries of sanitation and personal hygiene.
An attempt is made to have each home and school construct a sanitary closet;
to have each person examined and, if necessary, treated for hookworm dis-ease;
to quarantine all cases of contagious diseases and stop the spread of
epidemics. The examination of school children with the treatment of all
who are found defective; the examination of adults in life extension work;
the vaccination against typhoid fever, smallpox and whooping-cough, are
emphasized. The plan also arranges for cooperation with the towns of the
county in providing inspection of hotels, restaurants, markets, and dairies,
and in encouraging sewer connections and other improvements in sanitation.
The county health department also has charge of the county home and jail
and convict camp.
METHODS
The Bureau of County Health Work, in order to accomplish its objects, is
cooperating with the following nine counties in a three-year plan of public
health work: Davidson, Forsyth, Lenoir, Nash, Northampton, Pitt, Robeson,
Rowan, and Wilson. The program of work in each county consists of definite
units on the more important health problems rather than an attempt to coyer
the entire field of county health activity in a short period of time. The more
important units of work are concerned with the prevention of soil pollution
and its attending diseases such as typhoid fever, infant diarrhea, the dysen-teries,
and hookworm; life extension work which contemplates the early
detection and prevention of the diseases of adult life; the medical inspection
and treatment of school children; the quarantine of infectious diseases; the
prevention of tuberculosis; and infant welfare work.
During the first year of the health department, three units of work are
undertaken: Quarantine, Soil Pollution, and the School Units. The Quaran-tine
Unit is the enforcement of the State quarantine law, and aside from
the educational work is largely clerical and can be done by the office assist-ants.
This unit, of course, is continued throughout the entire three years.
28 North Carolina ]3<)ard of Health
The School Unit is also a required unit and takes up the greater part of the
second six months' work of the first year. The work of the School Unit has
been to obtain a record of the physical condition of every school child in
each county and to get as many of the defective children treated as possible.
During the past eighteen months especial attention has been called to the
dangers of denial defects and the importance of their treatment. In this
work the Jsureau of Medical Inspection of Schools has cooperated and a full
report of the dental work has been published by Dr. Geo. M. Cooper, the
director of that Bureau.
Briefly stated, the activity of the Soil Pollution Unit is, as far as is
practicable, to have an official of the health department visit every rural
home (white and colored) in the county and collect specimens and give
treatment for hookworm disease. This official attempts to teach the people
the importance of providing sanitary closets at their homes. As part of the
educational campaign, the health oflncer gives lectures and demonstrations
at the school houses, churches, and other convenient gathering places in each
community where the unit is being conducted. Health literature is also dis-tributed,
and an effort is made to educate the people along the lines of gen-eral
disease prevention. Special efforts are also made to have the towns and
villages of the county provide and enforce sanitary measures, and to have the
larger towns establish full time sanitary departments. The Soil Pollution
Unit continues intensively for six months, more or less, and is carried on
by from three to five field assistants, who reside in the communities in
which they are conducting the work. These assistants work, of course,
under the direction of the health officer. After the intensive campaign the
Soil Pollution Unit is continued by one assistant who devotes his entire
time to visiting the various sections of the county, in order to keep before
the people the necessity of rural sanitation, and in continuing work in com-munities
which did not complete their sanitary work during the intensive
campaign. This assistant also collects specimens and gives treatments for
hookworm disease.
An important phase of the Soil Pollution Unit is the collection of. statistics
from each home and each family, these statistics being of great value to the
future work of the health department.
The Life Extension Unit begins in the second year of the health depart-ment.
It consists of making thorough physical exarninations of adults in
order to detect any danger signals which might later, if untreated, develop
into serious handicaps to the individual. Before beginning this work the
health officer spends ten days or two weeks at the State Sanatorium for
Tuberculosis where he is given a post-graduate course in physical diagnosis.
An intensive campaign of two months is then conducted by the health officer
for educational work and to advertise the features of life extension work,
especially emphasizing the value of periodic physical examinations. At
the county seat and at branch oflJices at convenient places in the county,
adults are examined after a routine plan which was inaugurated by the Life
Extension Institute. After the intensive campaign the health officer set-3
aside certain hours, or perhaps a whole day, each week for the examination
of applicants. In this way the unit is carried on through the second and
third years of work. The medical officers of the State Tuberculosis Sana-torium
act as a consulting board to the county health officers and have
arranged to cooperate in examination of difficult cases.
Seventeenth Biennial Report 29
Definite work is conducted against tuberculosis. This consists of lectures
and demonstrations regarding the disease and in making physical examina-tions
of persons who are suspected of having the disease. Each case of tuber-culosis
in the county is regularly visited by some representative of the county
health department in order to see that proper precautions are being taken
to prevent the spread of the disease.
It is planned to add the Infant Hygiene Unit at the beginning of the third
year of each county health department. The purpose of the work will be
to lower the death rate among babies and young children by educating the
mothers as to the best means of caring for their children. The health officer
will be assisted by a trained nurse and it is planned to secure the cooperation
of the physicians and mothers. An important feature of the Infant Hygiene
Unit will be the control of the practice of midwifery by requiring every mid-wife
to register with the health department and obtain a license after demon-strating
a knowledge of hygiene and obstetrics.
In addition to the outlined units of health work the county may provide
other units which may be found to be desirable or necessary; all such addi-tional
units being conducted, of course, under the supervision of the county
health department. In the same way, any community, town, or city in the
county may arrange with the county and State boards of health to have its
special work conducted by the county department.
In each county the health officer has had medical supervision of the county
home, jail, and chain-gangs. During the epidemic of influenza the county
departments took the lead in organizing the local forces in combatting the
disease.
BUDGETS
As has already been stated, each county health department is organized
on a three-year plan and is under the joint control of the State and county
boards of health. The State Board of Health and the International Health
Board assist by suggesting the best methods of conducting the county de-partment
and also financially by providing (each contributing an equal por-tion)
50 per cent of the budget of each county health department during the
first year, 40 per cent the second year, and 25 per cent the third year. The
budgets for the county health departments are as follows:
Fiist Second Third
Year. Year. Year.
Health officer, salary $ 2.100 $ 2,100 $ 2,400
Traveling 600 600 750
Clerical assistant, salary 600 600 900
Fixtures and supplies 500 100 100
Contingent Fund 140 140 140
Soil Pollution Unit '. 2.430 900 900
Quarantine and disinfection 100 100 100
School Work Unit 500 500 500
Life Extension Unit 400
Infant Hygiene Unit • ... 100
$ 6,970 $ 5,440 $ 5,890
FORCE EMPLOYED
The central office of the Bureau of County Health Work has a force of
two—a medical director and a stenographer. The salary of the medical
director is paid in full by the International Health Board, no part of it
30 North Carolina Board of Health
being paid by the State Board of Health. Tlie salary of the stenographer
is $70 per month. The State Board of Health provides the office, office equip-ment,
supplies and printing, and the traveling expenses of the medical
director.
The duties of the State Director are to secul^e county appropriations, select
county health officers, inaugurate and direct the work of each county depart-ment,
pay regular visits to each county and report the progress of the work
to the State Board of Health, collect and compile county reports, prepare
literature for the county work, and have supervision of the financial pro-ceedings
of the Bureau and of the cooperating counties.
Each county department is directed by a health officer who is appointed
by and is an official of the State Board of Health. The health officer is given
an adequate corps of assistants to enable him to give as near as possible each
unit of work to his entire county. An office assistant is provided for the en-tire
three years of work. During the intensive soil pollution campaign from
three to five assistants are provided for the field work. After the first six
months, a field worker for follow-up work is employed for the remainder
of the three years. In the medical inspection of school unit the health officer
is assisted by a dentist and other specialists.
The following is a list of the county health departments with the name
of the health officer and the date on which the work began:
County. Health Officer. Work Began.
Nash Dr. G. W. Botts July 1, 1917*
Davidson Dr. E. F. Long July 1, 1917
Wilson Dr. L. J. Smith July 15, 1917
Northampton Dr. F. 'M. Register August 1, 1917
Lenoir Dr. J. S. ^Mitchener August 15, 1917
Pitt Dr. C. P. Fryer December 1. 1917t
Robeson Dr. W. A. McPhaul December 1, 1917
R owan Dr. A. J. Warren January 1, 1918
Forsyth Dr. A. C. Bulla January 1. 1918
RESULTS obtained
1. statistical.—The following statistics, when consiidered in connection
with the outlined plan of work given above, will convey some idea of what
has been accomplished during the seventeen months of work already com-pleted:
the central office
Number of letters received 2,471
Number of letters mailed 2.566
Number of mimeographed letters sent out 5,397
Number of forms prepared 54
Number of articles prepared 107
Number of packages of literature and supplies sent 464
Number of telegrams sent 91
Number of days spent out of office on official business 193
Number of addresses given 55
Number of visits to county health departments 167
*The work in Nash County "was suspended from August 15 to November 15, 1918.
tThe work in Pitt County was suspended from January 1 to May 1, 1918.
Seventeenth Biennial Keport 31
THE COUNTY DEPARTMENTS
(An aggregate of 120 months work.)
1. Number of public meetings held 591
(Attendance, 53,807.)
2. Lectui'es at schools 378
(Attendance, 33,643.)
3. Number of letters sent out 29,173
4. Number of newspaper articles published 815
5. Number of sanitary closets built 7,364
6. Number of specimens examined for hookworm disease 20,834
7. Number of people treated for hookworm disease 3,928
8. Diseases quarantined and visited:
Whooping cough 1.774 Visited 240
Measles 1,536 Visited 45
Diphtheria 263 Visited 28
Scarlet fever 105 Visited 59
Typhoid fever 530 Visited 121
Smallpox 135 Visited 61
Infantile Paralysis 5 Visited 1
Epidemic Meningitis ... 9 Visited 19
9. Number of schools visited 479
10. Number of children examined by teachers 38,969
11. Number of children examined by health officers 12.699
12. Number of children having defects remedied 6,171
13. Number of children having dental defects remedied 5,354
14. Number of physical examinations of adults* 1,528
15. Number of people vaccinated against ayphoid fever 37,234
16. Number of people vaccinated against smallpox 6.450
17. Number of people vaccinated against whooping-cough 56
18. In the towns of Wilson, Salisbury, Kinston, Lexington, and Thomas-ville
the following special work was accomplished:
a. Visits by health nurses 1,673
b. Hotels, cafes, and markets inspected 2,545
c. Dairies inspected . . .
.' 138
d. Microscopical examinations of milk 61
e. Sewer connections 746
/. Sanitary privies (Wilson pail type) cleaned 54,321
AVERAGE M'ORK OF ONE DEPARTMENT FOR ONE MONTH
These nine departments organized by the Bureau of County Health Work
had been in operation for an aggregate of 120 months up to November 30,
1918. The following is the average work of one of the county departments for
one month:
1. Eight public lectures with an attendance of 729 people.
2. Seven newspaper health articles published in the county papers.
3. Sixty-one rural homes constructed sanitary privies.
4. One hundred and seventy-one people examined for hookworm disease
and 33 of these treated.
*Life extension work (the physical examination of adults) is a unit of work taken up during
the second year of each health department. The statistics given here are for only four county
departments.
32 ISToRTH Caroi-ina Board of Health
5. Four schools visited by the health officer.*
6. Three hundred any twenty-five school children examined by the teachers
working under the direction of the health officer.*
7. One hundred and six school children personally examined by the health
officer.*
8. Fifty-one of the children found defective by the health officer were
treated.*
9. Thirty-two adults given physical examinations by the health officer.
10. Three hundred and ten people vaccinated against typhoid fever.
11. Fifty-four people vaccinated against smallpox.
12. County quarantine work performed satisfactory and included the quar-antining,
according to the State law, of 43 cases of infectious diseases.!
13. Medical attention was given the county dependents who were inmates
of the county home, the jail, and the chain-gangs.
DETAILED REPORT OF COUNTY DEPARTMENTS
A. Davidson County
(17 months work.)
1. Number of public meetings 193
(Attendance, 19,772.)
2. Number of newspaper articles published 61
3. Number of sanitary closets built 1,614
4. Number of people examined for hookworms 4,642
5. Number of people treated for hookworm disease. 411
6. Number of schools visited 27
7. Number of children examined by teachers 3,172
8. Number of children examined by health officers 1,680
9. Number of children having defects remedied 1,157
10. Number of children having dental defects remedied 986
11. Number of physical examinations of adults 147
12. Number vaccinated against typhoid fever 1,710
13. Number vaccinated against smallpox 1,196
B. Forsyth County
(11 months work.)
1. Number of public meetings 70
(Attendance, 7,004.)
2. Number of newspaper articles published 119
3. Number of sanitary closets built 488
4. Number of people examined for hookworms 2,555
5. Number of people treated for hook worm disease 149
6. Number of schools visited 59
7. Number of children examined by teachers 1,354
8. Number of children examined by health officers 2,702
9. Number of children having defects remedied 744
10. Number of children having dental defects remedied 389
11. Number vaccinated against typhoid fever 758
12. Number vaccinated vaccinated against smallpox 105
*In considering the school work note should be taken of the fact that in North Carolina the
rural schools are in session from only 4 to 6 months each year. Hence, the average school
work of the health department during the months that school is in session would be from 3
to 2 times that shown in items 5, 6, 7, and 8.
tWhen a case of infectious disease is reported to the health department the house in which
the patient resides is placarded, the family is instructed as to the care of the patient to
prevent the spread of the disease, the nearby school authorities are notified of the existence
of the disease and the teachers are provided with literature regarding the disease, this
literature being sent through the school to each home in the community.
Seventeenth Biennial Report 33
C. Lenoir County
(15 months work.)
1. Number of public meetings 174
(Attendance, 8,842.)
2. Number of newspaper articles published 151
3. Number of sanitary closets built 627
4. Number of people examined for hookworms 4,319
5. Number of people treated for hookworm disease 1,661
6. Number of schools visited 104
7. Number of children examined by teachers 3,290
8. Number of children examined by health officers 154
9. Number of children having defects remedied 394
10. Number of children having dental defects remedied 389
11. Number of physical examinations of adults 175
12. Number vaccinated against typhoid fever 9,178
13. Number vaccinated against smallpox 327
D. Kash County
(14 months work.)
1. Number of public meetings 72
(Attendance, 8,150.)
2. Number of newspaper articles published 49
3. Number of sanitary closets built 747
4. Number of people examined for hookworms 1,587
5. Number of people treated for hookworm disease 193
6. Number of schools visited 78
7. Number of children examined by teachers 4,553
8. Number of children examined by health officers 449
9. Number of children having defects remedied 665
10. Number of children having dental defects remedied 665
11. Number vaccinated against typhoid fever 1,493
12. Number vaccinated against smallpox 172
E. Northampton County
(15 months work.)
1. Number of public meetings 154
(Attendance, 18,515.)
2. Number of newspaper articles published 105
3. Number of sanitary closets built 1,187
4. Number of people examined for hookworms 2,545
5. Number of people treated for hookworm disease 975
6. Number of schools visited 119
7. Number of childi'en examined by teachers 4,104
8. Number of children examined by health officers 1,866
9. Number of children having defects remedied 571
10. Number of children having dental defects remedied 563
11. Number vaccinated against typhoid fever 11.170
12. Number vaccinated against smallpox 763
F. Pitt County
(8 months work.)
1. Number of public meetings 37
(Attendance 3,767.)
2. Number of newspaper articles published 78
3. Number of sanitary closets built 146
4. Number of people examined for hookworms 628
5. Number of people treated for hookworm disease 145
6. Number of schools visited 20
7. Number of children examined by teachers 1.430
8. Number of children examined by health officers 818
3
34 !N^ORTH Carolina Board of Health
9. Number of children having defects remedied 145
10. Number vaccinated against typhoid fever 3,226
11. Number vaccinated against smallpox 881
G. Roheson County
(12 months v^^ork.)
1. Number of public meetings 110
(Attendance, 10,786.)
2. Number of newspaper articles published 120
3. Number of sanitary closets built 956
4. Number of people examined for hookworms 62
5. Number of people treated for hookworm disease 150
6. Number of schools visited 56
7. Number of children examined by teachers 9,550
8. Number of children examined by health officer 2,127
9. Number of children having defects remedied 1,602
10. Number of children having dental defects remedied 1,421
11. Number of physical examinations of adults 999
12. Number vaccinated against typhoid fever 2,634
13. Number vaccinated against smallpox 583
H. Rowan County
(11 months work.)
1. Number of public meetings 96
(Attendance, 8,246.)
2. Number of newspaper articles published 31
3. Number of sanitary closets built 1,499
4. Number of people examined for hookworms 1,848
5. Number of people treated for hookworm disease 115
6. Number of schools visited 44
7. Number of children examined by teachers 6,054
8. Number of children examined by health officers 1,221
9. Number of children having defects remedied 126
10. Number vaccinated against typhoid fever 4,664
11. Number vaccinated against smallpox 259
7, Wilson County
(17 months work.)
1. Number of public meetings 56
(Attendance, 3,468.)
2. Number of newspaper articles published 101
3. Number of sanitary closets built 100
4. Number of people examined for hookworms 93
5. Number of people treated for hookworm disease 24
6. Number of schools visited 84
7. Number of children examined by teachers 5,462
8. Number of children examined by health officers 1,882
9. Number of children having defects remedied 852
10. Number of children having dental defects remedied 941
11. Number of physical examinations of adults 209
12. Number vaccinated against typhoid fever 2,401
13. Number vaccinated against smallpox 2,164
2. Reduction in Death Rate.—The nine county health departments which
have been organized have been uniformly successful and have impressed the
citizens of the counties with their usefulness. It has been demonstrated be-yond
doubt that a county can lower its sick and death rates and that it is
economical for a county to do this. At this point it is interesting to note,
for example, the decrease in the number of cases and the number of deaths
from typhoid fever as a result of the soil pollution work.
Seventeenth Biennial Report 35
We have a record of the deaths from typhoid for the years 1914 to 1917,
inclusive. Also we have a record of the deaths from this disease from
January 1 to August 31, 1918—later statistics not being available. In the
five county departments organized in 1917 and conducted for more than a
year, the reduction in the number of deaths from typhoid is notable. And
when it is considered that there are an average of 10 cases for each death
from typhoid fever and that the average cost of each case is $400 we can
make an estimate of the saving in money as well as suffering in each county.
The statistics are as follows:
Northampton County had 14 deaths from 1914-1917, or an average of Zy^
deaths each year. No deaths from typhoid occurred from January to August
31, 1918.
Davidson County had 44 deaths from 1914-1917, an average of 11 cases for
each year. No deaths had been reported to August 31, 1918.
Nash County reported 42 deaths for the four years up to 1918, being an
average of 10% deaths each year. To August 31, 1918, only 1 death had been
reported from typhoid.
Lenoir County's average number of deaths each year from typhoid was
10%, meaning that there were 43 deaths during the years 1914-1917. Only
2 deaths occurred to August 31, 1918.
Wilson County had an average of 14^/4 deaths from typhoid or 57 deaths in
the years 1914-1917. To the end of August, 1918, only 2 deaths are reported.
In all nine of the counties there has been a marked decrease in the general
death rate, and especially in the number of deaths from typhoid, infant
bowel troubles, and the infectious diseases.
The experience being gained in the organization and conduction of county
health departments will no doubt prove of value to the State Board of Health
in determining the best plan of dealing with county health problems.
WOKK OF THE BUREAU OF MEDICAL IINSPEtTIO^V OF SCHOOLS
Character of Work
OBJECTIVES
The object of the work of the Bureau of Medical Inspection of Schools is
(1) to arouse the teachers of the elementary schools of North Carolina to
the necessity of making the same efforts to teach the children things they
should know for the development of their bodies and for the protection of
their health, that they make for their intellectual advancement; (2) to edu-cate
the children in public health matters; (3) to discover the children who
have remediable defects, and to have them treated while curable and before
the condition becomes chronic, and (4) to enlist the interest and to coordi-nate
the efforts of county authorities, school, health and commissional, for
the protection of the health of school children.
METHODS
In order to explain the methods of work in this department it is necessary
to consider the methods in relation to the objectives.
Method for Objective i.—Written instructions for teachers have been pre-pared
covering every phase of medical inspection of school children. Cards
for recording the exact history and results of the preliminary physical ex-amination
of each child have been prepared. All this literature has been
placed in the hands of the teachers, county by county, as the work progressed.
Lectures by competent physicians and specially trained nurses and others
have been made direct to teachers individually in small groups and in large
institute gatherings. Competent officials have made examinations of chil-dren
in the presence of teachers to demonstrate by example the need for the
examination, the purpose, and how to do it.
For Objective 2.—Health talks in simple language have been made to the
children from the first grade up. Leaflets and pamphlets on health subjects,
simply written, have been placed in their hands.
For Objective 3.—The methods devised to discover the defective children
are: (a) The teacher after consultation with the parents when necessary
and after personal study of each child records on a prepared card the findings
of such preliminary examination; (b) The cards are passed on to a com-petent
physician, who, after careful study, selects the cards representing
childi-en who are most in need of medical examination; (c) These children
are then called to a physician's office and examined, or a physician or nurse,
or both, visit the school and make the examination, giving advice to the
parent and urging the administration of necessary treatment, either medi-cal,
dental, surgical, or special; (d) Special arrangements are made for club
operations and dental treatment which are fully described under Results Ob-tained
of this department.
For Objective .).—County superintendents of schools, county commissioners,
county boards of education, and county boards of health are visited and in-dividually
and officially besought to make adequate provision for the en-forcement
of this law, in spirit as well as letter.
Seventeenth Biennial Report 37
routine work
Biennial period ending December 31, 1918.
Letters received " 3,152
Letters written: Individual 4.665
Multigraph 5,960
Total 10,625
Reports prepared 24
Articles written: Bulletin 20 (words) 11,845
Other publications, 28 (words) 25,836
Pamphlets prepared 5
Days spent out of office on official business 197
Pieces of literature distributed 482,956
Addresses delivered : Number 432
Total attendance 41,532
MONTHLY AVERAGE
Letters received 131
Letters written : Individual 194
Multigraph 248
Total 442
Reports prepared 1
Articles written : Bulletin 1
Other publications 1
Pamphlets prepared 1
Days spent out of office on official business 8
Pieces of literature distributed 20,123
Addresses delivered : Number 18
Total attendance 1,730
• force employed
Director of Bureau, three part-time physicians, six part-time dentists, three
part-time nurses, one stenographer and clerk.
budget
Amount received from Executive Department $7,500.00
Amount received from Special State Funds 2.024.97
Amount received from counties 56.06
results obtained
Some of the tangible results of the work of this department may be enum-erated
as follows:
1. More than 7,000 defective children have been treated in the public
clinics established by the State Board of Health working in conjunction
with the authorities of a few counties. A total of 10,670 children have been
treated. The condition of these children was found through the system of
medical inspection.
2. A preliminary physical examination of about 160,000 school children
was made by some three thousand teachers. Several thousand of these
children have been treated as a direct result of that examination, and of
which no records have been obtained.
3. About one hundred cases of trachoma, a dangerous eye disease, was
discovered in four counties; and most of the cases treated satisfactorily.
4. Ten thousand eight hundred and ninety-two school children were ex-amined
by specially trained registered nurses.
38 XoRTH Carolixa Board of Health
5. Thirty-eight thousand seven hundred and eighteen school children were
examined by physicians. These examinations were carefully made, and
many hundreds of cases of serious conditions were found. For example,
two children in one county were found to be in the active stages of tuber-culosis.
Both were in school with other children. Both of them were sent
to the State Sanatorium where they were able to regain their health.
6. Free traveling dental service was provided for the rural schools in
nine counties, the first of the kind for strictly rural school children at public
expense in the United States. Two hundred and twenty-seven different dis-pensaries
were held and 6.678 small school children given free dental treat-ment.
Such in brief are some of the specific results of the activities of the
Bureau of Medical Inspection of Schools.
>VORK OF THE STATE LABOKATORY OF HIGIEAE
Character of Work
The work of a public health laboratory is properly limited to those fields
of usefulness which are strictly practical. Where other agencies exist the
necessary work of health education and propaganda should be left to them.
With these ideals in view, the State Laboratory of Hygiene ha,s always ad-dressed
its efforts to some definite practical piece of work. When it has been
necessary, on account of limited funds, to choose between different lines of
work, the choice has been for that work which promised the widest help to
the greatest number of the State's inhabitants. Specifically this work has
been done under the following heads:
1. Analyses of water from public supplies and from commercial springs.
2. Examination of specimens for the purpose of diagnosis.
3. Pasteur treatment of persons infected with rabies.
4. Manufacture and distribution of vaccines and antitoxins.
The average monthly work for the years 1917 and 1918 is as follows:
Water 175
Sputum 132
Blood for typhoid 91
Blood for malaria 17
Throat swabs for diphtheria ' 59
Pus for gonorrhea 6
Brains for rabies 42
Intestinal parasites 119
Tissue for cancer 7
Urine 25
Blood for syphilis 245
(After February, 1918.)
Blood for gonorrhea 4
(After February, 1918.)
Miscellaneous 14
Pasteur patients (three weeks treatment each), average per month. 28
Typhoid vaccine distributed (average doses per month) 20,698
Whooping-cough vaccine (average doses per month) 658
Smallpox vaccine (average doses per month) 2,465
Diphtheria antitoxin (bought and distributed at cost in 1917, manu-factured
and distributed pi^actically free in 1918) average units
per month 1.005.000
Tetanus antitoxin (1918) average units per month 2,200
Also small amount tuberculin, material for Schick test and several other
biological products.
FORCE EMPLOYED
The force employed consists of a director, one bookkeeper, four assistant
bacteriologists, one chemist, one serologist, one manufacturing serologist, one
laboratory assistant, one janitor and stableman, and one charwoman. In addi-tion,
it is necessary to employ several extra assistants, usually medical stu-dents,
during the busy summer months.
40 North Carolina Board of Health
BUDGET
The income for the two years July 1, 1916 to June 30, 1918, as reported to
the Legislative Reference Librarian is as follows:
Appropriation $26,250.00
Water tax 11.723.12
Diphtheria antitoxin 48.50
Pasteur treatments 1,054.14
Fees 1,955.17
$ 41,030.93
Less amount used for permanent Improvements 1.179.63
$ 39,851.30
At the beginning of the fiscal year December 1, 1916, there remained un-expended
fi'om previous appropriation approximately $7,000. This balance
was due to the fact that the completion of the new laboratory buildings had
been delayed and the new antitoxin work could not be undertaken to best ad-vantage
until the new buildings were occupied.
In spite of the utmost economy a deficit of approximately $4,000 existed
at the close of the year November 30, 1918. Two thousand dollars of this was
covered by a loan from Dr. Rankin and the balance remained as an over-draft
and as unpaid bills. On the annual income of approximately $20,000,
the State Laboratory of Hygiene is able to demonstrate a many-fold return.
The vaccines alone which were distributed free in 1918 would have cost the
consumers $128,678.00 if it had been necessary for them to buy at retail
prices. Diphtheria antitoxin is now available to rich and poor alike and a
further saving in cost of $7,241.00 has been made. It is impossil)le to esti-mate
the number of lives saved, nor the value to the medical profession and
to the patients of the diagnostic work, but it is a matter of deiBonstration
that the services of the laboratory have extended, during the one year 1918,
to 144.000 different individuals, representing every county and almost every
community in the State.
The plans for the next two years call for the development of the existing
lines of work and the ability to seize any new opportunity that may occur.
For instance, it is hoped that out of the many different vaccines now used
to combat the influenza epidemic some one will be demonstrated as efficient.
If this is the case, the laboratory wants to be in position to make use of it at
once.
Taking into consideration only the deficit that now exists and the most
conservative estimate of the needs of further development, it is necessary
to have an annual appropriation of $25,000.
Respectfully submitted.
C. A. Shore, Director.
WORK OF THE Bl KEAl OF EPIDEMIOLOGY
Cliaracter of Work
OBJECTIVES
To prevent and control the occurrence of whooping cough, measles, diph-theria,
scarlet fever, smallpox, typhoid fever, infantile paralysis, cerebro-spinal
meningitis, and ophthalmia neonatorum (sore eyes in the new-born).
METHODS
Section 1—The County Unit
1. A quarantine officer for each county in the State has been secured and
placed in charge of the quarantine work of the county, under the super-vision
of the Bureau of Epidemiology. His duties are as follows:
(a) To secure reports from parents and physicians of all cases of com-municable
diseases.
{h) To keep an accurate record in his office of all reports.
(c) To transmit all reports daily to the Bureau of Epidemiology.
id) 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.
(e) To inform the teachers in the community where the disease exists
that the disease is present, and to supply them with rules and regulations
governing the school while the disease is present, and with pamphlets de-scriptive
of the disease, its dangers, cause, mode of infection, and methods
of control, to be distributed through the children to the parents represented
in the school.
(/) To make the presence and locations of diseases known to the public
by publishing monthly in the county paper the names and addresses of all
cases reported during the month. This calls the attention of the public to
any cases not reported.
((j) To investigate all cases of suspected contagions which have not been
reported, to determine the nature of the disease.
{h) To secure, at the beginning of each school in the county, a disease
census* of the school children. This record is to be kept on file in his office
for a reference guide to determine what action is necessary to protect the
school from a disease when it occurs in the school community.
(i) To enforce the laws, rules, and regulations governing the control of
communicable diseases.
(i) To make monthly reports to the Bureau of Epidemiology of all the
work, educational, administrative, or otherwise, done during the month.
The pay of a quarantine officer depends upon satisfactory work, as detei--
mined by the monthly report.
Section 2—The State Unit
1. The daily reports of each of the communicable diseases are recorded by
the Bureau of Epidemiology by the counties, townships, and municipalities
in which they occur. These are permanent records of the Bureau, and they
show the number, location, and increase or decrease in the number of cases
of each disease from month to month and from year to year. The reports of
cases are also temporarily recorded, geographically, on maps with colored
*By disease census is meant a census of the school children showing the number immune to
certain diseases by previous attacks.
42 XoRTH Cakolixa Board of Health
tacks. A separate map of the State is used foi* each disease, and the tacks
are inserted in the towns or townships where the cases exist. These maps
show the number and distribution of cases, the rate of development, and the
direction of travel of each disease. Epidemics in the developmental stage
are detected by watching the daily reports and pin maps, and when one is
discovered or anticipated a systematic campaign is instituted to stop it.
Epidemics are handled in the following way:
(a) The people in the community are notified by handbills of the presence
of the disease and are given instructions how to prevent the development of
further cases.
(&) A history of each case is solicited so as to show the relation of the
case to the usual sources of infection.
(c) In epidemics of typhoid fever, diphtheria, or smallpox, arrangements
are made for having the susceptible people of the community protected
against the disease by vaccination. The people are notified of such arrange-ments
and are encouraged to avail themselves of the opportunity.
(d) An investigation of the sanitary and hygienic conditions in the im-mediate
vicinity of each case is made.
(e) The facts in the history of the cases and the findings of the sanitary
and hygienic conditions are tabulated according to epidemiological methods,
so that the exact sources of infection are determined.
(/) Recommendations of the necessary measures for the control and pre-vention
of the disease are made to the proper authorities.
(g) When the nature of the disease is such that public gatherings are per-missible,
a public meeting is held to advise the public as to the modes of in-fection,
dangers, and measures necessary for the control of the disease, for
it is through the cooperation of the public that diseases are controlled.
(7i) State-wide publicity is given epidemics, to warn the people of the
presence of the disease, to force the local authorities to take action to stop
its spread, and to educate the people in disease prevention.
(i) Twenty epidemics were investigated and assistance given in the sup-pression
of the disease. The value of this work can not be estimated, but
we feel assured that many cases of disease and many deaths have been pre-vented.
Safe water was secured for one town; a sewerage system assured
at another, and a safe water supply assured at another. Hundreds of people
have been vaccinated.
2. Weekly telegraphic and monthly written reports of all cases of infectious
and contagious diseases reported to the Bureau of Epidemiology are made to
the Surgeon General, United States Public Health Service, Washington, D. C.
These reports have been made since June, 1918. when the appointments of
the State Epidemiologist as Collaborating Epidemiologist and of the county
and city quarantine officers as Assistant Collaborating Epidemiologists were
secured.
3. All deaths from the reportable diseases reported to the Bureau of Vital
Statistics are checked against the reports of cases, to see if the cases which
resulted in death were reported. If not, then proper action is taken against
the person failing to report.
4. All report cards, blank forms, educational posters, placards and litera-ture
on the reportable diseases, and all rules and regulations governing the
control of the diseases, are prepared by the Secretary and the Epidemiologist
of the State Board of Health, and distributed to the various quarantine offi-cers
by the Bureau of Epidemiology. Seventy blank forms, pamphlets, rules,
posters, placards, etc., have been prepared and distributed.
5. The one per cent (IVc) silver nitrate solution used as a prophylactic
against sore eyes in the new-born is supplied to all physicians and midwives
Seventeenth Biennial Report 43
of the State free of charge, with instructions as to its use, and blank re-quest
cards are furnished for ordering more of the prophylactic when it is
needed.
6. Investigations of counties are made from time to time by trained in-spectors,
to determine:
(a) If the county quarantine officer is doing his duty. His records are
examined, and he is questioned as to his knowledge of quarantine work.
Several cases recently reported are visited to see if proper literature has
been supplied to the family and if quarantine was established. These in-vestigations
brought trained inspectors in contact with fifty-five county
quarantine officers, who were given personal instruction in quarantine work
and support in furthering the quarantine measures. Through this intimate
contact with the quarantine officers much interest in the work has been
created among them, with good results.
(b) If the physicians are reporting promptly all cases. The physicians
who have reported but few cases recently are visited to ascertain if they
have treated any cases which they have not reported.
(c) Special efforts are made to learn of unreported cases. These are
visited to ascertain the nature of the disease and why they were not re-ported.
The person found responsible for neglecting to make the report
is dealt with according to law. These investigations, together with the
investigations of the deaths of unreported cases, have been responsible for
seventy-seven indictments of physicians and others, with seventy-four con-victions.
(d) The findings in the investigations of counties have been prepared, sub-mitted
to the editors, and published in the county papers. These publications
give the people an opportunity to know what is going on in the county in
disease prevention, and often they inspire some conscientious person to in-form
us of unreported cases which need to be dealt with.
7. Twenty-three public talks on the communicable diseases, their spread
and control, have been given with an attendance of 1,638 people.
RESULTS OBTAINED
Result 1. In 1918, 29,787 cases of communicable diseases were reported to,
and received the official attention of the Bureau. The households in which
these diseases existed were quarantined, placarded, and instructed (a) as to
the danger of the disease to the patient, and the methods for lessening its
danger; (&) the danger of the disease to other members of the family, and
the means for preventing their infection; (c) the danger of the disease to
the community, and the measures by which the household might protect
the community. As a further measure, 3,598 school populations, in which
communicable diseases appeared, were notified of the occurrence of the dis-ease,
and the teachers were furnished with popular pamphlets for distribu-tion,
through the children of the school, to the homes in the community,
notifying the community of the appearance of the disease, its danger, its
method of infection, and the means for avoiding contracting it. The total
number of homes thus warned and informed was approximately 65,000. That
there would have been thousands of cases of contagious diseases in addi-tion
to the number that actually occurred had not the foregoing method
of prevention been carried out, is beyond a reasonable doubt.
Result 2. The prevention of typhoid fever is an epidemiological proced-ure,
and, therefore, the reduction in this disease, which has been associated
wath a vigorous campaign against it, while extending over a period of five
years antedating the establishment of the Bureau, should be accounted for
44 A'oKTH Cakolixa Board of Health
under the work of this Bureau. The reductions in the deaths and cases from
typhoid fever in North Carolina for the last five years (we have no record
of cases and deaths prior to this period) are as follows;
1914. Deaths 839. Cases 8,390
1915. Deaths 744. Cases 7,440
1916. Deaths 700. Cases 7,000
. 1917. Deaths 628. Cases 6,280
1918. Deaths 502. Cases 5,020
It will be observed that there has been a decrease in this flve-year period
of 337 deaths and 3,370 cases.
Typhoid fever occurs among adults usually at the most active period of life,
at a time when economists estimate life to be worth $4,000 per capita. This
estimate applied to the 337 lives saved each year means a saving of $1,348,000
to the State of North Carolina. This is not all. To prevent 337 deaths from
typhoid fever, it was necessary to prevent ten times as many cases, as the
average fatality from typhoid is 10 per cent; therefore, in addition to 337
lives saved, there were 3,370 persons prevented from having a disease which
lasts an average of six weeks and which costs, estimating the value of the
time lost from sickness, the cost of nurses, the cost of drugs, and the amount
paid physicians, about $200 per case. The prevention, then, of 3,370 cases
at $200 each means an additional saving to the State of $674,000.
Result 3. The Kureau of Epidemiology has supplied silver nitrate to all
physicians and midwives of the State in order that they might comply with
the law requiring that this remedy for the prevention of gonorrheal blindness
in the new-born be applied at birth to the eyes of all babies. While the law
is still new and as yet imperfectly complied with, it is a conservative estimate
to assume that the prophylactic has been used in half of the births, that, is
40,000.
The records of the Blind Institute indicate that before the passage of this
law there had been a minimum of 12^^ cases of blindness from gonorrheal
ophthalmia for every 10,000 births. It is known that this prophylactic solution
applied to the eyes of the new-born will prevent at least 80 per cent of blind-ness
in those that would otherwise become infected and lose their sight. On
this estimate, the Bureau is entitled to claim the prevention of 48 cases of
blindness; but in order that we may be too conservative rather than claim
too much, let us assume that we prevented only 20 cases of blindness in North
Carolina last year. Ten of the 20 blind will die before they reach an age
when they become an expense to the State as well as to the parents. This
leaves ten dependents, which cost the State to make them independent, self-supporting,
$185 a year at the Blind Institute for ten years, or $1,850 for each
case of blindness, or, for the ten, a total cost of $18,500.
Result Jf. In 1918, the Bureau made 154 sanitary inspections of hotels,
59 inspections of jails, 34 inspections of convict camps, and 15 inspections of
State institutions—a total of 262 inspections. These institutions were
marked by a score-card method, and the results of the inspection pub-lished
in the newspapers and the Bulletin with the result that there has
been considerable sanitary improvement in the conduct of hotels, county
and State institutions, greater comfort and greater safety to the traveling
public and inmates of the institutions.
Result ). The Bureau, through an arrangement with the Federal Gov-ernment,
secured the appointment ' of all quarantine officers as Federal
Seventeenth Biennial Report 45
officers without pay, except the nominal $1 per j'ear required by Congress.
Through this arrangement, the quarantine work of the State and the coun-ties
may be done without the use of postage, under the frank. The postage
thus saved the State and the counties amounts to not less than $5,000 a
year.
Result 6. The Bureau secured, through certain cooperation rendered the
United States Army, 30,000 doses of typhoid vaccine in the form of what is
known as lipo-vaccine—a vaccine used in the Army and Navy with which one
instead of three hypodermic injections produces an immunity. The value of
the 30,000 doses, and the expense saved for administration^ two-thirds of the
treatment being unnecessary, may be estimated at a saving of at least
$5,000.
OFFICE ROUTINE
The following tabular estimate for the years 1917 and 1918, based upon
seventeen monthly reports, shows the routine work of the Bureau:
Letters received 2,792
Letters written : Individual 2,349
:\Iultigraphed 37,933
Total 40,282
Post cards received (replies to typhoid letters), 5 months 487
Packages of supplies sent out 4,590
Packages of silver nitrate sent out 11,400
Lectures prepared 3
Press articles prepared 8
Forms prepared (for records and reports, placards, pamphlets) 70
Cases of communicable diseases reported and recorded 36,662
Cases of ophthalmia neonatorum reported and recorded 15
Cases of influenza reported and recorded. 3 months (approximate) . . . .109,419
FIELD WORK
Trips made 66
Quarantine officers visited 121
Counties investigated 55
Reports published 6
Epidemics investigated 20
Addresses delivered 24
Total audience 1,663
Prosecutions 77
Convictions 74
Inspections : Jails 59
Convict camps 34
Hotels 156
State institutions 16
Total 265
IXFLUEXZA RELIEF WORK
Counties visited 11
Communities visited 19
Corps of relief workers organized 9
quarantine officers' REPORTS
(16 months)
Reports made 1.288
Homes visited 6,688
Schools notified of diseases 5.013
Public notices posted (smallpox) 1,922
School diseases censuses returned by teachers 9,873
Indictments 45
Publications 1,884
46 ISToRTH Carolina Board of Health
AVERAGE MONTHLY ROUTINE WORK, 1917-1918
Letters received 164
Letters written : Individual 138
Multigraphed 2,231
Total 2.369
Postcards received (replies to typhoid letters) 97
Packages of supplies sent out 270
Packages of silver nitrate sent out 671
Lectures prepared 3/17
Press articles prepared 8/17
Forms prepared (for records and reports, placards, pamphlets) 4
Cases of communicable diseases reported and recorded 2,157
Cases of ophthalmia neonatorum reported and recorded 1
Cases of influenza reported and recorded (approximate) 36,473
FIELD WORK
Trips made 4
Quarantine ofl^cers visited 7
Counties investigated 3
Reports published 6/17
Epidemics investigated 1
Addresses delivered 1
Total audience 98
Prosecutions 5
Convictions 4
Inspections : Jails 4
Convict camps 2
Hotels 9
State institutions 1
Total 16
QUARANTINE OFFICERS' REPORTS
Reports made 81
Homes visited 418
Schools notified of diseases 313
Public notices posted (smallpox) 120
School disease censuses returned by teachers 617
Indictments 3
Publications 118
WORK OF THE BUREAU OF VITAL STATISTICS
Character of Work
OBJECTIVE
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 num-ber
of illegitimate births; (e) the number of stillbirths; (/) all of the afore-going
data as to births with respect to each county, town 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 other states, and other countries. Such information is necessary in
forming conclusions as to vital conditions in North Carolina and in the en-actment
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 in North Carolina; (c) the number of deaths, by races and the
death rates by races in North Carolina; (d) the number of deaths among in-fants
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
number of deaths from the more important causes of death; that is to say,
the number of deaths from typhoid fever, from tuberculosis, diphtheria, in-fantile
diarrheas, etc., amounting altogether to a classification of about forty
separate causes of death; (/) all of the aforegoing data classified according
to county, town and city. This information is absolutely necessary to under-stand
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 1 and 2. information necessary for the public welfare, and avail-able
under the operation of the vital statistics law, has been briefly indi-cated.
But the vital statistics law not only supplies information to legisla-tures.
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 invaluable;
also, in matters of proving age where the fact of age is in question, as for
voting, as for the right to marry, as for the right to enter certain indus-tries,
to enter school, or as to liability for military service, etc.
METHODS
The Bureau of Vital Statistics secures the birth and death certificates for
the birth and deaths occurring in North Carolina through approximately
fourteen hundred local registrars, appointed by the chairmen 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 chapter 109, section 22. Public
Laws of 1913. The county pays the local registrars 2.5 cents for each birth
and death certificate furnished by them to the office of the State Registrar
at Raleigh. The vital statistics law makes it the duty of the doctors and
48 XoRTir rARoi,i]\rA Board of Health
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 filing the death certificate.
The birth and death certificates filed with the local registrars of the State
are sent to the State Registrar on the fifth of the month succeeding the
month in which the birth or death occurred. The certificates received in
the office of the State Registrar are examined, and, if incorrect or incom-plete
(as a large per cent of them are) effort is made to secure the infor-mation
necessary to complete them. The certificates are then classified and
tabulated according to county 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 objective.
ROUTINE WORK OF BtJREAtT
The routine work of the Bureau of Vital Statistics is indicated in the fol-lowing
table:
WORK OF BUREAtr OF VITAL STATISTICS DURING YEARS 1917-1918
Item. wn. 1918.
Letters received 18,273 15,992
Postals received 2,558 909
Undertaker's reports received 6,083 5,839
Local and deputy acceptance papers received 5,655 293
Provisional death certificates received 12 15
Supplemental reports received 2,642 2,354
Violation blanks received 235 179
Letters written: Individual 26,025
Multigraph 24.862
Total letters 50.887
Letters written: Individual 30,577
Multigraph 11,407
Total 41.984
Postal cards sent out 5,286 1,667
Acceptance papers sent out to registrars 1,755 231
Packages supplies sent out 4,658 7,957
Certificates received: Deaths 33,914
Births 77,063
Stillbirths 7.019
Total 117,996
Certificates received: Deaths 42.061
Births 75.764
Stillbirths 6.669
Total 124,494
Indexing: 1017. 1918.
1916. Births (last 9 months) Completed
1917. Births Completed
1917. Deaths Completed
1918. Births 66 2/3%
1918. Deaths 83 1/3%
Miscellaneous tables made 29 44
Tables completed for Biennial Report (1916) Completed
Tables completed for Biennial Report (1917) 4
Cards punched and proof read (1916) Completed
Cards punched and proof-read (1917) Completed
Index cards proof-read, assorted and filed 101,726 59.169
Index cards proof-read and assorted (1916) 52,708
Cards furnished (decedents from tuberculosis) 3,261 2,705
Number convictions secured 13 . 17
Seventeenth Biennial Keport 49
MONTHLY AVERAGE
Letters received 1,428
Postals received 144
Undertakers' reports received 497
Local and deputy acceptance papers received 248
Provisional death certificates received 1
Supplemental reports received 208
Violation blanks received 17
Letters written : Individual 2,358
Multigraph 1,511
Total . 3,869
Postal cards sent out 290
Acceptance papers sent out 83
Packages supplies sent out 526
Certificates received (births, deaths, stillbirths) 10,104
Per cent of indexing of births for entire year completed each month. .
.
10%*
Per cent of indexing of deaths for entire year completed each month. .
8%
Miscellaneous tables made 3
Index cards filed 6,704
Index cards proof-read and assorted 6,704
Cards furnished (decedents from tuberculosis) 249
Number convictions secured 1
Tables for 1916 (Annual Repoi-t) t
Tables for 1917 (Annual Report) t
Cards punched and proof-read for 1916 and 1917 t
RESULTS OBTAINED
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 infor-mation,
vi^ith its vital bearing upon the public health needs of the State and
with the public health accomplishments of the State, is readily and com-pletely
available.
As a mere indication of the practical value of the work of this Bureau,
we may point out the fact that the birth rate of North Carolina is four in
excess of the highest birth rate of any other State in the Union to wit, Michi-gan,
with a birth rate of 28.4, and that the death rate in North Carolina, not-withstanding
the high birth rate, giving us an exceptionally large age
group of tender years with high fatalities, is exceptionally low, the lowest
of any of the old States of the Union, the lowest of any State on the Atlantic
or Gulf Coast. To be brief, the vital records of the State show that North
Carolina is one of the healthiest States in the Union.
Another sample bit of information of great value is the relative birth
rates and death rates of the two races, the white birth rate being 32.2 and
the colored birth rate being 31.1, 1.1 less than the white birth rate, while
on the other hand the white death rate is 11.2 and the colored death rate
is 17.0. Here we see that the white race in North Carolina is making a net
gain of 34,511 citizens a year while the colored race is making a net gain
of only 10,775 citizens per year.
Another sample of information obtained through the Bureau of Vital Sta-tistics
is the record of the State in the decrease of typhoid fever as indicated
*During years 1917 and 1918 percentage of births indexed for 1916, 75 per cent, 1917,
100 per cent, 1918. 66 2-3 per cent, making a monthly average of 10 per cent,
timpossible to estimate amount of work completed per month.
50 iSToRTH Caroli^'a Board of Health
in the following table of deaths and cases of this disease during the last five
years, that is, the five years for which we have had a vital statistics law
with a record of deaths:
1914. Deaths 839. Cases 8,390*
1915. Deaths 744. Cases 7.440
1916. Deaths 700. Cases 7,000
1917. Deaths 628. Cases 6,280
1918. Deaths 502. Cases 5,020
*Estimatecl on known average fatality of 10 cases per 1 death.
WORK OF THE BUREAU OF INFANT HYGIENE
Character of Work
OBJECTIVE
The objective of this Bureau is to take official cognizance of, and to direct
remedial measures of established value to, the appalling death rate in North
Carolina within the first five-year period of life. When we realize that more
than one-third of all deaths that occur in this State are in the first five-year
age group, or, to be exact, that 11,749 out of a total of 34,005 deaths for last
year were under five years of age, we must see the absolute necessity for
some positive action rather than a policy of indifference or inactivity in
this large vital field.
Of the 11,749 deaths, 7.825 are under two years of age and are due to three
principal causes: 3,153 are stillbirths, due, in a large percentage of the cases,
to an abnormal and unnecessary interruption of pregnancy; 2,04G occur in
the first month of life from causes usually grouped under the general term
as congenital debility many cases coming within this group being of a pre-ventable
nature; 2,626 result from diarrheal diseases of infants within the
first two years of life, and 90 per cent of these are either being raised on
artificial food, or have been weaned and, in their second year, are being
adjusted to a diet consisting largely of cow's milk. Of course, the weaning
of a child at about the termination of its first year of life is right, but in
the transition from the milk of the mother to the milk of the cow and other
articles of diet, intelligence in infant feeding counts for much.
A large per cent of the deaths of infants within the first five-year period
of life, and more especially within the first two years, is due to two main
causes: (1) carelessness, and (2) lack of essential information as to the
hygiene of pregnancy and infancy. Prenatal hygiene, or the hygiene of
pregnancy, when understood, even when superficially considered, will have,
as it has had elsewhere, far-reaching influence in preventing the premature
interruption of pregnancy from many causes that are avoidable, and thus
will be reduced the large number of stillbirths and waste of life occurring
annually in this State; moreover, this same knowledge regarding precau-tions
to be taken by pregnant women will have much to do with decreasing
the number of deaths occurring within the first month of life usually cer-tified
to as being due to congenital weakness. An extensive and intensive
educational campaign directed to impressing mothers with the value of breast
feeding as against artificial feading, and with the necessity of a certain
amount of essential information regarding the preparation of artificial food
for infants, will be in North Carolina as it has been in other places coinci-dent
with the decrease in the number of deaths of infants under two years
of age from diarrheal diseases.
METHODS
The methods of the Bureau of Infant Hygiene may be conveniently di-vided
into two classes: (1) those with the State as the unit; (2) those
with the county as the unit.
The methods with the State as the unit consist of securing the names
and addresses of (a) as many pregnant women as possible; (h) of securing
the names and addresses of the mothers of as many artificially fed infants
within the first year of life as possible, and (c) the names and addresses of
52 I^ORTH Carolina Board of Health
mothers with infants in the second year of life who are suffering from diges-tive
disturbances. The methods for obtaining these names and addresses
consist of appeals made to nurses, doctors, women's clubs, philanthropic or-ganizations,
and county health officers, for cooperation and for furnishing
the addresses of mothers—prospective and real—and of invitations extended
generally through the State Board of Health Bulletin and the press of the
State to any mother or pregnant woman who may be interested to the extent
of permitting this Bureau to render any service to her within its power.
With the addresses of possibly interested cases of pregnancy, and of mothers,
this Bureau, by a carefully prepared series of letters (a correspondence
course) and by educational pamphlets, seeks to interest them, to create a
close bond of real sympathy between itself and the women, and to assist
them in every way possible in either the conduct of their pregnancy or care
for their children, or both.
The methods with the county as the unit will be carried out largely
through the use of a nurse specially trained in a knowledge of the hygiene
of pregnancy and of infancy. This nurse will be paid partly by county funds,
partly by State funds, and the prospect is bright for securing a Federal fund
to be used in defraying the cost of the nurse. The nurse will (a) organize
in the county a number of mothers clubs, and will give a regular, well con-sidered
and planned course of instruction to these clubs, endeavoring by this
means to develop to the highest possible degree a general knowledge of the
hygiene of pregnancy and infancy among the women of the county; (6) The
nurse will get in touch with, and will instruct and supervise the work of
the midwives of the county through a county ordinance prohibiting careless
or incompetent midwives from attending a case of labor; (c) The nurse will
encourage the pregnant women of the county, by the assistance she renders
them, to consult with her, to allow her to advise them, and to help them.
The nurse can be of considerable assistance to these women through the
information she can give, through making examinations of urine and re-porting
to their attending physician, and through making examinations of
the pelvis or bony canal to detect, anticipate, prepare for, and avoid the
unnecessary complications of labor; (d) The nurse can keep a tack-map
of a county, the tacks of one color indicating the homes of babies that are
being raised on the bottle, and tacks of another color indicating babies
within their second summer suffering from digestive troubles. She can
make frequent visits to the homes of these children, advising with the moth-ers
and assisting them in taking care of the children. This is, briefly, the
county method that will be carried out under the direction of the Bureau of
Infant Hygiene.
THE ROUTINE WORK OF THE BUREAU
~
Letters received 160
Magazines and bulletins received and reviewed 24
Letters written : Individual 102
Multigraph (6 f