|
small (250x250 max)
medium (500x500 max)
Large
Extra Large
large ( > 500x500)
Full Resolution
|
|
II IP iii'l i Pi ! Cbc LitJcarp of ti^s Clnitiersitp of Jl^ortb Carolina CntJotoeD bp ^^t SDialectic ano pf)ilantl)ropfc ^mttits 1 TWENTY-FIRST BIENNIAL REPORT OF THE NORTH CAROLINA STATE BOARD OF HEALTH JULY 1, 1924 - JUNE 30, 1920 "7 Members of the State Board of Health o Elected by the North Carolina Medical Society Cyrus Thompson, M.D. Term expires 1931 D. A. Stanton, M.D. Term expires 1931 W. S. Rankin, M.D. Term expires 1929 Thomas E. Anderson, M.D. Term expires 1929 Appointed by the Governor Richard H. Lewis, M.D., LL.D. Term expires 1931 E. J. Tucker, D.D.S. Term expires 1931 James P. Stowe, Ph.G. Terms expires 1927 J. Howell Way, M.D. Term expires 1929 A. J. Crowell, M.D. Term expires 1929 Letter of Transmittal Raleigh, N. C, December 1, 1926. His Excellency, A. W. McLean, Governor of North Carolina. My Dear Sir:—Under authority of chapter 118, Article 1, section 7050, Consolidated Statutes of North Carolina, I have the honor to submit the Biennial Report of the State Board of Health for the period July 1, 1924, to June 30, 1926. Very respectfully yours, Chas. O'H. Laughinghouse, Secretary and Treasurer. Preface Ten years ago the experiment was tried of including in the Biennial Report only that information not easily obtain-able from other sources, and of omitting information largely of details and statistics of little general interest. The experiment proved so satisfactory that the same principles have since been followed. In the present report the arrange-ment by fairly independent sub-divisions is continued, so that it is possible to read and understand any part of the report without reading the entire report. An annual report , of the vital statistics records of the State is now being issued. Public Health Work in North Carolina In the seventies Dr. Thomas Fanning Wood, of Wilmington, caught the vision of the possibilities of public health work to North Carolina. How fully he grasped the far-reaching consequences of his idea, how clearly he saw the ever-growing hosts of lives saved as a result of his vision and in-spiration, we shall never know. We do know that the vision never left him, and that under its sway he worked, through the Medical Journal which he edited and through the North Carolina State Medical Society, until his influence reached the people of the State in their General As-sembly of 1877, with the effect that on February 12, 1877, the North Caro-lina State Board of Health was born. Ours was the twelfth State board of health to be established. Without treating the development of the newly-established board with that thoroughness that could be termed history, we think it enough to set down here in chronological order the principal events in the life and growth of the North Carolina State Board of Health. 1877. Board created. Consisted in the beginning of entire State Medical Society. Society acted through a committee. Annual appropri-ation, $100. 1878. First educational pamphlet issued. Subject, "Timely Aid for the Drowned and Suff"ocated." Annual appropriation, $100. 1879. The General Assembly reconstituted the Board of Health. Made it to consist of nine members: six appointed by the Governor, three elected by the State Medical Society. Term of office, five years. Dr. Thomas F. Wood elected first Secretary of the Board, May 21. Other legislative provisions: (1) Chemical examination of water, and (2) organization of county boards of health, composed of all regular practicing physicians and, in addition, the mayor of the county town, the chairman of the board of county commissioners, and the county surveyor. Four educational pamphlets issued. Subjects: "Disinfection, Drainage, Drinking-water, and Disin-fectants;" "Sanitary Engineering;" "Methods of Performing Post-mortem Examinations;" "Limitation and Prevention of Diph-theria." Annual appropriation, $200. 1881. General Assembly passed a law requiring registration of vital statistics at annual tax listing; law ineffective. Annual appro-priation, $200. 1885. General Assembly made county boards of health more efficient; allowed printing privileges not to exceed $250 annually. Annual appropriation, $2,000. 1886. Bulletin made its appearance in April. Pamphlet on "Care Eyes and Ears," by Dr. Richard H. Lewis, printed and distributed. Subse-quent Legislature provided for extra edition of 10,000 copies for general distribution. Annual appropriation, $2,000. 1888. Yellow fever epidemic in Florida and refugees to Western North Carolina demonstrated value of a Board of Health to cope with situation. Annual appropriation, $2,000. 8 North Carolina Board of Health 1892. Dr. Thomas F. Wood, the Secretary of the Board, died August 22. Dr. Richard H. Lewis elected Secretary to succeed Dr. Thomas F. Wood, September 7. Annual appropriation, $2,000. 1893. Legislative provisions: (1) Laws improving the reporting of con-tagious diseases, (2) the protection of school children from epi-demics, (3) protecting the purity of public water supplies, and (4) regulation of common carriers. Legislature provided that Governor appoint five of the nine members of the Board of Health, that the State Medical Society elect four, and that the term of office of the members of the State Board of Health be reduced from five to two years. The $250 printing limit was removed. Pamphlet on quarantine and disinfection was prepared and re-printed by many of the State papers. Annual appropriation, $2,000. 1894. A number of public health conferences were arranged and held in diff"erent towns of the State. Bulletin was increased from a mailing list of 800 to 1,200. Annual appropriation, $2,000. 1895. Dr. Albert Anderson and Dr. W. T. Pate were elected bacteriologists for the board. Annual appropriation, $2,000. 1896. Board passed a resolution requiring chemical and bacteriological examinations of municipal water supplies. Dr. Venable of Chapel Hill, undertook the chemical examination, and Drs. Anderson and Pate the bacteriological examination. Board also directed Mr. John C. Chase, the engineer member, to inspect all municipal water plants in the State. Annual appropriation, $2,000. 1897. General Assembly enacted law requiring county superintendents of health to be elected by county commissioners, and reduced term of office to one year. Annual appropriation, $2,000. 1899. General Assembly improved the laws protecting public water sup-plies. Smallpox prevailed extensively in the State. Dr. Henry F. Long, and later, on Dr. Long's resignation, Dr. Joshua Tayloe were employed to travel over the State, consulting with and advising the local sanitary authorities as to proper means for protecting the public. Annual appropriation, $2,000. 1900. State Board of Agriculture, on request of State Board of Health, agreed to examine samples of v/ater from public water supplies until Board of Health could provide its own examiner. Annual appropriation, $2,000. 1901. State Board of Embalmers, with representatives of State Board of Health, established. County health work placed in the hands of county sanitary committees composed of county commissioners and two physicians which commissioners elected to serve with them. Term of office of county superintendent of health made two years. Annual appropriation, $2,000. 1903. General Assembly enacted law permitting Board of Health to charge $5 for each analysis of a public water supply, this fee to be used in paying Department of Agriculture for services of examiner. Dr. C. W. Stiles, U. S. P. H. S., before the State Medical Society at Hot Springs, called attention to prevalence of hookworm disease in the South. Dr. J. L. Nicholson and Dr. W. S. Rankin, working under State Board of Health during fall Twenty-first Biennial Reiport 9 of 1903 and spring of 1904, showed great prevalence of this disease in North Carolina. Annual appropriation, $2,000. 1904. A stenographer was employed. One hundred and twenty thousand pamphlets on tuberculosis were printed and distributed. There was a renewal and an extension of cooperative work between the Board of Health and the State press, a number of articles dealing with hygienic and sanitary subjects being furnished the papers and published in them. Annual appropriation, $2,000. 1905. General Assembly established State Laboratory of Hygiene; im-posed water tax of $64 on all public water companies; voted $600 annually for support of Laboratory. Small appropriation made it necessary for the Department of Agriculture to continue to assist State Board of Health. Annual appropriation, $2,600. 1906. The North Carolina Association for the Study and Prevention of Tuberculosis was organized. Annual appropriation, $2,600. 1907. Two thousand dollars appropriated for the State Laboratory of Hygiene. Pasteur treatment provided. State Sanatorium for treatment of tuberculosis founded: $15,000 appropriated for permanent improvements and $5,000 for maintenance.. A law requiring the separation of tuberculous prisoners from other prisoners was enacted. Annual appropriation, $4,000. 1908. January 1, Dr. C. A. Shore became Director of State Laboratory of Hygiene. Annual appropriation, $4,000. 1909. General Assembly provided for (1) whole-time State Health Officer; (2) collection of vital statistics of towns having a population of 1,000 or over; (3) that all public water companies file plans and specifications of their plants with the State Board of Health, and that the State Board of Health pass necessary rules and regula-tions for the care of public watersheds and plants and furnish such rules and regulations and other advice to those having charge of public water supplies; (5) that counties provide free diphtheria antitoxin for county indigents, and (6) that the maintenance appropriation for the Sanatorium be increased from $5,000 to $7,500, and an additional $30,000 be granted for perma-nent improvements. Dr. Richard H. Lewis resigned as Secretary of the Board, and Dr. W. S. Rankin was elected as his successor, beginning his official work July 1. Annual appropriation, $10,500. 1910. General effort to interest the people and State organizations in public health work. Bulletin increased from 3,500 edition to 10,500 edition. Addresses on public health work delivered to Conference of County Superintendents of Schools, State Federation of Women's Clubs, State Press Association, and Sanitary Sunday observed in April. Dr. John A. Ferrell elected, February, As-sistant Secretary for Hookworm Eradication; began work under State Board of Health and Rockefeller Sanitary Commission. First effort in the eradication of hookworm disease was to interest school teachers, in the disease and through their assistance ex-amine and treat the children, and thereby reach the community. Three bottled spring waters sold on the market examined, found polluted, and public attention called to the pollution. Annual appropriation, $10,500. 10 North Carolina Board of Health 1911. Legislature established county boards of health to take the place of the county sanitary committees; county board of health com-posed of chairman board of county commissioners, county superin-tendent of schools, mayor of county town, and two physicians selected by the three county officials to serve with them. Legis-lature also abolished quarantine for smallpox and improved the quarantine laws. One thousand dollars annually appropriated to contract with antitoxin manufacturers for State supply of high-grade diphtheria antitoxin, with result that price of antitoxin was cut to one-fourth former price, saving the citizens of the State over $30,000 annually. Bulletin increased from 11,500 copies to 20,000 copies each edition; closer cooperation with press of State developed; regular weekly press articles prepared and sent to papers; increase in numbers of popular pamphlets for distribution. Hookworm work this year largely educational through the school forces and investigative through county dispensaries; thousands of children found infected and treated. Strong sentiment began to make itself felt for better health work by counties, four counties employing whole-time county health officers. Mainte-nance appropriation for State Sanatorium increased to $12,500, with $20,000 voted for permanent improvements. Annual appro-priation, $22,500. 1912. Bulletin increased to 40,000 edition; number of popular pamphlets dealing with different diseases increased; press work improved; educational work of Board along all lines amplified. Secretary of Board of Health called attention of conjoint meeting of State Medical Society and State Board of Health to the relative im-portance of health problems and the bearing of this subject upon the proper apportionment of health funds; instrumental in pass-ing a resolution to the effect that pellagra was an interstate prob-lem, not a State problem, and requesting the Federal Government to deal with pellagra as a Federal problem; resolution responsible, to considerable extent, for successful effort on part of Hon. John M. Faison's securing Congressional appropriation of $45,000 for the study of pellagra by the Federal Government. Hookworm work extended and county funds appropriated to supplement State and Rockefeller Foundation for this work. Annual appropriation, $22,500. 1913. General Assembly passed Model Vital Statistics Law with $10,000 appropriation for its enforcement. County superintendents of health changed to either county physician or county health officer. Educational efforts of Board continued and enlarged. Hookworm work along same line as year before increased in amount. Dr. John A. Ferrell resigned as Assistant Secretary to accept position with the central office of the Rockefeller Sanitary Commission in Washington, D. C. Dr. C. L. Pridgen succeeded Dr. Ferrell. The movement for improved county health work had by this time resulted in ten counties electing whole-time county health officers. The State Sanatorium for Treatment of Tuberculosis turned over by Extra Session of 1913 to the management of State Board of Health. Annual appropriation, $40,500. Twenty-first Biennial Report 11 1914. Preceding work of the Board continued. Board of Health took over management of Sanatorium; started out under many diffi-culties on account of the institution owing many debts and the appropriation being limited. Hookworm work changed to com-munity work directed to the installation of sanitary privies in all homes. Laboratory began to produce and distribute free anti-typhoid vaccine. Dr. C. L. Pridgen resigned as Director Hook-worm Eradication, and Dr. W. P. Jacocks succeeded him. Annual appropriation, $40,500. 1915. General Assembly makes State vital statistics law conform to National model by requiring burial permits in rural communities; enacts legislation permitting county commissioners and towns and cities to appropriate money for support of tuberculous citizens in State Sanatorium; provides $15,000 for purchase and building of antitoxin plant; appropriates $60,000 for payment of Sanatorium debts and new buildings and other improvements, and $25,000 annually for maintenance and $10,000 for extension anti-tubercu-losis work. Educational work greatly extended: Bulletin now 47,000; traveling public health exhibit shown at fairs and other assemblages; press work greatly developed through employment of journalist for whole time; stock lectures with lantern slides supplied public speakers in different parts of the State; com-munity soil pollution work under Dr. W. P. Jacocks stops in May, and Bureau of County Health Work with Dr. G. M. Cooper at its head, succeeds, beginning work in June. Considerable amount of work done for improvement of prison conditions. The unit system of county health work gets a good start: over 52,000 people given three complete vaccinations against typhoid fever, and medical inspection of schools put on in one county. Annual appropriation, $50,500. 1916. North Carolina was admitted to the Registration Area for deaths. To the educational agencies of the Board was added a self-supporting moving picture health show. Many saw this show during the year, and, seeing, believed in health work as never before. Bulletin had to be discontinued temporarily for lack of printing funds, but before discontinuance reached 51,000 edition. Cooperation with University in developing a plan and putting on a home post-graduate course in medicine, giving first course to 169 doctors. Put into operation an optional system of hotel inspection, with grading and publishing scores. Continued unit system of county health work, giving three anti-typhoid injections to 48,000, making 100,000 immunized in summers of 1915 and 1916. Did complete medical inspection of five counties and with inspection a large amount of educational work as to sanitary and hygienic living. Secured effort by Federal Children's Bureau to develop unit of child hygiene work, the Bureau using two employees to work in Cumberland and Swain counties for about eight months. Laboratory of Hygiene buys land and erects its own building. Sanatorium making a decided impression on the State. Annual appropriation, $55,500. 12 North Carolina Board op Health 1917. The General Assembly passed the following important health legis-lation: Chapter 263, entitled "An act to prevent and control the occurrence of certain infectious diseases in North Carolina;" chapter 244, entitled "An act to provide for the physical ex-amination of the school children of the State at regular inter-vals;" chapter 276, entitled "An act for the cooperative and effective development of rural sanitation;" chapter 257, entitled "An act to prevent blindness in infancy, designating certain powers and duties and otherwise providing for the enforcement of this act;" chapter 66, entitled "An act to provide for the sanitary inspection and conduct of hotels and restaurants;" chap-ter 286, entitled "An act to regulate the treatment, handling and work of prisoners." Following the enactment of this legislation, administrative ma-chinery, consisting of a Bureau of Epidemiology under the direc-tion of Dr. A. McR. Crouch, a Bureau for the Medical Inspection of Schools under the direction of Dr. Geo. M. Cooper, and a Bureau for County Health Work, under the direction of Dr. B. E. Wash-burn, was established. Dr. Washburn, an officer of the Inter-national Health Board, was loaned to the State without cost and the International Health Board, in addition to furnishing Dr. Washburn, appropriated $15,000 annually for rural sanitation in accordance with the provisions of chapter 276. The United States Public Health Service in February, 1917, de-tailed Dr. K. E. Miller to study county health work in different sections of the country and to establish for demonstration pur-poses, in Edgecombe County, department of health on an economic basis easily within the financial reach of the average county. The State Laboratory of Hygiene moved into its own building January 15, 1917. The State was admitted to the registration area of the Union for births in January, 1917, the Bureau of the Census having found after investigation that our birth registration was 96 per cent, complete. The special campaign against typhoid fever begun so satis-factorily in 1915, was continued. Free vaccination of the people, however, was interferred with by the difficulty in securing medical officers to do the work, the preparedness program of the Govern-ment having caused many physicians and nurses to enter the Army and Navy; nevertheless, a total of 30,000 citizens of the State were vaccinated as a direct result of the Board's activities, and many thousands of others were vaccinated by the physicians of the State as a result of the educational work of the Board directed to impressing the people with the value of vaccination as a means of prevention for typhoid fever. In December, 1917, life extension work as developed by the Life Extension Institute of New York, which consisted briefly of the free physical examination of interested citizens for the pur-pose of advising them as to their physical condition and needed hygienic reform and medical treatment, was begun on a county basis. The funds necessary for this work were appropriated Twenty-first Biennial Report 13 partly by the State and partly by the counties in which the life extension work was carried out. Dr. Amzi J. Ellington, who at the time was a resident physician in the New York City Hospital and who had during his residency in that institution studied the methods of the Life Extension Institute under Dr. Eugene Lyman Fisk, was employed and placed in charge of the work. Life ex-tension work was carried out in Vance, Alamance, Lenoir and Robeson counties, and resulted in the full physical examination of 4,000 citizens. This work was very favorably received, and the outlook for its continued development seemed excellent when, with the declaration of war and the call for physicians to enter the military service of the country, Dr. Ellington enlisted in the Medical Corps of the Army. For this reason, and for the further reason that it has been almost impossible to secure health officers during the past two years, the work was not resumed. The educational work of the State Board of Health consisted in the issuance of eight Bulletins, each monthly edition amount-ing to 45,000, and a daily newspaper health article. The Bureau continued its moving picture show exhibit and, in addition, pre-pared probably the best three-dimension educational exhibit in the United States. In 1917 the following exhibits were given: motion picture entertainments, 236; traveling public health ex-hibits, 32; special exhibits, 58; stereopticon entertainments, 3 — to a total of 95,000 people. Arrangements were made for the preparation of newspaper plate, which was sent to- and extensively used by 202 papers having a total circulation of 303,000. A large part of this newspaper material was prepared by the well-known authority and publicist in matters of sanitary and hygienic education, Dr. W. A. Brady, of Elmira, New York. The annual appropriation for the State Board of Health was $60,772.16. The annual appropriation for the State Laboratory of Hygiene was $12,500, and this, in addition to $9,087.22 in fees permitted under the laws of the State to be paid to the Laboratory for special work, provided the Laboratory with a total annual budget of $21,587.22. 1918. Much of the work this year was influenced by the war and had to do with preparedness. The State Health Officer visited Washing-ton, at the request of the Council of National Defense and as chairman of a committee of State Health Officers, on a number of occasions for conferences with respect to preparedness measures, provisions for the control of venereal diseases, arrange-ments for coordinating the control of infectious diseases in the civilian population with their control in cantonments, and to arrange, if possible, with the Public Health Service and the Surgeon-General of the Army for preserving the personnel of State health departments during the war. The State Health Officer also made a visit to the States of South Carolina, Georgia, Alabama and Florida for the Council of National Defense in order, if possible, to interest the Governor, the State Board of Health, and the State Council of Defense in venereal disease control. 14 North Carolina Board of Health Considerable time was given to assisting Major John W. Long, Medical Aide to the Governor, in the work of organizing the Medical Advisory Boards and in interesting physicians in enter-ing the medical service of the Army and Navy, and, later in the year, in inducing the physicians of the State to become members of the Volunteer Medical Service Corps. Partly as a result of these activities, the Surgeon-General of the Army assigned Major Joseph J. Kinyoun to assist the State Board of Health in the control of communicable diseases, the Board being under no financial obligation for Major Kinyoun's assistance; and as a result of the successful termination of the activities of various interests looking to a more effective control of venereal diseases, the Kahn-Chamberlain Bill passed Congress, and made available to the State of North Carolina, and without condition $23,988.61 for venereal disease work. The Laboratory during this year began the distribution of a high grade of diphtheria anti-toxin. The Bureau of Medical Inspection of Schools developed, and with a degree of success that we may say established, free dental clinics for the public schools of the State. The Bureau also de-veloped to a successful extent an arrangement in the form of adenoid and tonsil clubs for the practical and economic treatment of public school children suffering from these defects. The Bureau of Epidemiology employed two third-year medical students, equipped them with motorcycles, and put them into the field to investigate infringements of the quarantine law. Sufficient convictions were obtained to impress the medical pro-fession with the determination of the State to enforce its health laws, and a fairly satisfactory compliance with the laws regarding the reporting of communicable diseases was brought about. The Bureau of Venereal Diseases, paid for by the Federal appro-priation, was established in September under the directorship of Dr. James A. Keiger, of Charlotte, N. C. Mr. Warren H. Booker, for the last seven years the efficient director of the Bureau of Engineering and Education, left in September for Red Cross work in France, the work of his bureau being continued, with the exception of the engineering work, by Mr. Ronald B. Wilson. As a result of Mr. Booker's leaving, cer-tain funds became available, and a Bureau of Infant Hygiene, under the directorship of Mrs. Kate Brew Vaughan, was organized late in 1918. Perhaps the most outstanding feature of the health work dur-ing the year 1918 was the epidemic of influenza. The epidemic began early in October and caused in October alone 6,056 deaths; in November 2,133 deaths; and in December 1,497 deaths, a total during the last three months of 9,686 deaths. The annual appropriation for the State Board of Health for 1918 was $73,210.38. The annual appropriation for the State Laboratory of Hygiene was $12,500. The Laboratory, during this year, collected $8,532.48 Twenty-first Biennial Report 15 in fees for special work, so that the total income of the Laboratory for this year was $21,032.48. 1919. The General Assembly passed the following important health legis-lation: Chapter 71, entitled "An act to prevent the spread of disease from insanitary privies;" chapter 192, entitled "An act to provide for the physical examination and treatment of the school children of the State at regular intervals;" chapter 206, entitled "An act for the prevention of venereal diseases;" chapter 213, entitled "An act to require the provision of adequate sanitary equipment for public schools;" chapter 214, entitled "An act to obtain reports of persons infected with venereal diseases;" chap-ter 215, entitled "An act for the repression of prostitution;" and chapter 288, entitled "An act to amend chapter 671, Public-Local Laws of 1913, relating to the injunction and abatement of certain nuisances." The Bureau of Engineering and Inspection was organized in April. The engineering work of the Board had been suspended with the resignation of Mr. Warren H. Booker in September, 1918, Mr. Booker having gone to France to engage in tuberculosis work under the direction of the Red Cross. Between September, 1918, and April, 1919, the engineering problems coming before the Board had been referred and very kindly and effectively taken care of by Col. J. L. Ludlow of Winston-Salem. Mr. H. E. Miller, an engineer and a graduate of the University of Michigan, was placed in charge of the new bureau, and his brother. Dr. K. E. Miller, of the United States Public Health Service, was detailed by the Service to assist him in the organization of his work. Mr. H. E. Miller and Dr. K. E. Miller spent the spring and sum-mer and a part of the fall in studying various types of privies, in preparing plans for the construction and maintenance of privies, and in preparing the necessary notices and literature to inform the people of the objects and requirements of the new privy law. On May 1st Dr. A. J. Warren, health officer of Rowan County, was appointed to and accepted the position of Assistant Secretary of the Board. On July 1st Mr. R. B. Wilson accepted the position of Director of Public Health Education. On August 1st Dr. A. McR. Crouch, Director of the Bureau of Epidemiology, resigned to accept a position with the city of Wil-mington. Dr. F. M. Register, whole-time health officer of Northampton County, succeeded Dr. Crouch as director of the bureau. In September Dr. J. R. Gordon, Director of the Bureau of Vital Statistics since 1914, resigned on account of impaired health, and on October 1st the Bureau of Epidemiology and the Bureau of Vital Statistics were combined and placed under the direction of Dr. Register. In September Mrs. Kate Brew Vaughan, Director of the Bureau of Infant Hygiene, resigned. The bureau was reorganized under an understanding with the American Red Cross and was enlarged to include, in addition to infant hygiene, the problem of public 16 North Carolina Board of Health health nursing, the name of the bureau being changed to that of "Bureau of Public Health Nursing and Infant Hygiene." Under the agreement with the Red Cross this bureau was to have an available appropriation of $12,000 a year, half of which was to be furnished by the American Red Cross and half by the State Board of Health. The personnel of the bureau and its plan of work, under the agreement, was made contingent upon the approval of both participating agencies, the American Red Cross and the State Board of Health. In December Miss Rose M. Ehrenfeld took charge of the new bureau and began its organi-zation and work. On October 1st Dr. Jas. A. Keiger, Director of the Bureau of Venereal Diseases, resigned and Dr. Millard Knowlton was appointed to succeed him. The typhoid campaign carried on during the summer through previous years, was continued in the summer of 1919, using third-year medical students, furnished either with automobile or motor-cycle for getting about. Campaigns were carried out in the fol-lowing counties: Bertie, Cabarrus, Chatham, Chowan, Columbus, Craven, Hertford, Iredell, Johnston, Lincoln, Onslow, Pasquotank, Perquimans, Randolph, Richmond, Rockingham, Stanly, Union, Warren, Wayne. A total of 49,076 were given complete vaccinations. The educational work of the Board consisted of the publication of a 48,000 monthly edition of the Bulletin, and the distribution of about 350,000 pieces of public health literature. The funds available during this fiscal year amounted to $198,549.14, of which $102,301.98 was from State appropriations and the remainder from outside sources. The appropriation for the State Laboratory of Hygiene for this year was $28,500; in addition to this, the Laboratory collected in fees for special work, for anti-toxin, and in water taxes a total of $14,344.02, making a total of $42,844.02 available for work of Laboratory. 1920. During this year there was a Special Session of the General As-sembly, lasting twenty days and held in the latter part of August. This Special Session passed an act amending the vital statistics law, making the fees for local registrars 50 cents instead of 25 cents for each certificate properly filed with the State Board of Health. On January 1st Dr. B. E. Washburn, who had had general direction of the cooperative county health work and who had rendered most acceptable service, was recalled by the International Health Board and detailed to take charge of their interests in Jamaica. Dr. K. E. Miller, of the United States Public Health Service, who had been detailed in January, 1917, to organize a model county health department in Edgecombe County and then, in 1919, to assist his brother, Mr. H. E. Miller, in organizing the work of the new Bureau of Engineering and Inspection, to which was assigned the duty of enforcing the State-wide privy act, Twenty-first Biennial Report 17 succeeded Dr. Washburn as Director of the Bureau of County Health Work. In January a cooperative effort with the United States Public Health Service and the International Health Board to demonstrate the possibilities and advantages of the eradication of malaria from certain towns and cities in the eastern part of the State was begun. The terms of cooperation were that the International Health Board and the State Board of Health were to pay one-half of the expenses of the local work and the town or city in which the work was done the other half, the Public Health Service furnishing, as its part, expert supervising personnel. The towns and cities chosen for this work were Goldsboro, Farmville, and Greenville, the budgets for each municipality being, respectively: Goldsboro, $13,670.98; Farmville, $5,000; and Greenville, $9,000, a total investment in this work of $27,670.98. Mr. A. W. Fuchs, Associate Sanitary Engineer, was detailed by the Service to have supervision of the work. In February Dr. A. J. Warren, Assistant Secretary of the State Board of Health, resigned his position in order to accept the appointment of city health officer of Charlotte, N. C. In the winter and spring of 1920, the North Carolina Land-owners Association, under the progressive leadership of Mr. W. A. McGirt, of Wilmington, undertook a very extensive educational campaign against malaria, which was carried on through the public schools of thirty-eight counties in Eastern North Carolina. A series of county and State prizes for the best essay on malaria by public school children were offered as an inducement to the school children to interest and inform themselves, and, indirectly, their parents, with regard to the importance of this disease. To make possible this work by the school children 75,000 malaria catechisms, prepared by Dr. H. R. Carter, of the United States Public Health Service, were distributed through the public schools of the eastern part of the State to the school children. Thousands of essays were written, and it is reasonable to believe that the campaign was one of the most successful public health educational attempts yet undertaken. In June it was found advisable to separate the Bureau of Epi-demiology and the Bureau of Vital Statistics which had, on ac-count of the scarcity of health officers, been placed under the directorship of a single bureau chief. Dr. F. M. Register. Dr. Register was appointed Director of the Bureau of Vital Statistics and Dr. J. S. Mitchener was appointed Director of the Bureau of Epidemiology. In April the Interdepartmental Social Hygiene Board assigned to the State Board of Health several workers for making a study of vice conditions in North Carolina towns and cities and for taking such steps as were found expedient for decreasing prosti-tution. This group of workers was withdrawn in September, on account of differences developing between them and Dr. Knowlton, chief of the Bureau of Venereal Diseases, with the understanding 18 North Carolina Board of Health that another group of workers would be assigned to this work at a later date. In June arrangements were made with the United States Public Health Service and the American Social Hygiene Association for the development of an elaborate educational unit on sex hygiene and venereal diseases designed to reach rural meetings through the use of picture films and a portable truck. An outfit con-sisting of several lectures and a moving picture truck began work in Cumberland County in August, and from its very beginning met a most cordial reception and gave every promise of developing into one of the most useful agencies for dealing with the venereal disease problem. During the year the anti-typhoid vaccination campaign was continued in Alamance, Bladen, Columbus, Duplin, Franklin, Gas-ton, Harnett, and Mecklenburg counties. Cooperative campaigns, in which the counties furnished the working personnel, were also carried on in Anson, Johnston and Rutherford counties. A total of 29,435 citizens have been vaccinated against the disease, and this does not include Columbus County, in which the work was just beginning when this report was completed. The educational work of the State Board of Health during this year consisted of a 48,000 monthly edition of the State Board of Health Bulletin and the distribution of approximately 350,000 pieces of public health literature. The funds available during this fiscal year amounted to $342,- 284.33, of which $176,152.61 was State appropriation and the remainder from outside sources. The appropriation for the State Laboratory of Hygiene for this year was $25,000; in addition to this, the Laboratory collected in fees for special work, for antitoxin and in water taxes, a total of $13,698.89, making a total of $38,698.89 available for the work of the Laboratory. The above amount being insufficient, the Special Session of the Legislature authorized a loan of $15,000 to enable the work of the Laboratory to be carried on, making a total of $53,698.89 available for the work of the Laboratory during this year. 1921. The Legislature meeting early in January of this year was asked by the Board to amend the State law restricting the salary of the executive off"icer of the Board to $3,000 annually, so as to make the salary $5,000. Such an amendment was passed. A further request from the Board was that legislation be enacted removing the inspection tax of forty cents from privies coming under the supervision of the Board of Health. Such an amend-ment to the State-wide Privy Law was also enacted. A bill was introduced in this session of the General Assembly under the initiative of Hon. Emmet H. Bellamy requiring a physical ex-amination of all applicants for marriage and making issuance of license contingent upon the physical qualifications of the appli-cant. The State Board of Health approved and supported Mr. Bellamy's bill, realizing, as did the author of the bill, that the proposed legislation was but a step in the right direction and was. Twenty-first Biennial Report 19 therefore, rather loosely drawn and left many things to be de-sired. The bill finally passed in amended form as chapter 129, Public Laws of 1921. The general health of the State for 1921, as indicated in the vital statistical records for that year, published by the United States Bureau of the Census, was good, and there was an im-provement in reduced death rates for a number of diseases, as well as a reduction in the general death rate over previous years. Another general condition of State-wide importance with a vital bearing on the work of the Board of Health which had to be taken into account was a considerable amount of misunder-standing between respective groups of the medical profession and the Board of Health regarding matters of policy. Many physi-cians, men in good standing professionally and men with high civic ideals, seemed to feel that the Board of Health had no well-considered and reasonable objectives in the field of public health as it is related to that of private practice. This general condition was responsible for the Board of Health seeking and availing itself of opportunities to meet the profession, both in county, district and State societies, and to discuss with the profession what it conceived to be the proper relation between public health activities and professional practice. This subject was presented to and considered by the State Medical Society in its conjoint meeting with the State Board of Health at Pinehurst in April, 1921. See transactions Medical Society of the State of North Carolina, pages 472-506. As a result of these various conferences between representative men engaged in public health work and the profession, the general condition of misunderstanding and some little friction had disappeared to a large extent by the latter part of the year. Nevertheless, the results of contact between those engaged in social medicine and private practice were such as to encourage further conferences and efforts to bring about a fuller recognition of mutual interests on the part of the public and the profession, and the ultimate adoption of a program of relations which would be to the mutual advantage of both parties. Perhaps the most important change inaugurated in State health administration during this year was the adoption of a cost basis for standardizing and measuring the efficiency of public health work in those counties in which the State participated financially. This new principle is fully described in the State Board of Health Bulletin for January, 1922, and a further dis-cussion of cost basis for public health work is unnecessary here except, perhaps, to say that it is apparently at least one of the first attempts to introduce the cost system of industry into government. The Bureau of Venereal Diseases, in charge of Dr. Millard Knowlton, established as a part of the war-time activities of the Board in cooperation with the Bureau of Venereal Diseases of the Federal Government, was combined with and made a part of the work of the Bureau of Epidemiology, under the general direc-tion of Dr. J. S. Mitchener. 20 North Carolina Board of Health Funds available for the year included: State appropriation, $275,000; miscellaneous receipts, $164,184.42; total, $439,184.42. 1922. In order to bring the records of this department into harmony with those of other State departments, in accordance with the act of the General Assembly of 1921, changing the fiscal year of the State so as to begin on July 1st each year, this report ends with June 30, 1922. It, therefoi'e, covers a period of nineteen months; one full fiscal year from December 1, 1920, to November 30, 1921; seven months from December 1, 1921, to June 30, 1922. Effective February 1, the American Red Cross Society abrogated the agree-ment existing since 1919 by which it jointly financed with the Board of Health, the Bureau of Public Health Nursing and Infant Hygiene. This bureau was reorganized April 1 as the Bureau of Maternity and Infancy, for its maintenance the State receiving $27,259.66 annually from the United States Government in ac-cordance with the Sheppard-Towner Act for the promotion of the welfare of mothers and infants. Dr. K. P. B. Bonner of More-head City, was secured as the director of the reorganized Bureau, with Miss Rose M. Ehrenfeld as supervisor of nursing and Mrs. T. W. Bickett in charge of educational work. The funds available during this period, and their distribution, were seven-twelfths of the amounts set out under the tabulation for 1921. The appropriation for the State Laboratory of Hygiene for the nineteen months between December 1, 1920, and June 30, 1922, • was $87,083.33; in addition to this, the Laboratory collected in fees for special work, for anti-toxin, and in water taxes, a total of $30,872.51, making a total of $117,955.84 available for the work of the Laboratory. 1922-23. In order to further develop local responsibility for the protection and promotion of the public health, and to quicken local initiative, a policy of decentralization was adopted by the Board. To carry out this policy there were made several changes in the organi-zation of the Board's executive staff. The Bureau of County Health Work was discontinued. The Bureau of Epidemiology was combined with the Bureau of Vital Statistics. Dr. G. M. Cooper, director of the Bureau of Medical Inspection of Schools, was ap-pointed Assistant Secretary, and Dr. J. S. Mitchener, director of the Bureau of Epidemiology, was transferred to the Bureau of Medical Inspection of Schools. Dr. K. E. Miller, who for four years had been loaned to the Board by the United States Public Health Service, and had directed the work of the Bureau of County Health Work, was recalled for duty elsewhere. The State was divided into four districts with Dr. E. F. Long, Dr. H. A. Taylor, Dr. M. L. Ilsley, and Miss Rose M. Ehrenfeld as district directors. This plan of organization became effective in the early spring of 1923 and was continued through the calendar year. Six vacancies in the membership of the Board occurred during the year, four by expiration of term, and two by resignation. The terms of Dr. J. Howell Way of Waynesville, and Dr. A. J. Crowell of Charlotte, appointed by the Governor, expired, and Twenty-first Biennial Report 21 they were respectively appointed to succeed themselves. The terms of Dr. Charles O'H. Laughinghouse of Greenville, and Dr. Thomas E. Anderson of Statesville, elected by the State Medical Society, expired, and they vi^ere respectively reelected. Mr. Charles E. Waddell of Asheville, appointed by the Governor in 1921, resigned and as his successor the Governor appointed Mr. James P. Stowe of Charlotte. Dr. F. R. Harris resigned to be-come health officer of Vance County, and to fill the unexpired term the Board elected Dr. D. A. Stanton of High Point. Dr. J. Howell Way was reelected president of the Board. The General Assembly of 1923 made provision for the con-stantly growing work of the Board, approving the budget as sub-mitted and appropriating for the Board the sum of $425,000. Legislation enacted included an act to provide for the sanitary manufacture of bedding, to create an independent board of direc-tors for the State Sanatorium, and to provide sanatorium facilities for tuberculosis convicts. The important new development during the year was the begin-ning of malaria control work in certain counties of the coastal plain area of the State. Through the courtesy of the International Health Board a member of its field staff". Dr. H. A. Taylor, was loaned to the Board for the purpose of making preliminary sur-veys, and areas in Lenoir and Pamlico Counties were selected for investigation. The results showed Pamlico County to be suitable for the initial demonstration, and a unit for the investigation and control of malaria was organized with Dr. Taylor as the director, the budget being contributed forty per cent, by the county, forty per cent, by the State, and twenty per cent, by the International Health Board. The progress of the work, and the results achieved, proved so satisfactory that in January, 1923, an additional unit was organized in Beaufort County, and in May Craven and Bladen counties were added to the list. Detailed re-sumes of this work is given elsewhere in this report, but it should be stated here that the success of the intensive malaria control measures has been even greater than was anticipated. While specializing on malaria control measures, the county units have at the same time carried on a general program of public health work. The International Health Board has continued its co-operative aid in giving twenty per cent, of the unit budget, and has continued the loan of Dr. Taylor, who has directed the work. In June the resignation of Dr. J. S. Mitchener as director of the Bureau of Medical Inspection of Schools was accepted, and Dr. Roy C. Mitchell, who had been engaged in special educational field work, was appointed to the vacancy. 1923-24. The Committee on Municipal Health Department Practice of the American Public Health Association requested the Secretary of the Board to become field director for the Committee in making a study of municipal health practices in the United States for the purpose of working out with and for the Committee a basis or set of principles on and through which city health depart-ments could be given classification or grading, and further for 22 North Carolina Board of Health giving such additional time as might be needed in assisting such departments in improving their organization and provision for work. The request was brought before a special meeting of the Executive Committee of the Board, and it directed the Secretary to take advantage of the opportunity oifered to become acquainted intimately and broadly with health administration in the cities of the country, and at the same time continue to exercise general supervision of, and executive control over, the work of the Board. In January the Secretary established official headquarters in New York City for the work of the Committee, and the general organ-ization of the executive staff of the Board was continued with the Assistant Secretary, Dr. G. M. Cooper, as administrative or director. During the period of his absence the Secretary has kept in close touch with the work of the Board through frequent reports and a number of visits to the office for conferences with members of the staff. For the more efficient administration of the field activities of the Board the four districts into which the State has been divided the previous were consolidated into two, with Dr. E. F. Long and Dr. H. A. Taylor as Deputy State Health Officers, as directors, assisted respectively by Dr. C. N. Sisk, formerly health officer of Forsyth County, and Dr. George Collins, formerly health officer of Mecklenburg County. At the annual meeting for the Board in April further steps were taken towards making effective the policy of decentralization adopted the previous year. This policy looks, in a broad way, to the diminishing of State personnel and the use of funds so made available for stimulating and paying county personnel, either whole or part time, to do work which formerly had been in all probability incorporated and carried on by full-time personnel employed by the Board. It was directed by the Board that all machinery and resources of the Bureau of Maternity and Infancy and of the Bureau of Medical Inspection of schools be converted into county machinery and resources, either full-time or part-time, the transformation to be brought about gradually to become effective not later than January 1, 1925. During the year a plan for the more adequate sanitary control of public milk supplies in the State was formulated. The de-velopment of this important new undertaking was assigned to the Bureau of Engineering and Inspection. Mr. Malcolm Lewis, a graduate of Massachusetts Institute of Technology, and with about seven years of experience in public health work, was secured for this particular unit of work. As developed at the present time this service has been largely an advisory one, the various municipalities having at their command the aid of the Board in improving local milk supply conditions. The malaria control campaign in the coastal plain area was enlarged by the addition of organized units in Columbus, Bruns-wick, and Hyde counties, making a total of seven counties in the State specializing on this plan of health work. The cooperative aid of the International Health Board was continued. Twenty-first Biennial Report 23 During the year Dr. Roy C. Mitchell, director of the Bureau of Medical Inspection of Schools, resigned. The work of the Bureau was continued under the supervision of the Assistant Secretary. Dr. M. L. Ilsley and Miss Rose M. Ehrenfeld, both district directors, resigned, and effective with the end of the fiscal year Dr. K. P. B. Bonner, director of the Bureau of Maternity and Infancy, resigned. The appropriation by the General Assembly was $275,000 and $300,000 respectively for the two years of the biennium. For the Laboratory of Hygiene the appropriation was $75,000 annually. The Present Biennium During the period covered by this report the work of the Board was directed by Dr. G. M. Cooper as Acting Secretary. For the first year of the biennium the Secretary and State Health Officer, Dr. W. S. Rankin, was serving as field director of the Committee on Municipal Health De-partment Practices of the American Public Health Association. He was consequently away from the office practically all of the time. In June, 1925, Dr. Rankin resigned to accept the directorship of the Hospital and Orphanage Division of the Duke Foundation. ' The Acting Secretary during the biennium had the aid of the Executive Committee of the Board in frequent meetings. The general plans and policies of the Board were continued. These are set forth in detail under the several divisions. The appropriation to the Board was for 1924-5, $340,000 and for 1925-6, $319,644. For the Laboratory of Higiene the appropriation was $70,000 annually. 24 North Carolina Board of Health THE NORTH CAROLINA STATE BOARD OF HEALTH Its Organization, Problems, Methods of Administration, and Principles of Public Health Work The North Carolina State Board of Health was created by an Act of the General Assembly of 1877. The appropriation for the work of the Board under the original Act was $100 annually. In the forty-seven years of its existence the Board has from time to time had its powers enlarged and its duties increased. For the fiscal year ending June 30, 1925, the appro-priation for the work of the Board was $455,000, exclusive of that made for permanent improvements and maintenance for the State Sanatorium for the treatment of tuberculosis, and the educational work of that institution. The North Carolina State Board of Health consists of the Board proper, composed of nine members, and the executive staff, which varies from time to time. Of the Board proper, five members are appointed by the Governor of the State, and four are elected by the State Medical Society. The term of office is six years, and the terms are so arranged that not more than four vacancies will occur in any one year. The organization of the Board embodies two important administrative principles: First, stability of organization and permanency of policies; second, the partnership of the State and the medical profession in the conservation of human life. The stability of the organization of the Board of Health depends funda-mentally upon the freedom of the Board from political changes brought about by either party or factional changes in the State government. The divorcement of the State Board of Health from politics depends largely upon the manner of selecting the members of the Board. Sudden or marked changes in the personnel of the Board under the present plan of organ-ization are impossible. This is true, first, because the members of the Board of Health are appointed for terms of six years and their terms of service expire, not in the same years, but in different years. The appoint-ment of new members of the Board, is therefore, gradual and not sudden. " In the second place, the personnel of the Board of Health is selected by two parties: one, the Governor, and the other, the State Medical Society. It is far less likely that two parties naming a Board would be dominated by political considerations than where one party names the Board. This division of the appointive and elective power, and this provision for the gradual exercise of that power by two parties guarantee the State Board of Health against the sudden changes of personnel and policy associated with a purely political organization. The State Board of Health is stable; its individual members come and go, but as an organized body it has continuity. This stability and continuity of organization is the responsible factor for the permanency of policies adopted by the Board. Political boards elected or appointed for two or four years are naturally inclined to adopt two- or 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 administra- Twenty-first Biennial Report 25 tion. This is not true of self-perpetuating bodies such as the Board of Health, that, as legally constituted, 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 relation of the medical profession to the work of disease prevention and the conservation of human life. The State recognizes the debt of society to that profession by which nearly all of the experimentation and dis-covery on which disease prevention is based, with the exception of the work of Pasteur, was contributed; the interest of organized medicine in the conservation of human life and the peculiar ability of organized medicine to advise the State as to the methods of disease prevention; and the necessity of securing from the medical profession first information in regard to the occurrence of deaths and their causes, and the appearance of epidemics. The executive staff of the Board consists of the executive officer and the heads of various bureaus or special divisions organized for the more efficient administration of policies and programs adopted by the Board. The executive officer is the Secretary of the BoaM, and State Health Officer. He is elected by the Board for a term of six years. The duties of the office require that this official should be a man with technical train-ing and experience, and, therefore, should be selected on account of his technical rather than of his political qualifications. It is, therefore, right that he should be selected by a specially qualified committee, that is, the State Board of Health, and not be elected in a general election, as would be the case if the office were a political one. The six-year term of office is in accordance with the idea of permanency of policies. The law requires that the Secretary, and State Health Officer, shall be a registered physician in the State, and that he shall not engage in private practice, but devote his time and energy to the work of the Board. The work of the State Board of Health is large and varied, and is, there-fore, apportioned among a number of bureaus, or special divisions, each directed by an administrative head chosen for his special training and ability. These bureaus in the present organization of the Board consist of the following: The State Laboratory of Hygiene, to examine water and diagnostic specimens, and to produce and distribute biological products, vaccines, and sera; the Bureau of Vital Statistics, to secure, correct, tabu-late, and publish information as to distribution and causes of deaths, and as to distribution of births; to secure reports of communicable diseases and epidemics, and direct measures for their control; the Bureau of Medical Inspection of Schools, to develop public interest in the health of school children as it is related to their education, and to stimulate more adequate treatment for their most common defects; the Bureau of County Health Work, to interest county authorities in providing efficient county health departments, and to advise with, correlate, and assist such departments; the Bureau of Maternity and Infancy, to develop a higher degree of public intelligence regarding the importance and the care of the problems of maternity and infancy; the Bureau of Engineering and Inspection, to exercise supervision over the construction and maintenance of public water supplies and sewerage, to inspect and enforce sanitary conditions of privies, jails, public institutions, hotels, etc. The Bureau of Tuberculosis is now administered as the Extension Division of the State Sanatorium for the 26 North Carolina Board of Health treatment of tuberculosis, which is operated under the direction of a special board of directors. The correlation of the work of the several bureaus, to insure a harmoni-ous and efficient administration of the work of the Board, is through the supei'vision and direction of the executive officer of the Board. The division of the executive staff into special bureaus has the advantage of giving individualism to the work of each bureau and thereby creating a laudable pride and a healthy rivalry among the various bureau directors. While each bureau is separate and independent of other bureaus, the work of the entire executive staff is coordinated, the work of the Board being given compactness by the relation of the bureaus to one another through the executive officer of the Board. The administrative heads of the several bureaus, or directors, are selected by the executive officer of the Board, their terms of service being dependent only upon their success or failure in discharging their duties. There are naturally many problems and duties which cannot be assigned to any of the special bureaus, which by their nature must be under the immediate direction of the executive officer. These may be briefly stated as follows: (1) to assume primary responsibility for the enforcement of the more important State health laws; (2) to consider and determine, with the advice and consent of the Board, what should be the more important public health policies of the State; (3) to secure the needed legislation that will make possible the adoption of desirable health policies; (4) to supervise and assist in the execution of established policies. The enforcement of law rests, in a general way and broadly, upon the judicial machinery of the State. On the other hand, it is not only the privilege but the duty of any citizen to see that the violation of any law is brought to the attention of the courts and dealt with. The more thorough understanding of the purposes and the character of the public health laws and the keener appreciation of their importance imposes in a special way upon the executive officer of the State Board of Health the duty of seeing that these particular laws are fully complied with. The duty of considering and formulating for the action of the Board what should be the more important public health policies of the State rests largely with the executive officer of the Board on account of its primary and general responsibility for the development of an effective program of human conservation. After the Board has considered and definitely decided upon a course of action it becomes the duty of the executive officer to bring to the attention of the people generally the need of the course of actio a approved by the Board, and to so inform, interest, and appeal to the public, and reflexively and directly to the General Assembly as to secure legislative approval and provision for the public health policies which have been adopted by the State Board of Health. The efficiency of any agency is conditioned largely upon the personnel who are employed in its activities. The responsibility of finding and securing persons properly qualified by native endowments, training, and experience to direct the special bureaus or divisions entrusted with carry-ing out the established policies of the Board rests largely upon the executive officer. Twenty-first Biennial Report 27 As has been heretofore pointed out, the organization of the executive work of the Board embraces a number of special bureaus which are held responsible for some definite State health policy, and which are so organ-ized as to be independent of each other. Naturally, these bureaus and divisions in the character of their work are closely related and some means of coordinating their activities is necessary. This means, the executive officer supplies. The majority of the calls by letter or person upon the Board for service can be and are referred to the special bureaus of the Board concerned directly with the sort of service called for in the letter or by the visitor. However, there are a number of calls upon the Board for services that are general in character, or not provided for by some special agency. These services necessarily have to be supplied by the executive officer. The interest and support of the people in public health is in proportion to their understanding of the problem. To reach people, therefore, with information as to what the public health needs of the State are and how the Board purposes to meet the needs is, of all the Board's duties, the most fundamental and the most important. Moreover, the educational work of the Board is of a general character, dealing with the interests of all the bureaus or special divisions and, therefore, belongs largely to the executive officer whose interest is not particular but general with respect to all health problems. The duty of receiving, disbursing, and accounting for the public moneys provided for the work of the Board is a duty that rests primarily upon the executive officer because of his primary and general responsibility for the interests of the Board. The methods of work followed depend largely upon the character of the duties which the executive officer seeks to discharge. For this reason it is well in the discussion of methods to relate them to the special duties of the executive officer as above set forth. Investigations as to the violations of the more important health laws of the State and the initiating of prosecutions where violations are found, are carried out largely as a part of the special activities of the Bureaus of Vital Statistics and Engineering and Inspection. These bureaus main-tain a field force of inspectors, which vary in number but average about twelve full-time officers. The responsibility falls upon the executive officer to see that the bureaus fearlessly and without discrimination en-force the important laws entrusted to their execution. The larger work of the executive officer in law enforcement, however, concerns itself with bringing to public attention the principal State health laws and the needs of their careful observance, and in this way building up a public senti-ment favorable to the observance of public health laws and sympathetic with the judicial machinery in imposing penalties upon those who violate them. In determining the public health policies for the State it is necessary: (a) that the executive officer secure information through special and regular reports on the vital statistics of the State, and in this way to be fully cognizant at all times of the vital conditions of the State as shown by the State's birth rate, the State's general death rate, the State's special death rates for certain diseases, the State's death rates by counties, by races, and by seasons; (b) that he secure information, through public 28 North Carolina Board of Health health literature, books and periodicals, as to the more recent develop-ments and discoveries in public health work; (c) that then by keeping in touch through conferences with other State health officers and Federal health officers, be thoroughly conversant with the methods and accomplish-ments of other State departments of health, and that he be alert to those larger interstate movements, especially those related to action by the Federal government, in order that whenever and wherever possible these larger movements may be influenced to the advantage of this State. To secure the necessary measures and appropriations for the develop-ment of the State health policies the people are informed, through bulle-tins, the newspapers, exhibits, and public addresses, as to vital conditions and as to necessary measures and appropriations for favorably influencing the vitality and physical efficiency of North Carolina people. In this way the effort is made to develop a favorable public sentiment for the develop-ment of the more important public health policies. The executive officer further seeks to find and interest certain individuals, qualified by heart and head and position, for influencing, introducing, and supporting in the General Assembly needed legislation. To find and secure, with the available means, a personnel for the bureau, division or agency of the Board that is to be relied upon for carrying into successful execution some special and important public health policy calls for an acquaintance with those who are in touch with men qualified for such positions, and a judgment of men on the part of the executive officer. This judgment of men by which an administrative officer selects his as-sistants is, of course, basic in the success or failure of an administration. In giving assistance to members of the executive staff charged with carrying out certain public health policies the executive officer attempts to keep in close touch with the work of each bureau or division through regular monthly reports, special reports, and conferences from time to time. Consideration for the right amount of assistance—not too much and not too little—is regarded as important. Too much supervision tends to smother individuality; on the other hand, too little supervision not infrequently results in a useless waste of time and funds. The general work of the Board is a matter largely of correspondence and conference. The correspondence is extensive both in volume and variety, and personal callers at the office of the Board require a con-siderable time devoted to conferences. For reaching the people with information on health problems which they need, and which is necessary to secure their interest in and their support of the policies of the Board several means are in use. Primarily there is The Health Bulletin, issued monthly throughout the year, con-sisting of from sixteen to sixty-four pages. This is sent free to any citizen requesting it, and the circulation monthly is now 58,000 copies. In addition there are issued special pamphlets on the more important health problems, information is disseminated through the newspapers by means of specially written articles, and public addresses, often illustrated with either stereopticon slides or motion pictures, are given. The, bookkeeping for all the bureaus or divisions is done in the executive office by means of a system approved by the State Auditor, and all pur-chases are made through one purchasing agent. Twenty-first Biennial Report 29 The State of North Carolina is composed of one hundred counties, of separate and self-governing political entities. In the administration of the public health policies of the State there are certain duties and re-sponsibilities which are recognized as devolving upon the State, through its established agency, the State Board of Health. There are certain other duties and responsibilities which are recognized as devolving upon the county, through its established agency, the County Board of Health. In a democratic government such as North Carolina, where local self-government by the people is firmly established as a basic principle, it is necessary to keep in mind and regard scrupulously these distincCions. The State is rightly held I'esponsible by all other States for the condition of its death rate. In discharging this responsibility two main avenues of service lie open. First, the State should assume those public health activities that can be carried on, practically speaking, only on a State-wide scale and through State administrative machinery. Second, the State should make use of its central position and federated authority to tactfully, progressively, and persistently 'lead, but not drive, the counties to a clearer recognition of their opportunities, privileges, duties, and responsibilities for local health conditions. Without entering into a discussion of the more important State-wide public health activities they may be classified and listed as follows: First, activities of common interest to all the counties and impracticable of county handling, such as: 1. State supervision over communicable diseases, for the reason that infection and contagion do not respect county boundaries. 2. The registration of births and deaths according to a standard system, for the reason that birth rates and death rates as between counties to have comparative value must be established by uniform practices. 3. The protection of the purity of streams from which public water supplies are taken, for the reason that many streams flow through several counties before reaching the one or the ones whose citizens make use of such for domestic purposes. Second, activities which for economic reasons, for rendering unnecessary duplication and multiplication of officials, machinery, and equipment, be-long properly to the State, such as: 1. The preparation, publication, and distribution of educational bulletins, pamphlets, and leaflets needed in public health administration, for the reason that the additional expense necessary for each county to prepare, publish and distribute such material would be alike unnecessary and extravagant. 2. Maintenance of common laboratory facilities by the State for the same reason as that for maintaining central common equipment for the preparation of educational equipment. Third, activities concerned with disease factors of such exceptional im-portance that the State cannot neglect them and at the same time carry the responsibility for a State-wide reduction in death rates, such as: 1. A State policy for dealing with tuberculosis. 2. A State policy for dealing with venereal diseases. 3. A State policy for dealing with the factors of infant mortality. 4. A State policy for dealing with the common defects of school children. 30 North Carolina Board of Health The county can be made to understand that, after the State has gone its full length in dealing with public health conditions by general measures, the county may do much more in a local and more intense manner for the preservation and promotion of its own health conditions—just as the intelligent individual, after both State and county have done all in their power to protect his health, may still do much more for himself than both governments combined. The State through its established agency co-operates on a definite plan in aiding the individual county to assume and efficiently discharge the purely local duties and responsibilities by both personal service and financial help. Through the forty-seven years of its existence the State Board of Health has consistently developed in the scope of its service to the people, and has in proportion grown in scope of organization and in amount of money expended in its work. It began with no paid personnel and an appropriation of $100. Today it has an executive officer with eight as-sistants in charge of special phases of the work, and the necessary addi-tional clerical personnel, having an annual appropriation of $455,000. The outstanding achievements of the Board have been the marked reduction in the general death rate, and the increased vitality of the people through the practical eradication of smallpox, typhoid fever, hookworm disease, and the winning fight being waged against malaria and tuberculosis. For three consecutive years the State has had the highest birth rate in the United States, and at the same time has maintained a death rate lower than that of the country as a whole. Twenty-first Biennial Re^'ort 31 STATE LABORATORY OF HYGIENE The following is a Report of the Work of the State Laboratory of Hygiene Covering the Period July 1, 1924—June 30, 1926 Specimens examined: Malaria 807 Typhoid 2,749 Feces 3,197 Rabies 3,231 Gonococci 2,351 Diphtheria '. 10,683 Sputum 4,132 Cultures for Typhoid 1,701 Urine 634 Pathology 410 Miscellaneous .- 282 Blood Culture 27 Wassermann 78,433 Water 9,004 Total 117,641 Vaccines and .Antitoxins Made and Distributed : Diphtheria Antitoxin (Units) 280,050.000 Pasteur Treatments Supplied 3,582 Doses of Typhoid Vaccine Distributed 1,485,836 Doses of Toxin-Antitoxin Distributed 412,333 Doses of Smallpox Vaccine Distributed 448,261 Number of Schick Tests 162.300 Number of Schick Control Tests 127,750 Number of Ampules of Neo-Arsphenamine Distributed 255,583 Tetanus Antitoxin Distributed (Units) 16,404,000 Pertussis Vaccine Distributed (CC) 63,737 Syringes Scarlet Fever Antitoxin Distributed 129 Autogenous Vaccines 239 No attempt is made, nor can be made, to estimate the value of the preser-vation of life and health which may have been accomplished by the work just outlined, but some of the results can be given a definite and accurate financial value. If there had been no State Laboratory of Hygiene in exist-ence, this work would have cost the citizens of the State the following amounts: 78,433 Wassermann tests @ $ 5.00 $ 392,165.00 9,004 Water examinations @ 5.00 45,020.00 30,204 Other examinations average @ 2.50 75,510.00 1,485,836 Doses of typhoid vaccine @ .50 742,918.00 63,737 Doses of pertussis vaccine @ .50 31,868.50 448,261 Doses of smallpox vaccine @ .15 67,239.65 412,333 Doses of toxin-antitoxin @ .50 206,166.50 3,582 pasteur antirabic treatments @ 25.00 89,550.00 32 North Carolina Board of Health 3,246 Schick tests @ $1.50 $ 4,869.00 2,555 Schick control tests @ 1.50 3,832.50 255,583 Ampules of neo-arsphenamine @ 1.00 255,583.00 Tetanus antitoxin: 9,572 1,500 unit packages @ $3.50 $ 33,502.00 417 5,000 unit packages @ 6.00 2,502.00 36,002.00 Scarlet fever antitoxin: 48 Therapeutic doses @ $6.00 $ 288.00 81 Prophylactic doses @ 3.00 243.00 531.00 Diphetheria antitoxin : 4,901 1,000 unit packages @ $2.00 $ 9,802.00 503 3,000 unit packages @ 3.50 1,760.50 3,264 5,000 unit packages @ 5.00 16,320.00 25,732 10,000 unit packages @ 7.50 192,990.00 220,872.50 Total , $2,172,127.65 Receipts are as follows: Appropriation $141,500.00 Water Tax 20,123.85 Sales Biological Products 38,311.10 Fees 2,893.32 $202,828.27 Twenty-first Biennial Report 33 REPORT FOR THE BUREAU OF VITAL STATISTICS AND DIVISIONS OF EPIDEMIOLOGY AND ' VENEREAL DISEASES Bureau of Vital Statistics Since the biennial report of 1923-1924, there has been taken from the Bureau of Vital Statistics, the distribution of silver nitrate, registration of midwives, and the Bureau of Venereal Diseases. While the Bureau of Vital Statistics and the Bureau of Epidemiology have a separate function, the whole is classified more or less together, especially as to number of letters sent out, and the general routine of office work. Other than this, the activities of each division will be taken up separately. Practically all field work for the Bureau of Vital Statistics and Epidemi-ology is done by the Director. We will first take up the work of the registration of the births and deaths occurring in North Carolina. Character of Work OBJECTIVES The objective of the Bureau of Vital Statistics is to secure a permanent record of the more important facts concerning the birth and death of every citizen of the State of North Carolina, and from such records to prepare card indices and tabular classifications in such manner as to make readily available on inquiry the following information : 1. (a) The total number of births occurring annually in the State: (b) the birth rate of the State, that is, the number of births per thousand of the population; (c) the birth rates by races, white and colored; (d) the number of illegitimate births; (e) the number of stillbirths attended by midwives; (g) the number of white births attended by physicians; (h) the number of white births attended by midwives; (i) the number of colored births attended by physicians; (j) the number of colored births attended by midwives; (k) all of the foregoing data as to births with respect to each county and city. These facts permit of comparisons of one part of the State with another, of the birth rate of the two races, and of the birth rate of this State with that of the other States and other countries. Such information is necessary in forming conclusions as to vital conditions in North Carolina and in the enactment of suitable legislation for dealing with these conditions. 2. (a) The number of deaths occurring in the State of North Carolina annually; (b) the death rate, that is, the number of deaths per thousand of the population;^ (c) the number of deaths, by races, and the death rates by races in North Carolina; (d) the number of deaths among infants and young children as compared with the births, and the total deaths as com-pared with the total births, with net gain in population; (e) the total number of deaths by months and year from each o.f the 209 causes appear-ing in the International List of Causes of Death; (f) the number of deaths according to age and to occupation; (g) the number of deaths according to age and the causes of death; (h) the number of "seasonal" deaths according to months; (i) all of the foregoing data classified according to 34 North Carolina Board of Health 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 one and two, information necessary for the public welfare and available under the operation of the vital statistics law has been briefly indicated. But the vital statistics law not only supplies information to legislatures, state and county commissioners, and other administrative bodies, which is necessary for framing conservation measures for human life, but it also records facts which may at any time become of great value to the individual. In matters of tracing ancestry, birth records are invalu-able; 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 industries, as to entering school, as to liability for military service, etc. METHODS The Bureau of Vital Statistics secures the birth and death certificates for the births and deaths occurring in North Carolina through approxi-mately fourteen hundred and fifty local registrars, appointed by the chair-man of the boards of county commissioners for the various townships and by the mayors for the various incorporated towns and cities of the State. The duties and powers of the local registrars are defined in Consolidated Statutes, section 7113. The county pays the local registrars fifty cents for each birth and death certificate furnished by them to the office of the State Registrar at Raleigh. The vital statistics law makes it the duty of the doctors and midwives in attendance on a birth to file a birth certificate with the local registrar of the district in which the birth occurs and makes the undertaker, or person acting as undertaker, responsible for the filing of the death certificate. The birth and death certificates filed with the local registrars of the State are sent to the Bureau of Vital Statistics on the fifth of the month succeeding the month in which the birth or death occurred. The certificates received in the oflfice of the Bureau of Vital Statistics are examined carefully, and if incorrect or incomplete (as a large per cent of them are) effort is made to secure the information neces-sary to complete them. Every parent of a legitimate child whose birth is reported is sent a card advising them of the date of birth and whether or not name appears on the certificate. This gives the parent an opportunity to send in to the office the name of the child, in case it does not appear on the certificate, or to make such change in name or date of birth necessary to make certificate an accurate record of birth. The certificates are then classified and tabulated according to county, townships and registration districts, according to races, according to age at death, according to cause of death, according to death rates and birth rates, etc., in order to make readily available upon request, the information mentioned under the head-ing of Objective. ROUTINE WORK The routine work in the registration of births and deaths is indicated in the following table. This covers period from July 1, 1924, through June 30, 1926, inclusive. Twenty-first Biennial Report 35 Letters and postals received 35,735 Casket dealers reports received 8,165 Supplementals received 3,630 Name cards received 14,865 Violation blanks received 114 Acceptance papers received - 2,909 Report cards received from local registrars 23 251 Letters written 25,484 Form letters sent 66,926 Postal cards sent 140,300 Packages of supplies sent 13,918 Indexing : Cards made 264,790 Cards proofread 249,915 Cards assorted 232,882 Cards filed 245,332 Credit certificates sent local registrars '. 4,130 Certified copies made 5,506 Tables made 366 Cards punched and proofread 69,023 Transcripts made and proofread 194,423 Cards furnished Dr. McCain, giving information as to deaths fi-om tuberculosis, monthly 5,321 Epidemiology forms made 432 Tabulation of births Number certificates made in triplicate 5 800 Permanent index cards checked 7,285 Sheets written : 16,272 Certificates Received: Births 172,996 Deaths 67,309 Stillbirths 16,678 *Total 256,983 Names checked on Undertakers reports with D. C 14,845 . Nitrate sent 4,786 RESULTS OBTAINED Of course there is always a large per cent of routine work that is impos-sible to put in a report of this kind, and without going into unnecessary detail, it may be said that the objective of this Bureau, as aforestated, has been reached, and that all of the information with its vital bearing upon the public health needs of the State and with the public health accomplish-ments of the State is readily and completely available. As a mere indication of the practicable value of the work of the reg'stra-tion of births and deaths, we may point out the fact that the birth rate of North Carolina is very high, the highest in the United States, and that the death rate in North Carolina, notwithstanding the high birth rate, giving ^This total includes letters and postals received for our other divisions. 36 North Carolina Board op Health us an exceptionally large age group of tender years with high fatalities, is exceptionally low, one of 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. DIVISION OF EPIDEMIOLOGY Character of Work OBJECTIVES To prevent and control the occurrence of whooping cough, measles, diph-theria, scarlet fever, infantile paralysis, cerebro-spinal meningitis, chicken-pox, septic sore throat, German measles, smallpox, typhoid fever, trachoma, syphlis, chancroid, gonorrhea, and ophthalmia neonatorum. METHODS Section 1—The County Unit A quarantine oflficer for each county and city having a separate health department in the State is appointed to be the Bureau's representative in the local field. His duties are as follows: (a) To secure reports from parents, teachers, and physicians of all com-municable diseases. (b) To keep an accurate record in his office of all reports. (c) To transmit all reports daily to the Division. (d) To supply the parent, guardian, or householder, when the disease is reported, with rules and regulations governing that person, with a placard to be posted on the house, and with a pamphlet descriptive of the disease, its dangers, cause, mode of infection, apd 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, and with a pamphlet descriptive of the disease, its dangers, cause, mode of spread, and methods of control, to be distributed through the children to the parents represented in the school. (f) To make the presence and locations of the disease known to the pub-lic by publishing notices in the county paper when the disease appears and advising means of prevention. (g) To furnish householders forms to report diseases in their community which have not been previously reported. (h) To investigate all cases of suspected contagions which have not been reported to determine the nature of the disease. (i) To enforce the laws, rules and regulations governing the control of communicable diseases. (j) To make monthly reports to the Division of Epidemiology of all the work, educational, administrative, or otherwise done during the month. Compiled Monthly Report of County Quarantine Officers July 1, 1924, to June 30, 1926 Cases reported by householder 9,028 Cases reported by nurses and health oflficers 14,192 Cases reported by physicians 39,277 Cases reported by teachers 2,156 Twenty-first Biennial Report 37 Total number of cases reported 64,919 Homes placarded 45,093 Articles published 372 Teachers certificates 3,744 Indictments 173 Section 2—The State Unit To g-ive the reader a fair idea of the work done by this Division, we have grouped the work under the following heads: (1) General office work not included in office work mentioned in report previously; (2) special work for the prevention of typhoid fever; (3) special work for the prevention of diphtheria; (4) special work for the prevention of venereal diseases; (5) special work for the prevention of sore eyes in the newborn. I. Office Work The daily reports of each of the communicable diseases are recorded by the Bureau of Vital Statistics—Epidemiology Division—by the counties 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 year to year. Weekly telegraphic and monthly written reports of all cases of infection and contagious diseases reported are made to the Surgeon-General, United States Public Health Service, Washington, D. C. Charts are kept showing number of deaths and number of cases, by months, from each of the communicable diseases. Monthly reports of the quarantine officers are given a detailed examina-tion by the Director, and where it is deemed necessary, letters are written to the quarantine officer and the county commissioners of the non-perform-ance of duty. All repoi-t cards, blank forms, educational posters, placards and literature on the reportable diseases, and all rules and regulations governing the con-trol of the diseases, are prepared and distributed to the various quarantine officers of the State by this Division. Summary of Office Work Circular letters 157,119 Oaths of office - 32 Bulletins sent 107,452 Packages of supplies sent 1,352 II. Special Work for Prevention of Typhoid Campaigns for giving free treatment to prevent typhoid fever and diph-theria are conducted in different counties of the State. The Division of Epidemiology circularizes the county and furnishes ad-vertising materials to the county for the mailing list made up from the tax books—(The Division makes up mailing list from the records of births in the county, filed with the Bureau of Vital Statistics.) The Division of Epidemiology pays for all clerical help needed in the counties to get out advertising, and pays for newspaper advertisements, etc. Physicians who participate in these campaigns are paid 8^/^ cents a single dose. Physicians make reports to the Division on forms supplied for the 38 North Carolina Board of Health purpose. These are checked and certifications sent to the County Com-missioners. Work for 1924 campaigns was completed in June, 1924, and included in the twentieth biennial report. In 1925, eighteen campaigns were conducted in the following counties: No. Taking County Three Doses 1. Avery 2,537 2. Beaufort - No Report* 3. Chowan - 494 4. Gates .- 1,593 5. Hertford - - 6,490 6. Hoke No Report* 7. Iredell 19,029 8. Lee 2,756 9. McDowell _ 3,652 10. Mitchell 1,219 11. Onslow 1,985 12. Pasquotank .....No report* 13. Scotland 4,189 14. Stokes 4,827 15. Union No report 16. Watauga 4,491 17. Yadkin 7,151 18. Yancey 7,833 Total : 74,460 In May and June, 1926, the following counties were circularized for cam-paigns against typhoid fever: Alamance, Catawba, Chatham, Dare, Forsyth, Lincoln, Martin,. Montgomery, Moore, Person, Randolph, Rocking-ham, Wayne. III. Special Work for the Prevention of Diphtheria Toxin-antitoxin campaigns for the prevention of diphtheria were con-ducted in 1924 and 1925, simultaneously with the typhoid campaigns. Work for campaigns for 1924 was practically completed in 1925. The counties and number taking complete treatments are listed in the follow-ing tables. Children between six months and six years were advised to take the treatment as in this age group seventy-five per cent of our deaths from diphtheria occur and most of the children are susceptible to the disease. No. Taking County Three Doses 1. Avery 265 2. Beaufort No report* 3. Chowan 38 4. Gates 188 5. Hertford 488 *Whole time counties. Twenty-first Biennial Report 39 No. Taking County Three Doses 6. Hoke No report* 7. Iredell 1,758 8. Lee 723 9. McDowell 1,109 10. Mitchell 350 11. Onslow ...: 775 12. Pasquotank No. report* 13. Scotland 561 14. Stokes 1,291 15. Union No report* 16. Watauga 200 17. Yadkin 1,512 18. Yancey 1,002 Total 10,260 Thirteen counties, Alamance, Catawba, Chatham, Dare, Forsyth, Lincoln, Martin, Montgomery, Moore, Person, Randolph, Rockingham, and Wayne were circularized in May and June, 1926, for toxin-antitoxin campaign. IV. Venereal Disease Division Since 1924 the distribution of neo-arsphenamine has been under the State Laboratory of Hygiene. The Federal appropriation for this work has been discontinued, so no education or remedial work has been carried on by this Bureau. However, we receive a large number of letters asking for bulletins, pamphlets and advice. These are all carefully answered and bulletins and pamphlets are mailed to those requesting them. There has been reported to this office the following number of cases of venereal diseases: Gonorrhea 4,683 Syphilis 6,372 Chancroid 358 Balanitis 5 *Whole time counties. 40 North Carolina Board of Health WORK OF THE BUREAU OF MEDICAL INSPECTION 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 each 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 discover the children who have remediable defects, and to have them treated while curable and before the condition becomes chronic. 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 1. Written instructions for teachers have been prepared, covering every phase of medical inspection of school children. Cards for recording the exact history and results of the preliminary physical examination 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 children in the presence of teachers to demonstrate by example the need for the examination, the purpose, and how to do it. 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. Method for Objective 2. 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 sent to the Bureau of Medical Inspection of Schools of the State Board of Health at Raleigh. The Bureau has competent agents, who carefully study and classify these cards into two groups, those representing supposedly normal or supposedly defective children. Immediately following this study, this agent, generally a trained nurse, visits the county and makes a re-examination of all children reported suffering from common defects: (c) Those of the children thought to be greatly in need of medical, surgical or dental service are advised of the fact, together with their parents, but before treatment is finally arranged for, competent medical examination is made; (d) Special arrangements are made for club operations and dental treatment, results of which are described under the head of Results Ob-tained of this department. ROUTINE WORK Articles written—Bulletin, 28; words 15,500 Other publications, 3; words 2,380 Pieces of literature distributed 850,000 Twenty-first Biennial Report 41 FORCE EMPLOYED Director of Bureau, one part-time physician, one full-time field super-visor of dentists, seven full-time dentists, seven full-time trained nurses, six part-time trained nurses, one part-time anesthetist, one part-time truck driver and hospital orderly, one part-time clerk, one part-time stenographer. BUDGET Annual amount allotted fi-om Executive Department $10,000.00 Annual amount allotted from special State funds 50,000.00 Amount received from counties 6,924.00 RESULTS OBTAINED Some of the tangible results of the work of this department may be enumerated as follows: 1. Thi-ough the system of medical inspection organized and maintained by this department for finding defective school children, 60,668 children have received free dental treatment in the public-school clinics during this period, paid for entirely by funds expended through this division of the State Board of Health; 54,130 permanent fillings have been placed, thereby saving that many permanent teeth, which would have been otherwise lost. The economic value of this specific assistance, as well as the educational influence on those children treated, and the more than 9,600 additional children examined by the dentists, but not treated, cannot be worth less than $10 per child treated, or $606,680. The dental clinics were conducted in seventy-two counties. 2. Following up the preliminary examination first made by the teachers and reported on the proper cards, specially trained nurses sent out by this department have re-examined 171,905 school children. These children had been reported by the teachers as possibly suffering from common defects.. Most of them were found to have one or more of the common physical defects, such as decayed teeth and diseased throats. No possible estimate of the immense educational value can be placed on this service to public-school children by teachers and nurses. 3. Tonsil and adenoid clubs have been originated and put into operation by this bureau for the purpose of following the examinations with treatment when needed. This activity has embraced twenty-seven counties in which clinics have been held. A total of 3,714 school children have been operated on in these clinics. The financial equivalent of one of these operations, negotiated through private methods, without considering the far-reaching effect on the whole life of the child of neglecting to have this important operation done, cannot be less than $50. In fact, the operation alone costs more in many places of the State. Thus the total money value of 3,714 successful operations is certainly not less than $185,700. But the most important consideration is that a very small percentage of the children so essentially helped could even have had the opportunity otherwise. 42 North Carolina Board of Health MALARIA CONTROL The Department created for the Investigation and Control of malarial fevers is financed jointly by the State Board of Health and the International Health Board. The main and primary object of the Department is to con-fine its eff'orts to studying the prevalence, geographic distribution of ma-larial fevers, factors responsible for transmission and to suggest to county health departments the most economical means of control. There is a secondary object of perhaps even greater importance which has guided the department in formulating its policies; this is the stimulation of a perma-nent interest and activity in the administration of public health activities whereby disease prevention can be carried on economically and on a large scale by free and generous support of full time county health departments. The department thus created has been instrumental in the organization of two additional county health units, thus making a total of nine county health departments whose duty it is to carry on control measures wherever the disease is prevalent enough to justify the eff"ort and the expenditure of public funds. The policies pertaining to the organization and conduct of the depart-ments undertaking malaria control are determined by the State Board of Health. The details pertaining to county organization has been delegated to a staff member of the International Health Board, who is executive head of the departments and who directs the field activities of the newly created county organizations in the control of the disease. Main Objectives County organizations created by joint funds of the International Health Board, State Board of Health, and counties for the investigation and con-trol of malarial fevers, have the prime objectives in view 1. Geographic distribution of the disease. 2. The incidence of the disease and the extent to which it is a menace to the health and economic efficiency of the people. 3. Factors responsible for transmission and spread. 4. The possibility of controlling the disease within the eco-nomic reach of the people. In order to explain the procedure followed by each county health organi-zation the methods and relation to the objectives as advised by the depart-ment will be considered. Method for Objective One Malaria a Rural Disease: Malaria is essentially a rural disease for the reason that the mosquitoes held responsible for the transmission of the disease are essentially a rural species and any reduction in the incidence of the disease will benefit the rural moi-e than the urban population. The serious loss from the disease is not due to the costs of treatment and deaths, but rather to the loss of efficiency of labor, loss in net crop productions and in the predisposition to other and more fatal diseases. Certain biological facts concerning the malarial mosquitoes explains the rural nature of the disease. While the mosquitoes which have been incrim-inated as the principal vectors of the disease are domestic in their adult habits, they may be considered only partially domestic in their breeding Twenty-first Biennial Report 43 habits as natui-al and permanent collections of surface water are more often selected for bi'eeding areas. The larvae of anopheles will thrive best in natural collections of water, such as, slowly running streams, edges of shallow ponds, barrow pits, and seepage areas. Permanent water collec-tions of this natux'e are common to rural and not to urban districts. The density of anopheles may be said to be in direct proportion to the oppor-tunities offered for propagation. That malaria is essentially a I'ural dis-ease is demonstrated by its disappearance from areas where the land has been drained and brought under cultivation. Since the reduction in the density of malarial mosquitoes is in direct ratio to the reduction in collections of surface water in which the mos-quitoes may breed, the control of the disease through the application of anti-mosquito measui'es in the aquatic stage is biological in scope. Method Used in Determining Prevalence and Geographic Distribution On completion of the organization of the departments, the health officers seek to outline or determine the areas of concentration of the disease in their respective counties, and, in view of the fact that malaria is essentially a rural disease, control measures are confined principally to the rural sec-tion and small villages of the county. The first step of the departments has been to gather data as to the apparent prevalence of the disease in the county by the examination of school children between the ages of 2 and 12 for enlarged spleens, the taking of history indices as to positive or negative malaria, the establishing of blood indices and the securing of mortality statistics from the State Board of Health. From the data elicited during this preliminary survey, the health officer obtains a fairly accurate idea as to the prevalence and distribution of the disease in his respective county. From such records it is naturally shown that certain foci of infection exist in the county and are the only areas requiring immediate control measures. Having established the area or areas where the disease is most prevalent, the department prepares a survey, or spot map, showing each home thereon in relation to permanent collections of water, with special reference to those streams breeding malaria mosquitoes. In areas where anti-mosquito measures are considered feasible, all the collections of water are indicated on the survey map and character indicated as to whether permanent or temporary. The density of mosquitoes in relation to occupied houses is a feature, also of the department. From the data elicited during this sur-vey the health officer is in a position to determine the most feasible and economical measures of control which in the tidewater section consists of a combination of all measures at our command. Examination of Children for Splenomylogy In order to elicit the smaller degree of enlargement and the better to determine the exact degree of enlargement in children, it is necessary to place the child in a recumbent position with the thighs and legs flexed. The examiner sits at the right side of the child with the head of the latter on the examiner's left. The child's clothing or belt is loosened so that the hand of the examiner can be freely placed upon the bare skin, below and above the costal margin on the left side of the abdomen. First the region between the costal margin and the umbilicus and be-tween the umbilicus and pelvis is palpated for the detection of spleenic 44 North Carolina Board of Health MALARIA Twenty-first Biennial Reiport 45 MALARIA 1921 1922 1923 a S. o a. ~ c ^ c (i'^ CI a. ^5 Q (1, 1924 a. 1925 3 14.0 3 3.6 6.8 4.5 9.4 9.5 34.3 47.3 Jones 10,096 3 29.7 Lee 13,713 -. .„... Lenoir 30,604 3 9.8 Lincoln 17,975 Macon 12,994 .... Madison ...20.083 .... Martin 21,297 McDowell ......17,262 Mecklenburg .82,806 Mitchell 11,421 .... Montgomery ..14,607 1 Moore 22,065 1 Nash 42,194 4 New Hanover 41,946 4 Northampton 23,317 8 Onslow 14,792 7 Orange 18,332 .... Pamlico 9,060 8 88.3 Pasquotank ....17,821 3 16.8 Pender 14,788 2 13.5 Perquimans 11,150 4 35.8 Person 19,223 .... Pitt 46,995 8 17.0 Polk 9,016 .... ...... Randolph 31,067 Richmond 26,478 .... Robeson 55,406 1 1.8 Rockingham ... 45,339 .... Rowan 45,072 2 4.4 Rutherford .....31,896 .... ...... Sampson 36,932 2 5.4 Scotland 15,636 .... Stanly 28,591 .... ...... Stokes 20,640 .... . Surry 32,891 .... Swain 13,660 _.. Transylvania .. 9,629 Tyrrell 4,849 1 20.6 Union 36,454 2 5.4 Vance 23,320 .... Wake ._. 76,998 2 2.5 Warren 21,798 1 4.5 Washington ...11,485 4 34.8 Watauga 13,620 .... Wayne 44,867 8 17.8 Wilkes 33,009 .... ..... Wilson 38,134 1 2.6 Yadkin 16,540 Yancey 15,560 10,218 13,921 31,303 18,050 13,065 20,083 21,609 17,594 84,213 11,278 14,607 22,516 42,949 42,830 23,405 14,851 18,623 9,060 17,921 14,788 11,158 19,389 47,945 9,138 31,207 27,085 54,674 46,132 45,745 32,209 37,552 15,660 29,365 20,683 33,175 13,950 9,846 4,849 36,737 23,667 78,226 21,934 11,522 13,477 45,685 33,252 39,014 16,639 15,871 4 39.1 4 12.7 1 4.9 2 9.2 5.9 1 2.3 3 7.0 5 21.3 4 26.9 6 56.2 2 11.1 2 13.5 2 17.9 4 8.3 1 1.8 4 8.7 3 7.9 2 41.2 6 16.3 2 2.5 1 4.5 2 4.3 3 7.6 10,341 14,130 32,003 18,126 13,137 20,083 21,921 17,927 85,620 11,278 14,607 22,967 43,704 43,714 23,493 14,910 18.914 9,060 18,021 14,788 11,166 19,555 48,895 9,261 31,347 27,692 54,674 46,926 46,419 32.522 38,172 15,684 30,139 20,726 33,459 14.240 10,063 4,849 37,020 24,014 79,454 22,070 11,560 13,477 46,503 33,495 39,894 16,738 16,182 5 48.3 3 9.3 2 9.1 5 5.8 1 6.8 1 4.3 3 6.8 6 25.5 3 20.1 12 132.4 1 5.5 2 13.5 2 10.2 3 6.1 2 4.3 1 2.6 1 3.3 1 2.9 1 20.6 1 2.7 3 3.7 1 4.5 8 69.2 7 15.0 10,463 14,338 32,702 18,201 13,208 20,083 22,234 18,259 87,028 11,278 14,607 23,419 44,460 44,599 23,583 14,970 19,206 9,060 18,123 14,788 11,175 19,722 49,846 9,385 31,488 28,299 54,647 47,720 47,093 32,835 38,792 15,708 30,913 20,770 33,743 14,530 10,280 4,849 37,303 24,361 80,682 22,207 11,598 13,477 47,321 33,738 40,744 16,837 16,493 1 9.5 4 17.9 4.2 6.7 4'.2 40.0 55.1 5.5 1 2.0 1 2.1 1 3.2 4 82.4 1.2 60.3 10.5 9.8 10,586 14,546 33,401 18,276 13,280 20,083 22,546 18,591 88,435 11,707 14,607 23,870 45,215 45,483 23,672 15,029 19,498 9,0b0 18,224 14,788 11,183 19,889 50,797 9,508 31,629 28,907 59,018 48,515 47,768 33,149 39,413 15,732 31,688 20,814 34^027 14,820 10,498 4,849 37,586 24,708 81,910 22,344 11,636 13,989 48,139 33,981 41,654 16,936 16,804 3 28.3 3 8.9 1 5.4 1 4.4 1 5.3 1 1.1 2 8.4 5 33.2 1 S.l 2 22.0 1 8.9 8 15.7 2 6.9 1 1.6 1 2.0 2 5.0 2 8.0 1 1.1 6 51.5 5 10.3 4 9.6 Total 2,614,335 172 6.5 2,649,982 177 August 16, 1926. 6.6 2,686,325 151 5.6 2,722,669 123 4.5 2,811,969 123 4.3 46 North Carolina Board of Health enlargement of the greater degree. If the spleen cannot be detected the child is insti'ucted to take a deep breath. The examiner places the tips of the fingers of his right hand on the abdomen just below the costal mar-gin and makes slight but not deep pressure just at the time the child takes a deep breath. If the spleen is enlarged it may be felt as it descends be-ing pushed down by the diaphragm during deep inspiration. Care must be taken not to press too deeply for then the descending margin of the spleen may not be felt. Spleens that are readily palpable or of the higher degrees of enlargement may be detected without the necessity of the child's taking a deep breath. The spleen may be palpated more easily in children between the years of two and twelve than those younger or older. The following classes of spleens are used : 1. Negative on deep inspiration. 2. Palpable on deep inspiration. 3. Palpable on normal inspiration but not one finger's-breadth below the costal margin. 4. One finger's-breadth below the costal margin on normal inspiration. 5. Two finger's-breadth below the costal margin on normal inspiration. 6. Three finger's-breadth belov; the costal margin on normal inspiration. History Index as to Positive or Negative Malaria For this purpose house to house surveys are made and the presence or absence of malaria is recorded for each individual for the two preceding years. Case histories are accepted as positive only when the individual gives a history of repeated periodicity. Parasitic Index As a further means of arriving at a conclusion as to the prevalence of the disease in a county, a parasitic index is established. For this purpose a thick, with a corresponding thin smear is taken from each person, will-ing to have it done. As the smears are taken they are numbered with the ordinary soft lead pencil by writing direct into the dried blood the serial number of the individual, which corresponds to the history index number. Thick smears are examined fifteen minutes and then five minutes before calling negative. Intensive Mosquito Survey The next step toward arriving at a solution of the mosquito problem in places where anti-mosquito measures are thought to be applicable consist in intensive surveys for the breeding places, in the collections of water indicated on the survey map. This is accomplished by one collecting adult mosquitoes from regular collecting stations, second, by collecting Larvae and Pupae and breeding them out. All collections made are classified as to species, character of water from which collected, whether permanent or temporary, and day of collection. Twenty-first Biennial Report 47 Method of Objective Three From the data elicited during the preliminary survey to determine the incidence and geographical distribution of the disease and biological factoi's responsible for transmission. The Health Officers, through the association of the general director, determines w^hat plan of procedure to make in formulating their program of control. Results Accomplished During the Organization Period of the Bureau It is physically impossible, with the present personnel, to resurvey all counties undertaking measures for the investigation and control of malaria fevers, as well as placing the department at a prohibitive cost, I am there-fore giving only one concrete example of what a county organization may expect in the way of reducing the incidence of the disease when the attack is made in an intensive way. Resurvey of South Creek Section BEAUFORT COUNTY South Creek is a small settlement located in the extreme southeastern part of Beaufort County, North Carolina, on an arm of the Pamlico River. The community is situated in a small tongue of land which divides an arm of the river into two branches, called Bond Creek and Muddy Creek. Neither of these creeks is more than a mile in length. From the broad northern point, the tongue gradually widens until at a distance of approxi-mately 1% miles it is a little over a mile wide. The land is quite level, as it is in all this region, and is only a few feet above sea leveh The ground water level is only 6 feet below the surface. Three or four small branches, which cut across the area, drain the excess water into the creeks. If these were kept in good condition, the natural drainage of the land would probably be fairly good. At the time this survey was made, these branches were almost completely dry, owing to long continued drought. Following is given the average precipitation for the past five years in Wenona and New Bern, two towns situated in opposite directions from South Creek, in adjoining counties. No records are kept in Beaufort County. 48 North Carolina Board of Health them out of employment. In 1925, owing to a severe local hailstorm, the farmers lost absolutely their entire crops, and many migrated to other localities. About Vs of the houses are now unoccupied. The present occu-pation of the remaining inhabitants are farming and fishing. The principal crops are corn and cotton, but the boll weevil has invaded this section as well as the rest of the State. Much of the land is cut over timber land, on which nothing is grown. My impression is that not over % the available land is under cultivation, and even this estimate may be high. Past History of Malaria The South Creek section has always been known as a bad malarial region. Accounts of blackwater fever are common, while, according to the inhabitants, every fall saw a visitation of the disease to a majority of the inhabitants. Of more interest than these accounts, are the doctor's reports. Dr. John Bonner, now Health Officer of Beaufort County, for many years lived in Aurora, and did most of the practice of South Creek. His interest in malaria, his principal source of income, led him to keep records of his calls for several years. His records show, that in the years 1920 to 1922, inclusive, there was a large number of calls for malaria every week, especially in September and October. The peak was reached in October, 1922, when in one week, he visited 45 new patients with malaria. In January, 1923, the newly-organized Health Department of Beaufort County, began a vigorous county-wide campaign against malaria. Blood examinations made on about 7,000 inhabitants of the county, showed a general average of 45% positive. In the South Creek section, of 239 white people examined 99, or 42% were positive; 789c were tertian, 20';c aestivo-autumnal, and 1% quartan. In the negro colored school, of 43 children examined, 30 were positive, a rate of 70 9o- During the succeed-ing summer and fall, the people were urged to take quinine according to Bass' treatment. According to my census, 56 people now present took the entire course of treatments, while 12 took part of the course. Some of them have continued taking treatments every year since that time. The county did not distribute the quinine free, but the people had to buy it. At the instance of the Health Officer, all storekeepers in the county agreed to sell it at cost. Immediately its price dropped from $1.50 or more to an average of 80 cents, and sales began to climb. There are three storekeepers in South Creek. They estimate their sales as follows: SALE QUININE IN POUNDS 1922 1923 1926 to date Store No. 1 2 16-18 less than three pounds. Store No. 2 2 15-20 none. Store No. 3 1.5 11-12 about 1 pound. From total sales of approximately five pounds in 1922, the amount rose in 1925 to over 42 pounds from these three stores alone. The price of quinine was somewhat less in Aurora, and it is reasonable to suppose that some quinine was bought in that town. At the same time the sale of chill tonics fell off, and only a little is sold now. If it did nothing else, this campaign certainly popularized the use of quinine. Twenty-first Biennial Report 49 Referring again to Dr. Bonner's records it will be seen that in 1923, at no time did his calls rise above seven per week, even in the season of greatest transmission. In 1924, the highest number seen was 12, in one week in October. Recox'ds for 1925 are not available, but the general im-pression is that there was very little malaria there the past season. This is probably true, especially since it was a year of deficient rainfall. Present Survey The present survey was undertaken during the second week in August, 1926, for the purpose of determining the amount of malaria present, and the opportunities for its transmission, and the reasons for any change that may have occurred. The survey was made by a house-to-house canvass, and the following information was secured: Name, age, sex, race, length of residence in locality, history of acute malaria within past year, type of house and condition of screens, and history of intensive quinine treatment. At the same time, spleen examination was made on all children under 15 years of age, and blood smears were taken from approximately half the people. After the history was concluded, the house was carefully searched for adult mosquitoes. Results of Survey A total of 161 persons were taken in the census, from 41 occupied houses. Seven occupied houses were not taken in the census, since the occupants were not at home when the census was made. Of this number 120 were whites, and 41 negroes. Separation was not made into the sexes, since this was not deemed important. The following gave a history of at least one chill, followed by fever and sweating, since March, 1925. Since the use of quinine is so general, and is taken for almost any ailment, it was difficult to elicit a history of more than three or four chills from anyone. 1925 1926 Mar1ch A2pril J2une4July4Aug.7Sept.2Oct.1Dec.1Marc2h Ma3y Jul1y Aug. Total 30 (Dupl) (Dupl) Whites, 22, Negroes, 8, and equally distributed through all ages. It is quite possible that some of these histories were not malarial. Following are the results of the blood and spleen examinations: Number Spleen Palpable Blood Age Examimd Examined No. % Examined Positive 0-2 5 3 .. - 2-4 10 10 • 6 1 5-9 25 25 4 18 10-14 31 23 3 22 15-19 11 -- ._ 8 20-39 41 -- - 16 40 up 88 -. - 12 161 61 7 11.5% 82 1 50 North Carolina Board of Health All spleens except one were only palpable on inspiration. The one was one finger's-breadth below the costal margin. A spleen rate of 11.5% indicates only a very moderate degree of endemicity. This is borne out by the results of the blood examinations, with only one positive out of 82 examined. It must be remembered, of course, that the malaria curve usually does not begin to rise until the first of August, and that this survey was made in an abnormally dry season as well. Nevertheless, it seems clear that there is only a small amount of malaria present when the survey was made, and that this condition has prevailed for the past few years. Distribution of Positive Cases—(Spleen and Blood) When spotted on the map of the area, it is seen that four of the eight cases are grouped in the center of greatest population, near the point of land, and, at least at the time of the survey, fairly distant from any breeding places for mosquitoes. Two more cases occur in the same point, but somewhat removed from the other four, and these are situated near several large ditches, which at the time of survey were dry. The ditches are not shown in the map. The two remaining cases are scattered. One palpable spleen occurred in a house which is reported to have had several cases of blackwater fever in the past few years. The last case occurred in March, 1926, according to the doctor's report, but the child was not prostrated, and soon recovered. This child is still taking quinine regularly. Length of Residence of Positives All eight positive cases (spleen and blood) have lived in the area all their lives. The one blood positive case was in a boy just three years old, whose mother, when the blood was taken, said she was sure the boy had malaria. We had been giving him small doses of quinine, but had stopped it some time previous to our visit. Comparison of Findings in 192.3 and 1926, in Those People Present Both Years From the original records of the 1923 work, I secured the results of the blood examinations in those people who were still present at the time of the survey in 1926. Following is a summary of the results: 1923 1926 No. Cases Present No. Neg, • Positive Pos. Pos. Both Years Vivax. Falcip. Quart. Spleen Blood 69 32 31 6 2.0 The 1926 figures should not be expressed in percentages, since these people, all of whom were examined in 1923, were not all examined in 1926. There is, however, a marked reduction in the incidence of malaria in these two years. Adult Mosquito Catches At the same time that the census was made, opportunity was taken to look for mosquitoes in the houses. Twenty-two of the total of 41 houses were carefully searched. A total of four anophelines, all quadrimaculatus, were found. Two of these were found in house No. 1, and two in house No. 2. These may have come from a ditch just outside the area which was not searched for larvae. Twenty-first Biennial Report 51 Probable Causes for Decrease in Malaria in the Area While it is impossible to state the exact amount of malaria which used to be present, there seems to be no doubt that formerly the disease was very prevalent. The fact that 45Vo of the people of the county were found with parasites is indicative of this especially during the autumn. It also seems to be true that the incidence of malaria has decreased remarkably in the past three or four years. I shall now take up some of the possible causes of this decrease. 1. Intensive Quinine Treatments in 1923 and Succeeding Years. As already described, examination in 1923 showed 45% of the people with one or more classes of malaria parasites in their blood. The indica-tions are that the intensive treatment was successful. Fifty-six (56) people now present took the full course of treatment prescribed, and 12 others completed part of the course. In addition to the 1923 campaign, in 1924 and again in 1925, blood smears were made from a large number of people in the area, and those positive were urged to take treatment. The fact that quinine sales increased about 10 times in 1923 indicates that a large amount was used. The intensive treatments of 1923 doubtless sterilized the blood of a fairly large percentage of the population that year, and the treatments of the succeeding years did the same thing for a lesser number. Even in the presence of the vector in considerable numbers, this must have had an effect in reducing the transmission. The rainfall of 1923 was only slightly below normal, probably not enough so to influence the amount of anopheles breeding. It is the consensus of opinion that quinine treat-ments was the greatest single factor in reducing malaria in that year, although it alone probably cannot be held responsible for the decrease. Perhaps the greatest good from this campaign, however, was the popularization of quinine in adequate doses for chills. The lessons learned that year have certainly not been forgotten. It is common to find people who are now taking quinine every autumn, because they were taught to do so by the health officials. They also use it whenever they have a chill, instead of chill tonic; and they use it in large enough doses to have a therapeutic effect. 2. Rainfall. The rainfall in 1923 was slightly below normal; that of 1924 fifteen inches above normal, and a slight increase in the amount of malaria prob-ably occurred, but 1925, and 1926 have been years of abnormally low rainfall. At the time of the 1926 survey, all the usual water courses were dry, or practically so. Conditions were distinctly unfavorable for mosquito breeding, and as a consequence the mosquito index was undovibtedly low and hence transmission was perhaps almost nil. It would be interesting to see what effect the late August rains will have on breeding. 3. Drainage. While a drainage district has been formed and is in operation in an adjoining area, the value of the land does not permit such a district to be formed in South Creek. As stated elsewhere, natural drainage is prob-ably good except in a few low-lying areas, and this drainage has been 52 North Carolina Board of Health favored by a few well-placed ditches which have been dug. Once a year these ditches are cleaned out by the farmers, but during all the rest of the year they are not
Click tabs to swap between content that is broken into logical sections.
Title | Biennial report of the North Carolina State Board of Health |
Other Title | Report of the North Carolina State Board of Health. |
Creator | North Carolina. State Board of Health. |
Date | 1924; 1925; 1926 |
Subjects |
North Carolina. State Board of Health--Statistics--Periodicals Public health--North Carolina--Statistics--Periodicals Public Health--North Carolina |
Place | North Carolina, United States |
Time Period | (1900-1929) North Carolina's industrial revolution and World War One |
Description | Report covers two calendar years (13th-18th); (19th) covers Dec. 1, 1920-June 30, 1922; thence each covers July 1-June 30 years.; Printer: 13th (1909/10)-18th (1919/20) by Edwards & Broughton; 19th (1921/22)-20th (1923/24) by Bynum; 21st (1925/26)-<44th (1970/72)> unnamed. |
Publisher | Raleigh :The Board,1911- |
Agency-Current | North Carolina Department of Health and Human Services |
Rights | State Document see http://digital.ncdcr.gov/u?/p249901coll22,63754 |
Physical Characteristics | v. ;24 cm. |
Collection | Health Sciences Library, University of North Carolina at Chapel Hill |
Type | text |
Language | English |
Format | Reports |
Digital Characteristics-A | 7,868 KB; 138 p. |
Series | Biennial report of the North Carolina State Board of Health |
Digital Collection |
Ensuring Democracy through Digital Access, a North Carolina LSTA-funded grant project North Carolina Digital State Documents Collection N.C. Public Health Collection |
Digital Format | application/pdf |
Related Items | Printer: 13th (1909/10)-18th (1919/20) by Edwards & Broughton; 19th (1921/22)-20th (1923/24) by Bynum; 21st (1925/26)-<44th (1970/72)> unnamed. |
Title Replaces | North Carolina. Board of Health../1 |
Audience | All |
Pres File Name-M | pubs_edp_biennialreportboardofhealth19241926.pdf |
Pres Local File Path-M | \Preservation_content\StatePubs\pubs_edp\images_master\ |
Full Text | II IP iii'l i Pi ! Cbc LitJcarp of ti^s Clnitiersitp of Jl^ortb Carolina CntJotoeD bp ^^t SDialectic ano pf)ilantl)ropfc ^mttits 1 TWENTY-FIRST BIENNIAL REPORT OF THE NORTH CAROLINA STATE BOARD OF HEALTH JULY 1, 1924 - JUNE 30, 1920 "7 Members of the State Board of Health o Elected by the North Carolina Medical Society Cyrus Thompson, M.D. Term expires 1931 D. A. Stanton, M.D. Term expires 1931 W. S. Rankin, M.D. Term expires 1929 Thomas E. Anderson, M.D. Term expires 1929 Appointed by the Governor Richard H. Lewis, M.D., LL.D. Term expires 1931 E. J. Tucker, D.D.S. Term expires 1931 James P. Stowe, Ph.G. Terms expires 1927 J. Howell Way, M.D. Term expires 1929 A. J. Crowell, M.D. Term expires 1929 Letter of Transmittal Raleigh, N. C, December 1, 1926. His Excellency, A. W. McLean, Governor of North Carolina. My Dear Sir:—Under authority of chapter 118, Article 1, section 7050, Consolidated Statutes of North Carolina, I have the honor to submit the Biennial Report of the State Board of Health for the period July 1, 1924, to June 30, 1926. Very respectfully yours, Chas. O'H. Laughinghouse, Secretary and Treasurer. Preface Ten years ago the experiment was tried of including in the Biennial Report only that information not easily obtain-able from other sources, and of omitting information largely of details and statistics of little general interest. The experiment proved so satisfactory that the same principles have since been followed. In the present report the arrange-ment by fairly independent sub-divisions is continued, so that it is possible to read and understand any part of the report without reading the entire report. An annual report , of the vital statistics records of the State is now being issued. Public Health Work in North Carolina In the seventies Dr. Thomas Fanning Wood, of Wilmington, caught the vision of the possibilities of public health work to North Carolina. How fully he grasped the far-reaching consequences of his idea, how clearly he saw the ever-growing hosts of lives saved as a result of his vision and in-spiration, we shall never know. We do know that the vision never left him, and that under its sway he worked, through the Medical Journal which he edited and through the North Carolina State Medical Society, until his influence reached the people of the State in their General As-sembly of 1877, with the effect that on February 12, 1877, the North Caro-lina State Board of Health was born. Ours was the twelfth State board of health to be established. Without treating the development of the newly-established board with that thoroughness that could be termed history, we think it enough to set down here in chronological order the principal events in the life and growth of the North Carolina State Board of Health. 1877. Board created. Consisted in the beginning of entire State Medical Society. Society acted through a committee. Annual appropri-ation, $100. 1878. First educational pamphlet issued. Subject, "Timely Aid for the Drowned and Suff"ocated." Annual appropriation, $100. 1879. The General Assembly reconstituted the Board of Health. Made it to consist of nine members: six appointed by the Governor, three elected by the State Medical Society. Term of office, five years. Dr. Thomas F. Wood elected first Secretary of the Board, May 21. Other legislative provisions: (1) Chemical examination of water, and (2) organization of county boards of health, composed of all regular practicing physicians and, in addition, the mayor of the county town, the chairman of the board of county commissioners, and the county surveyor. Four educational pamphlets issued. Subjects: "Disinfection, Drainage, Drinking-water, and Disin-fectants;" "Sanitary Engineering;" "Methods of Performing Post-mortem Examinations;" "Limitation and Prevention of Diph-theria." Annual appropriation, $200. 1881. General Assembly passed a law requiring registration of vital statistics at annual tax listing; law ineffective. Annual appro-priation, $200. 1885. General Assembly made county boards of health more efficient; allowed printing privileges not to exceed $250 annually. Annual appropriation, $2,000. 1886. Bulletin made its appearance in April. Pamphlet on "Care Eyes and Ears," by Dr. Richard H. Lewis, printed and distributed. Subse-quent Legislature provided for extra edition of 10,000 copies for general distribution. Annual appropriation, $2,000. 1888. Yellow fever epidemic in Florida and refugees to Western North Carolina demonstrated value of a Board of Health to cope with situation. Annual appropriation, $2,000. 8 North Carolina Board of Health 1892. Dr. Thomas F. Wood, the Secretary of the Board, died August 22. Dr. Richard H. Lewis elected Secretary to succeed Dr. Thomas F. Wood, September 7. Annual appropriation, $2,000. 1893. Legislative provisions: (1) Laws improving the reporting of con-tagious diseases, (2) the protection of school children from epi-demics, (3) protecting the purity of public water supplies, and (4) regulation of common carriers. Legislature provided that Governor appoint five of the nine members of the Board of Health, that the State Medical Society elect four, and that the term of office of the members of the State Board of Health be reduced from five to two years. The $250 printing limit was removed. Pamphlet on quarantine and disinfection was prepared and re-printed by many of the State papers. Annual appropriation, $2,000. 1894. A number of public health conferences were arranged and held in diff"erent towns of the State. Bulletin was increased from a mailing list of 800 to 1,200. Annual appropriation, $2,000. 1895. Dr. Albert Anderson and Dr. W. T. Pate were elected bacteriologists for the board. Annual appropriation, $2,000. 1896. Board passed a resolution requiring chemical and bacteriological examinations of municipal water supplies. Dr. Venable of Chapel Hill, undertook the chemical examination, and Drs. Anderson and Pate the bacteriological examination. Board also directed Mr. John C. Chase, the engineer member, to inspect all municipal water plants in the State. Annual appropriation, $2,000. 1897. General Assembly enacted law requiring county superintendents of health to be elected by county commissioners, and reduced term of office to one year. Annual appropriation, $2,000. 1899. General Assembly improved the laws protecting public water sup-plies. Smallpox prevailed extensively in the State. Dr. Henry F. Long, and later, on Dr. Long's resignation, Dr. Joshua Tayloe were employed to travel over the State, consulting with and advising the local sanitary authorities as to proper means for protecting the public. Annual appropriation, $2,000. 1900. State Board of Agriculture, on request of State Board of Health, agreed to examine samples of v/ater from public water supplies until Board of Health could provide its own examiner. Annual appropriation, $2,000. 1901. State Board of Embalmers, with representatives of State Board of Health, established. County health work placed in the hands of county sanitary committees composed of county commissioners and two physicians which commissioners elected to serve with them. Term of office of county superintendent of health made two years. Annual appropriation, $2,000. 1903. General Assembly enacted law permitting Board of Health to charge $5 for each analysis of a public water supply, this fee to be used in paying Department of Agriculture for services of examiner. Dr. C. W. Stiles, U. S. P. H. S., before the State Medical Society at Hot Springs, called attention to prevalence of hookworm disease in the South. Dr. J. L. Nicholson and Dr. W. S. Rankin, working under State Board of Health during fall Twenty-first Biennial Reiport 9 of 1903 and spring of 1904, showed great prevalence of this disease in North Carolina. Annual appropriation, $2,000. 1904. A stenographer was employed. One hundred and twenty thousand pamphlets on tuberculosis were printed and distributed. There was a renewal and an extension of cooperative work between the Board of Health and the State press, a number of articles dealing with hygienic and sanitary subjects being furnished the papers and published in them. Annual appropriation, $2,000. 1905. General Assembly established State Laboratory of Hygiene; im-posed water tax of $64 on all public water companies; voted $600 annually for support of Laboratory. Small appropriation made it necessary for the Department of Agriculture to continue to assist State Board of Health. Annual appropriation, $2,600. 1906. The North Carolina Association for the Study and Prevention of Tuberculosis was organized. Annual appropriation, $2,600. 1907. Two thousand dollars appropriated for the State Laboratory of Hygiene. Pasteur treatment provided. State Sanatorium for treatment of tuberculosis founded: $15,000 appropriated for permanent improvements and $5,000 for maintenance.. A law requiring the separation of tuberculous prisoners from other prisoners was enacted. Annual appropriation, $4,000. 1908. January 1, Dr. C. A. Shore became Director of State Laboratory of Hygiene. Annual appropriation, $4,000. 1909. General Assembly provided for (1) whole-time State Health Officer; (2) collection of vital statistics of towns having a population of 1,000 or over; (3) that all public water companies file plans and specifications of their plants with the State Board of Health, and that the State Board of Health pass necessary rules and regula-tions for the care of public watersheds and plants and furnish such rules and regulations and other advice to those having charge of public water supplies; (5) that counties provide free diphtheria antitoxin for county indigents, and (6) that the maintenance appropriation for the Sanatorium be increased from $5,000 to $7,500, and an additional $30,000 be granted for perma-nent improvements. Dr. Richard H. Lewis resigned as Secretary of the Board, and Dr. W. S. Rankin was elected as his successor, beginning his official work July 1. Annual appropriation, $10,500. 1910. General effort to interest the people and State organizations in public health work. Bulletin increased from 3,500 edition to 10,500 edition. Addresses on public health work delivered to Conference of County Superintendents of Schools, State Federation of Women's Clubs, State Press Association, and Sanitary Sunday observed in April. Dr. John A. Ferrell elected, February, As-sistant Secretary for Hookworm Eradication; began work under State Board of Health and Rockefeller Sanitary Commission. First effort in the eradication of hookworm disease was to interest school teachers, in the disease and through their assistance ex-amine and treat the children, and thereby reach the community. Three bottled spring waters sold on the market examined, found polluted, and public attention called to the pollution. Annual appropriation, $10,500. 10 North Carolina Board of Health 1911. Legislature established county boards of health to take the place of the county sanitary committees; county board of health com-posed of chairman board of county commissioners, county superin-tendent of schools, mayor of county town, and two physicians selected by the three county officials to serve with them. Legis-lature also abolished quarantine for smallpox and improved the quarantine laws. One thousand dollars annually appropriated to contract with antitoxin manufacturers for State supply of high-grade diphtheria antitoxin, with result that price of antitoxin was cut to one-fourth former price, saving the citizens of the State over $30,000 annually. Bulletin increased from 11,500 copies to 20,000 copies each edition; closer cooperation with press of State developed; regular weekly press articles prepared and sent to papers; increase in numbers of popular pamphlets for distribution. Hookworm work this year largely educational through the school forces and investigative through county dispensaries; thousands of children found infected and treated. Strong sentiment began to make itself felt for better health work by counties, four counties employing whole-time county health officers. Mainte-nance appropriation for State Sanatorium increased to $12,500, with $20,000 voted for permanent improvements. Annual appro-priation, $22,500. 1912. Bulletin increased to 40,000 edition; number of popular pamphlets dealing with different diseases increased; press work improved; educational work of Board along all lines amplified. Secretary of Board of Health called attention of conjoint meeting of State Medical Society and State Board of Health to the relative im-portance of health problems and the bearing of this subject upon the proper apportionment of health funds; instrumental in pass-ing a resolution to the effect that pellagra was an interstate prob-lem, not a State problem, and requesting the Federal Government to deal with pellagra as a Federal problem; resolution responsible, to considerable extent, for successful effort on part of Hon. John M. Faison's securing Congressional appropriation of $45,000 for the study of pellagra by the Federal Government. Hookworm work extended and county funds appropriated to supplement State and Rockefeller Foundation for this work. Annual appropriation, $22,500. 1913. General Assembly passed Model Vital Statistics Law with $10,000 appropriation for its enforcement. County superintendents of health changed to either county physician or county health officer. Educational efforts of Board continued and enlarged. Hookworm work along same line as year before increased in amount. Dr. John A. Ferrell resigned as Assistant Secretary to accept position with the central office of the Rockefeller Sanitary Commission in Washington, D. C. Dr. C. L. Pridgen succeeded Dr. Ferrell. The movement for improved county health work had by this time resulted in ten counties electing whole-time county health officers. The State Sanatorium for Treatment of Tuberculosis turned over by Extra Session of 1913 to the management of State Board of Health. Annual appropriation, $40,500. Twenty-first Biennial Report 11 1914. Preceding work of the Board continued. Board of Health took over management of Sanatorium; started out under many diffi-culties on account of the institution owing many debts and the appropriation being limited. Hookworm work changed to com-munity work directed to the installation of sanitary privies in all homes. Laboratory began to produce and distribute free anti-typhoid vaccine. Dr. C. L. Pridgen resigned as Director Hook-worm Eradication, and Dr. W. P. Jacocks succeeded him. Annual appropriation, $40,500. 1915. General Assembly makes State vital statistics law conform to National model by requiring burial permits in rural communities; enacts legislation permitting county commissioners and towns and cities to appropriate money for support of tuberculous citizens in State Sanatorium; provides $15,000 for purchase and building of antitoxin plant; appropriates $60,000 for payment of Sanatorium debts and new buildings and other improvements, and $25,000 annually for maintenance and $10,000 for extension anti-tubercu-losis work. Educational work greatly extended: Bulletin now 47,000; traveling public health exhibit shown at fairs and other assemblages; press work greatly developed through employment of journalist for whole time; stock lectures with lantern slides supplied public speakers in different parts of the State; com-munity soil pollution work under Dr. W. P. Jacocks stops in May, and Bureau of County Health Work with Dr. G. M. Cooper at its head, succeeds, beginning work in June. Considerable amount of work done for improvement of prison conditions. The unit system of county health work gets a good start: over 52,000 people given three complete vaccinations against typhoid fever, and medical inspection of schools put on in one county. Annual appropriation, $50,500. 1916. North Carolina was admitted to the Registration Area for deaths. To the educational agencies of the Board was added a self-supporting moving picture health show. Many saw this show during the year, and, seeing, believed in health work as never before. Bulletin had to be discontinued temporarily for lack of printing funds, but before discontinuance reached 51,000 edition. Cooperation with University in developing a plan and putting on a home post-graduate course in medicine, giving first course to 169 doctors. Put into operation an optional system of hotel inspection, with grading and publishing scores. Continued unit system of county health work, giving three anti-typhoid injections to 48,000, making 100,000 immunized in summers of 1915 and 1916. Did complete medical inspection of five counties and with inspection a large amount of educational work as to sanitary and hygienic living. Secured effort by Federal Children's Bureau to develop unit of child hygiene work, the Bureau using two employees to work in Cumberland and Swain counties for about eight months. Laboratory of Hygiene buys land and erects its own building. Sanatorium making a decided impression on the State. Annual appropriation, $55,500. 12 North Carolina Board op Health 1917. The General Assembly passed the following important health legis-lation: Chapter 263, entitled "An act to prevent and control the occurrence of certain infectious diseases in North Carolina;" chapter 244, entitled "An act to provide for the physical ex-amination of the school children of the State at regular inter-vals;" chapter 276, entitled "An act for the cooperative and effective development of rural sanitation;" chapter 257, entitled "An act to prevent blindness in infancy, designating certain powers and duties and otherwise providing for the enforcement of this act;" chapter 66, entitled "An act to provide for the sanitary inspection and conduct of hotels and restaurants;" chap-ter 286, entitled "An act to regulate the treatment, handling and work of prisoners." Following the enactment of this legislation, administrative ma-chinery, consisting of a Bureau of Epidemiology under the direc-tion of Dr. A. McR. Crouch, a Bureau for the Medical Inspection of Schools under the direction of Dr. Geo. M. Cooper, and a Bureau for County Health Work, under the direction of Dr. B. E. Wash-burn, was established. Dr. Washburn, an officer of the Inter-national Health Board, was loaned to the State without cost and the International Health Board, in addition to furnishing Dr. Washburn, appropriated $15,000 annually for rural sanitation in accordance with the provisions of chapter 276. The United States Public Health Service in February, 1917, de-tailed Dr. K. E. Miller to study county health work in different sections of the country and to establish for demonstration pur-poses, in Edgecombe County, department of health on an economic basis easily within the financial reach of the average county. The State Laboratory of Hygiene moved into its own building January 15, 1917. The State was admitted to the registration area of the Union for births in January, 1917, the Bureau of the Census having found after investigation that our birth registration was 96 per cent, complete. The special campaign against typhoid fever begun so satis-factorily in 1915, was continued. Free vaccination of the people, however, was interferred with by the difficulty in securing medical officers to do the work, the preparedness program of the Govern-ment having caused many physicians and nurses to enter the Army and Navy; nevertheless, a total of 30,000 citizens of the State were vaccinated as a direct result of the Board's activities, and many thousands of others were vaccinated by the physicians of the State as a result of the educational work of the Board directed to impressing the people with the value of vaccination as a means of prevention for typhoid fever. In December, 1917, life extension work as developed by the Life Extension Institute of New York, which consisted briefly of the free physical examination of interested citizens for the pur-pose of advising them as to their physical condition and needed hygienic reform and medical treatment, was begun on a county basis. The funds necessary for this work were appropriated Twenty-first Biennial Report 13 partly by the State and partly by the counties in which the life extension work was carried out. Dr. Amzi J. Ellington, who at the time was a resident physician in the New York City Hospital and who had during his residency in that institution studied the methods of the Life Extension Institute under Dr. Eugene Lyman Fisk, was employed and placed in charge of the work. Life ex-tension work was carried out in Vance, Alamance, Lenoir and Robeson counties, and resulted in the full physical examination of 4,000 citizens. This work was very favorably received, and the outlook for its continued development seemed excellent when, with the declaration of war and the call for physicians to enter the military service of the country, Dr. Ellington enlisted in the Medical Corps of the Army. For this reason, and for the further reason that it has been almost impossible to secure health officers during the past two years, the work was not resumed. The educational work of the State Board of Health consisted in the issuance of eight Bulletins, each monthly edition amount-ing to 45,000, and a daily newspaper health article. The Bureau continued its moving picture show exhibit and, in addition, pre-pared probably the best three-dimension educational exhibit in the United States. In 1917 the following exhibits were given: motion picture entertainments, 236; traveling public health ex-hibits, 32; special exhibits, 58; stereopticon entertainments, 3 — to a total of 95,000 people. Arrangements were made for the preparation of newspaper plate, which was sent to- and extensively used by 202 papers having a total circulation of 303,000. A large part of this newspaper material was prepared by the well-known authority and publicist in matters of sanitary and hygienic education, Dr. W. A. Brady, of Elmira, New York. The annual appropriation for the State Board of Health was $60,772.16. The annual appropriation for the State Laboratory of Hygiene was $12,500, and this, in addition to $9,087.22 in fees permitted under the laws of the State to be paid to the Laboratory for special work, provided the Laboratory with a total annual budget of $21,587.22. 1918. Much of the work this year was influenced by the war and had to do with preparedness. The State Health Officer visited Washing-ton, at the request of the Council of National Defense and as chairman of a committee of State Health Officers, on a number of occasions for conferences with respect to preparedness measures, provisions for the control of venereal diseases, arrange-ments for coordinating the control of infectious diseases in the civilian population with their control in cantonments, and to arrange, if possible, with the Public Health Service and the Surgeon-General of the Army for preserving the personnel of State health departments during the war. The State Health Officer also made a visit to the States of South Carolina, Georgia, Alabama and Florida for the Council of National Defense in order, if possible, to interest the Governor, the State Board of Health, and the State Council of Defense in venereal disease control. 14 North Carolina Board of Health Considerable time was given to assisting Major John W. Long, Medical Aide to the Governor, in the work of organizing the Medical Advisory Boards and in interesting physicians in enter-ing the medical service of the Army and Navy, and, later in the year, in inducing the physicians of the State to become members of the Volunteer Medical Service Corps. Partly as a result of these activities, the Surgeon-General of the Army assigned Major Joseph J. Kinyoun to assist the State Board of Health in the control of communicable diseases, the Board being under no financial obligation for Major Kinyoun's assistance; and as a result of the successful termination of the activities of various interests looking to a more effective control of venereal diseases, the Kahn-Chamberlain Bill passed Congress, and made available to the State of North Carolina, and without condition $23,988.61 for venereal disease work. The Laboratory during this year began the distribution of a high grade of diphtheria anti-toxin. The Bureau of Medical Inspection of Schools developed, and with a degree of success that we may say established, free dental clinics for the public schools of the State. The Bureau also de-veloped to a successful extent an arrangement in the form of adenoid and tonsil clubs for the practical and economic treatment of public school children suffering from these defects. The Bureau of Epidemiology employed two third-year medical students, equipped them with motorcycles, and put them into the field to investigate infringements of the quarantine law. Sufficient convictions were obtained to impress the medical pro-fession with the determination of the State to enforce its health laws, and a fairly satisfactory compliance with the laws regarding the reporting of communicable diseases was brought about. The Bureau of Venereal Diseases, paid for by the Federal appro-priation, was established in September under the directorship of Dr. James A. Keiger, of Charlotte, N. C. Mr. Warren H. Booker, for the last seven years the efficient director of the Bureau of Engineering and Education, left in September for Red Cross work in France, the work of his bureau being continued, with the exception of the engineering work, by Mr. Ronald B. Wilson. As a result of Mr. Booker's leaving, cer-tain funds became available, and a Bureau of Infant Hygiene, under the directorship of Mrs. Kate Brew Vaughan, was organized late in 1918. Perhaps the most outstanding feature of the health work dur-ing the year 1918 was the epidemic of influenza. The epidemic began early in October and caused in October alone 6,056 deaths; in November 2,133 deaths; and in December 1,497 deaths, a total during the last three months of 9,686 deaths. The annual appropriation for the State Board of Health for 1918 was $73,210.38. The annual appropriation for the State Laboratory of Hygiene was $12,500. The Laboratory, during this year, collected $8,532.48 Twenty-first Biennial Report 15 in fees for special work, so that the total income of the Laboratory for this year was $21,032.48. 1919. The General Assembly passed the following important health legis-lation: Chapter 71, entitled "An act to prevent the spread of disease from insanitary privies;" chapter 192, entitled "An act to provide for the physical examination and treatment of the school children of the State at regular intervals;" chapter 206, entitled "An act for the prevention of venereal diseases;" chapter 213, entitled "An act to require the provision of adequate sanitary equipment for public schools;" chapter 214, entitled "An act to obtain reports of persons infected with venereal diseases;" chap-ter 215, entitled "An act for the repression of prostitution;" and chapter 288, entitled "An act to amend chapter 671, Public-Local Laws of 1913, relating to the injunction and abatement of certain nuisances." The Bureau of Engineering and Inspection was organized in April. The engineering work of the Board had been suspended with the resignation of Mr. Warren H. Booker in September, 1918, Mr. Booker having gone to France to engage in tuberculosis work under the direction of the Red Cross. Between September, 1918, and April, 1919, the engineering problems coming before the Board had been referred and very kindly and effectively taken care of by Col. J. L. Ludlow of Winston-Salem. Mr. H. E. Miller, an engineer and a graduate of the University of Michigan, was placed in charge of the new bureau, and his brother. Dr. K. E. Miller, of the United States Public Health Service, was detailed by the Service to assist him in the organization of his work. Mr. H. E. Miller and Dr. K. E. Miller spent the spring and sum-mer and a part of the fall in studying various types of privies, in preparing plans for the construction and maintenance of privies, and in preparing the necessary notices and literature to inform the people of the objects and requirements of the new privy law. On May 1st Dr. A. J. Warren, health officer of Rowan County, was appointed to and accepted the position of Assistant Secretary of the Board. On July 1st Mr. R. B. Wilson accepted the position of Director of Public Health Education. On August 1st Dr. A. McR. Crouch, Director of the Bureau of Epidemiology, resigned to accept a position with the city of Wil-mington. Dr. F. M. Register, whole-time health officer of Northampton County, succeeded Dr. Crouch as director of the bureau. In September Dr. J. R. Gordon, Director of the Bureau of Vital Statistics since 1914, resigned on account of impaired health, and on October 1st the Bureau of Epidemiology and the Bureau of Vital Statistics were combined and placed under the direction of Dr. Register. In September Mrs. Kate Brew Vaughan, Director of the Bureau of Infant Hygiene, resigned. The bureau was reorganized under an understanding with the American Red Cross and was enlarged to include, in addition to infant hygiene, the problem of public 16 North Carolina Board of Health health nursing, the name of the bureau being changed to that of "Bureau of Public Health Nursing and Infant Hygiene." Under the agreement with the Red Cross this bureau was to have an available appropriation of $12,000 a year, half of which was to be furnished by the American Red Cross and half by the State Board of Health. The personnel of the bureau and its plan of work, under the agreement, was made contingent upon the approval of both participating agencies, the American Red Cross and the State Board of Health. In December Miss Rose M. Ehrenfeld took charge of the new bureau and began its organi-zation and work. On October 1st Dr. Jas. A. Keiger, Director of the Bureau of Venereal Diseases, resigned and Dr. Millard Knowlton was appointed to succeed him. The typhoid campaign carried on during the summer through previous years, was continued in the summer of 1919, using third-year medical students, furnished either with automobile or motor-cycle for getting about. Campaigns were carried out in the fol-lowing counties: Bertie, Cabarrus, Chatham, Chowan, Columbus, Craven, Hertford, Iredell, Johnston, Lincoln, Onslow, Pasquotank, Perquimans, Randolph, Richmond, Rockingham, Stanly, Union, Warren, Wayne. A total of 49,076 were given complete vaccinations. The educational work of the Board consisted of the publication of a 48,000 monthly edition of the Bulletin, and the distribution of about 350,000 pieces of public health literature. The funds available during this fiscal year amounted to $198,549.14, of which $102,301.98 was from State appropriations and the remainder from outside sources. The appropriation for the State Laboratory of Hygiene for this year was $28,500; in addition to this, the Laboratory collected in fees for special work, for anti-toxin, and in water taxes a total of $14,344.02, making a total of $42,844.02 available for work of Laboratory. 1920. During this year there was a Special Session of the General As-sembly, lasting twenty days and held in the latter part of August. This Special Session passed an act amending the vital statistics law, making the fees for local registrars 50 cents instead of 25 cents for each certificate properly filed with the State Board of Health. On January 1st Dr. B. E. Washburn, who had had general direction of the cooperative county health work and who had rendered most acceptable service, was recalled by the International Health Board and detailed to take charge of their interests in Jamaica. Dr. K. E. Miller, of the United States Public Health Service, who had been detailed in January, 1917, to organize a model county health department in Edgecombe County and then, in 1919, to assist his brother, Mr. H. E. Miller, in organizing the work of the new Bureau of Engineering and Inspection, to which was assigned the duty of enforcing the State-wide privy act, Twenty-first Biennial Report 17 succeeded Dr. Washburn as Director of the Bureau of County Health Work. In January a cooperative effort with the United States Public Health Service and the International Health Board to demonstrate the possibilities and advantages of the eradication of malaria from certain towns and cities in the eastern part of the State was begun. The terms of cooperation were that the International Health Board and the State Board of Health were to pay one-half of the expenses of the local work and the town or city in which the work was done the other half, the Public Health Service furnishing, as its part, expert supervising personnel. The towns and cities chosen for this work were Goldsboro, Farmville, and Greenville, the budgets for each municipality being, respectively: Goldsboro, $13,670.98; Farmville, $5,000; and Greenville, $9,000, a total investment in this work of $27,670.98. Mr. A. W. Fuchs, Associate Sanitary Engineer, was detailed by the Service to have supervision of the work. In February Dr. A. J. Warren, Assistant Secretary of the State Board of Health, resigned his position in order to accept the appointment of city health officer of Charlotte, N. C. In the winter and spring of 1920, the North Carolina Land-owners Association, under the progressive leadership of Mr. W. A. McGirt, of Wilmington, undertook a very extensive educational campaign against malaria, which was carried on through the public schools of thirty-eight counties in Eastern North Carolina. A series of county and State prizes for the best essay on malaria by public school children were offered as an inducement to the school children to interest and inform themselves, and, indirectly, their parents, with regard to the importance of this disease. To make possible this work by the school children 75,000 malaria catechisms, prepared by Dr. H. R. Carter, of the United States Public Health Service, were distributed through the public schools of the eastern part of the State to the school children. Thousands of essays were written, and it is reasonable to believe that the campaign was one of the most successful public health educational attempts yet undertaken. In June it was found advisable to separate the Bureau of Epi-demiology and the Bureau of Vital Statistics which had, on ac-count of the scarcity of health officers, been placed under the directorship of a single bureau chief. Dr. F. M. Register. Dr. Register was appointed Director of the Bureau of Vital Statistics and Dr. J. S. Mitchener was appointed Director of the Bureau of Epidemiology. In April the Interdepartmental Social Hygiene Board assigned to the State Board of Health several workers for making a study of vice conditions in North Carolina towns and cities and for taking such steps as were found expedient for decreasing prosti-tution. This group of workers was withdrawn in September, on account of differences developing between them and Dr. Knowlton, chief of the Bureau of Venereal Diseases, with the understanding 18 North Carolina Board of Health that another group of workers would be assigned to this work at a later date. In June arrangements were made with the United States Public Health Service and the American Social Hygiene Association for the development of an elaborate educational unit on sex hygiene and venereal diseases designed to reach rural meetings through the use of picture films and a portable truck. An outfit con-sisting of several lectures and a moving picture truck began work in Cumberland County in August, and from its very beginning met a most cordial reception and gave every promise of developing into one of the most useful agencies for dealing with the venereal disease problem. During the year the anti-typhoid vaccination campaign was continued in Alamance, Bladen, Columbus, Duplin, Franklin, Gas-ton, Harnett, and Mecklenburg counties. Cooperative campaigns, in which the counties furnished the working personnel, were also carried on in Anson, Johnston and Rutherford counties. A total of 29,435 citizens have been vaccinated against the disease, and this does not include Columbus County, in which the work was just beginning when this report was completed. The educational work of the State Board of Health during this year consisted of a 48,000 monthly edition of the State Board of Health Bulletin and the distribution of approximately 350,000 pieces of public health literature. The funds available during this fiscal year amounted to $342,- 284.33, of which $176,152.61 was State appropriation and the remainder from outside sources. The appropriation for the State Laboratory of Hygiene for this year was $25,000; in addition to this, the Laboratory collected in fees for special work, for antitoxin and in water taxes, a total of $13,698.89, making a total of $38,698.89 available for the work of the Laboratory. The above amount being insufficient, the Special Session of the Legislature authorized a loan of $15,000 to enable the work of the Laboratory to be carried on, making a total of $53,698.89 available for the work of the Laboratory during this year. 1921. The Legislature meeting early in January of this year was asked by the Board to amend the State law restricting the salary of the executive off"icer of the Board to $3,000 annually, so as to make the salary $5,000. Such an amendment was passed. A further request from the Board was that legislation be enacted removing the inspection tax of forty cents from privies coming under the supervision of the Board of Health. Such an amend-ment to the State-wide Privy Law was also enacted. A bill was introduced in this session of the General Assembly under the initiative of Hon. Emmet H. Bellamy requiring a physical ex-amination of all applicants for marriage and making issuance of license contingent upon the physical qualifications of the appli-cant. The State Board of Health approved and supported Mr. Bellamy's bill, realizing, as did the author of the bill, that the proposed legislation was but a step in the right direction and was. Twenty-first Biennial Report 19 therefore, rather loosely drawn and left many things to be de-sired. The bill finally passed in amended form as chapter 129, Public Laws of 1921. The general health of the State for 1921, as indicated in the vital statistical records for that year, published by the United States Bureau of the Census, was good, and there was an im-provement in reduced death rates for a number of diseases, as well as a reduction in the general death rate over previous years. Another general condition of State-wide importance with a vital bearing on the work of the Board of Health which had to be taken into account was a considerable amount of misunder-standing between respective groups of the medical profession and the Board of Health regarding matters of policy. Many physi-cians, men in good standing professionally and men with high civic ideals, seemed to feel that the Board of Health had no well-considered and reasonable objectives in the field of public health as it is related to that of private practice. This general condition was responsible for the Board of Health seeking and availing itself of opportunities to meet the profession, both in county, district and State societies, and to discuss with the profession what it conceived to be the proper relation between public health activities and professional practice. This subject was presented to and considered by the State Medical Society in its conjoint meeting with the State Board of Health at Pinehurst in April, 1921. See transactions Medical Society of the State of North Carolina, pages 472-506. As a result of these various conferences between representative men engaged in public health work and the profession, the general condition of misunderstanding and some little friction had disappeared to a large extent by the latter part of the year. Nevertheless, the results of contact between those engaged in social medicine and private practice were such as to encourage further conferences and efforts to bring about a fuller recognition of mutual interests on the part of the public and the profession, and the ultimate adoption of a program of relations which would be to the mutual advantage of both parties. Perhaps the most important change inaugurated in State health administration during this year was the adoption of a cost basis for standardizing and measuring the efficiency of public health work in those counties in which the State participated financially. This new principle is fully described in the State Board of Health Bulletin for January, 1922, and a further dis-cussion of cost basis for public health work is unnecessary here except, perhaps, to say that it is apparently at least one of the first attempts to introduce the cost system of industry into government. The Bureau of Venereal Diseases, in charge of Dr. Millard Knowlton, established as a part of the war-time activities of the Board in cooperation with the Bureau of Venereal Diseases of the Federal Government, was combined with and made a part of the work of the Bureau of Epidemiology, under the general direc-tion of Dr. J. S. Mitchener. 20 North Carolina Board of Health Funds available for the year included: State appropriation, $275,000; miscellaneous receipts, $164,184.42; total, $439,184.42. 1922. In order to bring the records of this department into harmony with those of other State departments, in accordance with the act of the General Assembly of 1921, changing the fiscal year of the State so as to begin on July 1st each year, this report ends with June 30, 1922. It, therefoi'e, covers a period of nineteen months; one full fiscal year from December 1, 1920, to November 30, 1921; seven months from December 1, 1921, to June 30, 1922. Effective February 1, the American Red Cross Society abrogated the agree-ment existing since 1919 by which it jointly financed with the Board of Health, the Bureau of Public Health Nursing and Infant Hygiene. This bureau was reorganized April 1 as the Bureau of Maternity and Infancy, for its maintenance the State receiving $27,259.66 annually from the United States Government in ac-cordance with the Sheppard-Towner Act for the promotion of the welfare of mothers and infants. Dr. K. P. B. Bonner of More-head City, was secured as the director of the reorganized Bureau, with Miss Rose M. Ehrenfeld as supervisor of nursing and Mrs. T. W. Bickett in charge of educational work. The funds available during this period, and their distribution, were seven-twelfths of the amounts set out under the tabulation for 1921. The appropriation for the State Laboratory of Hygiene for the nineteen months between December 1, 1920, and June 30, 1922, • was $87,083.33; in addition to this, the Laboratory collected in fees for special work, for anti-toxin, and in water taxes, a total of $30,872.51, making a total of $117,955.84 available for the work of the Laboratory. 1922-23. In order to further develop local responsibility for the protection and promotion of the public health, and to quicken local initiative, a policy of decentralization was adopted by the Board. To carry out this policy there were made several changes in the organi-zation of the Board's executive staff. The Bureau of County Health Work was discontinued. The Bureau of Epidemiology was combined with the Bureau of Vital Statistics. Dr. G. M. Cooper, director of the Bureau of Medical Inspection of Schools, was ap-pointed Assistant Secretary, and Dr. J. S. Mitchener, director of the Bureau of Epidemiology, was transferred to the Bureau of Medical Inspection of Schools. Dr. K. E. Miller, who for four years had been loaned to the Board by the United States Public Health Service, and had directed the work of the Bureau of County Health Work, was recalled for duty elsewhere. The State was divided into four districts with Dr. E. F. Long, Dr. H. A. Taylor, Dr. M. L. Ilsley, and Miss Rose M. Ehrenfeld as district directors. This plan of organization became effective in the early spring of 1923 and was continued through the calendar year. Six vacancies in the membership of the Board occurred during the year, four by expiration of term, and two by resignation. The terms of Dr. J. Howell Way of Waynesville, and Dr. A. J. Crowell of Charlotte, appointed by the Governor, expired, and Twenty-first Biennial Report 21 they were respectively appointed to succeed themselves. The terms of Dr. Charles O'H. Laughinghouse of Greenville, and Dr. Thomas E. Anderson of Statesville, elected by the State Medical Society, expired, and they vi^ere respectively reelected. Mr. Charles E. Waddell of Asheville, appointed by the Governor in 1921, resigned and as his successor the Governor appointed Mr. James P. Stowe of Charlotte. Dr. F. R. Harris resigned to be-come health officer of Vance County, and to fill the unexpired term the Board elected Dr. D. A. Stanton of High Point. Dr. J. Howell Way was reelected president of the Board. The General Assembly of 1923 made provision for the con-stantly growing work of the Board, approving the budget as sub-mitted and appropriating for the Board the sum of $425,000. Legislation enacted included an act to provide for the sanitary manufacture of bedding, to create an independent board of direc-tors for the State Sanatorium, and to provide sanatorium facilities for tuberculosis convicts. The important new development during the year was the begin-ning of malaria control work in certain counties of the coastal plain area of the State. Through the courtesy of the International Health Board a member of its field staff". Dr. H. A. Taylor, was loaned to the Board for the purpose of making preliminary sur-veys, and areas in Lenoir and Pamlico Counties were selected for investigation. The results showed Pamlico County to be suitable for the initial demonstration, and a unit for the investigation and control of malaria was organized with Dr. Taylor as the director, the budget being contributed forty per cent, by the county, forty per cent, by the State, and twenty per cent, by the International Health Board. The progress of the work, and the results achieved, proved so satisfactory that in January, 1923, an additional unit was organized in Beaufort County, and in May Craven and Bladen counties were added to the list. Detailed re-sumes of this work is given elsewhere in this report, but it should be stated here that the success of the intensive malaria control measures has been even greater than was anticipated. While specializing on malaria control measures, the county units have at the same time carried on a general program of public health work. The International Health Board has continued its co-operative aid in giving twenty per cent, of the unit budget, and has continued the loan of Dr. Taylor, who has directed the work. In June the resignation of Dr. J. S. Mitchener as director of the Bureau of Medical Inspection of Schools was accepted, and Dr. Roy C. Mitchell, who had been engaged in special educational field work, was appointed to the vacancy. 1923-24. The Committee on Municipal Health Department Practice of the American Public Health Association requested the Secretary of the Board to become field director for the Committee in making a study of municipal health practices in the United States for the purpose of working out with and for the Committee a basis or set of principles on and through which city health depart-ments could be given classification or grading, and further for 22 North Carolina Board of Health giving such additional time as might be needed in assisting such departments in improving their organization and provision for work. The request was brought before a special meeting of the Executive Committee of the Board, and it directed the Secretary to take advantage of the opportunity oifered to become acquainted intimately and broadly with health administration in the cities of the country, and at the same time continue to exercise general supervision of, and executive control over, the work of the Board. In January the Secretary established official headquarters in New York City for the work of the Committee, and the general organ-ization of the executive staff of the Board was continued with the Assistant Secretary, Dr. G. M. Cooper, as administrative or director. During the period of his absence the Secretary has kept in close touch with the work of the Board through frequent reports and a number of visits to the office for conferences with members of the staff. For the more efficient administration of the field activities of the Board the four districts into which the State has been divided the previous were consolidated into two, with Dr. E. F. Long and Dr. H. A. Taylor as Deputy State Health Officers, as directors, assisted respectively by Dr. C. N. Sisk, formerly health officer of Forsyth County, and Dr. George Collins, formerly health officer of Mecklenburg County. At the annual meeting for the Board in April further steps were taken towards making effective the policy of decentralization adopted the previous year. This policy looks, in a broad way, to the diminishing of State personnel and the use of funds so made available for stimulating and paying county personnel, either whole or part time, to do work which formerly had been in all probability incorporated and carried on by full-time personnel employed by the Board. It was directed by the Board that all machinery and resources of the Bureau of Maternity and Infancy and of the Bureau of Medical Inspection of schools be converted into county machinery and resources, either full-time or part-time, the transformation to be brought about gradually to become effective not later than January 1, 1925. During the year a plan for the more adequate sanitary control of public milk supplies in the State was formulated. The de-velopment of this important new undertaking was assigned to the Bureau of Engineering and Inspection. Mr. Malcolm Lewis, a graduate of Massachusetts Institute of Technology, and with about seven years of experience in public health work, was secured for this particular unit of work. As developed at the present time this service has been largely an advisory one, the various municipalities having at their command the aid of the Board in improving local milk supply conditions. The malaria control campaign in the coastal plain area was enlarged by the addition of organized units in Columbus, Bruns-wick, and Hyde counties, making a total of seven counties in the State specializing on this plan of health work. The cooperative aid of the International Health Board was continued. Twenty-first Biennial Report 23 During the year Dr. Roy C. Mitchell, director of the Bureau of Medical Inspection of Schools, resigned. The work of the Bureau was continued under the supervision of the Assistant Secretary. Dr. M. L. Ilsley and Miss Rose M. Ehrenfeld, both district directors, resigned, and effective with the end of the fiscal year Dr. K. P. B. Bonner, director of the Bureau of Maternity and Infancy, resigned. The appropriation by the General Assembly was $275,000 and $300,000 respectively for the two years of the biennium. For the Laboratory of Hygiene the appropriation was $75,000 annually. The Present Biennium During the period covered by this report the work of the Board was directed by Dr. G. M. Cooper as Acting Secretary. For the first year of the biennium the Secretary and State Health Officer, Dr. W. S. Rankin, was serving as field director of the Committee on Municipal Health De-partment Practices of the American Public Health Association. He was consequently away from the office practically all of the time. In June, 1925, Dr. Rankin resigned to accept the directorship of the Hospital and Orphanage Division of the Duke Foundation. ' The Acting Secretary during the biennium had the aid of the Executive Committee of the Board in frequent meetings. The general plans and policies of the Board were continued. These are set forth in detail under the several divisions. The appropriation to the Board was for 1924-5, $340,000 and for 1925-6, $319,644. For the Laboratory of Higiene the appropriation was $70,000 annually. 24 North Carolina Board of Health THE NORTH CAROLINA STATE BOARD OF HEALTH Its Organization, Problems, Methods of Administration, and Principles of Public Health Work The North Carolina State Board of Health was created by an Act of the General Assembly of 1877. The appropriation for the work of the Board under the original Act was $100 annually. In the forty-seven years of its existence the Board has from time to time had its powers enlarged and its duties increased. For the fiscal year ending June 30, 1925, the appro-priation for the work of the Board was $455,000, exclusive of that made for permanent improvements and maintenance for the State Sanatorium for the treatment of tuberculosis, and the educational work of that institution. The North Carolina State Board of Health consists of the Board proper, composed of nine members, and the executive staff, which varies from time to time. Of the Board proper, five members are appointed by the Governor of the State, and four are elected by the State Medical Society. The term of office is six years, and the terms are so arranged that not more than four vacancies will occur in any one year. The organization of the Board embodies two important administrative principles: First, stability of organization and permanency of policies; second, the partnership of the State and the medical profession in the conservation of human life. The stability of the organization of the Board of Health depends funda-mentally upon the freedom of the Board from political changes brought about by either party or factional changes in the State government. The divorcement of the State Board of Health from politics depends largely upon the manner of selecting the members of the Board. Sudden or marked changes in the personnel of the Board under the present plan of organ-ization are impossible. This is true, first, because the members of the Board of Health are appointed for terms of six years and their terms of service expire, not in the same years, but in different years. The appoint-ment of new members of the Board, is therefore, gradual and not sudden. " In the second place, the personnel of the Board of Health is selected by two parties: one, the Governor, and the other, the State Medical Society. It is far less likely that two parties naming a Board would be dominated by political considerations than where one party names the Board. This division of the appointive and elective power, and this provision for the gradual exercise of that power by two parties guarantee the State Board of Health against the sudden changes of personnel and policy associated with a purely political organization. The State Board of Health is stable; its individual members come and go, but as an organized body it has continuity. This stability and continuity of organization is the responsible factor for the permanency of policies adopted by the Board. Political boards elected or appointed for two or four years are naturally inclined to adopt two- or 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 administra- Twenty-first Biennial Report 25 tion. This is not true of self-perpetuating bodies such as the Board of Health, that, as legally constituted, 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 relation of the medical profession to the work of disease prevention and the conservation of human life. The State recognizes the debt of society to that profession by which nearly all of the experimentation and dis-covery on which disease prevention is based, with the exception of the work of Pasteur, was contributed; the interest of organized medicine in the conservation of human life and the peculiar ability of organized medicine to advise the State as to the methods of disease prevention; and the necessity of securing from the medical profession first information in regard to the occurrence of deaths and their causes, and the appearance of epidemics. The executive staff of the Board consists of the executive officer and the heads of various bureaus or special divisions organized for the more efficient administration of policies and programs adopted by the Board. The executive officer is the Secretary of the BoaM, and State Health Officer. He is elected by the Board for a term of six years. The duties of the office require that this official should be a man with technical train-ing and experience, and, therefore, should be selected on account of his technical rather than of his political qualifications. It is, therefore, right that he should be selected by a specially qualified committee, that is, the State Board of Health, and not be elected in a general election, as would be the case if the office were a political one. The six-year term of office is in accordance with the idea of permanency of policies. The law requires that the Secretary, and State Health Officer, shall be a registered physician in the State, and that he shall not engage in private practice, but devote his time and energy to the work of the Board. The work of the State Board of Health is large and varied, and is, there-fore, apportioned among a number of bureaus, or special divisions, each directed by an administrative head chosen for his special training and ability. These bureaus in the present organization of the Board consist of the following: The State Laboratory of Hygiene, to examine water and diagnostic specimens, and to produce and distribute biological products, vaccines, and sera; the Bureau of Vital Statistics, to secure, correct, tabu-late, and publish information as to distribution and causes of deaths, and as to distribution of births; to secure reports of communicable diseases and epidemics, and direct measures for their control; the Bureau of Medical Inspection of Schools, to develop public interest in the health of school children as it is related to their education, and to stimulate more adequate treatment for their most common defects; the Bureau of County Health Work, to interest county authorities in providing efficient county health departments, and to advise with, correlate, and assist such departments; the Bureau of Maternity and Infancy, to develop a higher degree of public intelligence regarding the importance and the care of the problems of maternity and infancy; the Bureau of Engineering and Inspection, to exercise supervision over the construction and maintenance of public water supplies and sewerage, to inspect and enforce sanitary conditions of privies, jails, public institutions, hotels, etc. The Bureau of Tuberculosis is now administered as the Extension Division of the State Sanatorium for the 26 North Carolina Board of Health treatment of tuberculosis, which is operated under the direction of a special board of directors. The correlation of the work of the several bureaus, to insure a harmoni-ous and efficient administration of the work of the Board, is through the supei'vision and direction of the executive officer of the Board. The division of the executive staff into special bureaus has the advantage of giving individualism to the work of each bureau and thereby creating a laudable pride and a healthy rivalry among the various bureau directors. While each bureau is separate and independent of other bureaus, the work of the entire executive staff is coordinated, the work of the Board being given compactness by the relation of the bureaus to one another through the executive officer of the Board. The administrative heads of the several bureaus, or directors, are selected by the executive officer of the Board, their terms of service being dependent only upon their success or failure in discharging their duties. There are naturally many problems and duties which cannot be assigned to any of the special bureaus, which by their nature must be under the immediate direction of the executive officer. These may be briefly stated as follows: (1) to assume primary responsibility for the enforcement of the more important State health laws; (2) to consider and determine, with the advice and consent of the Board, what should be the more important public health policies of the State; (3) to secure the needed legislation that will make possible the adoption of desirable health policies; (4) to supervise and assist in the execution of established policies. The enforcement of law rests, in a general way and broadly, upon the judicial machinery of the State. On the other hand, it is not only the privilege but the duty of any citizen to see that the violation of any law is brought to the attention of the courts and dealt with. The more thorough understanding of the purposes and the character of the public health laws and the keener appreciation of their importance imposes in a special way upon the executive officer of the State Board of Health the duty of seeing that these particular laws are fully complied with. The duty of considering and formulating for the action of the Board what should be the more important public health policies of the State rests largely with the executive officer of the Board on account of its primary and general responsibility for the development of an effective program of human conservation. After the Board has considered and definitely decided upon a course of action it becomes the duty of the executive officer to bring to the attention of the people generally the need of the course of actio a approved by the Board, and to so inform, interest, and appeal to the public, and reflexively and directly to the General Assembly as to secure legislative approval and provision for the public health policies which have been adopted by the State Board of Health. The efficiency of any agency is conditioned largely upon the personnel who are employed in its activities. The responsibility of finding and securing persons properly qualified by native endowments, training, and experience to direct the special bureaus or divisions entrusted with carry-ing out the established policies of the Board rests largely upon the executive officer. Twenty-first Biennial Report 27 As has been heretofore pointed out, the organization of the executive work of the Board embraces a number of special bureaus which are held responsible for some definite State health policy, and which are so organ-ized as to be independent of each other. Naturally, these bureaus and divisions in the character of their work are closely related and some means of coordinating their activities is necessary. This means, the executive officer supplies. The majority of the calls by letter or person upon the Board for service can be and are referred to the special bureaus of the Board concerned directly with the sort of service called for in the letter or by the visitor. However, there are a number of calls upon the Board for services that are general in character, or not provided for by some special agency. These services necessarily have to be supplied by the executive officer. The interest and support of the people in public health is in proportion to their understanding of the problem. To reach people, therefore, with information as to what the public health needs of the State are and how the Board purposes to meet the needs is, of all the Board's duties, the most fundamental and the most important. Moreover, the educational work of the Board is of a general character, dealing with the interests of all the bureaus or special divisions and, therefore, belongs largely to the executive officer whose interest is not particular but general with respect to all health problems. The duty of receiving, disbursing, and accounting for the public moneys provided for the work of the Board is a duty that rests primarily upon the executive officer because of his primary and general responsibility for the interests of the Board. The methods of work followed depend largely upon the character of the duties which the executive officer seeks to discharge. For this reason it is well in the discussion of methods to relate them to the special duties of the executive officer as above set forth. Investigations as to the violations of the more important health laws of the State and the initiating of prosecutions where violations are found, are carried out largely as a part of the special activities of the Bureaus of Vital Statistics and Engineering and Inspection. These bureaus main-tain a field force of inspectors, which vary in number but average about twelve full-time officers. The responsibility falls upon the executive officer to see that the bureaus fearlessly and without discrimination en-force the important laws entrusted to their execution. The larger work of the executive officer in law enforcement, however, concerns itself with bringing to public attention the principal State health laws and the needs of their careful observance, and in this way building up a public senti-ment favorable to the observance of public health laws and sympathetic with the judicial machinery in imposing penalties upon those who violate them. In determining the public health policies for the State it is necessary: (a) that the executive officer secure information through special and regular reports on the vital statistics of the State, and in this way to be fully cognizant at all times of the vital conditions of the State as shown by the State's birth rate, the State's general death rate, the State's special death rates for certain diseases, the State's death rates by counties, by races, and by seasons; (b) that he secure information, through public 28 North Carolina Board of Health health literature, books and periodicals, as to the more recent develop-ments and discoveries in public health work; (c) that then by keeping in touch through conferences with other State health officers and Federal health officers, be thoroughly conversant with the methods and accomplish-ments of other State departments of health, and that he be alert to those larger interstate movements, especially those related to action by the Federal government, in order that whenever and wherever possible these larger movements may be influenced to the advantage of this State. To secure the necessary measures and appropriations for the develop-ment of the State health policies the people are informed, through bulle-tins, the newspapers, exhibits, and public addresses, as to vital conditions and as to necessary measures and appropriations for favorably influencing the vitality and physical efficiency of North Carolina people. In this way the effort is made to develop a favorable public sentiment for the develop-ment of the more important public health policies. The executive officer further seeks to find and interest certain individuals, qualified by heart and head and position, for influencing, introducing, and supporting in the General Assembly needed legislation. To find and secure, with the available means, a personnel for the bureau, division or agency of the Board that is to be relied upon for carrying into successful execution some special and important public health policy calls for an acquaintance with those who are in touch with men qualified for such positions, and a judgment of men on the part of the executive officer. This judgment of men by which an administrative officer selects his as-sistants is, of course, basic in the success or failure of an administration. In giving assistance to members of the executive staff charged with carrying out certain public health policies the executive officer attempts to keep in close touch with the work of each bureau or division through regular monthly reports, special reports, and conferences from time to time. Consideration for the right amount of assistance—not too much and not too little—is regarded as important. Too much supervision tends to smother individuality; on the other hand, too little supervision not infrequently results in a useless waste of time and funds. The general work of the Board is a matter largely of correspondence and conference. The correspondence is extensive both in volume and variety, and personal callers at the office of the Board require a con-siderable time devoted to conferences. For reaching the people with information on health problems which they need, and which is necessary to secure their interest in and their support of the policies of the Board several means are in use. Primarily there is The Health Bulletin, issued monthly throughout the year, con-sisting of from sixteen to sixty-four pages. This is sent free to any citizen requesting it, and the circulation monthly is now 58,000 copies. In addition there are issued special pamphlets on the more important health problems, information is disseminated through the newspapers by means of specially written articles, and public addresses, often illustrated with either stereopticon slides or motion pictures, are given. The, bookkeeping for all the bureaus or divisions is done in the executive office by means of a system approved by the State Auditor, and all pur-chases are made through one purchasing agent. Twenty-first Biennial Report 29 The State of North Carolina is composed of one hundred counties, of separate and self-governing political entities. In the administration of the public health policies of the State there are certain duties and re-sponsibilities which are recognized as devolving upon the State, through its established agency, the State Board of Health. There are certain other duties and responsibilities which are recognized as devolving upon the county, through its established agency, the County Board of Health. In a democratic government such as North Carolina, where local self-government by the people is firmly established as a basic principle, it is necessary to keep in mind and regard scrupulously these distincCions. The State is rightly held I'esponsible by all other States for the condition of its death rate. In discharging this responsibility two main avenues of service lie open. First, the State should assume those public health activities that can be carried on, practically speaking, only on a State-wide scale and through State administrative machinery. Second, the State should make use of its central position and federated authority to tactfully, progressively, and persistently 'lead, but not drive, the counties to a clearer recognition of their opportunities, privileges, duties, and responsibilities for local health conditions. Without entering into a discussion of the more important State-wide public health activities they may be classified and listed as follows: First, activities of common interest to all the counties and impracticable of county handling, such as: 1. State supervision over communicable diseases, for the reason that infection and contagion do not respect county boundaries. 2. The registration of births and deaths according to a standard system, for the reason that birth rates and death rates as between counties to have comparative value must be established by uniform practices. 3. The protection of the purity of streams from which public water supplies are taken, for the reason that many streams flow through several counties before reaching the one or the ones whose citizens make use of such for domestic purposes. Second, activities which for economic reasons, for rendering unnecessary duplication and multiplication of officials, machinery, and equipment, be-long properly to the State, such as: 1. The preparation, publication, and distribution of educational bulletins, pamphlets, and leaflets needed in public health administration, for the reason that the additional expense necessary for each county to prepare, publish and distribute such material would be alike unnecessary and extravagant. 2. Maintenance of common laboratory facilities by the State for the same reason as that for maintaining central common equipment for the preparation of educational equipment. Third, activities concerned with disease factors of such exceptional im-portance that the State cannot neglect them and at the same time carry the responsibility for a State-wide reduction in death rates, such as: 1. A State policy for dealing with tuberculosis. 2. A State policy for dealing with venereal diseases. 3. A State policy for dealing with the factors of infant mortality. 4. A State policy for dealing with the common defects of school children. 30 North Carolina Board of Health The county can be made to understand that, after the State has gone its full length in dealing with public health conditions by general measures, the county may do much more in a local and more intense manner for the preservation and promotion of its own health conditions—just as the intelligent individual, after both State and county have done all in their power to protect his health, may still do much more for himself than both governments combined. The State through its established agency co-operates on a definite plan in aiding the individual county to assume and efficiently discharge the purely local duties and responsibilities by both personal service and financial help. Through the forty-seven years of its existence the State Board of Health has consistently developed in the scope of its service to the people, and has in proportion grown in scope of organization and in amount of money expended in its work. It began with no paid personnel and an appropriation of $100. Today it has an executive officer with eight as-sistants in charge of special phases of the work, and the necessary addi-tional clerical personnel, having an annual appropriation of $455,000. The outstanding achievements of the Board have been the marked reduction in the general death rate, and the increased vitality of the people through the practical eradication of smallpox, typhoid fever, hookworm disease, and the winning fight being waged against malaria and tuberculosis. For three consecutive years the State has had the highest birth rate in the United States, and at the same time has maintained a death rate lower than that of the country as a whole. Twenty-first Biennial Re^'ort 31 STATE LABORATORY OF HYGIENE The following is a Report of the Work of the State Laboratory of Hygiene Covering the Period July 1, 1924—June 30, 1926 Specimens examined: Malaria 807 Typhoid 2,749 Feces 3,197 Rabies 3,231 Gonococci 2,351 Diphtheria '. 10,683 Sputum 4,132 Cultures for Typhoid 1,701 Urine 634 Pathology 410 Miscellaneous .- 282 Blood Culture 27 Wassermann 78,433 Water 9,004 Total 117,641 Vaccines and .Antitoxins Made and Distributed : Diphtheria Antitoxin (Units) 280,050.000 Pasteur Treatments Supplied 3,582 Doses of Typhoid Vaccine Distributed 1,485,836 Doses of Toxin-Antitoxin Distributed 412,333 Doses of Smallpox Vaccine Distributed 448,261 Number of Schick Tests 162.300 Number of Schick Control Tests 127,750 Number of Ampules of Neo-Arsphenamine Distributed 255,583 Tetanus Antitoxin Distributed (Units) 16,404,000 Pertussis Vaccine Distributed (CC) 63,737 Syringes Scarlet Fever Antitoxin Distributed 129 Autogenous Vaccines 239 No attempt is made, nor can be made, to estimate the value of the preser-vation of life and health which may have been accomplished by the work just outlined, but some of the results can be given a definite and accurate financial value. If there had been no State Laboratory of Hygiene in exist-ence, this work would have cost the citizens of the State the following amounts: 78,433 Wassermann tests @ $ 5.00 $ 392,165.00 9,004 Water examinations @ 5.00 45,020.00 30,204 Other examinations average @ 2.50 75,510.00 1,485,836 Doses of typhoid vaccine @ .50 742,918.00 63,737 Doses of pertussis vaccine @ .50 31,868.50 448,261 Doses of smallpox vaccine @ .15 67,239.65 412,333 Doses of toxin-antitoxin @ .50 206,166.50 3,582 pasteur antirabic treatments @ 25.00 89,550.00 32 North Carolina Board of Health 3,246 Schick tests @ $1.50 $ 4,869.00 2,555 Schick control tests @ 1.50 3,832.50 255,583 Ampules of neo-arsphenamine @ 1.00 255,583.00 Tetanus antitoxin: 9,572 1,500 unit packages @ $3.50 $ 33,502.00 417 5,000 unit packages @ 6.00 2,502.00 36,002.00 Scarlet fever antitoxin: 48 Therapeutic doses @ $6.00 $ 288.00 81 Prophylactic doses @ 3.00 243.00 531.00 Diphetheria antitoxin : 4,901 1,000 unit packages @ $2.00 $ 9,802.00 503 3,000 unit packages @ 3.50 1,760.50 3,264 5,000 unit packages @ 5.00 16,320.00 25,732 10,000 unit packages @ 7.50 192,990.00 220,872.50 Total , $2,172,127.65 Receipts are as follows: Appropriation $141,500.00 Water Tax 20,123.85 Sales Biological Products 38,311.10 Fees 2,893.32 $202,828.27 Twenty-first Biennial Report 33 REPORT FOR THE BUREAU OF VITAL STATISTICS AND DIVISIONS OF EPIDEMIOLOGY AND ' VENEREAL DISEASES Bureau of Vital Statistics Since the biennial report of 1923-1924, there has been taken from the Bureau of Vital Statistics, the distribution of silver nitrate, registration of midwives, and the Bureau of Venereal Diseases. While the Bureau of Vital Statistics and the Bureau of Epidemiology have a separate function, the whole is classified more or less together, especially as to number of letters sent out, and the general routine of office work. Other than this, the activities of each division will be taken up separately. Practically all field work for the Bureau of Vital Statistics and Epidemi-ology is done by the Director. We will first take up the work of the registration of the births and deaths occurring in North Carolina. Character of Work OBJECTIVES The objective of the Bureau of Vital Statistics is to secure a permanent record of the more important facts concerning the birth and death of every citizen of the State of North Carolina, and from such records to prepare card indices and tabular classifications in such manner as to make readily available on inquiry the following information : 1. (a) The total number of births occurring annually in the State: (b) the birth rate of the State, that is, the number of births per thousand of the population; (c) the birth rates by races, white and colored; (d) the number of illegitimate births; (e) the number of stillbirths attended by midwives; (g) the number of white births attended by physicians; (h) the number of white births attended by midwives; (i) the number of colored births attended by physicians; (j) the number of colored births attended by midwives; (k) all of the foregoing data as to births with respect to each county and city. These facts permit of comparisons of one part of the State with another, of the birth rate of the two races, and of the birth rate of this State with that of the other States and other countries. Such information is necessary in forming conclusions as to vital conditions in North Carolina and in the enactment of suitable legislation for dealing with these conditions. 2. (a) The number of deaths occurring in the State of North Carolina annually; (b) the death rate, that is, the number of deaths per thousand of the population;^ (c) the number of deaths, by races, and the death rates by races in North Carolina; (d) the number of deaths among infants and young children as compared with the births, and the total deaths as com-pared with the total births, with net gain in population; (e) the total number of deaths by months and year from each o.f the 209 causes appear-ing in the International List of Causes of Death; (f) the number of deaths according to age and to occupation; (g) the number of deaths according to age and the causes of death; (h) the number of "seasonal" deaths according to months; (i) all of the foregoing data classified according to 34 North Carolina Board of Health 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 one and two, information necessary for the public welfare and available under the operation of the vital statistics law has been briefly indicated. But the vital statistics law not only supplies information to legislatures, state and county commissioners, and other administrative bodies, which is necessary for framing conservation measures for human life, but it also records facts which may at any time become of great value to the individual. In matters of tracing ancestry, birth records are invalu-able; 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 industries, as to entering school, as to liability for military service, etc. METHODS The Bureau of Vital Statistics secures the birth and death certificates for the births and deaths occurring in North Carolina through approxi-mately fourteen hundred and fifty local registrars, appointed by the chair-man of the boards of county commissioners for the various townships and by the mayors for the various incorporated towns and cities of the State. The duties and powers of the local registrars are defined in Consolidated Statutes, section 7113. The county pays the local registrars fifty cents for each birth and death certificate furnished by them to the office of the State Registrar at Raleigh. The vital statistics law makes it the duty of the doctors and midwives in attendance on a birth to file a birth certificate with the local registrar of the district in which the birth occurs and makes the undertaker, or person acting as undertaker, responsible for the filing of the death certificate. The birth and death certificates filed with the local registrars of the State are sent to the Bureau of Vital Statistics on the fifth of the month succeeding the month in which the birth or death occurred. The certificates received in the oflfice of the Bureau of Vital Statistics are examined carefully, and if incorrect or incomplete (as a large per cent of them are) effort is made to secure the information neces-sary to complete them. Every parent of a legitimate child whose birth is reported is sent a card advising them of the date of birth and whether or not name appears on the certificate. This gives the parent an opportunity to send in to the office the name of the child, in case it does not appear on the certificate, or to make such change in name or date of birth necessary to make certificate an accurate record of birth. The certificates are then classified and tabulated according to county, townships and registration districts, according to races, according to age at death, according to cause of death, according to death rates and birth rates, etc., in order to make readily available upon request, the information mentioned under the head-ing of Objective. ROUTINE WORK The routine work in the registration of births and deaths is indicated in the following table. This covers period from July 1, 1924, through June 30, 1926, inclusive. Twenty-first Biennial Report 35 Letters and postals received 35,735 Casket dealers reports received 8,165 Supplementals received 3,630 Name cards received 14,865 Violation blanks received 114 Acceptance papers received - 2,909 Report cards received from local registrars 23 251 Letters written 25,484 Form letters sent 66,926 Postal cards sent 140,300 Packages of supplies sent 13,918 Indexing : Cards made 264,790 Cards proofread 249,915 Cards assorted 232,882 Cards filed 245,332 Credit certificates sent local registrars '. 4,130 Certified copies made 5,506 Tables made 366 Cards punched and proofread 69,023 Transcripts made and proofread 194,423 Cards furnished Dr. McCain, giving information as to deaths fi-om tuberculosis, monthly 5,321 Epidemiology forms made 432 Tabulation of births Number certificates made in triplicate 5 800 Permanent index cards checked 7,285 Sheets written : 16,272 Certificates Received: Births 172,996 Deaths 67,309 Stillbirths 16,678 *Total 256,983 Names checked on Undertakers reports with D. C 14,845 . Nitrate sent 4,786 RESULTS OBTAINED Of course there is always a large per cent of routine work that is impos-sible to put in a report of this kind, and without going into unnecessary detail, it may be said that the objective of this Bureau, as aforestated, has been reached, and that all of the information with its vital bearing upon the public health needs of the State and with the public health accomplish-ments of the State is readily and completely available. As a mere indication of the practicable value of the work of the reg'stra-tion of births and deaths, we may point out the fact that the birth rate of North Carolina is very high, the highest in the United States, and that the death rate in North Carolina, notwithstanding the high birth rate, giving ^This total includes letters and postals received for our other divisions. 36 North Carolina Board op Health us an exceptionally large age group of tender years with high fatalities, is exceptionally low, one of 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. DIVISION OF EPIDEMIOLOGY Character of Work OBJECTIVES To prevent and control the occurrence of whooping cough, measles, diph-theria, scarlet fever, infantile paralysis, cerebro-spinal meningitis, chicken-pox, septic sore throat, German measles, smallpox, typhoid fever, trachoma, syphlis, chancroid, gonorrhea, and ophthalmia neonatorum. METHODS Section 1—The County Unit A quarantine oflficer for each county and city having a separate health department in the State is appointed to be the Bureau's representative in the local field. His duties are as follows: (a) To secure reports from parents, teachers, and physicians of all com-municable diseases. (b) To keep an accurate record in his office of all reports. (c) To transmit all reports daily to the Division. (d) To supply the parent, guardian, or householder, when the disease is reported, with rules and regulations governing that person, with a placard to be posted on the house, and with a pamphlet descriptive of the disease, its dangers, cause, mode of infection, apd 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, and with a pamphlet descriptive of the disease, its dangers, cause, mode of spread, and methods of control, to be distributed through the children to the parents represented in the school. (f) To make the presence and locations of the disease known to the pub-lic by publishing notices in the county paper when the disease appears and advising means of prevention. (g) To furnish householders forms to report diseases in their community which have not been previously reported. (h) To investigate all cases of suspected contagions which have not been reported to determine the nature of the disease. (i) To enforce the laws, rules and regulations governing the control of communicable diseases. (j) To make monthly reports to the Division of Epidemiology of all the work, educational, administrative, or otherwise done during the month. Compiled Monthly Report of County Quarantine Officers July 1, 1924, to June 30, 1926 Cases reported by householder 9,028 Cases reported by nurses and health oflficers 14,192 Cases reported by physicians 39,277 Cases reported by teachers 2,156 Twenty-first Biennial Report 37 Total number of cases reported 64,919 Homes placarded 45,093 Articles published 372 Teachers certificates 3,744 Indictments 173 Section 2—The State Unit To g-ive the reader a fair idea of the work done by this Division, we have grouped the work under the following heads: (1) General office work not included in office work mentioned in report previously; (2) special work for the prevention of typhoid fever; (3) special work for the prevention of diphtheria; (4) special work for the prevention of venereal diseases; (5) special work for the prevention of sore eyes in the newborn. I. Office Work The daily reports of each of the communicable diseases are recorded by the Bureau of Vital Statistics—Epidemiology Division—by the counties 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 year to year. Weekly telegraphic and monthly written reports of all cases of infection and contagious diseases reported are made to the Surgeon-General, United States Public Health Service, Washington, D. C. Charts are kept showing number of deaths and number of cases, by months, from each of the communicable diseases. Monthly reports of the quarantine officers are given a detailed examina-tion by the Director, and where it is deemed necessary, letters are written to the quarantine officer and the county commissioners of the non-perform-ance of duty. All repoi-t cards, blank forms, educational posters, placards and literature on the reportable diseases, and all rules and regulations governing the con-trol of the diseases, are prepared and distributed to the various quarantine officers of the State by this Division. Summary of Office Work Circular letters 157,119 Oaths of office - 32 Bulletins sent 107,452 Packages of supplies sent 1,352 II. Special Work for Prevention of Typhoid Campaigns for giving free treatment to prevent typhoid fever and diph-theria are conducted in different counties of the State. The Division of Epidemiology circularizes the county and furnishes ad-vertising materials to the county for the mailing list made up from the tax books—(The Division makes up mailing list from the records of births in the county, filed with the Bureau of Vital Statistics.) The Division of Epidemiology pays for all clerical help needed in the counties to get out advertising, and pays for newspaper advertisements, etc. Physicians who participate in these campaigns are paid 8^/^ cents a single dose. Physicians make reports to the Division on forms supplied for the 38 North Carolina Board of Health purpose. These are checked and certifications sent to the County Com-missioners. Work for 1924 campaigns was completed in June, 1924, and included in the twentieth biennial report. In 1925, eighteen campaigns were conducted in the following counties: No. Taking County Three Doses 1. Avery 2,537 2. Beaufort - No Report* 3. Chowan - 494 4. Gates .- 1,593 5. Hertford - - 6,490 6. Hoke No Report* 7. Iredell 19,029 8. Lee 2,756 9. McDowell _ 3,652 10. Mitchell 1,219 11. Onslow 1,985 12. Pasquotank .....No report* 13. Scotland 4,189 14. Stokes 4,827 15. Union No report 16. Watauga 4,491 17. Yadkin 7,151 18. Yancey 7,833 Total : 74,460 In May and June, 1926, the following counties were circularized for cam-paigns against typhoid fever: Alamance, Catawba, Chatham, Dare, Forsyth, Lincoln, Martin,. Montgomery, Moore, Person, Randolph, Rocking-ham, Wayne. III. Special Work for the Prevention of Diphtheria Toxin-antitoxin campaigns for the prevention of diphtheria were con-ducted in 1924 and 1925, simultaneously with the typhoid campaigns. Work for campaigns for 1924 was practically completed in 1925. The counties and number taking complete treatments are listed in the follow-ing tables. Children between six months and six years were advised to take the treatment as in this age group seventy-five per cent of our deaths from diphtheria occur and most of the children are susceptible to the disease. No. Taking County Three Doses 1. Avery 265 2. Beaufort No report* 3. Chowan 38 4. Gates 188 5. Hertford 488 *Whole time counties. Twenty-first Biennial Report 39 No. Taking County Three Doses 6. Hoke No report* 7. Iredell 1,758 8. Lee 723 9. McDowell 1,109 10. Mitchell 350 11. Onslow ...: 775 12. Pasquotank No. report* 13. Scotland 561 14. Stokes 1,291 15. Union No report* 16. Watauga 200 17. Yadkin 1,512 18. Yancey 1,002 Total 10,260 Thirteen counties, Alamance, Catawba, Chatham, Dare, Forsyth, Lincoln, Martin, Montgomery, Moore, Person, Randolph, Rockingham, and Wayne were circularized in May and June, 1926, for toxin-antitoxin campaign. IV. Venereal Disease Division Since 1924 the distribution of neo-arsphenamine has been under the State Laboratory of Hygiene. The Federal appropriation for this work has been discontinued, so no education or remedial work has been carried on by this Bureau. However, we receive a large number of letters asking for bulletins, pamphlets and advice. These are all carefully answered and bulletins and pamphlets are mailed to those requesting them. There has been reported to this office the following number of cases of venereal diseases: Gonorrhea 4,683 Syphilis 6,372 Chancroid 358 Balanitis 5 *Whole time counties. 40 North Carolina Board of Health WORK OF THE BUREAU OF MEDICAL INSPECTION 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 each 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 discover the children who have remediable defects, and to have them treated while curable and before the condition becomes chronic. 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 1. Written instructions for teachers have been prepared, covering every phase of medical inspection of school children. Cards for recording the exact history and results of the preliminary physical examination 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 children in the presence of teachers to demonstrate by example the need for the examination, the purpose, and how to do it. 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. Method for Objective 2. 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 sent to the Bureau of Medical Inspection of Schools of the State Board of Health at Raleigh. The Bureau has competent agents, who carefully study and classify these cards into two groups, those representing supposedly normal or supposedly defective children. Immediately following this study, this agent, generally a trained nurse, visits the county and makes a re-examination of all children reported suffering from common defects: (c) Those of the children thought to be greatly in need of medical, surgical or dental service are advised of the fact, together with their parents, but before treatment is finally arranged for, competent medical examination is made; (d) Special arrangements are made for club operations and dental treatment, results of which are described under the head of Results Ob-tained of this department. ROUTINE WORK Articles written—Bulletin, 28; words 15,500 Other publications, 3; words 2,380 Pieces of literature distributed 850,000 Twenty-first Biennial Report 41 FORCE EMPLOYED Director of Bureau, one part-time physician, one full-time field super-visor of dentists, seven full-time dentists, seven full-time trained nurses, six part-time trained nurses, one part-time anesthetist, one part-time truck driver and hospital orderly, one part-time clerk, one part-time stenographer. BUDGET Annual amount allotted fi-om Executive Department $10,000.00 Annual amount allotted from special State funds 50,000.00 Amount received from counties 6,924.00 RESULTS OBTAINED Some of the tangible results of the work of this department may be enumerated as follows: 1. Thi-ough the system of medical inspection organized and maintained by this department for finding defective school children, 60,668 children have received free dental treatment in the public-school clinics during this period, paid for entirely by funds expended through this division of the State Board of Health; 54,130 permanent fillings have been placed, thereby saving that many permanent teeth, which would have been otherwise lost. The economic value of this specific assistance, as well as the educational influence on those children treated, and the more than 9,600 additional children examined by the dentists, but not treated, cannot be worth less than $10 per child treated, or $606,680. The dental clinics were conducted in seventy-two counties. 2. Following up the preliminary examination first made by the teachers and reported on the proper cards, specially trained nurses sent out by this department have re-examined 171,905 school children. These children had been reported by the teachers as possibly suffering from common defects.. Most of them were found to have one or more of the common physical defects, such as decayed teeth and diseased throats. No possible estimate of the immense educational value can be placed on this service to public-school children by teachers and nurses. 3. Tonsil and adenoid clubs have been originated and put into operation by this bureau for the purpose of following the examinations with treatment when needed. This activity has embraced twenty-seven counties in which clinics have been held. A total of 3,714 school children have been operated on in these clinics. The financial equivalent of one of these operations, negotiated through private methods, without considering the far-reaching effect on the whole life of the child of neglecting to have this important operation done, cannot be less than $50. In fact, the operation alone costs more in many places of the State. Thus the total money value of 3,714 successful operations is certainly not less than $185,700. But the most important consideration is that a very small percentage of the children so essentially helped could even have had the opportunity otherwise. 42 North Carolina Board of Health MALARIA CONTROL The Department created for the Investigation and Control of malarial fevers is financed jointly by the State Board of Health and the International Health Board. The main and primary object of the Department is to con-fine its eff'orts to studying the prevalence, geographic distribution of ma-larial fevers, factors responsible for transmission and to suggest to county health departments the most economical means of control. There is a secondary object of perhaps even greater importance which has guided the department in formulating its policies; this is the stimulation of a perma-nent interest and activity in the administration of public health activities whereby disease prevention can be carried on economically and on a large scale by free and generous support of full time county health departments. The department thus created has been instrumental in the organization of two additional county health units, thus making a total of nine county health departments whose duty it is to carry on control measures wherever the disease is prevalent enough to justify the eff"ort and the expenditure of public funds. The policies pertaining to the organization and conduct of the depart-ments undertaking malaria control are determined by the State Board of Health. The details pertaining to county organization has been delegated to a staff member of the International Health Board, who is executive head of the departments and who directs the field activities of the newly created county organizations in the control of the disease. Main Objectives County organizations created by joint funds of the International Health Board, State Board of Health, and counties for the investigation and con-trol of malarial fevers, have the prime objectives in view 1. Geographic distribution of the disease. 2. The incidence of the disease and the extent to which it is a menace to the health and economic efficiency of the people. 3. Factors responsible for transmission and spread. 4. The possibility of controlling the disease within the eco-nomic reach of the people. In order to explain the procedure followed by each county health organi-zation the methods and relation to the objectives as advised by the depart-ment will be considered. Method for Objective One Malaria a Rural Disease: Malaria is essentially a rural disease for the reason that the mosquitoes held responsible for the transmission of the disease are essentially a rural species and any reduction in the incidence of the disease will benefit the rural moi-e than the urban population. The serious loss from the disease is not due to the costs of treatment and deaths, but rather to the loss of efficiency of labor, loss in net crop productions and in the predisposition to other and more fatal diseases. Certain biological facts concerning the malarial mosquitoes explains the rural nature of the disease. While the mosquitoes which have been incrim-inated as the principal vectors of the disease are domestic in their adult habits, they may be considered only partially domestic in their breeding Twenty-first Biennial Report 43 habits as natui-al and permanent collections of surface water are more often selected for bi'eeding areas. The larvae of anopheles will thrive best in natural collections of water, such as, slowly running streams, edges of shallow ponds, barrow pits, and seepage areas. Permanent water collec-tions of this natux'e are common to rural and not to urban districts. The density of anopheles may be said to be in direct proportion to the oppor-tunities offered for propagation. That malaria is essentially a I'ural dis-ease is demonstrated by its disappearance from areas where the land has been drained and brought under cultivation. Since the reduction in the density of malarial mosquitoes is in direct ratio to the reduction in collections of surface water in which the mos-quitoes may breed, the control of the disease through the application of anti-mosquito measui'es in the aquatic stage is biological in scope. Method Used in Determining Prevalence and Geographic Distribution On completion of the organization of the departments, the health officers seek to outline or determine the areas of concentration of the disease in their respective counties, and, in view of the fact that malaria is essentially a rural disease, control measures are confined principally to the rural sec-tion and small villages of the county. The first step of the departments has been to gather data as to the apparent prevalence of the disease in the county by the examination of school children between the ages of 2 and 12 for enlarged spleens, the taking of history indices as to positive or negative malaria, the establishing of blood indices and the securing of mortality statistics from the State Board of Health. From the data elicited during this preliminary survey, the health officer obtains a fairly accurate idea as to the prevalence and distribution of the disease in his respective county. From such records it is naturally shown that certain foci of infection exist in the county and are the only areas requiring immediate control measures. Having established the area or areas where the disease is most prevalent, the department prepares a survey, or spot map, showing each home thereon in relation to permanent collections of water, with special reference to those streams breeding malaria mosquitoes. In areas where anti-mosquito measures are considered feasible, all the collections of water are indicated on the survey map and character indicated as to whether permanent or temporary. The density of mosquitoes in relation to occupied houses is a feature, also of the department. From the data elicited during this sur-vey the health officer is in a position to determine the most feasible and economical measures of control which in the tidewater section consists of a combination of all measures at our command. Examination of Children for Splenomylogy In order to elicit the smaller degree of enlargement and the better to determine the exact degree of enlargement in children, it is necessary to place the child in a recumbent position with the thighs and legs flexed. The examiner sits at the right side of the child with the head of the latter on the examiner's left. The child's clothing or belt is loosened so that the hand of the examiner can be freely placed upon the bare skin, below and above the costal margin on the left side of the abdomen. First the region between the costal margin and the umbilicus and be-tween the umbilicus and pelvis is palpated for the detection of spleenic 44 North Carolina Board of Health MALARIA Twenty-first Biennial Reiport 45 MALARIA 1921 1922 1923 a S. o a. ~ c ^ c (i'^ CI a. ^5 Q (1, 1924 a. 1925 3 14.0 3 3.6 6.8 4.5 9.4 9.5 34.3 47.3 Jones 10,096 3 29.7 Lee 13,713 -. .„... Lenoir 30,604 3 9.8 Lincoln 17,975 Macon 12,994 .... Madison ...20.083 .... Martin 21,297 McDowell ......17,262 Mecklenburg .82,806 Mitchell 11,421 .... Montgomery ..14,607 1 Moore 22,065 1 Nash 42,194 4 New Hanover 41,946 4 Northampton 23,317 8 Onslow 14,792 7 Orange 18,332 .... Pamlico 9,060 8 88.3 Pasquotank ....17,821 3 16.8 Pender 14,788 2 13.5 Perquimans 11,150 4 35.8 Person 19,223 .... Pitt 46,995 8 17.0 Polk 9,016 .... ...... Randolph 31,067 Richmond 26,478 .... Robeson 55,406 1 1.8 Rockingham ... 45,339 .... Rowan 45,072 2 4.4 Rutherford .....31,896 .... ...... Sampson 36,932 2 5.4 Scotland 15,636 .... Stanly 28,591 .... ...... Stokes 20,640 .... . Surry 32,891 .... Swain 13,660 _.. Transylvania .. 9,629 Tyrrell 4,849 1 20.6 Union 36,454 2 5.4 Vance 23,320 .... Wake ._. 76,998 2 2.5 Warren 21,798 1 4.5 Washington ...11,485 4 34.8 Watauga 13,620 .... Wayne 44,867 8 17.8 Wilkes 33,009 .... ..... Wilson 38,134 1 2.6 Yadkin 16,540 Yancey 15,560 10,218 13,921 31,303 18,050 13,065 20,083 21,609 17,594 84,213 11,278 14,607 22,516 42,949 42,830 23,405 14,851 18,623 9,060 17,921 14,788 11,158 19,389 47,945 9,138 31,207 27,085 54,674 46,132 45,745 32,209 37,552 15,660 29,365 20,683 33,175 13,950 9,846 4,849 36,737 23,667 78,226 21,934 11,522 13,477 45,685 33,252 39,014 16,639 15,871 4 39.1 4 12.7 1 4.9 2 9.2 5.9 1 2.3 3 7.0 5 21.3 4 26.9 6 56.2 2 11.1 2 13.5 2 17.9 4 8.3 1 1.8 4 8.7 3 7.9 2 41.2 6 16.3 2 2.5 1 4.5 2 4.3 3 7.6 10,341 14,130 32,003 18,126 13,137 20,083 21,921 17,927 85,620 11,278 14,607 22,967 43,704 43,714 23,493 14,910 18.914 9,060 18,021 14,788 11,166 19,555 48,895 9,261 31,347 27,692 54,674 46,926 46,419 32.522 38,172 15,684 30,139 20,726 33,459 14.240 10,063 4,849 37,020 24,014 79,454 22,070 11,560 13,477 46,503 33,495 39,894 16,738 16,182 5 48.3 3 9.3 2 9.1 5 5.8 1 6.8 1 4.3 3 6.8 6 25.5 3 20.1 12 132.4 1 5.5 2 13.5 2 10.2 3 6.1 2 4.3 1 2.6 1 3.3 1 2.9 1 20.6 1 2.7 3 3.7 1 4.5 8 69.2 7 15.0 10,463 14,338 32,702 18,201 13,208 20,083 22,234 18,259 87,028 11,278 14,607 23,419 44,460 44,599 23,583 14,970 19,206 9,060 18,123 14,788 11,175 19,722 49,846 9,385 31,488 28,299 54,647 47,720 47,093 32,835 38,792 15,708 30,913 20,770 33,743 14,530 10,280 4,849 37,303 24,361 80,682 22,207 11,598 13,477 47,321 33,738 40,744 16,837 16,493 1 9.5 4 17.9 4.2 6.7 4'.2 40.0 55.1 5.5 1 2.0 1 2.1 1 3.2 4 82.4 1.2 60.3 10.5 9.8 10,586 14,546 33,401 18,276 13,280 20,083 22,546 18,591 88,435 11,707 14,607 23,870 45,215 45,483 23,672 15,029 19,498 9,0b0 18,224 14,788 11,183 19,889 50,797 9,508 31,629 28,907 59,018 48,515 47,768 33,149 39,413 15,732 31,688 20,814 34^027 14,820 10,498 4,849 37,586 24,708 81,910 22,344 11,636 13,989 48,139 33,981 41,654 16,936 16,804 3 28.3 3 8.9 1 5.4 1 4.4 1 5.3 1 1.1 2 8.4 5 33.2 1 S.l 2 22.0 1 8.9 8 15.7 2 6.9 1 1.6 1 2.0 2 5.0 2 8.0 1 1.1 6 51.5 5 10.3 4 9.6 Total 2,614,335 172 6.5 2,649,982 177 August 16, 1926. 6.6 2,686,325 151 5.6 2,722,669 123 4.5 2,811,969 123 4.3 46 North Carolina Board of Health enlargement of the greater degree. If the spleen cannot be detected the child is insti'ucted to take a deep breath. The examiner places the tips of the fingers of his right hand on the abdomen just below the costal mar-gin and makes slight but not deep pressure just at the time the child takes a deep breath. If the spleen is enlarged it may be felt as it descends be-ing pushed down by the diaphragm during deep inspiration. Care must be taken not to press too deeply for then the descending margin of the spleen may not be felt. Spleens that are readily palpable or of the higher degrees of enlargement may be detected without the necessity of the child's taking a deep breath. The spleen may be palpated more easily in children between the years of two and twelve than those younger or older. The following classes of spleens are used : 1. Negative on deep inspiration. 2. Palpable on deep inspiration. 3. Palpable on normal inspiration but not one finger's-breadth below the costal margin. 4. One finger's-breadth below the costal margin on normal inspiration. 5. Two finger's-breadth below the costal margin on normal inspiration. 6. Three finger's-breadth belov; the costal margin on normal inspiration. History Index as to Positive or Negative Malaria For this purpose house to house surveys are made and the presence or absence of malaria is recorded for each individual for the two preceding years. Case histories are accepted as positive only when the individual gives a history of repeated periodicity. Parasitic Index As a further means of arriving at a conclusion as to the prevalence of the disease in a county, a parasitic index is established. For this purpose a thick, with a corresponding thin smear is taken from each person, will-ing to have it done. As the smears are taken they are numbered with the ordinary soft lead pencil by writing direct into the dried blood the serial number of the individual, which corresponds to the history index number. Thick smears are examined fifteen minutes and then five minutes before calling negative. Intensive Mosquito Survey The next step toward arriving at a solution of the mosquito problem in places where anti-mosquito measures are thought to be applicable consist in intensive surveys for the breeding places, in the collections of water indicated on the survey map. This is accomplished by one collecting adult mosquitoes from regular collecting stations, second, by collecting Larvae and Pupae and breeding them out. All collections made are classified as to species, character of water from which collected, whether permanent or temporary, and day of collection. Twenty-first Biennial Report 47 Method of Objective Three From the data elicited during the preliminary survey to determine the incidence and geographical distribution of the disease and biological factoi's responsible for transmission. The Health Officers, through the association of the general director, determines w^hat plan of procedure to make in formulating their program of control. Results Accomplished During the Organization Period of the Bureau It is physically impossible, with the present personnel, to resurvey all counties undertaking measures for the investigation and control of malaria fevers, as well as placing the department at a prohibitive cost, I am there-fore giving only one concrete example of what a county organization may expect in the way of reducing the incidence of the disease when the attack is made in an intensive way. Resurvey of South Creek Section BEAUFORT COUNTY South Creek is a small settlement located in the extreme southeastern part of Beaufort County, North Carolina, on an arm of the Pamlico River. The community is situated in a small tongue of land which divides an arm of the river into two branches, called Bond Creek and Muddy Creek. Neither of these creeks is more than a mile in length. From the broad northern point, the tongue gradually widens until at a distance of approxi-mately 1% miles it is a little over a mile wide. The land is quite level, as it is in all this region, and is only a few feet above sea leveh The ground water level is only 6 feet below the surface. Three or four small branches, which cut across the area, drain the excess water into the creeks. If these were kept in good condition, the natural drainage of the land would probably be fairly good. At the time this survey was made, these branches were almost completely dry, owing to long continued drought. Following is given the average precipitation for the past five years in Wenona and New Bern, two towns situated in opposite directions from South Creek, in adjoining counties. No records are kept in Beaufort County. 48 North Carolina Board of Health them out of employment. In 1925, owing to a severe local hailstorm, the farmers lost absolutely their entire crops, and many migrated to other localities. About Vs of the houses are now unoccupied. The present occu-pation of the remaining inhabitants are farming and fishing. The principal crops are corn and cotton, but the boll weevil has invaded this section as well as the rest of the State. Much of the land is cut over timber land, on which nothing is grown. My impression is that not over % the available land is under cultivation, and even this estimate may be high. Past History of Malaria The South Creek section has always been known as a bad malarial region. Accounts of blackwater fever are common, while, according to the inhabitants, every fall saw a visitation of the disease to a majority of the inhabitants. Of more interest than these accounts, are the doctor's reports. Dr. John Bonner, now Health Officer of Beaufort County, for many years lived in Aurora, and did most of the practice of South Creek. His interest in malaria, his principal source of income, led him to keep records of his calls for several years. His records show, that in the years 1920 to 1922, inclusive, there was a large number of calls for malaria every week, especially in September and October. The peak was reached in October, 1922, when in one week, he visited 45 new patients with malaria. In January, 1923, the newly-organized Health Department of Beaufort County, began a vigorous county-wide campaign against malaria. Blood examinations made on about 7,000 inhabitants of the county, showed a general average of 45% positive. In the South Creek section, of 239 white people examined 99, or 42% were positive; 789c were tertian, 20';c aestivo-autumnal, and 1% quartan. In the negro colored school, of 43 children examined, 30 were positive, a rate of 70 9o- During the succeed-ing summer and fall, the people were urged to take quinine according to Bass' treatment. According to my census, 56 people now present took the entire course of treatments, while 12 took part of the course. Some of them have continued taking treatments every year since that time. The county did not distribute the quinine free, but the people had to buy it. At the instance of the Health Officer, all storekeepers in the county agreed to sell it at cost. Immediately its price dropped from $1.50 or more to an average of 80 cents, and sales began to climb. There are three storekeepers in South Creek. They estimate their sales as follows: SALE QUININE IN POUNDS 1922 1923 1926 to date Store No. 1 2 16-18 less than three pounds. Store No. 2 2 15-20 none. Store No. 3 1.5 11-12 about 1 pound. From total sales of approximately five pounds in 1922, the amount rose in 1925 to over 42 pounds from these three stores alone. The price of quinine was somewhat less in Aurora, and it is reasonable to suppose that some quinine was bought in that town. At the same time the sale of chill tonics fell off, and only a little is sold now. If it did nothing else, this campaign certainly popularized the use of quinine. Twenty-first Biennial Report 49 Referring again to Dr. Bonner's records it will be seen that in 1923, at no time did his calls rise above seven per week, even in the season of greatest transmission. In 1924, the highest number seen was 12, in one week in October. Recox'ds for 1925 are not available, but the general im-pression is that there was very little malaria there the past season. This is probably true, especially since it was a year of deficient rainfall. Present Survey The present survey was undertaken during the second week in August, 1926, for the purpose of determining the amount of malaria present, and the opportunities for its transmission, and the reasons for any change that may have occurred. The survey was made by a house-to-house canvass, and the following information was secured: Name, age, sex, race, length of residence in locality, history of acute malaria within past year, type of house and condition of screens, and history of intensive quinine treatment. At the same time, spleen examination was made on all children under 15 years of age, and blood smears were taken from approximately half the people. After the history was concluded, the house was carefully searched for adult mosquitoes. Results of Survey A total of 161 persons were taken in the census, from 41 occupied houses. Seven occupied houses were not taken in the census, since the occupants were not at home when the census was made. Of this number 120 were whites, and 41 negroes. Separation was not made into the sexes, since this was not deemed important. The following gave a history of at least one chill, followed by fever and sweating, since March, 1925. Since the use of quinine is so general, and is taken for almost any ailment, it was difficult to elicit a history of more than three or four chills from anyone. 1925 1926 Mar1ch A2pril J2une4July4Aug.7Sept.2Oct.1Dec.1Marc2h Ma3y Jul1y Aug. Total 30 (Dupl) (Dupl) Whites, 22, Negroes, 8, and equally distributed through all ages. It is quite possible that some of these histories were not malarial. Following are the results of the blood and spleen examinations: Number Spleen Palpable Blood Age Examimd Examined No. % Examined Positive 0-2 5 3 .. - 2-4 10 10 • 6 1 5-9 25 25 4 18 10-14 31 23 3 22 15-19 11 -- ._ 8 20-39 41 -- - 16 40 up 88 -. - 12 161 61 7 11.5% 82 1 50 North Carolina Board of Health All spleens except one were only palpable on inspiration. The one was one finger's-breadth below the costal margin. A spleen rate of 11.5% indicates only a very moderate degree of endemicity. This is borne out by the results of the blood examinations, with only one positive out of 82 examined. It must be remembered, of course, that the malaria curve usually does not begin to rise until the first of August, and that this survey was made in an abnormally dry season as well. Nevertheless, it seems clear that there is only a small amount of malaria present when the survey was made, and that this condition has prevailed for the past few years. Distribution of Positive Cases—(Spleen and Blood) When spotted on the map of the area, it is seen that four of the eight cases are grouped in the center of greatest population, near the point of land, and, at least at the time of the survey, fairly distant from any breeding places for mosquitoes. Two more cases occur in the same point, but somewhat removed from the other four, and these are situated near several large ditches, which at the time of survey were dry. The ditches are not shown in the map. The two remaining cases are scattered. One palpable spleen occurred in a house which is reported to have had several cases of blackwater fever in the past few years. The last case occurred in March, 1926, according to the doctor's report, but the child was not prostrated, and soon recovered. This child is still taking quinine regularly. Length of Residence of Positives All eight positive cases (spleen and blood) have lived in the area all their lives. The one blood positive case was in a boy just three years old, whose mother, when the blood was taken, said she was sure the boy had malaria. We had been giving him small doses of quinine, but had stopped it some time previous to our visit. Comparison of Findings in 192.3 and 1926, in Those People Present Both Years From the original records of the 1923 work, I secured the results of the blood examinations in those people who were still present at the time of the survey in 1926. Following is a summary of the results: 1923 1926 No. Cases Present No. Neg, • Positive Pos. Pos. Both Years Vivax. Falcip. Quart. Spleen Blood 69 32 31 6 2.0 The 1926 figures should not be expressed in percentages, since these people, all of whom were examined in 1923, were not all examined in 1926. There is, however, a marked reduction in the incidence of malaria in these two years. Adult Mosquito Catches At the same time that the census was made, opportunity was taken to look for mosquitoes in the houses. Twenty-two of the total of 41 houses were carefully searched. A total of four anophelines, all quadrimaculatus, were found. Two of these were found in house No. 1, and two in house No. 2. These may have come from a ditch just outside the area which was not searched for larvae. Twenty-first Biennial Report 51 Probable Causes for Decrease in Malaria in the Area While it is impossible to state the exact amount of malaria which used to be present, there seems to be no doubt that formerly the disease was very prevalent. The fact that 45Vo of the people of the county were found with parasites is indicative of this especially during the autumn. It also seems to be true that the incidence of malaria has decreased remarkably in the past three or four years. I shall now take up some of the possible causes of this decrease. 1. Intensive Quinine Treatments in 1923 and Succeeding Years. As already described, examination in 1923 showed 45% of the people with one or more classes of malaria parasites in their blood. The indica-tions are that the intensive treatment was successful. Fifty-six (56) people now present took the full course of treatment prescribed, and 12 others completed part of the course. In addition to the 1923 campaign, in 1924 and again in 1925, blood smears were made from a large number of people in the area, and those positive were urged to take treatment. The fact that quinine sales increased about 10 times in 1923 indicates that a large amount was used. The intensive treatments of 1923 doubtless sterilized the blood of a fairly large percentage of the population that year, and the treatments of the succeeding years did the same thing for a lesser number. Even in the presence of the vector in considerable numbers, this must have had an effect in reducing the transmission. The rainfall of 1923 was only slightly below normal, probably not enough so to influence the amount of anopheles breeding. It is the consensus of opinion that quinine treat-ments was the greatest single factor in reducing malaria in that year, although it alone probably cannot be held responsible for the decrease. Perhaps the greatest good from this campaign, however, was the popularization of quinine in adequate doses for chills. The lessons learned that year have certainly not been forgotten. It is common to find people who are now taking quinine every autumn, because they were taught to do so by the health officials. They also use it whenever they have a chill, instead of chill tonic; and they use it in large enough doses to have a therapeutic effect. 2. Rainfall. The rainfall in 1923 was slightly below normal; that of 1924 fifteen inches above normal, and a slight increase in the amount of malaria prob-ably occurred, but 1925, and 1926 have been years of abnormally low rainfall. At the time of the 1926 survey, all the usual water courses were dry, or practically so. Conditions were distinctly unfavorable for mosquito breeding, and as a consequence the mosquito index was undovibtedly low and hence transmission was perhaps almost nil. It would be interesting to see what effect the late August rains will have on breeding. 3. Drainage. While a drainage district has been formed and is in operation in an adjoining area, the value of the land does not permit such a district to be formed in South Creek. As stated elsewhere, natural drainage is prob-ably good except in a few low-lying areas, and this drainage has been 52 North Carolina Board of Health favored by a few well-placed ditches which have been dug. Once a year these ditches are cleaned out by the farmers, but during all the rest of the year they are not |
|
|
|
1 |
|
A |
|
B |
|
C |
|
D |
|
F |
|
G |
|
L |
|
M |
|
N |
|
O |
|
R |
|
S |
|
T |
|
V |
|
W |
|
|
|