?■»' ■KJlOl N7E6n iiiiii HuU Qfallegc of :?^grtcult«re At QfotncU MntBBretta 3tlfara, ?J. f . Htbrarg Child Health in ;rie County, New York The report of a brief co-operative in- quiry into conditions relating to child health and the agencies for dealing with them, in the rural sections and villages of Erie County, New York, Nov. -Dec, 1921. Reprinted from the Supplement to Mother and Child, Magazine of the American Child Hygiene Association, issue of May, 1922 The National Child Health Council Seventeenth and D Streets Northwest Washington, D. C. Cornell University Library The original of tiiis book is in tine Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924003500943 Table of Contents I. Introduction 1-4 II. Summary 4-16 Recommendations 14-16 III. The Under School Age Child 16-21 Recommendations 20-21 IV. Medical School Inspection 21-27 Recommendations _ 25-27 V. Medical Service 27 Recommendation 27 VI. Nursing in Relation to the Child 27-33 Recommendations — 32-33 VII. Health Teaching in the Schools 33-46 Recommendations 43-46 VIII. Organization of Children 46-48 Recommendations 48 IX. Recreation _ 48-50 Recommendations 50 X. Nutrition of Children 50-59 Recommendations ■. 57-59 XL Health Officers 59-65 Recommendation 64-65 XII. Alental Hygiene of Children 65-80 Recommendations 76-80 XIII. The Health of Dependent Children 80-82 Recommendations _ 82 XIV. Health and Working Certificates 83-88 Recommendations - 88 Additional Material - 89 Child Health in Erie County, New York L INTRODUCTION The National Child Health Council was formed late in 1920 by six national organizations as a common meeting ground for coordina- tion of activities relating ito the health of children. How the field services of national associations for children may be increasingly the result of common planning and correlation is one of the important problems that have been presented for solution. As a first step toward finding an answer ito this question a co- operative inquiry into child health in some one county was decided upon. It was agreed that the chief object of the inquiry should be to aid the development of strong and effective coordination of local health work, in the interests of an adequate and balanced child health program. But it was also agreed that no recommendation should be made to increase the comprehensiveness of the immediate program of local child health activities at the expense of the development of such effective local coordination. The first invitation came from Erie County, New York. The following representatives joined in requesting such an inquiry, under the Council's auspices, into conditions in the rural areas and villages of that county: „ „ , ^, . . „ , ^ Mr. Frank S. McGraw, Chairman Buffalo Chapter, American Red Cross..,, „, xt c- i. Mrs. Florence Noye, secretary Buffalo Foundation — „ Dr. Frances M. Hollingshead, Director Buffalo Tuberculosis Association Mr. Hugo Brown, Secretary District Nursing Association Mrs. Anne L. Hansen, Superintendent Erie County Board of Child Welfare... Mrs. Blanche Devine Erie County Board of Supervisors... Mr. Robert C. Palmer, Chairman Erie County Charities and Correc- tions Mr. Frank M. Stage, Deputy Commissioner Erie Couin> Cliildren's Aid Society— Mr. Douglas P. Falconer, Director Krie County Home Bureau _ Mrs. Cleo B. Xuld, Cliairmau Executive Committee Erie County Medical .\ssociation Dr. Arthur G. Bennett, President Erie County Physicians' Protective Association _ Dr. John H. Pryor, President Junior Red Cross - _ _Mrs. Charlotte Glenny School District Xo. 1 _.Mr. C. A. Heist, Superintendent School District No. 2 Mr. Henry A. Dann, Superintendent School District No. 3 Mr, William E. Pierce, Superintendent School District No. 4 Mr. Edgar D. Ormsby, Superintendent School District No. 5 Mr. William E. Bensley, Superintendent State Department of Health ,Dr. Edward Clark, District Sanitary In- spector The State Department of Health and the State Department of Education both expressed their approval of the invitation of the local Erie County group that such a study be made and offered their co- operation. The organizations which participated in this study through a staff member or a delegated representative were : American Child Hygiene Association American Red Cross Child Health Organization of America National Child Labor Committee National Organization for Public Health Nursing National Tuberculosis Association National Committee for Mental Hygiene New York Child Labor Committee It is not possible to list the names of all who were consulted to a greater or less extent in the preparation of plans for the Erie County study, and in 'the preparation of the malterial included in this report. The Council wishes to make acknowledgment especially to the follow- ing departments, bureaus and organizations or representatives of them: American Social Hygiene Association Federal Children's Bureau National Health Council New York State Department of Education New York State Department of Health U. S. Bureau of Education U. S. Public Health Service The actual period of the field work upon which this report is based was slightly less than two weeks, beginning November 28, 1921. The statements of fact and recommendations are herewith pre- sented, not as a report of a comprehensive survey but merely as a primary contribution toward the coordination of health work for children. They deal with present conditions as found in Erie County and are not necessarily considered applicable elsewhere. II. SUMMARY Erie Cnunty* presents a widely varied picture of .Vmerican child life, including, as it does, a rapidly developing manufacturing area radiating from the City of Buffalo and some completely rural sections in the southern lowland and mountainous districts, in some of the least accessible of which may be found many of the charadteristics of farm life as it was in this country during the latter part of the last centun'. Urbax axd Rural Devkxcpafent — 'Bufifalo, situated on I.a]erhaps are taxed out of proportion to their means, needs to be recognized in justice to the citizens and the schools of those districts. The enlargement of school districts under a plan that shall be satisfactory and not an imposition upon the people of the State is being studied by the Committee of 21. As a distinct contribution to health, those interested in the welfare of school children should support any sound proposals for legislation that will remove the grave handicaps of the present school district system. III. THE UNDER SCHOOL AGE CHILD While in many communities in which material progress has been made in the health program it is the child from 2 to 5, inclusive, who has not received adequate attention, it is true of Erie County outside of the large centers of population that the health of all children under the school age period, including infants, is one of the most vital prob- lems demanding immediate consideration that is not being fully dealt with. The high infant mortality rate in certain sections of the county and the well known fact of development of defects under the school age which show an increasing tendency toward permanent physical impairment if neglected, are sufficient evidence of the need for early and intensive plans for this age group. IS Prenatal Care — ^The relative improvement in health and reduction in deaths among children for whom there has been prenatal care has been strikingly shown by studies of work of the Maternity Center As- sociation of New York, of the Instructive Visiting Nurses Associa- tion of Boston, and elsewhere. In Erie County an analysis of 876 of the 984 infant deaths in the rural parts of the county for 1915 to 1920 inclusive shows that 46 per cent, of these deaths were due to con- genial debility, accidents at birth, congenital malformations and pre- maturity, this exceptionally high percentage furnishing a most elo- quent plea foir attention to prenatal care. No organized prenatal work was found in the parts of the county studied. The community nurses, as they come in contact with ex- pectant mothers, give advice, but this reaches only a very small frac- tion of those who could be thus benefited. According to physicians and health officers consulted, pregnant women report to their physi- cians in only a small percentage of cases. In one community where there were a large number of foreign-born the health officer stated that only about 10 per cent, of the mothers had obstretical care. The possibility of reduction of preventable deaths due to prenatal causes is a very hopeful one if there is increase of organized effort to that end. General Infant Mortality — The average infant mortality rate for the part of Erie County studied, which is largely rural, was 90.5 for the period from 1915 to 1920, inclusive. The infant mortality rate for the same period for the rural part of New York State was 84 and for the whole of the state including its largest centers was only 92. These figures show the great importance of the infant welfare problem in this section. Several townships and villages stand out prominently as having a high infant mortality rate covering the six-year period, especially Cheektowaga township and the villages of Depew (with a rate of 134.6), and Sloan (129.9) within this township. Undoubtedly these high rates are due to a great extent to the large foreign and industrial popu- lation. There are also in Cheektowaga township a number of chil- dren under institutional care. Springville had an infant mortality rate of 105.8, and Hamburg a rate of 113.4; Lancaster township, exclusive of Lancaster village, a rate of 123.6, and Tonawanda township, exclusive of Tonawanda City and Kenmore village, a rate of 120.9. During the six year's there were 984 deaths of infants under 1 year of age. Of this number 876 deaths were classified according to the cause of death. Nineteen per cent were due to respiratory diseases : 28 per cent, to gastric and intestinal diseases ; 46 per cent, to con- 19 genital debility, accidents at births, or congi-nital malformations or pre-maturity ; 2 per cent, to communicable diseases, and 5 per cent, to all other causes. There were 9 deaths from tuberculous meningitis and 3 from syphilis. Birth Rate — The area studied has a general birth rate of 20.3 and is below the average for the state in 1920, which was 22.5, but higher than that for the rural part of the state, which was 18.7. As might be expected the birth rates are high in the townships where the foreign population is large as Cheektowaga, Concord, Blasdell village, Angola and Famham. Infant and Preschool Consultations — Throughout the county there were during the past year only six consultation centers for under school age children. (1) A consultation for demonstration purposes was held once a month at Hamburg village by the Red Cross, but there was no nursing follow-up. (2) A weekly consultation was held at Kenmore in the Y. M. C. A. Building, with an average attendance of 25. A half day a week follow-up work was given by the Riverside nurse. (3) A consultation was held at Riverside in the high school, with a small attendance. The follow-up work was done by the community nurse. (4) Williamsville held a consultation once in two weeks, which had a very small attendance. A community nurse did the follow-up. (5) The town of Lancaster held a weekly clinic which had a small attendance, and the follow-up work was done by the community nurse. (6) A consultation was held in Akron which was discontinued. There are on an average, 1,800 births a year in the rural part of Erie County. Using the life table to determine the number of children living at each of the ages up to 5 on the basis of 1,800 births a year, there are found to be approximately 8,000 children of pre-school age in the county. Probably not many more than 100 of these were reached by the pre-school consultations described above. The health centers in Buffalo which have clinics for infants and small children do not accept cases from outside the city limits. There were several itinerant consultations conducted by the State Board of Health in several sections of Erie County last year. These 20 were in Akron, Williamsville, and East Aurora. In all, 406 children were examined, of which 112 were under two years of age, 262 between 2 and 6, and 32 of school age. None of these had been examined be- fore. Only 64 of the total number were found to have no defects. The others had 1, 2, 3, 4, 5 or more defects. Only 16 were recom- mended for hygienic correction. The remaining 316 were recommend- ed as in need of medical observation and care. Although the mortality for the pre-school group (2 to 5 years of age) is relatively low as compared to that of infants, the damage rate, due to prevalence of contagious diseases and neglect in correct- ing defects, is excessively high and is reflected in the mortality and morbidity of later years. From the high mortality due to congenital defects, accidents at birth, and prematurity it is obvious that there is an important prob- lem of obstetrics. There should be an excellent opportunity for a com- mittee of pediatricians and obstetricians to cooperate with the Erie County health council and any committees active in child health prob- lems through helping to improve standards of obstetrical work and through increasing the use of educational and clinical facilities by those in charge of consultation centers and the medical profession generally. Recommendations Every physician, nurse and nutrition worker of Erie County who serves the smaller cities and towns, as well as every health officer and the medical examiners of school children, are potential allies who can be organized effectively for a thorough program for consultations for the pre-school child and for follow-up in the home, with advice to parents on feeding, health habits, the correction of defects, and the prevention of communicable diseases. 1. It is recommended that the Erie County health council shall proceed at once to organize a definite program for health of the under school age child, including consultation centers throughout the county and the promo- tion of this work through all the existing health resources. Not only could the present consultation centers be materially strengthened but they could be increased four or five times in number and still no more than adequately serve the needs of the county. 2. It is recommended that the health council create a special com- mittee; on the under school age child, which shall see that this program is modified to meet new conditions as they arise and that it is being followed actively. The pediatric and obstetrical departments of the Buffalo Medical School and the City Health Department would undoubtedly cooperate 21 heartily with such a committee and help in arranging for consultation service where it is desired. The Buffalo Foundation, with its facilities for stud}', research and standardization should also be a material help, in addition to the State Sanitary Supervisor' and Supervising Nurse for the district, the American Red Cross and the Buffalo Tuberculosis Association, all of which are vitally interested in such a program for the under school age child and are promoting work along this line as far as possible under present conditions. 3. It is recommended that those interested in the health of the child under school age in Erie County proceed at once to confer with the Child Hygiene Division of the State Department of Health, as to the possibility of an intensive child hygiene campaign in Erie County, in which full advantage may be taken of the facilities which will be available to the state. IV. MEDICAL SCHOOL INSPECTION A state law requires that every school child shall be examined by a phyisician once each year and that the school authorities shall employ a physician for this purpose. If a certificate of examination of a child from a practicing physician in good standing is offered the authorities it must be accepted by them in place of an examination by the school examiner. Purpose The purpose of these examinations is to obtain a clear picture of the condition of the child from the physical and mental standpoint, to reveal any defects which he may have and their relation to his physical and mental activities, to indicate definitely such corrections of defects as should be made, and in general to serve as a guide for the teacher, the physician, the nurse, and especially the parent, in raising the stan- dard of the child's health. The examinations of school children, while valuable, have fallen short of this ideal in many respects. ^^'IDE Variation in Examinations Inquiry revealed a great variety in the character of these examina- tions. Time — In one school the teacher reported that the physician had examined 30 children in 45 minutes and even briefer times of exami- nations were quoted from other schools. In another school it was stated that the physician had examined 14 children in VA hours. Standards — The standards of examinations also have shown oreat discrepancies and few of them have been thorough. Although most of the physicians appreciated the need of removing the clothng to 22 the waist in order to secure a proper examination of the heart and lungs it is rarely done, and one examiner objected to doing it on the grounds that he could hear through a brick wall with his phinete- scope. One physician gave as a reason for inadequate examinations the lack of proper examining rooms, although in the largest school in his district he had used the teachers' rest room for examining the children. Another physician stated that he went to the children's homes for more thorough chest examinations in cases with suspicious symptoms. While most of the defects recorded are tonsil and adenoid condi- tions, defective vision and carious teeth there is a great variety in the relative numbers of these defects found in different schools in the same year and also in all the districts from one year to another. This would indicate a marked difference in the character of the examinations as it can scarcely be accounted for on any other ground. It is probably due not only to differences in diagnostic methods but also to the fact that in many communities the examining physician is changed fre- quently. Defects indicating malnutrition were recorded in only a small percentage of cases prior to the special weighing and measuring campaign during 1920-1921, when a higher percentage of the children under weight was found. Emi'ployment and Pay — In two instances physicians stated that they did not receive enough pay to justify a better examination. One of these physicians was paid 75 cents per child and the other 50 cents. The latter stated that he spent about five minutes on each child. In one village all the physicians and one osteopath were paid $1.00 per child by the school authorities. None of the examinations in this vil- lage were made in the schoolroom. In one village the health officer stated that he wished to persuade the school board to make a similar arrangement, as he did not wish to give the inspection work to a rival physician and believed that he would be criticised for employing himself because he was a member of the board of education. In this village no examination records were found in the schools of a date later than 1917. The health officer claimed that he had examined the children free of charge in order to escape criticism. Among 14 phy- sicians 5 were paid 75 cents per child, 5 were paid 50 cents per child, 3 were paid $1.00 per child, and one was paid 25 cents per child. Re- ports were received of exceptional cases in which the pay ranged up- ward from 10 or 15 cents per child. Lack of Supervision of Selection and Work It is clear from the facts that there is no adequate supervision of the selection of these physicians and that the type of work done by 23 tlKiii could be vastly improved' it there were centralized supervision nearer at hand than Albany. This absence of an effective force for securing desirable standards for school medical examinations is ob- viousl}- the chief reason for most of the hast\- and ineffective work done by the examiners. 1,.\I.K OF C'ONFIDENCI-: IX THE Ex.\ M I .\.\T10NS Much dissatisfaction was expressed by teachers and others with the character of the medical examinations. In some instances it was definitely claimed that corrections of jjhysical defects were neg- lected by the parents because they did not have faith in the quality of the examination. In a few instances teachers stated that the examiner had reported children as having normal teeth, while observation by the teacher had shown several badly decayed teeth. One of the most effective methods of securing confidence in medi cal examinations is to have the parents present during the examina- tions to observe the methods by which they are made and have the findings explained to them so that they will have a real basis of under- standing upon which to make their efforts for correction. No school was found where the parents had been present at the time of the ex- aminations of children and in the majority of cases no invitation had been issued to them to be present. Examinations of Real I'aluc Through the courtesy of the State Medical Inspector of Schools it has been possible to compare the tabulated records of the exami- nations for the five school districts covered in this inquiry during the past five years. These tables show a net increase in the total number of children examined yearly during this period and a percentage of these having defects treated which, while low, is nevertheless worth while. The fact that in 1920-1921 out of 11,218 defects found 2,963, or about 26 per cent, were "treated" is an indication that this work is producing results of real value even though the exammations are in many cases superficial and the follow-up work is often lacking. FoLLOW-UP OF Physical Examinations The most effective method of correcting the defects discovered through medical examinations combines, first, a stimulation of the individual child's personal interest in securing such correction in a way that does not stigmatize him as defective, and, second, a follow- up visit in the home to stimulate parental action, the latter being prop- erlv i^art of the work of the school nurse. 24 The usual practice is to send the report of the physical examina- tion, in case there is a physical defect, to the parents, in order that the child may be taken to the family physician. This report is, as a rule, in the smaller schools sent by the teacher. The records are usually kept in each class room and a report is sent to the Division of Medical School Inspection of the State Department of I'Mucation. Where a nurse is employed the follow-up is done by her. In a few schools the health officer has taken a real interest in obtaining these corrections and visited the parents during his rounds of practice. In two town- ships where this method was especially effective the health officer was the only practicing physician in the township. Where there has been the usual competition the physicians have been more reluctant to do follow-up work. In some instances, where there have been no school nurses, the physical training teachers have shown a commendatory in- terest and have been fairly effective in obtaining corrections. In some cases they have even visited the homes, but they usually depend upon talks with the children. In a very few instances the teacher visited the parents and persuaded them to make coirrections. Because of the gen- eral lack of adequate nursing follow-up in the schools the interest of the parents too often depends largely upon a formal notice to the home This means that in the great majority 'of cases the value of the medical examination is wholly or partly lost. This condition can only be remedied by a county-wide plan for public health nursing, in- cluding school nursing, such as proposed in the nursing section of this report. Facilities for Corrections Much of the surgical work that has resulted from the medical examinations has been done in Buffalo. A few of the rural physicians have done tonsil operations but most of them have preferred to send their patients to Buffalo hospitals or specialists. One school medical examiner reported that tonsil operations were done by one of the hos- pitals in Buffalo for $6.00, and that the school nurse had taken as many as 40 children for such operations. A high percentage of cases of eye defects which were treated were referred to Buffalo oculists or clinics. There is no consistent plan for securing correction of these defects because of the lack of central planning and supervision of this work. In indigent cases, except where the public health nurse has exerted her influence, children needing glasses have not, as a rule, received attention. One child, boarded out by the county, was found who could not afford glasses and although the school examiner had recommended them and the teacher realized the importance of the need 25 the matter was not followed through in such a way that glasses were secured. Except in a few communities where the local dentists and the public health nurse had done enough educational work to result in a fairly large number of children having fillings made in their first teeth, there was very general failure to secure proper correction of dental defects. Too often the physicians or dentists have recommended that severely decayed first teeth be retained in order to prevent malforma- tions, without advice as to the proper treatment that would prevent serious results from the presence of the untreated teeth. Unfortunately in a number of townships there were no dentists available and here again no organized effort was evident to bring facilities for dental cor- rection to the children or the children to them. Coordination Between ^Medical Examinations and General Health Work A large number of medical examiners are also health officers. In the districts of 19 health officers surveyed by the District Sanitary Supervisor it was found that 57 per cent, of the school districts in the areas under the health officers' jurisdiction were also covered by them as medical examiners. On the other hand, there is little if any genu- ine coordination between these two types of work. Undoubtedly a great deal of improvement in health work generally would result from such coordination. While this is a problem that is being discussed and will be dealt with on a state-wide basis it may not be amiss, in the recommendations to follow, to suggest certain principles which seem sound in dealing with it in any locality. Recom m endations 1. It is recommended that coordination between medical examinations and general health work in local communities should conform to the fol- lowing principles : (a) The administration of medical work in the schools, especially in rural areas and small communities, should be under one administra- tive control. (b) The jurisdiction of neither the school authorities nor of the health authorities of the county should be relinquished but both should be administered through one administrative head, whether on the pay roll of the schools or of the nearest health administration unit. (c) There should be definite written agreement in advance, subscribed to by both the schools and the health authorities, outlining the scope and jurisdiction of medical work in the schools. 2. It is recommended that there be some method of check upon the se- lection and pay of school examiners through the state authorities or prefer- ably through a county representative in charge of this type of work. 26 Such a check would greatly add to the effectiveness of the work of the examiners, particularly in those cases where the examiner is doing satisfactory work but is likely to be changed at the whim or political preference of the school trustee, or perhaps because he is unwilling to accept a fee that is inadequate for good work. It should set some reasonable minimum for pay for thorough examination. Such a check would also probably result in eliminating the indis- criminate handling of examinations by physicians in their offices, as it was noted in one community. 3. It is recommended that there be central county supervision not only of the selection but of the work of the school medical examiners. The improvement in the methods of communicable disease con- trol through the limited state supervision of health officers by the State Department of Health and its representatives, through health officer conferences and schools, etcetera, suggest ways in which stan- dards of local school work could be improved through such super- vision. Conferences, demonstrations and pediatric clinics, through the co- operation of the Buffalo Medical School and the County Medical Society, could be used for interesting and stimulating the local phy- sicians in improving methods and setting higher standards. This su- pervision and educational work could be most economically adminis- tered through a county health unit or department of health, in coop- eration with the educational authorities. In a number of cases where the local examiner is also the health officer, such a plan would be particularly satisfactory not only in avoiding the building up of a sepa- rate system of supervision, but because it would fit in with the prece- dent already established for supervising work of these men through the sanitary supervisor. The fullest cooperation of the local physicians is essential and the County Medical Society should be of the greatest help in planning for and carrying out any measures for raising the standards of school medical examinations and follow-up work. 4. It is recommended that facilities be provided in the schools, as far as possible, for utilizing the time of the medical examiner to the fullest ad- vantage through clerical service, proper equipment and examining room. The value of the school nurse or other trained health worker in weighing and measuring of children, taking preliminary records, and doing such type of inspection work as has been approved by the phy- sicians, has been demonstrated wherever tried. The provision in schools of satisfactory .rooms for examinations probably will depend 27 too often upon some ,satislactor\- basis for combination of school dis- tricts and eventually the elimination of the one rdcim, one teacher school buildint;-. V. MEDICAL SERVICE The practicino^ physicians are fairly well distributed over the county. There is probablv no community with a serious lack of medi- cal service. Nearly every part of the county is not far from ex- cellent automobile roads. In the territory covered b}' the 19 health officers questioned by the state sanitarv supervisor there was, on the average, one physician for every 1,360 inhabitants, while for the whole county, including Buffalo, there is about one physician for every 700 inhabitants. The State Medical Society reports that there are 80 ph}-sicians in Erie County outside of Buffalo, Lackawanna and Tona- wanda. This would mean an average of approximately one physician for 1,300 inhabitants. Of the physicians of Erie County 85 per cent, are graduates of the I^juffalo Medical School, but those in the rural areas are not receiv- ing the clinical advantages, opportunities for consultation and contacts with the most progressive medical developments that come to their fellow-practitioners in Buffalo. It is vital to the whole problem of child health that it shall be supported by the members of the medical profession and that they shall guide its medical as])ects. The busy practitioners in the smaller communities should, just as far as possible, have the advantages of the best pediatric experience. Some experi- ments in graduate extension work for physicians have been tried bv the faculty of the medical school. The medical school clinics and hos- pitals of Buffalo offer unusual opportunities for extension work for the benefit of medical service throughout the county. Graduate courses adapted to the needs of the rural physicians, conducted during the summer or for short periods on one or two days a week might result in the attendance of a number of physicians. Clinics, under the County Aledical Society, throughout the county should develop a wide use of such service by the physicians in the smaller communities. It is recommended that the County Medical Society and the Buffalo Medi- cal School give especial attention to the possibilities of graduate extension service in pediatrics and other branches of medicine for the benefit of the physicians of the smaller communities of Erie County. VI. NURSING IN RELATION TO THE CHILD It is an accepted fact that the development of our nation depends very materially upon the care given our children today. Also there are very few that will dispute the statement that one of the most pow- 28 erful factors in conserving and promoting child health is tiie public health nurse. The nursing problem of Erie County is not radically different from that of many other counties in the country. It is widely different in different parts of the county (outside of Buffalo, Lancaster, Lacka- wanna, Tonawanda and Gowanda). In many sections of the county there is an urgent, almost pathetic need for even the most casual sort of public health nursing. The Problem A crude but striking indication of the need for more attention to nursing in Erie County will be found in the infant death rates and tuberculosis death rates cited in the summary at the beginning" of this report. No more striking illustration of the need for nurses could be given than the figures of the State Department of Educaion, show- ing thousands of defects discovered among school children as to which no corrections are reported. It is a well known fact that the follow-up visit of the school nurse is the most effective method of securing the correction of such defects, supplementing the work of the teacher with the individual child. The vital part that the public health nurse plays in the organization and building up of child consultation clinics and in supplementing the work of the private physician, the health officer and the school medical examiner generally is too well known to need discussion here. As an indication of the children's problem, which demands in- creased nursing service in Erie County it should be noted that there are over 19,000 children registered in the public and parochial elemen- tary schools in Erie County in the five school districts touched in this inquiry. There were 1903 births during 1920 in the area studied and 147 infant deaths, indicating an immediate need for special considera- tion of an infant and maternal welfare program. Community Nurses — There are four general community nurses outside of those larger centers which were not included in this inquiry, one employed by each of the following villages : Williamsville, Akron and Kenmore, in addition to the one employed by the Red Cross in East Aurora. This work cannot be praised too highly as pioneer work paving the way for a complete public health program in one of the most ef- fective possible ways. In some instances it is fairly intensive, as pub- lic health nursing goes with the present shortage of nurses, but every 29 one of tliese comnuinity muses feels inadequate to meet the full prob- lem. With practically all of the nursing problems of the community on their shoulders they have only been able to give prenatal advice in a small percentage of cases in their territories, without attempting intensive effort along this line. A hopeful beginning is being made in several communities in the development of infant consultations hut the ])re-school problem is receiving only incidental attention, if any. American Red Cross Nursing Service — ^The conimonly accepted concept of the functions of a voluntary organization, vv^hich is that it shall develop and prove the value of worthwhile activities, has been followed by the Red Cross nursing service in Erie County. Com- munity nursing service is first demonstrated and promoted by the Red Cross Chapter and with the relinquishing of their nurses to the community, new educational programs are developed. In conjunction with the giving of bedside care, nurses have given health talks in the schools, public and parochial ; have held clinics ; have initiated Little Mothers' Leagues, and have taught home hygiene classes. One espe- cially important piece of work has been the holding of such classes in the Normal School as a part of the regular training course for teachers. Tuberculosis Nurses — Three nurses and one supervisor employed by the Buffalo Tuberculosis Association visit all parts of the county, concentrating especially upon tuberculosis problems, but rendering any assistance that they feel is required where there is no one else meeting the need. It is primarily upon these nurses that the respon- sibility falls for following up the tuberculous cases reported and pa- tients discharged from the sanitorium, as well as arranging for ad- mittance to the sanitorium. In two or three instances the community nurse is very largely assuming this responsibility, working closely with the tuberculosis nurse as the specialist in that field, and undoubt- edly this sort of cooperation can be considerably extended. In addition, the nurses have promoted an educational campaign from the point of view of prevention of tuberculosis, giving this subject an emphasis which otherwise it would not have had. The work of these nurses has been facilitated by the use of two automobiles, enabling them to cover a much wider area than otherwise would have been possible. Schools — All of the community nurses and tuberculosis nurses hold themselves ready to assist the schools as far as possible in view of their other duties. The attention that the nurses are able to give to the schools varies a great deal. Some of them make inspections of the pupils, especially in the villages where there ^re community nurses 30 some assist the physician with his inspections, and they all, so far as their duties permit, attempt to follow up children living in the terri- tories covered by them whom they know to have defects. Also they stand ready to assist the schools and the teachers, so far as they have time to do so, in teaching health habits and in giving talks to the pupils. As a rule each nurse visits the village schools in the area covered by her but is able to visit the rural schools infrequently if at all. The school nursing problem in the village is not usually being handled ade- quately, even where the most intensive community nursing is being carried on, and nursing assistance and follow-up work for the rural schools are wholly inadequate. It is easy to understand why so large a percentage of defects are not corrected and why there is such an in- sistent desire on the part of the school officials and teachers generally for real nursing help. There are three "health teachers" located in three high schools un- der the new classification adopted by the State Department of Edu- cation whereby school nurses have qualified as health teachers and taken charge of physical education work and other activities in the schools. The broadening of the educational duties of these nurses in the school buildings appears to tend to diminish, if not to eliminate, their home visiting. In view of the general need for more rather than less follow-up work in the home, this subject merits the careful consideration of the educational authorities. ApEQUACY OF Number of Nurses in General In Erie County in the area included in this nursing study there was a population in 1920 of 91,906 served by 11 public health nurses. This gives a rate of one nurse to 8,355 people. Authoritative stan- dards as to the desirable number of nurses for adequate attention to public health problems, including that of the child, require one nurse to every 2,000 population, which indicates a demand for 46 nurses in this area of Erie County. Even at the rate of one to every 3,000 there would be 31 nurses required — an increase of 20 over the present num- ber. There are three pertinent reasons why twenty additional nurses cannot be placed at once in the field. (1) Communities have not a full appreciation of the need for such an adequate public health nursing service, and it is always a sound policy to see that there is a community understanding and a de- sire for progressive health admmistration before proceeding too rap- idly to add new services. 31 (2) At present funds are not available, which is of minor consid- eration, for when a desire for health is intense and real, funds will be available for the development of preventive measures even more than for the enlargement of curative organizations. (3) A sufficient number of properly trained public health nurses is not available. There should be no question, however, that all interested in public health in Erie County should work consistently and continuously for an increase in the number of public health nurses throughout the county as well as for coordination of the work that is done now, to be under the auspices of a county health council which would greatly stimulate local work. Also in doing this the effort should be made in every instance to see that an automobile and its maintenance is pro- vided for, as only two of the general nurses and two of the tuberculo- sis nurses have cars, which means that the rural communities are very largely neglected and the work that is done is greatly hampered. Supervision — ^The following is a list of nurses who have some supervisory duties in Erie County : (1) State Department of Education: Headquarters in Albany, N. Y. (a) Director of nurses, supervisor of all nurses employed by Boards of Education. (2) State Department of Health : Headquarters in Albany, N. Y. (a) Director of nurses, assisted by 14 special supervisors of county work, 8 after care of poliomyelitis nurses, and 9 nurses who are assigned to Special Divisions of the State Department of Health. (b) One of the 14 special nursing supervisors mentioned above has headquarters in Buffalo, Rochester and Jamestown ; she reports to two Sanitary District Supervisors ; there are five counties, includ- ing Erie, under her supervision in one district alone. (3) American Red Cross : Divisional Headquarters, New York City. (a) Two State Supervisors of Nurses, one of whom has supervi- sion of Erie County. (4) State Charities Aid Association — Tuberculosis Committee: Headquarters, New York City. (a) One Director of Nurses, who serves Erie County through the Chief Nurse of the Buffalo Tuberculosis Association. Coordination — A hearty spirit of cooperation exists between the various nurses in Erie County with few exceptions. There has been exchange of service in several instances, such as in the weighing and measuring campaign promoted by the Junior Red Cross and assist- ed by the tuberculosis nurses and others, in some instances of medical examinations and in the reference of patients to agencies best able to help them. 32 Actual coordination of efforts is well developed, in one or two instances where the community nurse is carrying on the tuberculosis program in contact with the Tuberculosis League. It cannot be said that there is any serious lack of coordination, simply because the demand for nurses throughout the county so far exceeds the supply that each has a field which is little touched, if at all, by the others. Undoubtedly, however, the desirable relationships between the tuber- culosis nurses and the community nurses can be extended throughout the county to the advantage of all concerned. Even more important would be the meeting of the supervisors and of individual nurses of the county for common planning, adjust- ment of program, and the more general promotion of the special in- terests of each. Through such common conference and planning a constructive maternal and infancy welfare program would probably receive far greater relative attention than it has in the past; also probably a well-adjusted school nursing program would be evolved. It is conceivable also that with the development of closer coordina- tion between the work of the tuberculosis nurses and the community nurses, some of the former might be released for more intensive gen- eral public health nvtrsing, including both children's work and tuber- culosis work, in some of the rural areas which at present are recei-lfing relatively little attention. Recommendations 1. It is recommended that a conference be called of all of the nurses in the county with the object of studying individual plans of nursing service and common nursing problems which have not been met. 2. It is recommended that as a result of such a study a definite pro- gram of nursing service for the county be outlined which shall provide, so far as possible, for concentration on a complete nursing program for each community and eliminate duplication of effort to the greatest extent. 3. It is recommended that as a natural corollary of such conferences and common planning joint consideration of the resulting plans be given by the county supervisors and divisional supervisors of national organiza- tions and state departments, with a view to facilitating such coordination further. 4. It is recommended that as a most important next step there be formed a permanent central nursing committee of Erie County composed of representative nurses and lay people from each group actively promoting nursing work, public and private, throughout the county, which should be a committee of the county public health council. Some of the functions of such a committee might be to arrive at the best standards for work, for uniforms, records, equipment, salaries, etcetera, to take an active interest in recruiting student nurses, and to keep the nursing program and activities up to date to meet changing conditions. 33 5. It is recommended that every effort be made by the Erie County Health Council, and any nursing committee that may be formed, to secure, at as early a date as possible, a county advisory nurse and more public health nurses for work throughout the rural sections and villages of the county. VII. HEALTH TEACHING IN THE SCHOOLS "The worth of any educational process is to be measured by its product. Health teaching in the school is successful to the degree that it conserves and promotes the health of the child." The mere acquisi- tion of facts on hygiene and physiology, no matter how important those facts may be, is worthless unless the learning leads to expression in hygienic habits of living, and a consciousness in the child of health as giving mental and physical strength and increase in the joy of life. The old methods of teaching physiology and hygiene from text- books have not been successful when measured by this standard. The facts learned have not been sufficiently related to the life of the individual child. A child may be told about certain health habits, but habits are not acquired in that way. If the child is actually to make that habit his own, his interest must be aroused and the formation of that habit must be secured by constant repetition associated in some degree with pleasure. Horace IVIann has said, "Habit is a cable — we must weave a thread of it every day until it becomes so strong we cannot break it." Therefore, if health teaching is to be successful in promoting the health of the individual child, the following points are essential : 1. The interest of the child must be aroused and sustained. 2. The essential health habits should be stressed and action on the part of the child secured. 3. There must be continuous opportunity for practicing the health habits over a considerable period of time. 4. The approach should be made always from the positive point of view in order that the child may gain a positive ideal of health. A school health program by which such health teaching can be made most effective should include : A thorough physical examination for every child on entering school with the correction of remediable defects. A definite amount of time assigned in the curriculum for health inspection and instruction, including (a ) Regular weighing and measuring. (b) The teaching of essential health habits which should be supplemented by the correlation of health teaching with that of other subjects in the curriculum. A definite time for physical exercise and play in every grade. Special attention for malnourished children. 34 A hot mid-day lunch, especially for those who cannot get such a lunch at home, with the full use of the educational opportunities which it offers. Special provision for children with physical defects — eye, ear, etcetera. School buildings, equipment and surroundings of such character as to promote healthful living. The Weighing and Measuring of Pupils in the Schools — The questionnaires returned by teachers in 228 schools show that about 57 per cent of the schools have been equipped with scales. This is a big step forward in the development of the health program and has been made possible largely through the interest of the Junior Red Cross. Although the majority of the teachers have still to learn how to use this equipment effectively, the beginning has been made and the direct challenge of the scale and its records is bringing home to many teachers the necessity for vitalized health teaching. Fifty-five per cent of the schools returning questionnaires report that the children are weighed each month and in about 50 per cent of the schools where pupils are weighed, the interest of the parents is stimulated by sending the weight record home. In District No. 5, the Superintendent has made provision for the reporting of the weight on the regular monthly' home record card. In the small schools the weighing is done by the teacher, but in larger schools where there is a physical director or nurse there is a tendency to take this part of the program out of the hands of the grade teacher. In one school where the weighing and measuring was done by the school nurse, there was one scale and one nurse and 899 pupils. The school nurse would not be able to do anything else if she were to weigh each child each month, securing that personal contact with the child and the child's way of living which the monthly weighing affords. The teacher, on the other hand, who is in daily and hourly contact with the same child could supervise the weighing under the direction of the nurse and make the desired contact. Formal Lessons in Hygiene and Physiology — ^Answers to the questionnaires show that in 228 schools in the county formal lessons on hygiene from text-books are given in 50 per cent of the schools in Grade i 49 per cent of the schools in Grade 2 62 per cent of the schools in Grade 3 73 per cent of the schools in Grade 4 78 per cent of the schools in Grade 5 35 78 per cent of the schools in Grade 6 78 per cent of the schools in Grade 7 64 per cent of the schools in Grade 8 In addition, a fraction of i per cent stated that such lessons were given but did not specify the grades taught. The time spent on these text-book lessons, although not always specified, showed a range from 5 minutes a week to 5 hours a week. The amount of time given in most of the schools, however, lay between one-half an hour and one hour a week. It was interesting to note that for Grades 1-3 one-half hour was the time most generally allotted, and for grades 4-8 one hour was more general. The questionnaires did not show the distribution of this time in the curriculum but in the schools visited the teachers stated that hygiene and physiology were taught about three times a week. Textbooks Used in Grades in Schools Visited. (For complete list of text-books according to returns from teachers' questionnaires, see Addendum in original report, not printed here). Davison's Health Lessons, Books I and II, American Book Co. (most general, copyrighted 1910). Overton's Physiology. Winslow's Healthful Living. Use of Imaginative Supplementary Literature — "Clean Peter and the Children of Grubbylea," Longmans, Green & Co., publishers, was used in one school in connection with the first and second grade work and the teacher stated she had found it more productive of results in en- couraging habits of cleanliness than any health lesson she had been able to find. This was the only school visited where the use of imagina- tive suplementary literature was found. Recitation Based on Textbooks — Ohe ten-minute hygiene lesson for fourth and fifth grades in a one-room school was observed. The subject of milk and all of the possible ways by which milk may become contaminated were discussed. The children stated "that if the windows are unscreened flies may reach the milk and then it becomes poison." Each child in reciting used the word "poison" in connection with milk and there was little reference to the value of milk as a food, no efifort to discover how many children were drink- ing milk and no attempt to interest those who were not drinking milk, in the habit. In fact, the lesson tended to discourage milk drinking because of the constant association in the child's mind of milk with the word poison. The text-book used was examined and it was found that the chapter heading was "Milk may be a food or poison." The introductory 36 sentence stated "Milk is the most perfect food known" and yet two- thirds of the text is devoted to "when milk is poison" and there is one paragraph on "Milk as a food." This was only one class but the same text-book is used in 140 schools in Erie County and probably the average teacher in teaching from text would naturally stress the points stressed in the book. Too large a part of the health teaching in the grade schools in Erie County is confined to text-book lessons. This situation, however, is one which exists largely through the entire country and is in no way peculiar to Erie County. High Schools — The biology course given in the high schools contains a 12-week course in hygiene. The State Syllabus is followed very closely. About i week is spent on diet, and another on sanita- tion. Sanitation and the composition of foods are also touched on in the chemistry course but this latter is an elective course and so does not reach all the pupils. The average student takes this course in the first year of high school. High School Textbooks — (For complete list of textbooks accord- ing to return from teachers' questionnaires, see addendum to original report, not printed here.) Practical Biology, Smallwood, Revelly and Valey. Biology for High School, Smallwood, Revelly and Valey. Civic Biology, Dr. W. Hunter. It was not possible to observe the class-work in hygiene in the high schools as that section of the course had not yet been reached. Health Talks Based Upon Textbooks — Health talks are generally given to the lower grades to emphasize health habits. The majority of teachers questioned in regard to these talks were rather vague as to the method and content ; and a general impression was received that with every good intention of having these talks they were often sacrificed in the overcrowded curriculum or were reduced to a very few minutes once or twice a week, when the teacher gave the class or classes (sometimes all eight together) a rather formal summary of text-book facts. Correlation of Health Teaching With Other Subjects in the School Curriculum — 'An attempt was made through the teachers' questionnaires to find the number of schools where health teaching was being correlated with the teaching of other subjects in the curriculum. It was impossible, however, to drawf any satisfactory conclusion on this point as the answers of the teachers indicated that the question was not understood by a great number. The general impression re- 37 ceived, however, was that as a group the teachers did not realize the many opportunities for such teaching which other subjects present. Personal observation in the 28 schools visited substantiated this impression as in the majority of cases the suggestion of such possi- bilities came to the teacher as a brand new idea. In a few cases, however, teachers were correlating health with such subjects as spelling and English composition and in one school health plays were given. Only one teacher in the questionnaire group suggested that health posters were made and in only three schools visited were there indication of such work. From the large percentage of schools stating that formal classes in hygiene and physiology are given and from the vagueness of the answers in regard to correlation of health with other subjects, it is probably safe to conclude that the teachers, as a whole, do not yet appreciate the richness of the opportunities for health teaching which such correlation offers. When the teachers do realize this it will greatly assist in solving that problem of "not sufficient time" which confronts every rural school teacher. The Teaching of Health Habits in the Grades Through Pupil Health Club Organizations — ^The general plan for the Health Clubs is furnished by the Physical Education Department of the State of New York but the actual details and arrangements are in the hands of the individual teacher. The use of these Health Clubs is recommended but not required. Teachers' questionnaires show that 42 per cent of the schools answering have health clubs. In 10 of the 28 schools personally visited the Health Club was being conducted. The general outline as furnished the teachers calls for the enrollment of all the pupils into the Health Club. The duration of time covered varies from a few weeks to the entire school year. The teacher selects certain health habits which for the most part cover those habits relating to cleanliness and personal appearance, exercise and fresh air. Some teachers also included food habits and habits of rest but this was by no means general. Each morning the roll is called either by the teacher or a pupil secretary and each child responds with his record for the previous day. Too often in order to save time the child is allowed to state only those rules he has not kept, as in the following instances : The Secretary : "Johnny Burns." Johnny : "I did not sleep with my window open ; I did not brush my teeth this morning." 38 The Secretary: "Sallie Johnson." SalHe : "I did not go to bed before eight ; I did not sleep with my window up ; I did not drink milk." The Secretary : "Bobby Jones." Bobby : "Perfect." This negative method of conducting the club is obviously bad. Other teachers, noticeably those who had received more training in educational methods, gave the daily checking of habits more time and the children stated those habits which had been observed. The habits were in almost every case 6 in number and each habit scored 2 points, making a possible total of 12 points a day. These records were in many cases stowed away in the teacher's desk in a blank-book; in a few rare cases the Health Club records had a place of honor on the wall and perfect records received a star. In no school visited was there any encouragement of group competition observable. It was an individual record. One teacher sent on the questionnaire a very interesting description of a health club entitled "What I owe myself and the other fellow." One month the club keeps individual records and the next month the scoring is by teams. This variation serves to assist in sustaining interest and at the same time it stimulates a group spirit. Value of These Health Clubs — The value of these clubs in secur- ing results lies in the hands of the teacher. If the teacher was interested and enthusiastic, bending her energies to infuse vitality into the conduct of the club, it was observed that the children were really benefitting. On the other hand, where the conduct of the club was a purely perfunctory matter on the part of the teacher, it was also an unimportant factor in the life of the child and there was little effort to obey the club rules. One feature of the Health Club was the subject of much criticism on the part of the teachers, namely, tbe fact that the checking depended upon the word of the child. A number of teachers felt that this method offered a tremendous temptation to the child to be untruthful, and a few teachers stated they declined to organize Health Clubs for this reason. On the other hand, a large percentage of the teachers seemed to think that the children were very honest in their reports and that where any child made a false claim, public opinion in the school room was quick to correct the fault. Physical Exercise and Play in the Schools — ^In only 10 schools out of the 228 answering the questionnaire was the program for physical education under the supervision of a physical director. This 39 4 per cent of the schools having supervision, however, includes about 30 per cent of the pupils enrolled and indicates that these few directors have been placed at strategic points.. In 96 per cent of these 228 schools, therefore, with about 70 per cent of the pupil enrollment, the development of the program of physical education is entirely in the hands of the grade teachers without the supervision of a person especially trained in physical education. About 23 per cent of these unsupervised schools stated they felt the need of supervision, about 26 per cent did not answer the question, and 51 per cent expressed themselves as not needing such additional assistance. The questionnaires also showed that in 199 of the 228 schools there was supervised play either during school hours or after school. This play was supervised in 188 cases by the grade teacher who was helped in 5 cases Ijy school nurse or coach, older pupils or physical director. In 7 cases the play was supervised entirely by the physical director and others, and in 4 cases the person supervising was un- specified. The amount of time given both in school and outside was not stated in enough instances to indicate the general situation. It is significant, however, that 18 schools state that no supervision is given in school hours and that only 74 schools report that any supervised play is attempted outside of school hours. In the schools personally observed there were occasionally 2-minute relief drills, sometimes led by the grade teacher and less often by pupil leaders. The marked absence of answers from the teachers to a question in regard to existing recreational activities on the part of the pupils would indicate a probable lack of such opportunities. 96 schools have had play picnics or field days. 95 schools listed outdoor recreative activities such as jumping, running, baseball, basketball, skating, coasting and walking, and a very few spoke of indoor activities, such as dramatics, gymnastic work, and folk dancing. Some teachers classed "work at home," "work on the farm," "chores," "walking to school," "help with work at home," as recrea- tional activities, and a large number simply left the question un- answered. Supervisors of Physical Exercise and the Correlation of Their Work With the Grade Teacher — Two schools visited were under the supervision of a physical director. In one school the physical director was securing real cooperation from the grade teachers. Health Clubs had not been organized but the children were being interested in 40 health habits through correlation with other grade work. The phys- ical director was assisting the grade teachers, supplying suggestions and teaching material, and encouraging the development of new ideas and methods through a real interest in and constant contact with the work being done. A health play developed in the third grade had been given before the entire school during the auditorium period and another grade had another play in preparation for similar presentation. In the other school where a physical director was installed the teachers in the grades felt little responsibility for the health program. They did what the physical director requested, they conducted health clubs, and the rules of the health club were checked every morning, but there was no particular interest shown on the part of the teachers over the scope of this work. That food habits were entirely neglected did not seem to have occurred to many of them. They followed the form of the work but were not infusing spirit and vitality into the functioning of the club. The club was not theirs, it belonged to the Physical Education Department. The physical director frankly admitted that it had not occurred to him to include food habits in the club rules or to enlist the coopera- tion and the assistance of the domestic science teacher in this matter. Each grade teacher was supposed to give the relief drills during the day. Those questioned frankly stated they did not give all the relief drills called for in the program. One said that she usually gave one of the four required, as it was hard to find time and that she thought, because the children went to the physical director for a regular period of physical exercise, that the relief drills were not essential. There were scales in the school but last year the weighing and measuring had been done by the community nurse, who has since left, and a nutrition class for those found underweight had also been conducted by her. This year there is no community nurse and no one feels the responsibility of continuing the work. The health program of the school was not functioning because proper coordination was lacking and there was no correlation of the work. A third school visited had had a physical director last year but had been unable to secure one this year. The result was that all health work in the school had been discontinued. There were scales but last year the physical director did the weighing and measuring and organ- ized the health clubs in the grades. This year nothing has been done. The rural schools in the vicinity which had received the supervi-sion of the same physical director showed the same lack of initiative in regard to carrying on the health work. This situation indicates that the physical director had not done supervising work in its truest sense 41 but had done the actual work of the school room and in his absence the teachers felt not only unprepared and unequipped but also no responsibility to continue the work. Teaching and Adjiinistrative Staff — ^Health teaching should pri- marily be the responsibility of the grade teacher, and therefore it is impossible to consider the adequacy of staff in respect to numbers and salary only in its relation to health teaching. The problem involved touches the whole curriculum and is so wide and important that the consideration possible in such a brief study would be so superficial as to be entirely undesirable. A low standard of work in all subjects will accompany understaffing and insufficient salaries, but it is obvious that where, through over-work and under-pay, the persona! health of the teacher is impaired, that teacher's capacity for health teaching is immediately affected. To teach health successfully, the teacher should herself be healthy. Again the problem of training the teachers for health is closely bound up with the whole educational problem of teacher-training. The teacher who has never been taught herself how to live cannot teach others. Data in regard to the training of the teachers in the supervisory districts of Erie County were obtained through the courtesy of the State Department of Education and is given in addendum to original report, not printed here. It shows that the majority of teachers whohave had professional training, come from the teacher-ltraining classes and the Normal school. It is, therefore, important to ascertain what opportunities these groups now offer in health education to the pros- pective teacher. One Teachers' Training Class was visited in Springville which was conducted in connection with the High School. This year there were as many as 19 pupils of whom approximately 12 were High School seniors. These pupils were taking the training class work with their senior year work and would graduate from the High School and the Teachers' Training Class simultaneously. They would then be able to teach under a Teachers' Training Class certificate which "is valid in any district not maintaining an academic department in the supervisory district for which it is issued by the district superintendent of schools." Health education in this training class is apparently confined to 1. Formal text-book lessons in physiology and hygiene. 2. A brief discussion in relation to hot lunches. (This is con- ducted by the training class teacher. The opportunity for help and 42 guidance offered by the presence of a domestic science department in the same building has not as yet been utiHzed). 3. Observation of the methods used in the grade rooms in the building. (No adequate health program was functioning in these grades). Such limited general training cannot give the teacher an oppor- tunity to start her work with skill or real understanding of pedogogy. She must learn through experience and one has only admiration and respect for the work which many of these teachers have been able to accomplish. In the great majority of the schools visited, the teachers showed a fine spirit in their work and a real potentiality which addi- tional training would make very valuable. In respect to health teaching in particular the deficiency of training was shown in 1. Lack of health consciousness. 2. Lack of knowledge as to methods by which health teaching can be made successful. Many of the teachers realized that the health program was not effective and they wanted to know how to make it real. It was one of the problems which under the pressure of the work and the many demands on their time, they have been unable to solve for themselves. Normal Schools The health education course in the Buffalo Normal School is striving to create a health consciousness in the individual student. Physical education seems to receive the lion's share of attention and one received the impression that facts of physiology and hygiene were taught to the exclusion of adequate attention to methods of teaching health. Apparently there is no opportunity given the stu- dent for working out a correlation of health with other subjects in her work under critic teachers in the Practice School. That part of the general course relating to foods and diet is handled by teachers in the Physical Education Department and is not tied up in any way with the excellently equipped Vocational and Home- making Department. The responsibility for assisting in developing a health program in the Practice School does not devolve on the students in the Health Education Department. In the Summer School the only course in Health Education open to the general student is a short course in relief drills and play games. Channels by which Teachers Receive Stimulation and Help during School Terms: 1. Group conferences arranged by superintendents. 43 2. Conferences arranged by State. 3. Periodicals, such as "Normal Instructor and Primary Plans." Through none of these channels do the teachers seem to be receiv- ing adequate help as to methods of teaching as related to health or as to steps by which a vitalized health program may be developed. The superintendents are alive to the need of health work in the schools and have already done much to encourage and support those teachers who have initiated vitalized health teaching. Their opportunities for con- ferences with individual teachers are necessarily limited as each super- intendent has a large number of widely scattered schools to reach and no district supervisory assistance. Opportunity Offered by School Building, Equipment and Sur- roundings FOR Practice of Health Habits During School Hours. A large part of the child's day is spent in school surroundings — and it is obviously difficult for the teacher to talk about cleanliness, fresh air, exercise, etcetra, when the school environment itself precludes the practice of such habits. Actual conditions in the school buildings, as revealed by the answers to the questionnaires, are dealt with in a separate statement, but it seems desirable in this section on health teaching to point out the necessity of having the school buildings, equipment and surroundings of such a character as will promote healthful living. Very often, however, unsanitary conditions in the school room are simply the reflection of lack of health consciousness on the part of the teacher. It is, indeed, urgent that the schools be adequately equipped — inadequate schools v^'ill handicap the best teachers — but on the other hand it is equally urgent that the teachers be so trained that they will make the most of the opportunities at hand in creating an atmosphere of health in which the child may realize, in action, the health teaching he receives. Healthy children in a healthful school are the evidences of the success of a school health program. Recommendations It is recommended : I. That in teachers' training courses especial emphasis be placed on methods of teaching in relation to health and that students in such courses be given an opportunity to observe the practice of these methods in schools. That these teachers' training classes enlist the cooperation of as many departments in the school as possible in developing the course in health education. That correlation of health with other subjects in the teacher training course be developed so that the student may recognize the opportunities vifhich the various subjects offer in this respect. 44 That the special problems connected with the rural school be given particular attention, since the majority of the teachers holding training class certificates will, of necessity, accept positions in rural schools. II. That the normal schools in the course on health education give more attention to methods of teaching as related to health and that oppor- tunity be given to the practice schools for the development of a health pro- gram with the cooperation of the health education department. That the various departments in the normal school cooperate closely with the health education department in securing a wider correlation of health with all subjects in the curriculum of the practice school. By this means the prospective teacher may learn exactly the extent and kind of help she may expect from the various departments. III. That opportunity be given in the summer session of the normal school to give the teacher the training necessary for the promotion of an active health program. Such summer school sessions should offer in health education : 1. A content course (which should be required of all students who have not had sufficient previous grounding in physiology, hygiene and sanitation). 2. Methods course, with opportunity for observation in a practice school. The problems and difficulties peculiar to rural schools should be given particular attention in these courses. IV. That the rural teachers be stimulated to avail themselves of these opportunities by : 1. Personal interest of the superintendent. 2. Credits for promotion. 3. State aid. V. That provision be made for the services of a trained educational supervisor for the county, who can give the necessary time and attention to stimulating and guiding the teaching of health, especially in correlation with other subjects in the schools and to such general health educational activities as may be developed through cooperation between the schools and other community forces. Such a person should be well grounded in health as well as in educational subjects generally. VI. That in order to reach the rural teachers, especially those who are not reached through courses in teachers' training classes or normal schools, a district rural supervisor or helping teacher should be employed (who should be qualified to help and guide the grade teachers in the various phases of health education as well as in other questions, and also in devel- oping and sustaining a coordinated health program in the school.) Her assistance should be in the in the nature of advice and active demonstration (if necessary) and after the work has been initiated, she should return at frequent intervals to encourage and help the teacher in solving specific problems. If it is not practicable to employ such a helping teacher in each dis- trict, one should, by all means, be employed in one district for demon- stration purposes, to be paid preferably from public funds, but if this is impossible the salary to be secured through a committee on coordina- tion of the school health program of the Erie County Health Council. 45 That in such a case demonstration be made in connection with some live community group with the understanding that if the group is con- vinced of the value of the work it will undertake to continue it until such time as the educational system can make adequate provision for the su- pervision of rural health work. VII. That the district superintendent further encourage the adoption of an active health program in the schools. 1. Not only by continuing to take a personal interest in the health work which each school is developing, but also by giving special recogni- tion to original methods. 2. By encouraging a closer cooperation of the various departments and a wider correlation of health with other subjects. 3. By assisting the schools to obtain those changes in buddings, equip- ment and environment necessary to healthful school conditions. 4. By recommendation to the trustees of those text books on hygiene which have a positive emphasis. 5. By arranging in teachers' conferences that health work shall receive due recognition and stimulation. 6. By giving the monthly weight a place on the report card. 7. By securing, by trained persons, proper supervision of health work which shall include not only supervision of health teaching but also fol- low-up work in the correction of physical defects. VIII. That since the health club offers something which is capable of wide development in the hands of the teachers, and since the teachers as yet are not using this health club to the best advantage, normal schools, sum- mer health courses, and those press channels which already touch the teach- er be used to assist the teacher in developing the possibilities this health club offers and to make its work more vital and effective. This should be done in such a way that it does not add to the burden of an already over- crowded curriculum. The following points are suggested : 1. Care should be taken that the emphasis be always positive in char- acter. 2. The rules of health stressed should be the most lundamental and important ones. To include the arrangement of the necktie and the carry- ing of a clean handkerchief as 2 in a list of 6 health rules, either creates in the child's mind a wrong sense of values or a distrust of the importance of health habits. Also to combine two habits as "drink 2 glasses of milk and cocoa or four glasses of water" gives the child a wrong impression. 3. One weakness in the health club as it is generally conducted is the tendency to make it so routine that it become monotonous. Devices must be introduced from time to time to sustain the interest of the child and to stimulate increased practice of those habits which are receiving the least attention. 4. The monthly weighing should be connected in the child's mind with the activities of the health club, as a monthly statement of the results of health habits. 5. It seems possible in the lower grade rooms and in the rural schools to center all health teaching around the club and eliminate the formal class in physiology and hygiene. This would release a certain amount of time for the curriculum which would offer the teacher an opportunity for teach- 46 ing health habits through action. Health plays, health songs, health stories, health posters prepared in correlation with other subjects in the curriculum can be given the attention of all and discussed. This time will thus serve to define and clarify the ideas of the children in regard to the important health habits. Individual note books on health may be kept and the child encouraged to express himself as freely as possible in accu- mulating in this book all stories, poems, pictures, etcetera, relating to health. These books would serve to indicate to the teacher the progress the child has made in the development of health ideas and habits. IX. That the physical director should be a powerful factor in the health work of any school system, that his function should be to work with and through the grade teacher in the development of a coordinated health program. That the same relationship to the health teaching be maintained by the school nurse and the domestic science supervisor. The actual teaching should be done by the teacher, but she must be able to look for guidance and stimula- tion to the various experts. Unless this be the relationship of the work of the experts in the va- rious fields to the work of the grade teacher, there is bound to be a lack of coordination in the health program. The valuable contributions which each department can make to the health education of the individual child will be made even more valuable by such correlation. X. That a selected circulating library of educational books on health be made available to teachers and nurses as part of the plan of the Erie County Health Council. This will afford the teacher and the nurse an opportunity to keep in touch with the most recent and best books on subjects relative to health and health education. VIII. ORGANIZATION OF CHILDREN The latent resources of the child are coming to be recognized in- creasingly. The trend of education has for a long time been aw^ay from the old purely didactic method of teaching and toward the stimu- lation of thought on the part of the child himself. In spite of this the methods by which the child's initiative and responsibility and inde- pendence of thinking may be encouraged and given wider scope have not been given the prominence that they deserved until recently. While in the project method, the platoon school, and other educa- tional developments more attention has been given to meeting the problems of the individual, the possibility of organization on the part of children themselves is beginning to be recognized as of almost equal importance. The Club or League Method — We find the Boy Scout and Girl Scout movements outside of the schools or sometimes associated with them and reaching the middle and advanced elementary grades. In the schools Little Mothers' Leagues and Health Clubs are organized in many places and the Junior Red Cross is coming to play an increas- ingly prominent part. These clubs may promote such programs as the 47 Modern Health Crusade, weitrhing and measurins^ the children and following up the undernourished. Too often in the past health clubs in merely serving as conveni- ent ])ieces of machinery for promoting some jiarticular activities, have failed to develop their real possibilities to the child for his own self- development. For that reason they have been incidental and have not well served even the end for which they were organized. This is un- fortunately true of health clubs in the schools of Erie County in many instances as shown in the preceding section on Health Teaching in the Schools. It is doubtful whether it will be different until there is more direct supervisory help given the teachers of the rural schools by some- one who has the time to devote to this purpose as well as a conception of the real functions of such clubs. The superintendents understand the purposes of the clubs but cannot give adecjuate time to their de- velopment. Scout Organization — The programs of the Boy Scouts and the Girl Scouts are too well known to require discussion in detail here. That they can contribute largely to good health, through outings, health habits and the promotion of community health movements has been definitely shown again and again. Formerly some casual assistance was given by those active in the Boy Scout movement in Buffalo to troops in outlying sections of the county. For the past few months an organizer has been employed for the development of the Boy Scout movement throughout all sections of the county excluding Buffalo, and it is the hope of those interested in the Scouts that this will result in a largely increased development of troops, membership and interest. On November 7, 1921, there were 16 troops listed in the county excluding Buffalo, with 114 boys registered and 88 on the lists of local troops not yet registered. Apparently there has been friendly cooperation between leaders of the Catholic and Protestant churches and other agencies in promot- ing the work of Boy Scouts and on the part of the Scouts in support- ing community activities. It is recognized by all that the possibilities for the development of the program of the Boy Scouts have only been touched and that the opportunities for relating the Scouts to com- munity movements are almost unlimited. The Girl Scout Organization of Erie County is concentratino- its efforts very largely upon the development of the troops in the City of Buffalo, with a large field for work and only a beginning having- been made in organization. There are troops in five communities out- side of Buffalo, with a total registration of 123. Development of 48 further troops or stimulation of the work of those at present organ- ized in the county will have to wait upon additional funds or the time of someone to be given to this work. However, in the meantime, there ought to be opportunities for other organizations, including the Boy Scouts, to cooperate in the exchange of info^rmation and in the promotion of the Girl Scout movement through local groups, such, for instance, as the Clarence Community Council mentioned elsewhere in this report. Other Organizations — The Junior Extension work of the Farm Bureau also should offer many possibilities for cooperative effort with other organizations. The Protestant and Catholic Sunday Schools of the county al- ready have interested themselves in promoting various health activi- ties and other measures for the benefit of the community. Through officials of the Catholic Church and through the Erie County Sunday School Association, both of which are much interested in further de- velopment, there should be unusual opportunities for promoting all of the features of a broadly conceived county health and recreational program. Recommendations It is recommended : 1. That a committee on children's organizations be formed, including representatives of each of the groups in Erie County actively promoting such organization. 2. That this committee be a committee of the County Health Council. 3. That this committee on children's organizations map out a definite program through which the development of children's organizations to serve various purposes may be promoted by all groups in a cooperative way in several communities of the county, as a basis for further joint planning and effort. IX. RECREATION It is hardly necessary to submit extensive data showing the great importance of recreation as a factor in the health of the children of Erie County. Its contribution from the point of view of physical re- building, mental diversion, the lowering of social barriers thus making easier organized civic effort, and in various other ways is generally recognized. Recreation as it affects the health of children includes not only the healthful and enjoyable use of leisure time outside of the school but those activities in conjunction with the schools which afford a break in the monotony of mental work and under supervision illus- trate practically so many of the objectives of the school program, such 49 as the stimulation of civic ideals, of wholesome conception of health values, and the development of the body. A complete recreational pro- gram must include the activities of the pre-school age child if we are to teach the whole art of healthful living during this formative period. Recreational activities and the facilities which contribute to them are dealt with in several other sections of this report. No attempt will be made here to gather this material together as a presentation of the recreational problem of Erie County. From the section dealing with health in the schools and from the tabulation of the replies to questionnaires from school teachers on the subject of recreation it is obvious that it is a minor consideration in the school program. The actual provision of play space, the facilities which will assist in de- veloping wholesome play, and the amount of supervision from the teaching staff are all slight in comparison to what the importance of the problem demands. While adequate attention to this problem will quite likely not be given until there is a satisfactory plan worked out for combinaton of school districts, much could be done in the way of stimulating the teachers' conception of the possibilities of recreation In reply to the question "In what forms of recreative activities do the pupils generally engage" some answers indicate manual labor at home or on the farm or the simple walking to and from school as the ap- propriate answer. The program of the Home Bureau and the Junior Extension Work last year stimulated community sings, plays, pageants and picnics, ba not on a very extensive or systematic basis because of their many othei activities. In the preceding section of this report dealing with Organizatior of Children brief mention is made of the Boy Scout and Girl Seoul movements. It would be difficult to overestimate the possibilities oi these types of organization as wholesome, constructive forces for re- creation in the best sense of the word. The present limitations of these organizations, however, are such that their efforts are intensive in onl} a few places and in general need to be very much better coordinatec than they are in order to secure the best results. The activities of the Sunday School Associations also are referred to in the part of the re- port on children's organizations. The active and potential force o; these associations should be utilized to the fullest in the developmen- of a recreational plan. The contribution that such local organizations as the Clarence Community Organization, which is mentioned elsewhere in this report and such social centers as that in Collins can make to the developmen of recreational activities is very great. No complete recreational pro 50 gram for the county and no coordination of effort on the part of county-wide organizations can be successful unless it definitely recog- nizes the importance of having various activities clear through a local group organized on a basis that is representative of the community. Recommendation 1. It is recommended that the Erie County Health Council shall as early as possible give careful and earnest consideration to the promotion of recre- ation throughout Erie County, working especially through a committee on children's organizations and also in closest cooperation with the public and parochial school authorities. X. NUTRITION OF CHILDREN Because of the general prevalence of under-nourishment as one of the outstanding evidences of lack of physical development and vitality it is most important that a health program for Erie County shall give recognition to the problem of nutrition. An adequate plan for the solution of this problem must include the discovery and correction of defects vs^hich are so large a factor in malnourishment, as well as the teaching of the essentials of food requirements and food and health habits and general health supervision. There should be the right perspective as to nutritional problems in the work of physicians, nurses and teachers, as well as assistance and guidance of trained specialists in nutrition. From the many studies which have been made in various sections, of the country, it can safely be assumed that there is a serious condi- dition of under-nourishment among the children of any area which has not, over a period of several years, benefited from systematic and energetic preventive and corrective measures. Under-N ourishment Am-ong School Children — Among the 5,085, children weighed and measured in the recent campaign promoted by the Junior Red Cross in the rural schools of Erie County, 917, or 18 perc ent were found to be 10 per cent or more under- weight (590- were 7 per cent to 10 per cent under-weight, making a total of 1507 children who are 7 per cent or more under-weight). The school authorities are the first to recognize the seriousness of this problem in the Erie County schools and to urge that more at- tention be given to it. Food Habits of Children — It is impossible to give an analysis or an all inclusive statement of the food habits of the children of a large area. Those who are associated with the children daily over a long term are the best judges of what their habits are and of how they affect their general health and physical development. The following are some typical statements from teachers on th subject : "Bread and coffee constitute the chief diet of nianv of our chi dren." "My children eat chiefly meat and potatoes. They do not lit milk and eggs." "Dry bread and water is the lunch of many of our children." "Bologna sausage and bread is the lunch of many of our chi dren." "Many of our children use tobacco and tea and cof¥ee." "From visiting the homes of my children I find they eat mea' potatoes, pie and coffee. Their mothers think they are well fed whe they have meat and potatoes three times a day." "Some of my children are taking canned milk. They say it i cheaper for them because their parents ship their milk to town. Canne' milk is just as good, is it not?" The following is a statement from one of the public health nurses "In visiting the homes in the rural districts of Erie County, w find many children under-weight and apparently under-nourished. Ii some cases it is diseased tonsils or the presence of adenoids, but tli majority of cases investigated show that the food habits are at fault We find the children do not drink milk and sometimes they do no like it and the parent, not understanding the great value of milk an< well-balanced diet, does not urge and encourage them in the prope diet. In other homes the farmers sell their butter, milk and egg: and use canned evaporated milk and oleomargarine. A number o youngsters drink black tea and coffee. In these schools at the luncf hour I find them eating dry sandwches with no butter and nothinc but well water to drink. A few of the schools have taken up our sug gestions and started a hot lunch. In the Polish districts the childrei live chiefly on beer, dry bread and bologna sausage." The Teaching of Food Habits — Some attempt has been made ii the schools to give consideration to the subject of food and food hab its. The replies obtained from 228 schools regarding the teaching of food and food habits and the use of scales in the schools, indicatec more or less attention to this subject. According to the answers, 22 per cent of the schools are giving in struction by the grade teacher on eating slowly and at regular hours 38 per cent on food habits (unspecified), 20 per cent on the use of milk 9 per cent, on avoiding the use of tea and coffee, 2 per cent on the us( of vegetables, 2 per cent on the use of fruit, 6 per cent on drinking water, 2 per cent on toilet habits, 27 per cent on sleep, and 17 pei cent on exercise. 57 per cent of the schools are equipped with scales 42 per cent are without scales, 55 per cent are weighing the childrer monthly, 15 per cent are weighing them yearly, 49 per cent are report- ing the weights to parents, and 49 per cent are not reporting the weights to parents. 52 77 per cent of the instruction given on food and food habits is given by the grade teacher, 6 per cent by the nurse, 5 per cent by the physical director, only 1 per cent by the home-making teacher and 7 per cent by an unspecified person. 6, or 0.26 percento f the schools determine under-weight of the children by a physical examination, and none of the schools are con- ducting nutrition classes for under-weight children. In the 37 schools visited there were no nutrition classes con- ducted far under-weight children ; (2 schools were serving mid-morn- ing and mid-afternoon milk feeding to all children, especially to the under-weight children) ; 10 were giving food instruction to a part of the children. This instruction was given by the physical director in 1 school, the grade teacher in 4 schools and the home-making teacher in 5 schools. Home Making Teachers — Of the schools answering the question- naire 7, or 0.3 per cent employ a home-making teacher. These teach- ers reach 184, or 0.015 per cent of the 11,347 children' in these 228 schools through food courses. The services of these 7 home-making teachers are available to all the teachers in the schools in which they are employed. There were 5 home-making teachers in the schools visited. These teachers were giving instructions in nutrition and food preparation to high school girls, and in 3 schools to seventh and eighth grade girls. They were also supervising the school lunches and carrying on food projects with the girls in the homes. Through the projects they were introducing the simple rules of nutrition into the homes. In one of the schools visited the home-making teacher was voluntarily giving a course in nutrition to the grade teachers in the evening ; in two schools this teacher was giving talks on nutrition to the Parent-Teachers' Association and to groups of women in the afternoon and evening. Two schools visited have recently introduced the home-making course, and the enrollment in this department is necessarily very low. From observation in the schools visited it would appear to be de- sirable, if possible, so to arrange the home-making teachers' programs that they could be assigned to giving talks to the pupils at assembly periods, thus stimulating interest in nutrition, also to giving instruc- tion in nutrition to the grade teachers in their schools. This would be a means of reaching the children through the teachers in the schools employing home-making teachers. It must also be remembered that the instruction given in any subject to the children in the 263 schools in Erie County must come largely through the class-room teachers 53 and that it is only very recently that any attempt has been made t( give the teacher any understanding of nutrition. Therefore, it is evident, if the subject of nutrition is to be giver the proper emphasis in the school program, that the services of a per- son trained in nutrition should be available to the teachers in all th( schools. Where it is possible to free the services of the home econom- ics teacher (who has specialized in food and nutrition; for this work that should be done. The Problem of the Grade Teacher — The difficulties in the wa) of satisfactory education of children on this subject are illustrated by the following .remarks by some of the teachers : "If you would ask me what we need in our schools I would say good teaching on eating. But I don't know how to teach it, so I just talk about being properly nourished." "Oh, yes, I teach food. I tell them all about proteids, fats and all. Last week we talked about water giving vitamine." "Will you tell me a good book to study, so that I can know what to teach the children ? I have a hard time giving them what they like to eat. The last three days we have had macaroni, potatoes and bread pudding for lunch, and, my, how they like it !" "Some of the boys and girls, the puny ones, are beginning to be- lieve in food. I have been helping them to plan their menus and we are cutting out potatoes. You see they eat so much potatoes they get 'potato poisoning.' I just had to come out and tell them not to eat potatoes." "The trouble with so many of my children is they eat dandelions. Now anybody knows dandelions are bad for you." "Nearly all my children drink tea and coffee. They know better but they seem to be possessed, their parents tell them that they grew up on it and it didn't do them any hurt." "I have cocoa and milk for my children, but they won't drink it ; their fathers and mothers say it is all nonsense." "I wish you would tell me how to teach the children about the things they ought to eat. My principal says it is my business to be teaching and not cooking." "I will be glad to have the hot lunch, if some one will tell us what to serve and how to manage it." The Superintendent's Point of View — The following remarks, made by some of the district superintendents show that they have been seriously considering the question of nutrition in their schools. "I am wondering if scales and weighing are of any value without instruction in foods." "I want to give good instruction to my school. I would like six nutrition specialists in my district, but I should be glad to get one." "I have been thinking much about food, because I believe in feed- ing correctly. I am going to try to work it out first through the 54 home-making teachers and we are counting on this group to help us with the rest." Remark by Principal : "I intend to have a home-making teacher in my school and she will teach all the children the choice of food. She will teach the older boys and girls how to cook, also. I may need two such teachers, for I am going to have my school lunch supervised. I also am ;joing to have a physical training director and he is going to teach recreation, not military gymnastics." Interest Aroused in the Nutritional Problem — The weighing and measuring campaign, initiated by the Junior Red Cross and the State Department of Education, covering 296 rural school-rooms and a total of 5,065 children, aroused a great deal of interest, not only in the schools actually surveyed but in other schools. The school superin- tendents followed these studies and reported them to teachers and principals generally throughout the county. Through a cooperative plan in which the school trustee or, in a few instances the pupils themselves, paid $6.00 toward the purchase of a scale, the Junior Red Cross furnishing the remainder, 141 scales were purchased up to October 1, 1921. Through the weighing and measuring of children, especial atten- tion was directed to those under-weight, and in some cases the regular reporting of their under-weight to their parents has been a valuable resulting step. Its full value, however, cannot be realized unless this initial interest is followed up with stimulating and accurate advice to the parents and such thorough educational measures for all as will prevent the conditions found. The medical inspectors, as well as the school authorities, are conscious of this need. They are also con- scious of the need of a better opportunity for making thorough phy- sical examinations, in order that they may locate the nutritional dis- turbances in the children which will not be indicated merely by weight. Both the medical inspectors and nurses are anxious to have such food instruction given in the schools as will help to solve the health problems of the school children, and to have such food instruc- tion given to the mothers as will help to meet their problems in pre- natal and pre-school work. Hot Lunches — Of the 228 schools from which information was secured through the questionnaires sent out to the teachers, 96 schools, or 42 per cent, stated that they were equipped with stoves for prepar- ing lunches ; 132, or 57 per cent, were not equipped with these stoves ; 64, or 28 per cent, of these schools stated that they were serving a hot lunch; 45, or 19 per cent, stated that they were serving a hot lunch daily ; 30, or 13 per cent, were equi]5ped with stoves but not servinq' a lunch ; in 57, or 89 per cent, of the schools serving lunch the students assisted in its preparation: (in i school there was a mid-morning milk and cracker lunch served for under-weight children). In the 37 schools visited there were 10 in which hot lunches were served regu- larly. In 5 of these the menus were supervised by the home econo- mics teacher. In 4, milk was a part of the regular luncheon. In 2 of the schools visited, mid-morning and mid-afternoon milk feed- ing was offered to all children, but there were no data available from which to judge of the results. Traimng in Nutrition — There are unusual opportunities for im- provement of nutritional standards in Erie County through the train- ing of physicians, nurses and teachers as many receive this training within the county itself. Of the physicians of Erie County 85 per cent are graduates of the Buffalo Medical School. The private nurses of the county are from Buffalo hospitals. They receive their training in nutrition chiefly through the dietitians in these hospitals. The percentage of public health nurses from Buffalo hospitals in Erie County is comparatively small. Many of the public health nurses who- have been trained in Buffalo have been employed elsewhere. Perhaps the greatest possibility for assisting in solving the nu- trition problems of the children of Erie County through training, lies in the opportunities for the normal training of teachers. The home economics course in the Buffalo Normal School is a four-year course with B. S. degree. This compares favorably with training given in other institutions and the school ranks well among normal schools. The Buffalo Chapter of the Red Cross furnished a nutrition specialist for the Buffalo Normal School at the request of the Home Economics Department of that school, the State Supervisor of Home Economics, and the State Supervisor of Nutrition. Board of Child Welfare — Mothers' Allowance — Four years ago- the Board of Child Welfare recognized the need of having, along with their other workers, a specialist who could concentrate on homes where there were malnourished children and where the families need- ed instruction in meal planning, preparation of foods, household man- agement, sanitation, etcetera. Such a person, known as a Domestic Edu- cator, last year worked with 70 families and brought about a marked improvement in the home life of these families. The Board plans to have the domestic educator handle only the problem cases in home making, etc., as they recognize that in order to do this work, the do- mestic educator must make frequent calls and do rather intensive 56 work with the families under her care. They feel that the results of the work of the domestic educator are very satisfactory. Department of Charities and Corrections — The Department of Charities and Corrections, through the assistance of the Superinten- dent of the Poor, boards out and places out children. In accomplish- ing this work it uses placing-out ag-ents, who choose the homes with the thought of securing a place which is best fitted to the all-around development of the child. It has not yet had the services of a special- ist such as a domestic educator or nutrition worker, who could assist in securing and supervising homes for the children. Such a per- son wisely chosen would, no doubt, be valuable in problem cases in nu- trition, also in helping institutions in solving their problems in nutri- tion. Tuberculosis League and Red Cross — ■No attempt has been made to study especially the attention given to nutrition by nurses of the Tu- berculosis League and of the American Red Cross in their services in Erie County, as mentioned elsewhere in this report. It has not ma- terially differed from similar work by public health nurses generally, but should not be overlooked in an inquiry on the subject of nutrition. Both organizations agree that it is impossible for their nurses, with their other many duties, to give the fullest attention to this sub- ject. It is certainly not possible for them to organize such work for the schools or through special lecture and class work with clubs. Junior Extension Work — The Junior Extension Work in Erie County is carried on largely in the schools of the county. It is done after school hours and the projects are developed in the home. The food projects during the year were carried on in 13 townships and were distributed in 15 school districts in as many different commu- nities. In carrying on home-making projects the group of project work- ers were organized into a club with a local leader. They met with this local leader every two weeks on scheduled time. The director plans to see each group at least once a month. The local leaders are teachers in the majority of cases. The director is at present planning to have a community woman work with the teacher as an assistant local leader, or as leader, with the teacher as an assistant. As a result of the extension work in the schools, one high school has developed a home-making department, and in others home-making teachers have taken on junior project work in addition to their regular work. The training in nutrition given the girls through the food 57 projects includes the proper selection of foods, the planning, prepara tion and serving of simple dishes and meals, and food preservation The work has led to increased interest in the choice and preparatio: of foods and the formation of good food habits, which has resulted ii better nutrition for the entire family. 'Home Bureau Organization — The Home Bureau has at present time 31 recog nized community centers. Each one is composed of the school dis tricts which naturally center around it. There is a committee womai in each school district who is responsible for the work of the district These school district committee women comprise the community com mittee, elect their chairman and plan a program of work for thei community. For convenience, the county is divided into seven districts fo: holding local leader training schools. The county leader will hold om training school a month at each of the various centers, and have eacl community arrange to send its local leaders to the schools most con venient for them. The program for 1920-21 includes the following: (a) Lectures on food, food values, child feeding. (b) Exhibits of menus on food in cooperation with the city hos pital, the Erie County Fair, and the Thomas Indian School. (c) Home nursing courses and the courses in food preservation. (d) Milk campaign in the county. (e) Conduct of one nutrition clinic for 20 under-weight childrei and stimulation and assistance in introduction of hot lunche in rural schools. Coordination in Junior Extension ojid Hame Bureau Work — A to Junior Extension groups and the Home Bureau, the impression wa gained by those inquiring into the child health conditions in Eri County that their work was very valuable but could be made more si through systematic planning and correlation with work of the nurses home economics teachers and others, on a more definite basis for th entire county. Recommendations for Nutrition Program 1. In order to secure training for those who may take a part in a nutri- tion program in Erie County, it is recommended : a. That emphasis be placed in medical schools on training in diagnosis and treatment of nutritional diseases and malnutrition. b. That the hospitals training pupil nurses furnish adequate training 58 in nutrition for pupil nurses as well as correct nutrition for pa- tients. c. That colleges, universities and other institutions offering training to public health nurses furnish adequate training in nutrition for pub- lic health nurses as a part of both their regular and graduate courses. d. That teacher training courses and normal school courses preparing teachers for rural schools should give all teachers the fundamentals of a proper understanding of subject-matter in teaching nutrition as well as of health habits in general and methods as related to health. That training schools and normal schools should se- cure the cooperation of all departments in the school to bring about such training and to furnish opportunity for the students to have practice-teaching in the correlation and teaching of such subjects. e. That colleges, universities, and other institutions offering training for rural supervisors, or helping teachers, should furnish well rounded training in content and methods for handling all subjects taught in the rural schools, including nutrition and health habits. That especial emphasis be placed on training in correlation of all subjects taught in the rural schools, in order that the rural super- visor, or helping teacher, may work to the best advantage with the trained specialist in carrying on the work in her schools. f. That colleges, universities, normal schools and other institutions offering training for the home economics teachers offer special training in content and method in nutrition, and that similar train- ing be given home demonstration agents. g. That colleges, universities and other institutions offer such spe- cial training for nutrition specialists and nutrition workers as will fit these workers to meet recognized standards for such workers. II. In order to secure training for those who could now take a part in a nutrition program in Erie County, it is recommended : a. That the home-making or home economics teachers in the county should supervise menus offered at school lunches and be used as far as their program will permit to give instruction in nutrition to the grade teachers in the areas served by them. *b. That the program for normal schools serving the rural sections of Erie County, should definitely include method and content for the teaching of nutrition, properly correlated with the teaching of other health subjects. This should apply to the program offered by the Red Cross nutrition specialist at the Buffalo Normal School. c. That the Home Bureau manager, the home economics and home- making teachers and others interested in the proper presentation and follow-up of information on the subject of nutrition meet as a group to confer on present programs and to plan definitely more thorough and systematic cooperation in a program which shall serve the whole community, including the schools and the mothers in the homes, rather than promote separate programs. d. That the special rural supervisor or helping teacher (see page 13), shall particularly have charge of the correlation of the teaching 59 of nutrition and health habits, under such general health supervision and special nutritional supervision as may be available for the countj'. e. That the Erie County Health Council consider the program worked out by the group interested in nutrition, as part of the health pro- gram for the county, and that more home economics teachers (with a major in foods and nutrition) be appointed in the schools, and that the services of a trained nutritional consultant shall be avail- able to all engaged in health work, including nurses, physicians, helping teachers and supervisors of dependent children. *Notc: See the section of this report on health teaching. XL HEALTH OFFICERS The Part of the Health Officer — Too much emphasis cannot bi placed upon the importance of the health officer in the development of not only the general community health work, but of particular meas- ures for children. Unless private effort tends to build up, strengther and support the official health work of the community, whether in the schools or in the homes, the results are apt to lack full effectiveness and permanency. The health demonstration during the past three years m Arlington County, Virginia, is an excellent illustration of the vital part which the health officer can play in developing a live program for child health, as well as for public health generally. Numbers — In the area covered by this study there are 30 part time health officers, or an average of one for every 3,063 inhabitants. While this might seem a fairly adequate number, it is not possible to use it as a criterion because of the fact that these are part time men who are overwhelmed with many duties. A list of the tasks assigned by law to the local health officers in New York State compiled in 1914, disclosed 231 such specified duties. In view of the meager salary al- lowance for this position, and the still more meager allowance for pub- lic health activities, it is obviously impossible to expect satisfactory work under such conditions. Duties — Space will not permit an enumeration of all the duties expected of health officers. In general, each one is required by law to make a yearly sanitary survey of his coinmunity, to maintain contin- uous sanitary supervision over the territory under his jurisdiction, to grade the milk supply at least once a year, to enforce within his juris- diction the public health law and thfe sanitary code, to promote the spread of information as to the cause, nature and the prevention of 60 prevalent diseases and the preservation and improvement of health, to carry on public health educational work, and to attend the health of- ficers' school and conferences of health officers. Recording of births is handled by registrars who are required to report communicable diseases to the health officers. Supervision — The only supervision of the work of these health officers is through the District Sanitary Supervisor of the State De- partment of Health, who has not only Erie County, but four other counties under his charge. Manifestly it is impossible for him, in spite of much good work done, to give much individual attention to the problems of each of the 30 health officers in Erie County alone. Appropriations — The average appropriation for health work in the 19 health officer districts covered by the district sanitary super- visor in a survey of conditions was $718. Except for several districts with considerably larger appropriations this average would have been lower. The average per capita of health expenditures for these dis- tricts was 18 cents and the median 15 cents. Excepting two com- munities, each employing a public health nurse, the average was 14 cents per capita. The average salary of the 19 health offilcers was $387 and the median $300. It is hopeless to expect anything ap- proaching thorough public health work from such appropriations and salaries. The health officers devote only a minor fraction of their time to their official duties and their practices must be their main considera- tion. Lack of Emphasis on Child Health — ^The very natural result of this situation is that the health officers concentrate their attention primarily upon the handling of communicable diseases and the most gross and obvious violations of sanitary regulations, and give very little attention to other even more important health measures, includ- ing the urgent need for an effective child health program. It is greatly to their credit that a few health officers, in spite of these handicaps, have interested themselves in the starting of new lines of work, including the development of consultations for the under school age child. Although medical examinations of school children are in many cases conducted by the health officers, there is little effort to follow up these examinations in order to secure corrections. |Here also some of the health officers have gone beyond the dead level of mere fulfillment of the law and are trying to make their work tell in building up the children. This subject of school examinations and follow-up is dis- &1 cussed more fully, with suggestions, in the previous section on School Medical Inspection. SuPERVisiox OF r^IiLK — One of the functions of health officers, of especial interest from the point of view of safeguarding children, is ■'he supervision of the production and distribution of milk. In general little has been done to improve milk supplies in the rural areas of the county except where the State Department of Agriculture has secured the tuberculin test of cattle. The larger milk stations, cream- eries and condensories also have had a good influence on obtaining tu- berculin tests of cattle in various parts of the county. Local Inspections and Grading — The law requires that dairies selling in a community shall have a permit from the health officer who shall make a yearly inspection of them and grade their milk. In no^ case was it found that dairy inspection had been more frequent than once a year, and often the health officer had made only one or two such inspections all told. In few cases is the milk supply scored with the help of a bacteriological count. The Buffalo State Laboratory re- ports the receipt of 38 milk samples, coming from only three com- munities. Tuberculin Tests — In one village a veterinary employed to inspect dairies had given turberculin tests to all the cattle in these dairies. There is serious doubt as to how far the cattle have been tuberculin tested in other communities in spite of the impression of some of the health officers to the contrary. The County Agricultural Agent re- ports that, under the accredited herd plan, 187 cows were tested in 1920 and 247 in 1921. Possible Improvements — The supervision of the milk supply is. a problem that will not be satisfactorily solved except through whole time health officer service. Especially difficult is the enforcement of the law by the local practitioner who is hampered by considerations of his practice and the interests of his patients and friends. A good deal could be accomplished in improving the local milk supplies if a special official from the county (or the state) health de- partment could visit each community with reasonable frequency and inspect the dairies and check up the grading of the milk. Milk speci- mens sent to the Buffalo laboratory at frequent intervals would be a valuable check on the local grading and very helpful in the educa- tional work to create a demand for better milk. If special containers were furnished by the State Laboratory the samples could be taken to^ the laboratory by automobile and avoid the present excuse of difficulty of securing a proper container. 62 Pending the adoption of adequate public supervision of milk sup- plies, it is important that the mothers be taught by the public health nurse and physician the importance of pasteurizing or boiling all milk before given to their children. Communicable Diseases — 'Improvement in information concerning communicable diseases and methods of controlling them is probably the greatest achievement in local official health work in the rural sec- tions of the county. Most of the health officers seem to have an under- standing of sources and modes of infection and visit cases of com- municable disease reported by the physician himself, to instruct the family in isolation and measures of control. The placarding of homes for scarletina and diphtheria is common with the majority and many do this also for measles and whooping cough. Reporting — The reporting of communicable diseases by the phy- sicians may be taken to be fairly satisfactory from the evidence, al- though much could be done through follow-up service for improving isolation and detection of mild, unrecognized cases through the investi- gation of contacts and suspects. In one community the Red Cross nurse, under the direction of the health officer, had obtained reports of numerous cases not employing a physician, by investigating all re- ported suspects. A large percentage of the health officers were found to have dis- tributed state antitoxin. So far as could be learned the Schick test and toxin-antitoxin have not been used as a general preventive measure, although isolation of diphtheria carriers is fairly common. Wide Variation in Methods — However, there is wide variation in methods and great room for improvement. In one community the health officer felt strongly that it was inadvisable for a nurse to have anything to do with communicable diseases. Several health officers stated they did not visit homes of children sent home from school but depended upon the family physicians' report. A satisfactory working basis between the health officers and the schools for the handling of communicable diseases, as a general rule, has not been worked out. Thoroughgoing study of sources and modes of infection and control and farsighted preventive measures cannot be expected from the part- time health officer with many other duties, and is not found in the majority of cases. While other data were collected in this study as to present methods of handling communicable diseases, showing many possibilities for improvements in specific instances, the really outstanding need is whole-time health officer service to carry on those epidemiological, 63 sanitary and preventive measures necessarv to supplement the \v'iri< of the Kical health dfhcer. If such service is available and, at the .same time, adequate public health nursing service is provided, as outlined in the nursing section of this report, it will be possible to build ujj a thorough system of supervision of contagious diseases in the schools and homes. \'exere.\l Disease — Although the State Health Department has a division for venereal disease prevention and has developed an exten- sive program that is being carried out effectively, these activities have not reached into the rural areas of Erie County. In many cases health officers interviewed stated that they had no cases reported and some confided that a large percentage of the cases went to Buffalo for treat- ment in order to keep their trouble secret from their neighbors. The all-time health officer for the county or for subdivisions of the county as well as an increased number of public health nurses will accomplish much in the way of educational work that leads to prevention or prompt and proper treatment of venereal infections. The prenatal and infant welfare consultations recommended elsewhere should acomplish the same for mothers and infants. ^^^A.TER Supplies — ^lost of the incorporated villages have public water supplies which are approved by the director of sanitary engineer- ing of the State Health Department as provided for by the state law. "\\'ells and springs are the sources usually used in the rural communities. In some sections of the county there are fairly numerous springs said to come from limestone. The mountainous character of the country and the sparsely inhabited character of these sections, provide the only safeguard for these springs and wells in the limestone. Observations of some schools and answers to the questionnaire sent to all of them indicate a very general need not only of protection of the sources of water supply for the schools but of methods of handling the water used. Possibilities of State Assistance — JThe Division of Sanitation of the .^tate Health Department has done excellent work since its estab- lishment in 1906, during which time the number of sources of public supply treated either by filtration or chlorination has increased from 50 to 130, and the population served by such sources from 700,000 to 7,000,000. The personnel of this division was cut last year from 13 to 5 members, making it difficult for it to extend its work. The district sanitary supervisor cannot give much attention to this impor- tant question because of many other duties. ()4 Local Supervision — During the past year only 14 water specimens were sent to the Buffalo State Laboratory from only 5 different com- munities in the area included in this study, and only 29 to the Albany laboratory from 11 different communities. Among 19 health officers questioned regarding laboratory examinations of their local water supply, 8 replied that they did not know when the water had last been tested or stated that it had never been tested, while 1 other claimed that the water had last been tested 5 years ago, 5 others made the statement that their supply had been tested a year ago and 1 other claimed that he had received a report from the laboratory 6 months ago. It is obvious that not much improvement in the purity of water can be expected from the present supervision by part time health officers. Inadequacy of Present Methods — This is another example of work which needs to be done for the protection of public health which, according to all indications, will wait for the establishment of all-time health officer service for the county, or sub-divisions of it, to supplement the work done by the present part-time health officers. In the meantime the health agencies and their representatives in the county as far as possible should promote the use by families or individuals, who do not have a satisfactorily tested water supply, of simple forms of chlorination or of boiling the water, especially when there are cases of typhoid fever in the vicinity. Sewerage — Depew, East Aurora, and parts of West Seneca are fairly well sewered. Springville and North Collins have sewers for a part of the village, although Springville is said to have an unsatis- factory method of disposal. Septic tanks and cesspools are used for the homes of persons in better economic circumstances. In some sections cesspools are the rule, while in others septic tanks with sub- surface drainage have been operated successfully for several years and are coming into more and more use. The old-fashioned open- back privy is still used on a large percentage of the farms. The lack of community sentiment making against this nuisance is particularly noticeable in the sections where they have not yet obtained a sanitary toilet for their school. Recommendation Many instances have been cited in which great improvement could be effected in the work assigned by law and custom to health officers of the rural sections and villages of Erie County. Much might be G5 done in safeguarding:; milk and water supplies, in improving the control of communicable diseases, in bettering methods of sewage disposal, and in the organization of consultation centers for children, and in child hygiene work generally. Prior to and following the adop- tion of effective health measures of control a great deal needs to be done in the way of educating individuals in the home, in the schools, and in organized groups. However, as shown above, it is impossible to expect much more improvement over the present methods under the existing part-time and low-pay plan for local health officers. 1. It is recommended that one of the first considerations of the Erie County Health Council and of its constituent groups shall be to secure the services of a whole-time health officer for Erie County ana a whole-time health officer service as rapidly as possible for smaller administrative dis- tricts covering the rural sections and villages, to supplement the present work of part-time local health officers. It is obvious from the data given above that the services of all- time health officers are essential if satisfactory health work is to be done in the county, supplementing that of present part-time health officers. In addition to a county health officer, who is the first requi- site, there should be such officers in charge of districts not so large that each cannot keep in close touch with all the local physicians and school authorities and with public health nurses available for his assistance. Probably the county should, as soon as practicable, be divided' into 5 or 6 districts with an all-time health officer in each who can carry out those important epidemiological, sanitary and educational measures necessary to supplement the services at present rendered by the part-time man. XII. MENTAL HYGIENE OF CHILDREN The main purpose of the inquiries on mental hygiene in Erie County has been to bring to light the problems in the rural areas. Those facilities and agencies outside of the rural sections whose as- sistance is available to them for mental hygiene work, particularly in Buffalo, will also be dealt with briefly. This will make clear what are some of the county's most immediate resources. Public Schools — ^Because of some bearing which the Buffalo schools have upon the mental hygiene program of sections of the countv outside of Buffalo, a statement of the results of inquiries con- cerning mental hygiene work in the schools of that city will be sub- mitted in a supplementary report. This report may also deal with the city health department, hospital and dispensary facilities for assisting in this problem. 66 Outside of Buffalo little has been done especially for mental hygiene in the schools. In cities and larger villages with good-sized schools the school authorities are attempting to make special provision for atypical children. A Progressive School — ^Among the schools visited, one in Hamburg is especially noteworthy. One of its teachers has displayed an un- usual interest in this work, and with the support of the principal, equipped herself by taking special courses for psychometric work and for work with atypical children. Although this school had no special class, those children presenting special problems had been selected and given a great amount of individual attention, which is even better. In this school was found, as elsewhere, the usual handicap of lack of room, of funds, and of an adequate force of personnel trained for such work. The Small Ungraded School — In those parts of the county in which there are only small ungraded schools, there is no such thing as mental hygiene work. Practically in every school room visited were found, as might have been expected, one or more extremely back- ward, troublesome, delinquent, or otherwise mentally abnormal chil- dren. It would be impossible to make other than a general estimate of how many additional atypical children might be found upon thorough investigation. The Lockwood Law and the Number of Retarded Children — In this connection two points should be emphasized : (1) The Lockwood law, which provides that any school district which has 10 or more markedly retarded children shall establish a special class for them, often remains a dead letter. This is because practically nowhere in the county has the exact number of atypical children, for whom special classes should be provided, been scien- tifically determined. A thorough survey would undoubtedly reveal many school districts with 10 or more such children, either in the school or in their homes. In no other way can a basis for the enforce- ment of the Lockwood law in rural districts be established. Answers to a questionnaire which was sent to all the schools re- ported a total of 192 children, or 1.7 per cent, retarded three years or more. The percentage, however, on the basis of total registration varied between 0.7 in one supervisory district and 2.4 in another. Re- tardation alone, even if fully reported, cannot be an exact basis for the selection of cases requiring special attention from the standpoint of mental hygiene. 67 (2) The mentally abnormal pupils in rural schools arc not all of such children of school age residing in that district. In the Nassau County Survey in 1916 the bulk of mentally defective children of school age were to be found outside of the schools. It is likely that the most defective are precisely those that are not in the schools because of tlie great difficulty of managing them It is probable that conditions in Erie County are not markedly different in this respect from those in Nassau County and elsewhere. The health officer of one township reports as follows : "I know of many mentally deficient children living in this township. They have udt been committed to institutions but are cared for in their own homes. The schools are small here and the teachers do not object to their at- tending, otherwise I would have to see that they were expelled from the schools." A review of the conditions with relation to the mental hygiene of children in the small rural schools of the county reveals their many handicaps, particularly in the way of lack of trained personnel and lack ■ of space and facilities for special classes or instruction for the mentally deficient. The need for a combination of small school districts on a sound basis, as recommended on page 16, is very great from the stand- point of mental hygiene. Parochial Schools — A beginning has been made toward organizing mental hygiene work in the parochial school system, although special classes have not yet been developed either in the urban or in the rural parts of the diocese. Psychometric work has been introduced and the results of it have been found useful from the teaching standpoint. A physician is employed who has specialized in applied psychology, and in individual instances pupils have been transferred to special .classes in the city public schools by special arrangement. Further development of this work is receiving cautious consider- ation on the part of the authorities of the parochial schools. Orphan Asylums — ^The problems in the orphan asylums, pertaining to atypical children, are similar to those in the schools, excepting that ;in all probability the asylums have larger percentages of such children .to deal with, and that they not only teach but perform services which school children receive in their homes. Moreover, they have charge of many children younger than school age. Mentally Defectives a Serious Problem — In visits or correspon- ■ dence with 3 orphan asylums, a day nursery, a fresh air mission and .an Indian school, the information invariably given was that the care 68 of mentally abnormal children was not within the scope of these in- stitutions' activities. Just as invariably, however, it was revealed that a number of such children find their way into these institutions and con- stitute a vexing problem. Owing to the inadequacy of institutional provision by the state for such cases, orphan asylums are often forced to care for them indefinitelly. As it is not their policy to do such work, special classes, system- atic mental examinations or psychiatric work is not attempted by 'these institutions. One exception was noted in the county, namely, a group of Catholic institutions which has a special class and in which a certain amount of psychiatric work is done. (It should be noted that the Thomas Indian School is planning to introduce intelligence tests, and has the cooperation of the State Board of Charities in its plans.) There were found to be i8 other institutions for the care of or- phaned, dependent and delinquent children in Erie County, showing that the problem is a large one. (For list of these insti'tutions, see original report sent to Erie County group which invited this study.) An Illustration — As a special instance of some of the difficult problems occasionally confronting those in charge of orphan asylums the following may be mentioned : A boy of unknown parentage, judged to be about four years of age, was found on the doorstep of one of the institutions with a letter pinned to his dlothes stating that he had had meningitis and from that had become mentally defective. At the time of the visit to the insti- tution he had been there only a week or two. He bites other children, takes plates and other dishes from the table, digs his fingers into the food, will not use a fork or spoon, is very intractable, and on one occa- sion tried to throw a glassful of water at the attendant. He walks with an unsteady gait. faMs frequently, does not talk, but makes a great deal of noise. The attendant in charge of him thinks that he understands what is said to him, but is disobedient. None in the institution think that he is a suitable case for detention there, but they are experiencing difficulty in disposing of him. Valuable Opportunities for Observation — It is important to note the unusual opportunities for observation and study which exist in such of these institutions as care for infants of various ages. The sub- ject of anomalous behavior in infants Ims not received the attention and study zuhich it merits. Observations of individual infants here and there in private families, under conditions so varied as to interfere with judgment as to what might be inherent and what of external oricrin in the tendencies of the child, are not to be compared with similar (-.9 (il).servations that could be made in institutions where the infants are under more or less uniform or known conditions. In the ward for infants under i year of age in one asylum visited, the Sister in charge reported that peculiarities of a striking and per- sistent kind are frequently observed in some infants who thus are markedly distinguished from others. Some exhibit a habit of rolling the head on the pillow. Others have a habit of rolling the entire body in the crib, which seems to have a sedative efifect on the child, who is quiet when permitted to do this, and soon goes to sleep, the rolling sometimes continuing after the child fallls asleep and then ceasing gradually. Still others have a tendency to cry far more than is usual for infants, such crying being apparently attributable neither to hunger nor to discomfort of any kind from external cause. IxsTiTUTioNS Outside of Erie County — The following institutions outside of Erie County which are rendering or may render service to children of rural sections of the county should be especialdy mentioned as some of them care particularly for mental defectives and there is as a rule a high percentage of this class of children in institutions of the types represented by the others. Institutions for Mental Defectives — Syracuse State School, at Syracuse, New York, has 13 children from the entire area of Erie County ; 3 others have had applications filed and are on the waiting list. Rome State School, at Rome, New York, has 57 children from the entire area of Erie County ; while none are officially on the waiting list it is reported that many would be if any vacancies were known to exist. Letchworth Village, at Thiells, New York, has 17 children from the entire area of Erie County ; 2 others have had applications filed and are on the waiting list. It should be noted that the numbers of children given are from the entire area of Erie County. No at- tempt was made to segregate those from the rural sections and villages, i. e., the area covered by this report. Epileptics — Craig Colony, Sonyes, New York, has 11 children from the entire area of Erie County ; none are on the waiting list. Other Institutions — -New York School for the Blind, at Batavia, New York, has some children from Erie County although the exact number was not ascertained. The Jewish Orphan Home, at Roches- ter, New York, has 19 children from Erie County. Only in certain cases have they been able to arrange to have psychometric tests made. The annual report of that institution states that occasionally delin- quent and feeble-minded children are admitted there, although it is contrary to the declared policy of the institution to receive them. 70 When a child is discovered to have marked mentall abnormaUty, efforts are made to dispose of it either by discharge or by transfer to an institution for the feeble-minded. Delinquent Children — Such mental hygiene work as is done for delinquent children is carried on partly by the Children's Court of Buffalo, with which is connected a small Detention Home ; partly by the Children's Aid and Society for Prevention of Cruelty to Children which conducts an institution known as the Children's Shelter; and for the rest, by the justices of peace of the various townships in the county to whom is available the cooperation of the Chief Probation Officer of Erie County, whose office is in Buffalo. The Voltmte of Work — The volume of work of these agencies is striking. During the calendar year 1920, which is the last period for which official data are available in a published report, 1176 cases were disposed of by the Children's Court, of which 1060 were cases of boys and 116 girls. Of this number 134 boys arid 41 girls were committed to institutions such as the State Agriculturail and Industrial School, Industry ; St. Agnes' Training School for Girls, Buffalo ; New York State Training School for Girls, Hudson ; Society for the Protection of Destitute Roman Catholic Children, Lackawanna ; Berkshire Industrial School, Canaan, etcetera ; 335 cases were dis- charged, 258 reprimanded and discharged, 262 placed on probation ; of all those brought into court 209, or about 18 per cent, received a psy- chometric examination. Court Staff Needs — All Court cases are investigated by the Chief Probation Officer or one of his three assistants. The court authorities, however, feel that this work falls short of what it should be, both qualitatively and quantitatively. /; should include psychometric work, field investigations by psychiatric social workers capable of taking anamneses, and examinations by psychiatrists. Mental examiruxtions should not be limited, as they are now, to about a fifth of the cases going through the court, but should be applied to all. Children's Aid — The Children's Aid and Society for the Preven- tion of Cruelty to Children and Children's Shelter are now merged in one organization, housed in a modern building. About 600 children between the ages of 2 and 21 are admitted per year. The building has a capacity of 80 or 85 and is well equipped. Children are brought to this Shelter either by agents of the Society for the Prevention of Cruelty to Children, or by order of the courts, or when referred by other agencies. 71 This institution conducts a psychological clinic, which engages the full time services of a well trained psychologist. Almost all children receive a psychometric examination, as well as a sociological and phys- ical investigation. The clinic has available to it the volunteer services of an excellent psychiatrist, who is in private practice in the city. Between 4 and 5 per cent of all cases have heretofore been referred to him for psychiatric examination. Further development of this work is contemplated. Plans are now being discussed and will probably materialize in the near future, which will enable the superintendent to provide two wards for psychopathic children, where they may be kept under special observation. The work of this organization might be helped if more attention should be given to the psychiatric training of the social workers em- ployed and if more cases were referred for psychiatric examination. A merging of the work of the Children's Court with the work of this institution would, if feasible, justify the employment of a psychiatrist on full time and would obviate the need of depending upon free services. Rural Conditions and Facilities- — Outside of the City of Buffalo there are no special children's courts, delinquent children being brought, like other cases, before justices of the peace. There are also no places for detaining delinquent children pending investigation and trial and no facilities or personnel for either physical or mental examinations. Several justices were interviewed and all of them have been communi- cated with. They report that very few children are brought before them. One of them stated : "Since entering upon this office, I have had but one case of delinquency in a child, namely, in a giril about sixteen years of age who had previously been committed to the House of the Good Shepherd; later re-committed to the same institution, from which she ran away after breaking down doors, destroying furniture, and so forth. She was recaptured and her mother took charge of her again. Just where she is now, I am unable to say. There is no doubt in my mind that this unfortunate girl is mentally deficient." Another, who is both a justice of the peace and a school trustee, stated : "I know of no mental deficiency among the children in this neighborhood at this time. About the only cases that come before me are cases of truancy. Then the parents get it good and hard from me, for we make it as pleasant for the children in school as we can to make them want to come instead of playing hookey." Still another justice of the peace related the case of a boy who had been brought before him four years previously. This boy had been brought up in bad surroundings. His mother had almost no con- trol over him and he had a stepfather who often whipped him for trifling things, but paid no attention to serious wrongdoings. The boy had vicious tendencies. Once he took a kitten and cut out its eyes to see what it would do and then let it go. He stole knives, pencils and other articles at school. Once he stole a new copper boiler which his mother had purchased, broke it up and tried to sell it to the junk dealer. On other occasions he stole a cap and some small change out of a cash register in a store. He was committed to Industry, N. Y., for a year, but because of bad behavior there was kept a little longer. A couple of years later he took a girl out in a boat on the lake and they were both drowned. Most of the justices of the peace do not know that the various facilities in Buffalo for the examination of children would be available to them upon application, but those with whom this point was dis- cussed stated that the town would probably object on account of the expenses that would be involved in transportation. County Probation Work — The County Probation Officer's Head- quarters are in Bufifalo. He is supposed to have charge of children on probation in all parts of the county outside of the City of Bufifalo, those in the city being in charge of a special department which the city maintains for that purpose. Owing to the difficulty of transpor- tation and shortage of personnel, the County Probation Officer has had but little contact with the justices of the peace in the various townships, at least so far as delinquent children are concerned. Dur- ing the past fiscal year probably not over 15 or 18 juvenile delinquents have been cared for by the County Probation Officer. The number of cases of children brought into the courts, however, must have been greater. There is some prospect of an improvement in this situation through an increase of personnel in the department and through hav- ing an automobile made available to it for trips anywhere in the county. The County Probation Officer has various ways for having a child examined mentally, such as by taking it to one of the out-patient mental clinics conducted by the Buffalo State Hospital, or to the Chil- dren's Aid diagnostician. But usually he refers cases to a private physician who is engaged in psychiatric work and has the examination made on a fee basis. Not all children receive a psychiatric examina- tion. This is one of the many instances which show that a better coordination and use of the available facilities for making mental ex- aminations for children would result in more complete and more thorough work. 73 Dependent Children — The Erie County Board of Child Welfare reports that during the calendar year 1919, 334 families were given aid by their organization and during 1920 there were 273 families. All children received a physical examination either at one of the health centers in the city or in the city tuberculosis clinic, or by private physicians. During the year 1920, 1,167 children were examined. Only a small number received a mental examination ; namely, either those whom the physician making the physical examination especially re- ferred for such an examination, or those who were reported as doing very poorly at school. Owing to the difficulty and expense of transportation, the children in the rural parts of the county are seldom brought to the city for examination and hardly any of them are mentally examined. If va- rious parts of the county were visited by an itinerant mental clinic, all dependent children in the rural districts could receive a mental examination. The mothers of these children also could receive a men- tal examination and thus the law would be more strictly complied with. Mental Clinics — The out-patient mental clinics conducted by the state hospitals in Erie County consist of three by the Buffalo State Hospital, all in Buffalo, and one by the Gowanda State Hospital, also in Buffalo. Although both the Buffalo and Gowanda State Hospitals have an- nounced their readiness to examine either children or adults, at any time that they may be brought to the hospital, patients are very sel- dom thus referred to them. There is a strong and general disinclina- tion to go to an institution for the insane or to send a child there for an examination. Of the four out-patient clinics, two are as a rule used only for adults, while the remaining two, one conducted at the Jewish Com- munity House every Wednesday morning from 10 to 12, and the other at the Children's Hospital every Thursday afternoon from 2 to 4, are mainly for children. During the year ending June 30, 1921, 148 chil- dren under 16 years of age were examined in this clinic, but scarcely any of them came from the rural parts of the county, owing chiefly to the difficulty and expense of transportation. The great majority of these patients were diagnosed as mentally deficient or mentally re- tarded, but there were also cases of psychopathic personality, epilepsy and psychoneurosis and 23 were designated as normal. Full advan- tage of these clinics has not always been had, due apparently, to the lack of careful planning in advance as to the type of diagnostic 74 service which might best help the other organizations, but this is merely a matter of adjustment, as the personnel and equipment are of the highest quality. The Need of the Rural Areas — It is obvious that these clinics are not serving the rural areas of the county and a mere increase in numbers, even if in new locations, would still leave most of the out- lying sections without service. In order to make psychiatric service available for the schools, justices of the peace, overseers of the poor, health officers, and other organizations and officials throughout the county, it would be neces- sary to organize an itinerant mental clinic. Such a clinic could visit each of the 25 townships in the county outside of Buffalo twice each year, and should be arranged through the County Health Council in cooperation with any consultation or supervisory medical work for the schools. These visits, if announced in advance, would enable the rural authorities to have children and others selected for mental examina- tion, so that periodically the psychiatric problems in every commu- nity would be placed in the hands of those best able to deal with them efficiently. As far as the state hospitals are concerned, such an itinerant clinic would not involve the employment of more personnel or the expendi- ture of a greater amount of time than would be necessitated by the establishment of but one additional fixed out-patient cHnic with a sin- gle weekly session. The only added expense would be that of auto- mobile transportation once a week. If the two state hospitals in the county would divide between them this wo.rk so that the Buffalo State Hospital would send out its itiner- ant clinic to the townships in the northern half, and the Gowanda State Hospital to those in the southern half of the county, then for each of these institutions the establishment of such an itinerant clinic would involve but hklf the labor and time that would be required for the es- tablishment of one additional clinic in a fixed locality. If a cooperative plan for itinerant consultations involving more than one medical service should be worked out in cooperation with the proposed County Health Unit, this would mean decided economy in personnel and transportation. Outside of the work in their out-patient clinics, the state hospitals have seldom opportunities of rendering psychiatric service in cases of children. This is due to the striking rarity of psychoses in children under 16 years of age. At the present time there is not one patient un- der 16 years of age from Erie County in the Gowanda State Hospital, and but one in the Buffalo State Hospital. During the year ending 75: June 30, 1921, seven patients from Erie County under 16 were admitted to the two hospitals, three had had manic depressive psychoses and four had dementia praecox. Superintendent of the Poor — The County Superintendent of the Poor in Buffalo deals with dependent children as described in the suc- ceeding section of this report. He deals with mental disorders in childhood only in those marked cases in which the necessity for com- mitment to an institution for the epileptic or feeble-minded arises. Not Enough Institutions — Although the present incumbent of this office is very conservative in the matter of committing children to such institutions, feeling that it is a step justified only as a last resort and that even a definitely feeble-minded child should be first tried in a private home or on a farm before commitment is decided on, yet he finds the State's facilities for the care of children who must be com- mitted to such institutions very inadequate. At present he states that the county is compelled to maintain 15 children in the Brunswick Home in Amityville, L. I., a private institu- tion to which the county pays a certain amount per week for the main- tenance of these children. Not only are the facilities which the state provides for feeble- minded, epileptic, and otherwise mentally abnormal children inade- quate, but such facilities as are available are in institutions located for the most part hundreds of miles distant from Erie County. Owing to this circumstance the relatives of children who should be committed are often unwilling to consent to such commitment, as they would have to be taken so far from their homes that visiting would be ren- dered difficult or impossible. From the Superintendent of the Poor and from other sources we have learned that there is a great need for an institution for mental defectives in the western part of the state. Owing to the fact that the State makes such inadequate provision, Erie County has developed a plan to build at Alden, where it owns 900 acres of land, an institu- tion which would include an almshouse, penitentiary and a separate department for mental defectives. N euro-Psychiatrists in Private Practice — Erie County, especially Buffalo, is unusually well supplied with neuro-psychiatrists among its physicians. Outside of those who are on the medical staffs of the two state hospitals, there are in private practice at least 10 psychia- trists or neurologists interested in psychiatry, seven of whom have had state hospital experience. They are available for work on a fee basis ; but most, if not all, are also ready to offer their services, so far as they can spare the time, to public institutions, gratis. Some are on 76 the medical staff of the Buffalo City Hospital and others are employed on part time on a small salary basis by the Department of Health for psychiatric work. Recommendations — In order to formulate recommendations for the more purposeful utilization of existing facilities and resources of the county for the work of mental hygiene among children and for the creation of new facilities required to round out the existing organi- zations, it is necessary, first of all, to determine upon a general plan of mental hygiene activities as the goal to be attained. /. Work in the Schools — ^It would seem highly desirable to introduce in the schools the systematic practice of group tests of intelligence. On the basis of these tests and also on the basis of retardation in school work, anomalies of behavior and evidences of nervous or mental disease, children may be selected for individual examination. Perhaps the next step would be to provide for individual psychometric tests in all cases thus selected. The third step would be to investigate the home conditions in each case and to secure full anamneses with the aid of psychiatric social workers. These investigations and anamneses together with the general medical ex- aminations which school children receive, should form a basis for ex- plaining such phenomena as retardation, truancy, unruliness, and so forth. The final step would be an examination of the data already collected and of each atypical child individually by a trained psychiatrist which should lead to a diagnosis and recommendations for the treatment and dis- position of the case. The school system should further develop its facilities such as special classes, trained personnel, and so forth, for carrying out the recommenda- tions resulting from investigations of children as outlined above. 2. Work With Children Not in the Schools — Fot children who come to the attention by reason of nervous or mental disorders developing before or after school age and for those who come to attention by reason of de- pendency or delinquency, provision should be made for investigation along lines similar to those outlined above for school children. The plan here outlined would meet to a large extent the social hygiene needs of children, inasmuch as psychiatric problems are often found under- lying social diseases among them. The timely discovery and attack upon such problems would in many cases constitute a measure of social hygiene, that is to say, prevent venereal disease. For the rest social hygiene must be considered a part of any well-rounded plan of general health work. 3. Need of Trained Personnel — ^One of itne first needs brought to light by this study is that of trained personnel for the various functions in the work of mental hygiene. At the present time, owing to imperfect organiza- tion of existing facilities, it is not only true that the energies of the valuable personnel are inadequate for the work that has to be done, but also that these energies are employed in an uneconomical way. It should not be nec- essary for the psychiatrist of 15 or 20 years' experience to do psychometric work, or take anamneses, inasmuch as many teachers and others can readily be trained to do it. 77 It is recommended that teachers who are interested in such work be trained to perform group tests. Such work could be safely entrusted to them, as its object would never be the final and definite classification of children but only a preliminary classification intended as a basis for further investigation. Other teachers, possessing better qualifications of education and experience, should receive more advanced courses of training to fit them for the more responsible work of individual psychometric testing. A third group either of teachers, or school nurses, or social workers, should be given courses in psychiatric social work including practice work in field in- vestigations and obtaining psychiatric anamneses. Finally, a fourth group of teachers should be trained for various phases of work with atypical children in special classes. In the course of the survey, a canvass was made of those educational institutions in which such training might be provided. In the University of Buffalo, departments of both medicine and arts and sciences, extension courses and summer courses are already being given in applied psychology, abnormal psychology, and psychiatry. Conferences with heads of depart- ments have led to the conclusion that it would be entirely practicable to out- line and provide courses specially devised for training personnel for the va- rious kinds of mental hygiene work mentioned above. In the State Normal School in Buffalo there is an excellent department of psychology in which also far-reaching attempts have been made to de- velop summer courses in applied psychology. With the increase of the reg- lar normal school course from two to three years, further development of that work for all student teachers has been planned. Perhaps the most significant steps in this direction have been taken by the State Normal School in Geneseo in cooperation with the Craig Colony. This school conducts practical courses at the Craig Colony for the purpose of supplying special training to seniors who are interested in work with atypical children. Eight critic teachers have for nearly two years been maintained on full time at the Craig Colony, being paid from the budget from the Geneseo State Normal School a usual salary, minus a deduction of $240 a year in lieu of which they receive room, board, and laundry at the Colony. These teachers have organized classes of from 8 to 25 pupils selected from among the patients in the Colony. The teaching consists in academic work, weaving on looms, lace making, tatting, crocheting, plain sewing, rug making, carpentry, chair caning, toy making out of rags and out of wood, kindergarten training, physical culture and singing. Groups of about five or six student teachers are assigned to work at the Colony for a period of one week for each group. They derive from such an assignment an op- portunity to observe methods of instruction; a certain understanding of va- rious mental and physical handicaps which should help them to recognize them and make intelligent allowance for them upon encouniering them in the course of their teaching; also a certain amount of training In the work itself which is being taught to the children, such as various stitches, how to use a loom, and so forth. These courses are optional, but of about 200 senior students no fewer than 120 have signed their names to applications for them. They constitute, of course, only an introduction in the needed training, but it is a plan of the 78 normal school authorities to increase their scope and their variety so as to fit teachers for the various functions in mental hygiene work among school children, such as those enumerated above. This special development of tne Geneseo State Normal School would by no means eliminate the need for extension courses in Buffalo University, Buffalo State Normal School, and possibly in Canisius College. For those teachers whose work is in Buffalo it would be advantageous to have special courses offered in the local educational institutions, for only thus would they be enabled to utilize any spare time they may have during after- noons, evenings and Saturdays for getting such training. 4. Standards for Psychometric Work — ^Perhaps this is the proper place to refer to the uncontrolled and often incompetent psychometric work that is done in many places. It would seem to be the proper function of the American Psychological Association to decide upon standards of require- ments for the various kinds of psychometric work that has to be done. Those engaged in such work should be able to show that tliey have con- formed to such standards and should thereupon be officially certified by a proper committee of the Association, the certification specifying whether it be for administering group tests, or for individual tests in the capacity of assistant, or for independent work as professional psychologist. Courses of- fered by the universities, colleges and normal schools should be planned with a view to meeting such requirements. 5. Increased Institutional Accommodations Needed — Very often the rcoramendations which result from a psychiatric study of a child cannot be carried out on account of lack of necessary facilities. Some of the special needs have already been discussed. Those most keenly felt are a new insti- tution for the feeble-minded in the western part of the State of New York, perhaps in Erie County, and the establishment of special classes for atypical children in the public schools. It should be noted in this connection that, as far as parochial schools are concerned, the Lockwood Law is not man- datory but optional. 6. Psychiatric Service for Rural Areas — The greatest obstacles in the way of organizing special classes are encountered in rural parts of the county. The chief improvements will probably come through the combi- nation of school districts referred to on page 16 ; but even then rural schools will still be at a disadvantage in comparison with urban schools, for the reason that one school, even if it be a large one, cannot organize special bureaus such as a department of education of a large city has. While a larger rural school can develop personnel for group testing, individual testing, psychiatric social work and teaching of special classes, it cannot so readily secure the services of trained psychiatrists whenever needed. In order to help rural areas, and especially rural schools, meet the need for trained psychiatric service, organization of an itinerant mental clinic is recommended. This has already been referred to and its general plan described. Information secured from neuro-psychiatrists practicing in and around Buffalo indicates that some, if not all, would be willing to accept positions on the staff of such an itinerant clinic and thus relieve the state hospitals to some extent of the burden of carrying it on. However, such a clinic should be under the control of the state hospitals, just as the fixed clinics are in order to insure proper supervision, standards, records and reporits. It should, of course, conform to the plans and procedure for the 79 medical examination of school children, especially in so far as they relate to itinerant consultation or clinic work. 7. Organization for Continuing ITork — The next recommendation deals with the problem of so organizing and controlling the mental hygiene work in the county, especially among children, as to secure for it the highest measure of efficiency with the least expenditure of energy and resources. There should be some agency for co-ordinating the mental hygiene work of the schools of the city and of the rural parts of the county, orphan asy- lums, children's courts and justice courts, the Children's Aid Society, the Board of Child Welfare, the two state hospitals, the Department of Health of the City of Buffalo, the Department of Hospitals and Dispensaries, the Office of the County Superintendent of the Poor, and neuro-psychiatrists in private practice. In order to bring this about, it would perhaps be best to organize an Erie County Committee for Mental Hygiene as a Committee of the Erie County Health Council. To this committee might belong, ex-ofifiicio, officials who are concerned with the education, management and control of chil- dren, including not only heads of large departments, but also representatives of such groups as the school teachers, nurses, social workers, physicians, psychologists, probation officers, justices of the peace, and overseers of the poor. This committee, working through the County Health Council and with due regard to the importance of other health needs, should have as one of its objectives ■ the organization through paid workers of a complete pro- gram of mental hygiene work in each part of the county, as part of the gen- eral public health program. The objects of this committee should be care- fully formulated and among its functions should be that of furnishing scholarships to enable teachers, nurses, and others to take special courses of training provided by universities and colleges in extension teaching and summer sessions. It also should be one of its functions to hold from time to time meetings not only for its own members, but open also to the public, at which important subjects in mental hygiene should be discussed by compe- tent authorities in a way to be of educational value to those in attendance. S. Research — In general, tthe most obvious need for the development of mental hygiene among children — one which did not require a survey to bring it to light — is that of organizing research for increasing our knowl- edge of the mental disorders of childhood. Although psychiatry has made great strides in the last twenty-five or thirty years, this part of it has not kept pace with its general progress. Owing to the fact that any mental disorder occurring in childhood, no matter what its nature, is bound to act as an obstacle to development in in- telligence, the tendency has become prevalent to diagnose almost all cases as mental deficiency. This tendency has been strengthened by the undue reli- ance which it has become customary to place upon a showing made in psychometric tests. Should it prove possible to organize the work of mental hygiene among children along the lines indicated in the above recommendations, even only in some one county, unprecedented opportunities would be created for re- search in this branch of psychiatry. It need hardly be emphasized that, with the possible exception of eugenic measures, there is no more important field of psychiatric prophylaxis than that of work among children. It is, 80 therefore, to be hoped that either in Erie County or elsewhere, in the near future, some such organization as is here suggested may be developed and thus the stage set for research and further progress. , XIII. THE HEALTH OF DEPENDENT CHILDREN Dependent children of the rural part of Erie County are cared for by three agencies: the County Board of Child Welfare, which administers the widows' pensions ; the office of the Superintendent of the Poor for Erie County; and the Children's Aid Society, a volun- tary organization. The County Board of Child Welfare — The Board of Child Welfare during the year ending June 30, 1920, had 469 families and 1594 children under its care. Under the supervision of the Board there were, at the time of this study, 147 children under 16 years of age living in the rural sections and villages of Erie County. The County Board of Child Welfare is required by law to have a physical examination for all children under its supervision. The examination is at present done at the Diagnostic Clinic, connected with the Children's Hospital, and is probably rather carefully done there. If defects such as tonsils and adenoids are found, the children are usually sent to the Children's Hospital for operation immediately,, on order from the County Board of Child Welfare. The policy of the Board on nutritional problems in the homes of their children is dealt with in the section of this report on Nutrition, the mental hygiene of their charges is referred to in the section imme- diately preceding this one and the Board's attitude on the question of maintaining families in which there are children of working age whO' have not yet completed their schooling is described in the next section foillowing this one. The Superintendent of the Poor — ^At the time of this study there were reported to be approximately 2358 children under the charge of the Superintendent of the Poor of whom 1298 were in orphan asy- lums and other institutions, and 1060 were in boarding homes, in free private homes or with their mothers to whom maintenance was being paid by the county. At the time of the study 118 of these dependent children under supervision were from sections of the county covered by this study. This is about one-tenth of the whole outside of institutions, who are under the care of the Superintendent of the poor at any one time. Eighteen of these were dependent because of the illness or death of one or both parents from tuberculosis ; 22 were children of widows ; 81 41 had fathers who had deserted; 13 had fathers unable to work be- cause of illness or disability ; 8 were orphans ; 5 had feeble-minded mothers ; 3 were children of a father indicted for manslaughter, and 8 were motherless. ^ It is the custom of the Superintendent of the Poor's office to leave children with the mother wherever this is feasible, and to give her an allowance for their support. Sixty-eight of the 118 children werei living with their mothers, and 19 others were living with grandmother, aunt, or some member of the family, so that nearly three-fourths of these dependent children were being maintained in their own family homes. Eleven children were in regular boarding houses, 6 in free homes or adopted, and 14 in institutions. So far as physical examinations are made of those children not committed to an institution who are under the care of the Superinten- dent of the Poor, this is done through one of the health centers under the Department of Hospitals and Dispensaries. There is no way of determining the number of these examinations made, but it is apparent from records which were read that a thorough physical examination of dependent children is an exception rather than a rule unless they are committed to an institution. For those who are placed in boarding homes, there is no regular supervision by a trained health worker, a nurse, or a physician. It is left to the judgment of the boarding home keeper to decide whether the child should be taken to a physician or not. Children's Aid — In the Children's Aid Society there are two classes of children under its supervision; those who live in the county and who are neglected, and the children who are brought to the Shelter in Buffalo and are kept there for some time. The former class do not receive a regular physical examination as a routine, but the latter do have a very thorough examination and diagnosis. At the time of the study there were children from 23 families in the county under supervision by the Children's Aid Society, com- prising in all 82 children. Forty-one had come under supervision because of neglect; 10 because of non-support, (a single family); 6 because of abuse; 9 because of destitution; 10 because the mother had died of tuberculosis ; 3 for truancy ; t abandoned ; and 2 were tempo- rary cases while the mother was in the hospital. Fifty-eight were kept under supervision, the 10 contact tuberculosis cases were referred to the tuberculosis dispensary, 11 cases were referred to the Superin- tendent of the Poor, 2 truants were returned to their homes, and i child committed to the State Custodial School at Rome. Only II of these 82 children had had a thorough physical exam- ination. 82 Sick Children — Indigent children who need hospital care are ered at either the City Hospital, the Ernest Wende Hospital (for tagious diseases), the County Hospital, or the Children's Hospital, order from the Superintendent of the Poor. From such inquiries were made there was no evidence that children from rural sections the county, for whom hospital care was definitely recommended, led to receive such care. The chief problem in securing proper ;pital care for children in Erie County is one of the discovery of ise needing attention, proper diagnosis and follow-up so that the Idren may be sent to the hospitals when they need such attention. Dependent Children in Institutions — Because of the brief time lilable for this study of child health in Erie County it was impos- le to make a study of general health conditions and measures in the titutions for dependent children. XOMMENDATIONS (1) It is recommended that those children who come under the care of he Superintendent of the Poor receive a physical and mental examination IS a rule rather than in exceptional cases. (2) It is recommended that regular supervision of boarding homes by I trained health worker, preferably a trained nurse, be provided, to be sup- ilemented by medical attention to the children and medical supervision jf the home wherever needed. Note. Other recommendations relating to dependent children II be found in the sections of this report on mental hygiene and nu- tion and will not be repeated here. 83 XIV. HEALTH AND WORKING CERTIFICATES Requirements as to Health — According to Section 631, Sub. 4, of the New York State Compulsory Education Laws, a child between 14 and 16 years of age wishing to leave school to go to work must* together with certain other qualifications, have "reached the normal development of a child of his age" and be "in sound health and phys-- ically fit to perform the work he intends to do." The official respon- sible for deciding whether the above qualifications are met is the "medical officer of the board of health" of the town in which the child resides. If the qualifications are met the medical officer issues "to the minor a certificate of physical fitness stating these facts." If the minor is "found to be physically unfit," he is rejected and the employment certificating officer is notified so that an employment certificate may not be issued for the child. In rural districts since September ist, 1921, the employment certificating officer is by law the •district superintendent of the school district in which the child resides. To him are submitted for final approval all the required papers, in- cluding the physician's statement of a child's physical condition. In addition to the qualification of physical fitness to go to work a child must also fulfill several other requirements. His parent must sign a written application to his school principal for a school record certificate. He must obtain the school record certificate from his prin- cipal showing that he has complied with certain educational standards, e. g. if he is 14 years of age he must have co,mpleted the eighth grade of elementary school, if 15 he must have completed the sixth grade. He must have also have attended school for not less than 130 days in the preceding twelve months. He also is required to prove his age satisfactorily by means of a birth or baptismal certificate or other •document specified in the law. Again he must have written promise of prospective employment from an employer and finally if these pa- pers with the certificate of physical fitness are approved he must pass a literacy test in reading and writing simple sentences in the English language. A Sketch of the Problem — Erie County has 5 school districts with 5 separate district superintendents or supervisors, with a total school population of about 20,000 children between the ages of 7 and 21. 2.'] different town health officers in these 5 school districts have the legal •duty of giving the physical examinations to children applying for em- ployment certificates. The following outline gives a rough picture of the character of these districts : 84 Headquarters o n ^ 9^ H-.2; -HO CL»^ • W '. P O^ '. D* oO Character of District First District Clarence District Superinten- ent, Mr. Heist. Dis- ance from farthest chool, 28 miles. 4300 57 Pub. 5 Par. Farming and small towns near Buffalo. Children work in Buffalo and at home. Second District Lancaster District Superinten- lent, Mr. H. Dann. distance from farth- est school, 8 miles. 57 Pub. 15 Par. 40 Farming and small towns. Shops near Lancaster and at De- pew. Third District East Aurora District Superinten- ent, Mr. Pierce. Dis- ance from farthest ichool, 10 miles. 46 Pub. 5 Par. r4 Cath.T Ll Luth.J 99 Large farming dis- trict. Shops at East Aurora and Orchard Park. Fourth District North Collins District Superinten- lent, Mr. Ormsby. Distance from farth- ist school, 12 miles. 49 Pub. 4 Par. 103 Intensive farming district. Said to be one of most prosper- ous in U. S. Many- owner farmers. Small factories near Aurora and canneries in North CollinsI Fifth District Springville District Superinten- ient, Mr. Bensley. Distance from farth- ;st school, 15 miles. 2100 55 Pub. 2 Par. Farming district. Hypodermic needle factory at Springville and a few canneries. The Usual Procedure — When a child in the rural districts applies "or an employment certificate the school principal usually notifies the iistrict superintendent, unless informed that he will visit his school or Dne nearby at an early date, and also sends immediately to the State department of Education in Albany for a school record certificate Dlank that it may be filled in properly to present to the district super- ntendent. In all the school districts the principals have the blanks :or the parent's application and for the employer's statement and these ire often filled in previous to the visit of the district superintendent n order to save delay. However, as most of the children expect to 85 go to work on the farm or in the home the parent is also the prospec- tive employer and appears before the district superintendent and signs the blank in his presence. The children at the same time must also submit evidence of age. Other methods which are used to avoid delays are not in practice in all the districts or at all times. For instance, one district super- intendent pays especial attention to informing the different school principals when he expects to visit their schools, giving them an op- portunity in most cases to secure the school record blank from Albany beforehand and thus \j3 avoid possible delay; and another in addition to multigraphing instructions to all the teachers, informs them of the salient features of the law and gives his office hours at certain schools so that children may be sent to the nearest one on the specified date. The physician's statement as to the child's fitness is, especially in the case of one district, secured before the superintendent's visit to- gether with the other papers necessary for submission to him, and this means a saving of time, especially in cases where the health officer is too far away to fill in the necessary physical examination papers on the day of the superintendent's visit after the superintendent has re- viewed the application blank, employer's statement, etcetera. The superintendents are all desirous of making the administration of the law as easy as possible for the parents and children and for prospective employers in cases where they are not the parents. Through the exchange of information and the development of uniformity in methods, they can doubtless avoid a good many of the present delays. However, in instances where the child has applied within too short a time to have secured the school record blank from Albany it is impossible for the superiintendent to issue Bn employment certificate until this blank has been received. This means that in spite of any arrangements that might be made to the contrary, in some instances there will be unavoidable and undesirable delay, in cases where the child is fully qualified to receive the certificate, as the child must either wait until the next visit of the superintendent or go direct to him in the interim.* In the first district the superintendent's office is 28 miles from the farthest school, in the second about 8 miles, in the third and fourth about 10 miles, and in the fifth about 18 miles. In one district, where his office is centrally located, the superintendent has office hours every Monday. In actual practice children who are otherwise qualified but have not secured the school record blank from Albany, while waiting for *Bet\veen the dates of the writing of this report and its publication a law has been passed authorizing the Superintendent of School Districts to deputize individuals to act for them in this matter of employment certificates. This should materially expedite the process. 86 the return visit of the superintendent, go to work in the interim without the employment certificate. Refusal of Certificate — Aside from the fact that a child may apply who has not finished the grade requirements, and may be re- fused, (in this case not being technically considered an applicant) it is apparent that the only occasion on which a child may be legally re- fused a certificate is at the time the superintendent passes upon his documents and literacy and at the physical examination. As the ex- amining physician also is supposed to pass upon the evidence of age the possibility of rejection for unsatisfactory documents exists here also. Except in the first district the literacy test has been given to all children who have been granted employment certificates in the county. The district superintendent of the first district stated that he had not given this test because each of the four children applying held regent's certificates and he deemed it unnecessary. One child in the second dis- trict has been refused a certificate and made to return to school for failure to pass the literacy test, though in the seventh grade. The su- perintendent in this district requires the child to write a well formulated letter of some length. This child constitutes the only case, temporary or j>ermanent, of refusal for any cause in the county. The district su- perintendents are of the opinion, however, that most children can pass a simple literacy test even if not in the proper grade and that it is un- necessary except for backward or foreign children. Not Used for Correction of Defects — No child has been refused a certificate because of physical unfitness nor has any been held up tem- porarily while receiving treatment for minor defects. In fact, to the majority of the health officers interviewed, it had not, apparently, oc- curred that such a procedure was possible. They have assumed that the requirement of ^n employment certificate was sufficient prohi- bition and regarded their function as a mere matter of form through which the child was required to go before being granted a certificate. Again, since the new law made the district superintendents the issuing officer, the health officers, upon whom previously devolved the entire duty of passing upon documents and of issuance, have neglected to examine the submitted evidence of age though that is still their duty. This is now left to the district superintendents entirely. The health officers interviewed appeared to believe that their sole duty now is to pass upon the child's physical condition. The requirement of the law that a child shall be physically fit to g-o to work has no apparent effect in Erie County inasmuch as exami- 87 nations are admittedly perfunctory and health officers do not take ad- vantage of the opportunity to require children to take treatment for minor defects. Those expressing themselves were unanimous in re- garding these examinations as outside the province of the health officer as prescribed in the Public Health Law but they were divided however, in thinking a fee is desirable, some preferring it to be withdrawn from them altogether and others believing that a fifty cent or one dollar fee would reimburse them for the trouble. However, some ex- pressed the view that if paid a fee they would feel under obligations to do the work more carefully and also to hold up children temporarily as they would then be paid for the examination and not merely for signing a statement. Change ix Administration Approved — The district superintendents are satisfied to have the work of issuance in their hands, the majority believing that this change will bring greater care in the issuance of certificates. Although refusals are not common, they are much in- terested in keeping the child in school and believe that as time goes on they will have more opportunity to keep children in school than was the case under the health officer's administration. The District Super- intendents are of one accord in approval of the present law and made no suggestions for its improvement at present, although, they were in favor of raising the age to i6 years several years hence. Comment on Present Methods — On the other hand, it was felt there was opportunity for improvement of the administrative procedure between the local authorities and the State Department of Education. The chief difficulty is the necessity of sending to Albany for the school record certificate blank every time a child applies. Aside from the annoyance to the principal, the delay caused by such procedure as al- ready mentioned, is a serious matter and the .chief cause of illegal absence from school and of illegal employment, especially of those who have applied. Another source of complaint is the number of forms to be filled in and the trips some children have to make before finally securing the certificate for which they are qualified. At a joint meeting of the district superintendents and attendance officers with the in- spector for the State Department of Education, held in Bufifalo on December I2th, 1921, a resolution was passed to be presented to the State Department to the effect that the parents' application blank and school record certificate be combined so as to eliminate at least one form. The health officers state that the physical examination form is too 88 small but as they do not attempt to use it as intended they are not seriously hampered. Erie County Board of Child Welfare — ^The policy of the majority of this Board has been to keep children in school until i6. Several cases were noted where the mother had wanted to put the child to work or to keep the child at home to help her with other children and the Secretary has succeeded, sometimes with great difficulty in having the mother keep on taking the allowance. In a few cases scholarships to special schools have been secured for children past 14 and for some after 16, so that they might not have to go to work. When children have working papers the workers of the Board keep in touch with them and promote their advancement both in pay and position. The Board keeps track of school attendance of children under its supervision by obtaining monthly reports of attendance from teachers. These show conduct, work and attendance. The workers take up the matter with both attendance ofificers and mothers in case there is any laxity about school attendance. There has been difficulty in a few cases where the child was of working age but not able to fulfill requirements for a working certificate. The attendance in these cases has been poor and it has been difficult to control the children. In all the Board has only 147 children under 16 under supervision in Erie County, outside of Bufifalo, Tonawanda, Gowanda, Lancaster and Lackawanna. Recommendations 1. It is recommended that the physical examinations for employment certificates by the health officer be under the direct supervision of the pro- posed full-time health official of the county or subdivision of the county. Also that copies of the reports of the examinations be forwfarded to Al- bany by way of this health official, thus enabling him to check the effi- ciency of the work and note whether physical defects are permitted to pass unremedied and to influence the local health officers to see that these de- fects are corrected and that physically unfit children are excluded from em- ployment. The use of the child's school health record as one item upon which to judge of his fitness to go to work or of the necessity for the correction of defects before a permit is issued could be brought about through such supervision. 2. It is recommended that the School Superintendents determine upon the best standards of requirements for granting employment certificates and maintain them uniformly. 3. It is recommended that the State Department of Education modify the present system of requiring school record certificates to be obtained from Albany for individual applicants. 89 ADDITIONAL MATERIAL In the original report of this child health inquiry, which was sent to the representatives of Erie County, who requested it, were included several tables of facts and figures which, while of especial interest locally, did not seem to be of sufficiently general interest to justify the expense and space of publication in this edition of the report. These addenda gave the following information : 1. Lists of text-books used in the schools. 2. Tabulation of the training qualifications of teachers. 3. Mortality and birth rates by registration districts for the rural sections and villages of the county, 1915-1920, inclusive. 4. Statement from the State Department of Education sum- marizing the result of medical examinations, 1920-1921. 5. Tabulation of answers to questionnaire on school buildings and environment. 6. Table showing progress made in the control of communicable diseases. 90 4 iiS^OC®" 'Jnli'ersity Library i.N/Ebn [jealth in Erie County, New Yorl<.Th 3 1924 003 500 943 Jtii. II ;|ii;:;|||| h .! :