WHAT THE STATE SHALL DO IN THE CARE AND SUPERVISION . OF SCHOOL CHILDREN AN ADDRESS PRESENTED AT THE FOURTH INTERNATIONAL CONGRESS ON SCHOOL HY- GIENE AT BUFFALO, N. Y., AUGUST 25, 1913, BY Eugene H. Porter, M.A.,M.D..Dr.p.H. State Commissioner of Haalth , ISSUED BY THE NEW YORK STATE DEPARTMENT OF HEALTH DIVISION OF PUBLICITY AND EDUCATION ALBANY, N. Y, WHAT THE STATE SHALL DO IN THE CARE AND SUPERVISION OF SCHOOL CHILDREN The importance of this field of health work has long since been admitted by those familiar with the problems presented by the recent developments in sanitary science. We are fully persuaded that the best index of community health is the physical welfare of the school children in that community. So far there is agreement, but when we begin to consider methods of procedure, differences of opinion appear. It would seem very probable that any diversity of view regarding plans to be adopted for the proper care and supervision of school children would arise either from a lack of a comprehensive and firm grasp of the question or a failure to clearly discern just what definite results are to be accomplished. It ought to be very clear to everyone that if we efifectively guard the physical well being of our school children, teach them the funda- mental laws of health and train them in the observance of these laws, that we have gone a very great ways indeed not only in pro- tecting the health of the individual but in establishing and confirm- ing the health of communities and indeed of the State. Such an advance as that in health work would be one of the great founda- tion stones upon which might be successfully erected that ideal structure of public health protection which would actively and visibly promote and determine State and National efficiency and happiness. But if we are to supervise and care for our school children we must not only know what kind of care we are to give and what kind of supervision we are to exercise, but we must know some- thing definitely and accurately about the school children themselves. There is only one way in which we can find out anything about the children in our schools, and that is to examine them, and this examination must be made by those who have had some training in the work, who understand the vital points at issue, and are com- petent to bring out the facts that such an examination is searching for. Many examinations of school children have been held and the results of such examinations have been duly recorded on thousands and thousands of cards and buried in as many forgotten reports. It is not the examinations that do any good, nor the tabulated results that are of any value, but the use of these reports and their in- terpretation, and the intelligent work based upon them. The proper care and supervision of school children is preventive medicine in the highest sense of the term, and preventive medicine is the best and cheapest health insurance that a community can take out. Some time ago was begun the formation of hygienic committees for universities. These committees have employed an admirable scheme of investigation, have adopted wise measures for bettering the hygienic conditions of buildings and the health of the students. Such matters as ventilation, humidity, water, sweeping, toilets, gymnasiums, lodging-house inspection, medical adviser, emer- gency cases, health education are given full consideration, together with the various other subjects which have to do with the health and habits of life of students. Admirable as this scheme is and import- ant as it is as an example of what can and should be done, yet its greatest value lies in the illustration given of the value and power of such close and critical examination of the surroundings and physical condition of the students concerned. Of necessity it reaches but an infinitesimal part of those attending the schools and colleges in the Union. But what can be done for college students should be done for every school child in the United States. It is a curious fact, and by no means gratifying to our national pride, that when we wish to strongly illustrate the value of modern sanitary methods we draw our most striking illustrations from our island and provincial possessions. Modern sanitary science, for example, has abolished yellow fever in Cuba, discovered the cause and largely controlled the ravages of hookworm anemia in Porto Rico, barred yellow fever and Chagres fever from the Canal Zone, and isolated leprosy in Hawaii and the Philippines. This work has practically revolutionized conditions in our tropical possessions and enabled the President to say that in the short twelve years we have been responsible for our people in the Tropics, we have made more progress in the discovery of methods of prevention and cure of tropical diseases than all other countries have made in the past two centuries. This advance has been due to modern sanitary methods backed up by intelligent and authoritative ad- ministration. And the results show what intelligence and authority can do when joined together. We have indeed intelHgence in modern sanitary methods in these our United States, but it is not always backed by authority, and we have in the same place author- ity that is notably lacking in intelligence. Typhoid, pneumonia, tuberculosis, the black plague of venereal infection, are still ravaging the land. If they were tropical diseases how horrified we should be at their ravages and what active measures should we take to control and extirpate them. And yet I think it may be safely said that modern sanitation if permitted, if we could unite authority and intelligence in health matters as they should be united, could effect as marvelous changes here as it has in the Canal Zone or in Havana. Herbert Spencer said a long time ago that to be a good animal is the first requisite to success in life, and to be a nation of good animals is the first condition of national prosperity. It is true that we protect our cattle. The great State of New York, with nearly ten millions of people, spends many times more in looking after the health of the cattle of the State than it does for the health of its citizens. In 1909, the Health Department had $146,980, which was less than one-half of one per cent, of the total expense of the State Government. At the same time there was spent for the protection of game, fish and forests, $568,595.80. We are all familiar with the wastes of life in our country going on day by 'day and year by year. Some of us know that much of this sickness and death is absolutely preventable. We are aware that we do not need to know more just now regarding the prevention of disease, but we do need to apply the knowledge that we have immediately and without further delay. The attitude of the people is easily understandable. It is as Governor Hughes said a short time ago, " only because we are accustomed to this waste of life and are prone to think of it as one of the dispensations of Prov- idence, that we go about our business little thinking of the pre- ventive measures that are possible." The hog is fortunate in being an animal of commerce. If it were not, the waste of hog life would doubtless exceed that of human life. We are a generous people. After every disaster money flows in to relieve distress. A great epidemic occurs — towns, cities, states and even the Nation contribute liberally for the relief of the dis- tressed community. If it is right and proper for the State and the Nation to appropriate money for the relief of distress, it is certainly right and proper to contribute money for the prevention of distress, which means in most cases the prevention of disease. Our system of philaiuhropy is essentially false. It has developed naturally and in its early growth, animated by noble motives, susr taincd by high ideals, it did a great and beneficent work. But in- creasing knowledge has shown the futility of much of the mis- directed philanthropy of to-day. If a child is threatened with illiteracy, millions are forthcoming for its education, but the child that is threatened with preventable disease is told that just now nothing can be done ; wait until disease has attacked you and you are helpless. Then there is a hospital provided for you and you will be taken there and an attempt will be made to save your life. There are hospitals endowed for this very purpose. And there you have the matter in a nut-shell. It is not the curing of disease that is important ; it is the prevention of disease. Where one life may be saved by appropriate treatment, a thousand lives may be saved by timely preventive measures. The problems of health have to do principally with environment — home, street, school, business. And it is because this is so that it is worth trying to relate health instruction to industry and govern- ment, to preach health from the standpoint of industrial and national efficiency rather than of individual well-being. So that while the State cares for the child and undertakes his examination and his general health supervision, the real and important thing, the great result to be attained, is not so much the health and efficiency of the one child as it is the resulting increased efficiency in the com- munity itself. The supervision and care of the school child, his instruction in hygiene, necessarily brings in all the persons in his home, takes in the groups made up of friends and acquaintances, reaches out and eventually embraces the entire community, and so lifts up and elevates the standards of living. We must find some working program that will bring all these members of the groups mentioned, together, and make it easy for them to observe health standards, and we must remember that there is a great gap between health laws and health law enforcement. We are constantly making the mistake of concentrating our atten- tion upon the morals and pretensions of candidates and officials instead of judging government by what government does. It makes no particular difference just how our officials are exercising author- ity, but it makes a tremendous difference when what they do makes men freer in the enjoyment of health and earning power. In protecting health as in reforming government, as Allen says, " an ounce of efficient achievement is worth infinitely more than a moral explosion." Undoubtedly some legislation will be necessary if we are to make the progress we desire in the care of the physical welfare of our school children. Such legislation should be as brief, as simple, and as fitted to the place and the time and the people as possible. And it must be remembered that the value and permanence of the results that are sought for in any reform movement or in any type of governmental action, depend largely upon the adaptability of the movement undertaken and of the principles on which it is based and the special conditions of the time. If we wish, therefore, to improve the welfare of our schools we must study carefully the conditions of the State at this particular time and see to it that our movement in advance is adapted to these conditions. An instructive illustration of the great advance made in another field is shown by a proposed Children's Code of the State of New York, compiled by Justice Deuel of the Court of Special Sessions of the City of New York. He proposes to attain, among other things, the following four purposes : 1 Indubitable protection of the child against all suggestion of crime, hence the elimination of all objectionable references to him in the Penal Law and the Criminal Code, and the specific definition of juvenile delinquency. 2 Extension of the children's court, without any increased ex- pense, to every city, town and hamlet in the State, at the same time giving to each the home rule privilege of develop- ing and utilizing to the utmost the resources of the court. 3 The institution of uniform procedure and the acquisition of uniform statistical data throughout the State. 4 The legal employment of scientific agencies in the detection of mental or physical causes of waywardness which, uncor- rected, predisposingly lead to crime; and a procedure like- wise legal, compelling curative treatment. I cite these provisions of this proposed code simply to show what progress the legal profession has made in dealing with what may be called the criminal or perhaps the moral side of the child's nature. Such a code as that proposed by Justice Deuel would have been impossible in this State ten years ago and unthinkable twenty- five years ago. It will be noted that the underlying purpose of the judge is evidently the prevention of crime rather than the punish- ment of crime. In a paper so limited as this, it is only possible to give a brief outline as to what should be the duty of the State in its care of the school child. I have already said that the best index to com- munity health is the physical welfare of its school children. If we can fix upon the test to be applied at school of home conditions affecting both the child's health and his progress at school, it will be possible in the name of the school to correct those conditions if necessary, just as it will be easy to read the index, because the child is under study control for the greater part of the year from six to fourteen. This test should be the physical record of the child obtained by the examination and re-examination for the physical signs called for by the record card. This card, among other things, should register the weight, height, age and other measure- ments. It should take note of the nutrition, of enlarged glands, of cardiac or pulmonary diseases, of defective spine, chest or ex- tremities, of defective vision or hearing, of the condition of the teeth, of the palate, of the tonsils, of post-nasal growths, of de- ficient and defective nasal breathing, and of the mentality. When such a card as this is filled out for every child in a class, in a school or city, the story told points directly to the physical health rights neglected. In the examination of school children in New York city running from March, 1905, to January, 1908, 275,641 children were examined and 198,139, or 71.9 per cent., were found to be defective. If this percentage should obtain throughout the whole of the United States then the army of children would be 7 out of 10, or over 14,000,000. These figures have been vigorously attacked by those who do not believe that such a per- centage of the children in our public schools have any serious de- fects. But it is really not material whether these figures are exact or not. If they over-state the truth or under-state the truth, the health authorities of the country should find out. This record of physical examination is the only way in which the existence in a community of conditions prejudicial to health that particularly affect the child, can be discovered. The card record will show whether the child sleeps in a dark, ill-ventilated and crowded room, if he has too little to eat or the wrong things to eat, and whether he has eye trouble or adenoids or enlarged tonsils; whether he has defective lung capacity, which may mean improper breathing, or too little exercise or too little food. Let me say again that it is the use of information and not the measuring of information that improves the health. The mere examination of school children does little good. The examination tells what child should have special attention, what parents need to be warned against as to the condition of the child, and what home conditions need to be corrected. Let us keep clearly in mind the distinction between medical school inspection and medical school examination. Medical inspection is simply the search for communicable diseases ; medical examination is the search for physical defects, many of .which furnish the soil for contagion. Among the important defects which demand correc- tion, if the health and efficiency of the child are to be protected and his value as a future citizen of the commonwealth is to be preserved, are mouth breathing, diseased glands, which means adenoids and enlarged tonsils, ear troubles, eye strain, malnutrition, diseases of the teeth, and contagious diseases. It will be impossible in a brief paper of this character to discuss separately each of these defects, to attempt to point out their serious- ness, their frequently fatal results and the great importance of their correction. Those who have given this subject any considerable attention know full well that these conditions should be no longer neglected, but should be promptly, energetically and wisely cor- rected. For a working program for the supervision and care of school children, that suggested by Mr. Allen will serve at least as an ex- cellent basis for discussion and future action. First. A thorough physical examination of all candidates for teachers' positions. Second. A thorough physical examination of every single child in every single school upon entering, and periodically during the school life. Third. Supervision by physicians of hygienic practices in school- rooms and upon playgrounds. Fourth. Restriction of study hours at school and at home to limits compatible with health. Fifth. Establishment of follow-up plan to ensure action by parents to correct physical defects and to attend to physical needs. Sixth. The teaching of hygiene so that children will cultivate habits of health and see clearly the relation of health and vitality to personal happiness and the future efficiency. Seventh. Central supervision of school hygiene. Eighth. Information gained at school regarding conditions prej- udicial to community health should be published and made the basis of an aggressive campaign for the enforcement of sanitary laws. This is by no means all that Mr. Allen suggested, or that has been suggested by others, but it will serve excellently as an outline 8 to guide our ad\ance in the betterment of conditions in our schools. I am thoroughly con\'inced that this work should be in the hands of the health authorities, and that all medical examinations of school children should be made by competent physicians. This work of school inspection and examination gives us a clear view of some of tlie most important defects in the community health, and when to this picture is added that given by a sanitary survey of the same community, town or city, made by competent inspectors, which would take in the question of water supply, sewage disposal, tenement conditions, clean streets, etc., we have a pretty definite and accurate picture of the essential health conditions existent. With such sources of information the annual report of the Board of Health should give as clear a picture of the community's health for any past week or past quarter, as an accountant's books would give of the condition of any commercial business. Further- more, such a Board of Health should not only keep track of one community alone, but this community should be compared with other communities of similar size and each community compared with itself year by year. Such comparisons as these have not often been made and I do not know of a State where such records exist. I believe thoroughly that it is the duty of health authorities to compel all citizens under their jurisdiction to cultivate habits of health, and to punish all who persistently refuse to acquire those habits so far as the evils of neglect are in any sense a danger and a menace to the community. And one of the unlimited educational possibilities of health boards consists in their privilege to point out repeatedly and cumulatively the industrial and community benefits which result from habits of health, and the industrial and com- munity losses which result from habits of unhealthy living. And should it be thought that this health program encroaches upon indi- vidual liberty we may recall what one of the greatest and modern biologists has recently said : "As we march onward toward the true goal of existence, mankind will lose much of its liberty, but in return will gain a high measure of solidarity. The more exact and precise a science becomes, the less freedom we have to neglect its lessons." These new duties are before us and it is only by organized, en- lightened and persistent effort that we may hope to accomplish our ends. I thoroughly appreciate the fact that what I am proposing is more or less ideal, and yet I am as thoroughly convinced that within a few short years it will be realized that the plan proposed is absolutely practical and sane. A public official said a little while ago : " I am fully aware of how little I am doing and how little at best I shall have done when my time is up. Corrections and improvements in government, as in all things, may not be done at once, but only patiently and gradually and, may I say, charitably; explaining and teaching as you go, even as Isaiah says : ' Precept upon precept, line upon line ; here a little and there a little.' " I think we may wish that these words — modest, patient and charitable — could be hung above the desk of every ranting, de- nouncing reformer who labors to make the people believe that he holds the remedy for the complete and sudden reform of every exist- ing abuse, health or otherwise. Realizing then the limitations of human power, the existence of honest differences of opinion, the dependence of all true and lasting education and reform on the people themselves, let us march steadily onward and let us remember that the truest measure of civilization and of intelligence in the government of a State, is the support of its institutions of science and of health. For the science of our time in its truest sense, is not the opinion or prejudice, the strength or weakness of its votaries, it is the sum of our knowledge of nature with its infinite applications to State welfare, to State health, to State progress, and to the distribution of human happiness. r"; ^i? ^4 LIBRARY OF CONGRESS !i|||"lli|lll'!" 020 975 929 9