intJjeCtipoflfrttJgtfrk College of ^frpstciang ano burgeon* Hiferarp Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/surveyofpublicheOOschn A SURVEY OF THE PUBLIC HEALTH SITUATION ITHACA, NEW YORK 1914 BY FRANZ SCHNEIDER, JR. SANITARIAN DEPARTMENT OF SURVEYS AND EXHIBITS RUSSELL SAGE FOUNDATION NEW YORK CITY CENTRAL COMMITTEE FOR ITHACA SURVEY ITHACA, NEW YORK 1915 A SURVEY OF THE PUBLIC HEALTH SITUATION ITHACA, NEW YORK 1914 BY FRANZ SCHNEIDER, JR. SANITARIAN DEPARTMENT OF SURVEYS AND EXHIBITS RUSSELL SAGE FOUNDATION NEW YORK CITY CENTRAL COMMITTEE FOR ITHACA SURVEY ITHACA, NEW YORK 1915 ScV.5 CENTRAL COMMITTEE FOR ITHACA SURVEY Honorary Chairman Chairman Bodies represented Associated Charities Board of Education Board of Health Business Men's Association Catholic Church Central Labor Union Cornell University Federation of Women's Clubs Hebrew Association: Jewish Ladies' Aid Society Hebrew Congregation Housewives' League Industrial Service League Industrial Survey Ministers' Association Social Service League Mayor Thomas Tree Walter F. Willcox Representatives Mrs. V. D. Morse Miss Lillian M. Hoag Mr. E. H. Bostwick Mrs. G. S. Martin Prof. V. A. Moore Dr. I. W. Brewer Rev. C. W. Heizer* Mr. Bert R. Mitchell Dr. F. M. Mone Mr. Ysidro Reyna Mr. M. F. Nolan Mr. F. R. Woolever Mr. W. J. C. Wismar Prof. D. S. Kimball Prof. W. F. Willcox Mrs. F. E. Bates Mrs. F. A. Mangang Mrs. V. D. Morse Mrs. J. R. Rothschild Mr. J. R. Rothschild Mrs. P. A. Fish Prof. C. V. P. Young Mr. T. W. Summers Mr. H. G. Carpenter Rev. R. T. Jones Rev. J. A. Macintosh Miss Ada Powell Prof. J. A. Winans Executive Committee Prof. W. F. Willcox, Chairman Rev. J. A. Macintosh Mr. H. G. Carpenter Mrs. G. S. Martin Mrs. V. D. Morse, Secretary * Deceased. Table of Contents Page Preface 3 Introductory note 4 I. Ithaca's Public Health Problem 5 II. Vital Statistics 6 The Death Rate 6 The Birth Rate 7 Ward Differences 7 III. Communicable Diseases 8 Typhoid Fever 8 Children's Contagions 15 Tuberculosis 16 "Venereal Diseases 17 IV. Sanitary Conditions 18 Wells and Privies 18 City Water Supply 22 Sewerage and Sewer Disposal 23 V. City Health Department 24 Organization 24 Financial Treatment 25 Milk Inspection 26 Food Inspection 28 Control of Communicable Diseases 29 Infant Mortality 30 Publicity and Education 31 Record Keeping 31 VI. Summary and Conclusions 32 Recommendations 32 PREFACE Following the example of many larger cities, a survey of the health and housing conditions in Ithaca was made in 1914. The arrangements for the survey were in general charge of a central committee under the honorary presidency of the Mayor and including representatives of the City Boards of Education and Health, the Business Men's Association, the Federation of Women's Clubs, the Central Labor Union, Cornell University and several philanthropic organizations. This central committee elected an executive committee to take charge of the details. The survey itself was made by ex- perts from out of town. A preliminary examination of local conditions was made by Shelby M. Harrison, Director of the Department of Surveys and Exhibits of the Russell Sage Foundation, who spent two days in Ithaca for that purpose. The examination of health conditions was made by Franz Schneider, Jr., the health expert of the same Foundation, and that of hous- ing conditions by Miss Udetta D. Brown, who was recommended to the local committee by the National Housing Association. University students in the class in statistics cooperated in preparing many tables and in canvassing the city under direction of Mr. Schneider. They also tabulated the living population of Ithaca in 1910 from a set of 14,802 cards purchased from the Federal Census Bureau at Washington and thus laid the basis for some of the tables in the report. Owing to the difficulty of raising the amount of money needed, it has been found possible to include in this printed pamphlet nothing more than the report on health and that in a slightly abbreviated form. The survey cost in all about $600, of which about half came from the Federation of Women's Clubs, fifty dollars from the Business Men's Asso- ciation and the rest through subscriptions from various individuals. A list of those who have contributed to the expense of the survey will be found at the end of this report. To all in and out of Ithaca who have aided the committee in its work it takes pleasure in thus publicly expressing its cor- dial thanks. In closing its work the committee ventures to assure the interested public that the results reached and stated by the visiting experts have not been changed or colored by them or us in the interests of local pride or patriotism. We are prouder than ever of Ithaca but are not blind to the need for improvement. We all must know the facts as they are, if such as need change are to be changed. W. F. WILLCOX H. G. CARPENTER J. A. MacINTOSH MRS. G. S. MARTIN MRS. V. D. MORSE Executive Committee. INTRODUCTION This report is the result of field investigations carried on by the author in Ithaca during the ten days ending February 4, 1914. The manuscript of the report was transmitted to the Ithaca Central Survey Committee May 1, 1914, but publication was delayed because of lack. of funds. As descrip- tions of local conditions and recommendations for improvements are based on the situation existing at the time of the investigation, statements in the report do not in certain instances fit present conditions. The attempt has been made to note such changes by footnotes in the text, but it is possible that a few minor changes may have escaped notice. The brief time available for the survey prevented intensive investiga- tion of some of the more important public health problems— such as infant mortality and the venereal diseases — and the detailed inspection of certain sanitary conditions — such as the sewer system. It should be noted, however, that unusual local cooperation enabled the survey to be something more than a rapid running over of the situation. Thus it was possible to include, through the cooperation of Prof. W. F. Willcox and certain of his students at Cor- nell University a careful enumeration of wells and privies and a somewhat extended discussion of vital statistics. This cooperation has also made it possible to study the preventable mortality problems by ward. Other sub- jects that are discussed more fully than would ordinarily be possible in the time available are milk supply and city water supply; and in this connec- tion the author wishes to make grateful acknowledgement to Professors W. A. Stocking, Jr., H. N. Ogden, and E. M. Chamot. Others to whom thanks are due are Dr. Chauncey P. Biggs, Dr. I. M. Unger, Miss L. M. Hoag, City Clerk W. O. Kerr, various city employees, and a number of members of the class in statistics of Cornell University. The author wishes to make special acknowledgement to Dr. H. H. Crum, health officer and now district sanitary supervisor for the State Department of Health, for his very hearty and helpful cooperation; and to Prof. Walter F. Willcox for the kindest and most valued advice and assistance. FRANZ SCHNEIDER, JR. May, 1915. A Survey of the Public Health Situation in Ithaca I. ITHACA'S PUBLIC HEALTH PROBLEM Eleven years ago, in 1903, a great typhoid epidemic visited Ithaca. Close on 1,350 persons, or a tenth of the entire population, were obliged to submit to the hazards of the disease, and to the accompanying physical and economic losses. About eighty-two persons lost their lives. This epidemic, caused by an impure water supply, was such a tremendous object lesson in the importance of efficient public sanitation as to stir Ithaca to immediate action. The water supply was purified at large expense, and the great excess of typhoid disappeared. Other sanitary improvements were made; and the city settled down once more to routine life. Some typhoid, however, remained. The records of the succeeding ten years show that 389 cases were reported and that 23 persons died. This means an average of 39 cases a year and a yearly death rate of 16 per hun- dred thousand population, an amount of typhoid that has been considered normal for an American city with a safe water supply, and one that com- monly has been referred to as "residual." Formerly this residual typhoid was regarded as an unavoidable and somewhat mysterious evil; modern sani- tation, however, shows how it is caused, and the newer methods of control are eliminating it. Ithaca's residual typhoid commands special attention because it is typical of her general public health problem. Just as the typhoid excesses of 1903 and earlier were eliminated by filtration of the public water supply, so was her malaria — several thousand cases in 1904 and 1905 — eradicated by the extensive works constructed to drain swampy places. Other big public im- provements, already existing or subsequently constructed, such as the com- prehensive sewer system and the dykes to confine the several creeks, trans- formed the city into an excellent sanitary environment. Doubtless as a re- sult we find that Ithaca has since been free of excesses of the diseases that spread epidemic by way of the inanimate environment. Disease is spread, however, in another important way; that is, directly from person to person by "contact," or "contagion." The first method of spread, through the environment by the great public carriers, gives rise to the more striking excesses of disease; these excesses Ithaca, through her public improvements, has eliminated. The second method of disease spread, through intimate human contact, is less spectacular than the other but no less deadly. It is the mode of infection that contributes heavily to the "residuals," and it is in the suppression of this mode that municipal sanitation has made perhaps its greatest progress in the last decade. Ithaca's public health problem is, accordingly, that of a city which by extensive public improvements has eradicated the great excesses of pre- ventable disease, but in which residuals exist. The determination of the amount and distribution of these residuals, and the outlining of methods for their eradication, are among the prime objects of this survey. To attack these questions successfully recourse must be had to the city's vital statis- tics — its system of life and death bookkeeping. Experience justifies the pre- diction that the examination of these records will show that the amounts of preventable disease in Ithaca, even though residual, are well worth the city's careful attention. II. VITAL STATISTICS While the general death rate, or ratio of registered deaths to population, is of itself a rather unreliable index of a city's health history, some signifi- cant inferences may be drawn from an examination of the Ithaca rate. Taking the deaths for the years 1908 to 1912 and the population of 1910 as a basis, the city's death rate averages 16.2 per thousand population. Compared with New York State as a whole this rate is favorable; and the advantage is main- tained at nearly all ages of life, as is shown in the table below. COMPARISON OF DEATH RATES FOR VARIOUS AGE GROUPS, ITHACA AND NEW YORK STATE, 1908-1912* Age group Ithaca New York State In excess 0-1 113.0 144.0 State 1-4 13.7 17.3 State 0-4 32.9 44.2 State 5-9 4.6 3.9 Ithaca 10-14 1.6 2.4 State 15-19 4.6 3.7 Ithaca 20-24 6.7 5.2 Ithaca 25-29 6.9 6.4 Ithaca 30-34 6.5 7.8 State 35-39 6.3 9.7 State 40-44 7.7 11.9 State 45-49 12.5 14.9 State 50-54 14.7 19.2 State 55-59 22.3 27.1 State 60-64 28.1 37.6 State 65-69 49.7 53.7 State 70-74 71.9 76.9 State 75-79 103.0 110.7 State 80-84 154.0 166.2 State 85-Over 226.0 264.0 State In the only age groups having the city rates in excess, those of yougg people, the differences are slight and the numbers involved too small to give the indication much weight. The examination of Ithaca's death rate is, there- fore, reassuring, an impression that will be strengthened by the study of her death rates from specific communicable diseases. • Figures furnished by Prof. W. F. Willcox. 6 An examination of the city's death and birth rates by wards, such as is given in the table below, sheds an interesting light on conditions in Ithaca. The differences in the ward death rates, which range from 9.3 in Ward Four to 17.1 in Ward Two, are probably to a considerable degree the result of differ- ences in the age and sex distribution of the population; they are, however, es- pecially interesting in connection with the birth rate variations. DEATH RATE AND BIRTH RATE BY WARDS, ITHACA Mortality figures for 1909-1911; birth rate for 1911 Population Averagi i annual num- Death rate 1 Birth rate" Ward July 1, 1910 ber of death s a per 1,000 per 1,000 1 2,578 41 16.0 25.6 2 2,481 42 17.1 14.9 3 2,741 45 16.4 15.3 4 3,375 31 c 9.3 12.4 5 3,662 41 11.2 15.0 City 14,837 200 13.5 16.3 While these ward figures illustrate the general correspondence between a high birth rate and a high death rate, and while it. should be remembered that the rates are not for identical periods of time, it is worthy of note that in Wards Two and Three the death rate actually exceeds the birth rate. This fact is doubtless accounted for by the presence of an abnormal proportion of old persons in the populations of these wards. The relatively high birth rate, and the corresponding higher rate of natural increase, in Ward One, which em- braces the West Hill and Inlet district, is similarly to be accounted for by the relatively young and foreign population living in that part of the city. Most interesting in connection with these ward variations, and decidedly more significant from a public health standpoint, are the variations in ward mortality from certain of the big preventable causes. Ward rates for tubercu- losis and pneumonia, two of the most important diseases that come within the range of preventive measures, are shown in the table 'below, and it is evident that marked excesses occurred in Wards One and Three — the districts around the Inlet. a Residents only. b Includes 20 unregistered births. c Deaths of two students are included in the figures for Ward Four. The population figures, however, do not include students. DEATH RATES FROM TUBERCULOSIS AND PNEUMONIA BY WARDS, ITHACA, 1904-1913 Average yearly rates per 100,000 population. Residents only. Ward Tuberculosis Pneumonia Total 1 169.7 173.6 343.3 2 90.2 114.8 205.0 3 148.4 178.1 326.5 4 • 57.3 79.4 136.7 5 50.0 91.7 141.7 City 97.4 122.7 220.1 The conclusions to be drawn from this brief inspection of the city's vital statistics are that while the showing is on the whole good marked variations in mortality occur, that the city's hygienic problem centers in the west side and the lowlands around the Inlet, and that in these last districts serious life and health losses occur from preventable causes. These conclusions are con- sistent with those drawn from the studies of typhoid fever and sanitary con- ditions, which are to be found later in this report. It should be noted in passing that there is reason to believe that regis- tration of births in Ithaca is incomplete. The City Clerk's records show 222 births registered in 1911. For the same year, Miss Elma E. Cummings and Miss Margaret B. Cornell, of Cornell University, working under the direction of Professor Walter F. Will cox, discovered, by consulting baptismal records and by house-to-house canvass, 20 births that were unregistered. In other words, not more than 91.7 per cent of the births were registered. This pro- portion is unquestionably better than that prevailing throughout the state as a whole, and is inferior only to that in some of the larger cities; omission of registration is, however, contrary to law and often embarrassing to the indi- vidual in later life, while something near perfection should be attainable. Strengthening the city's health service, as recommended later in this report, would do much to eliminate this deficiency. III. COMMUNICABLE DISEASES Typhoid Fever Turning now to a more intensive study of the principal communicable diseases, first consideration appropriately may be given to typhoid fever. Not only is it a serious disease, but its persistence in Ithaca is, as we have seen, typical of the city's public health problem. For these reasons a care- ful examination of its recent history is especially important. The distribu- tion of cases by ward, for the last three years is given below. CASES OF TYPHOID FEVER BY WARD, ITHACA, 1911-1913 : ' Ward Number Per cent of cases of total 40 41.6 10 10.4 18 18.8 4 4.2 24 25.0 Per 10,000 population per year 50.6 13.1 21.4 3.9 21.4 Total ' 96 100.0 21.1 The figures in the last column, representing cases per 10,000 population, bring out the comparative prevalence of the disease in different parts of the city, and show that very marked variations exist. Ward One has obviously MAP I. LOCATION OF CASES OP TYPHOID FEVER, ITHACA, 1911-1913 Note the clustering of cases (114 in all) and the preponderance of the disease in the northern and western parts of the city. The open circles represent imported or student cases. Ithaca's typhoid is "residual" — about what is ordinarily to be found in a city with a safe water supply ; but it can be, and should be eliminated. suffered far more severely than the other wards, having over twice the rate occurring in the next worst ward and over twelve times that in the best ward. Map 1 indicates the more exact location of these cases, which, it will be observed, are chiefly in the west side and Inlet districts. a This table does not include 18 imported or student cases, which were distributed as follows: one case in Ward One; 11 cases in Ward Four; six cases in Ward Five. The variations in prevalence of typhoid seen above are, in this age, quite unnecessary, and are a positive indication that things are not as they should be in Ithaca. Typhoid is an infectious and preventable disease, which can be acquired only by taking through the mouth part of the bowel or bladder dis- charges of a previous patient. Certainly here is a circumstance that the com- munity should be able to prevent, and which it does prevent in most English and German cities. One significant piece of evidence as to the source of Ithaca's residual typhoid is offered by a comparison of the distribution of cases with that of wells and privies. The table below gives this comparison as between cases occurring in the last three years and wells and privies as enumerated in January, 1914. DISTRIBUTION OF TYPHOID CASES, WELLS, AND PRIVIES, ITHACA Per cent of Per cent of Per cent of wells, 1914 privies, 1914 typhi Did cases Wards 1911-1913 1 36.4 46.2 41.6 2 15.2 12.7 10.4 3 16.8 18.8 18.8 4 4.3 4.3 4.2 5 27.3 18.0 25.0 Total 100.0 100.0 100.0 Clearly there is a remarkable correspondence between the proportion of wells and privies and the proportion of typhoid fever. Ward One has about 40 per cent of the wells and privies and a little more than 40 per cent of the typhoid; Ward Four has four per cent of the former and four per cent of the latter; and the other wards show nearly as close a correspondence. Typhoid evidently lingers where wells and privies remain in use; and the first condition is undoubtedly very much a result of the second. Further evi- dence against the privy-well combination, and in exoneration of the city water supply, is offered by an examination of the case histories of typhoid as re- corded at the city health department to ascertain what water the patient had been drinking. This information for the last three years is shown below. POSSIBLE SOURCES OF RESIDUAL TYPHOID, ITHACA, 1911-1913 Number of cases Per cent of total City water used 6 5.3 Well water used 82 71.9 Water used unknown 8 7.0 Imported or students 18 114 15.8 Total 100.0 10 Thus 72 per cent of all persons having the disease used well water as against 5 per cent using the city supply. At the time of the great epidemic of 1903, before the installation of the filter plant, those using the city sup- ply were attacked, those using well water for the most part escaped. As a result confidence in wells was engendered, and this feeling has persisted. Now, however, it must be emphasized that circumstances are reversed, that the city supply shows by far the smaller proportion of cases, and that wells are relatively deserving of suspicion. While a good part of Ithaca's residual typhoid is undoubtedly chargeable to wells and privies,* and would disappear with the elimination of these sanitary makeshifts, it would be an error to assume that each and every case of the disease listed above as using well water is directly attributable to these I CASE A- CASES 3CHSZS ITHACA'S RESIDUAL TYPHOID Triangular block near Lehigh Valley station. Eight cases occurred during September and November of 1912 in the three houses indicated. Direct contact from person to person played an important part in the causation of this little outbreak, sources. A considerable number are "secondary;" that is, due to personal contact with a victim of the disease. Thus of the 114 cases occurring in the last three years 28 were so considered; in other words, 24.6 per cent of all cases, or 29.2 per cent if imported and student cases be excluded, were at- tributed to secondary infection. These cases arise from lack of efficient bedside disinfection of the patient's discharges. To test out this indication of the importance of secondary infection the case histories as furnished by the health officer were subjected to intensive study. It was readily apparent that in each of the three years under consid- * For further discussion of the dangers from wells and privies and the situation in Ithaca, see pages 18-19. 11 eration the localization of cases iwas very marked, little district outbreaks taking place, which while slower in progress and more restricted in scope than water or milk home epidemics are just as fatal to those attacked. In 1911 the disease centered around the so-called Pottery Building in Ward Five, in 1912 around a small triangular block near the Lehigh Valley Station, and in 1913 around two houses on Cliff Street. The detailed histories of these out- breaks were reconstructed as far as possible, and one of them is given below hy way of illustration. It should be remembered that the incubation period of typhoid — 'that elapsing between infection and the appearance of marked symptoms, is albout two weeks, and that patients may be infectious from the early stages well through convalescence. Typhoid Outbreak of 1912 Around the Lehigh Valley Station This series of cases started in September at 319 Westport Street, with two children named Lovell. The source of their disease is not positively known, although it is said they drank Inlet water from a well near its edge. On September 14th, a man named Bagley came down with the disease at 1002 West State Street, in a house located at the southeast corner of a small triangular block about 200 feet on each side. At the time of the sur- vey this little block contained eight houses, five privies, and eight wells. The privies and wells, being in the rear of the houses, abut, and there is ample opportunity for pollution of the wells and for flies to carry infection from the privies. At all events, eleven days after the Bagley case two 'children named Fatula, living in the same triangular block, at 903 West Buffalo Street, were taken sick. Back on Westport 'Street in the meanwhile at 327, Fred Letts, aged 11, and in close contact with the Lovell cases, developed the disease on September 25th, to be followed at the same address on November 5th by Lillle Lovell, mother of the two original cases. Returning to the triangle block, we find that on November 6th, eleven days after the first Fatula cases were reported, Dora Lynch, living next door at 905 West Buffalo, had contracted the infection. On November 22nd, Mike Fredorka, and at about the same time little John Fatula, were reported from the original Fatula house. Finally, on November 23rd, the mother and eight-year-old sister of Dora Lynch developed true cases. Two other cases appeared in the neighborhood: Andrew Molloch, aged twenty-nine, on October 26th, at 306 Brindley Street; and Mary Clark, aged seven, on November 15th, at 316 Brindley. Altogether this series represents 14 cases, of which nine were in all probability secondary. All the persons involved drank well water and all used privies. The stories of the outbreaks of 1911 and 1913 are much the same: a primary case or two followed by a series of others in the same family or immediate neighborhood, the cases following each other in about the incubation period of the disease. The 1911 outbreak included twelve cases of which at least half were contracted through personal contact. The Cliff Street group of 1913 gave ten cases, nine in two houses, and seven in all probability secondary. Together these three outbreaks contributed 36 cases — about one- third of all cases reported in the three years. The investigation also showed 12 that the outbreaks were a considerable expense to the city, not only in the matter of furnishing supplies, disinfecting material and supervision, but in the hospital care of a considerable number of persons. In other instances, the disease forced families to apply for aid at the Associated Charities. The existence of this secondary typhoid is a striking testimonial of the inability of some people to care for cases of typhoid at home without danger to themselves and others, and of the inability of the city health department, ITHACA'S RESIDUAL TYPHOID 512 Cliff Street, where four cases occurred in September, 1913. Two of these cases were secondary, home conditions rendering proper care of the patients and efficient disinfection of their discharges quite impossible. The well had been condemned by the health officer but was found in use (January, 1914). Note the opportunity for its pollution from the buildings above. as at present equipped, to break up the chain of infection. When it is clear that home conditions do not ensure efficient ibedside disinfection of the pa- tient's discharges and reasonable safety to other members of the family and the neighborhood, the patient should he removed to a hospital. Families are sometimes unwilling, however, to have members removed, and the health of- ficer doubted whether removal could be enforced in such cases. The State Commissioner of Health, in reply to inquiry on this point, gave an opinion, however, that a local ordinance could be enacted to remove a case of typhoid 13 or any other disease where in the judgment of the health officer it was neces- sary. The matter is evidently one in which the city should determine its power. While in most cases a trained and regularly employed health depart- ment nurse, working under the direction of the health officer can, 'by in- struction and re-instruction, see that other members of the family and neigh- borhood are protected from infection, cases will arise in which power of re- moval is needed, and in which it should be exercised. Such is the story of Ithaca's "residual" typhoid. It occurs almost en- tirely in districts where privies and wells are still used, and the foundation for much of it doubtless would be removed by the elimination of these con- ITHACA'S RESIDUAL, TYPHOID 221 Cliff Street, the house to the left. Five cases occurred here during October, 1913, to January, 1914, and a sixth case probably was contracted here. Ithaca's wells and privies should be eliminated as rapidly as possible and the health department should be given public health nurses to exercise adequate super- vision over cases of typhoid. Patients should be removed to a hospital when they cannot be cared for at home with safety to their family and the neigh- borhood. veniences. A considerable part of it, perhaps a third, is, at the same time, due to personal contact with patients — to imperfect disinfection of the pa- tients' discharges. The remedy for the latter condition obviously is closer supervision of cases by the health department, a state of affairs that re- quires more liberal financial resources for the department, but, fortunately, no very great expenditure. While the total amount of typhoid remaining in Ithaca is not large, as things go in this country, it can be much reduced, or nearly obliterated. The residual cases are a menace to the rest of the city, and probably are more expensive to care for after they develop than to prevent. 14 Children's Contagions Ithaca has in the last few years come off fortunately with regard to the contagious diseases of children. As will he seen from Table A, the amounts of scarlet fever, diphtheria, and whooping cough have been small; and except for an epidemic of the diffioult-tc~restriet measles in 1911, the record of the last few years has been gratifying. The essential points to be observed in combating these diseases are similar to those necessary for the elimination of secondary typhoid; that is, early reporting of cases and efficient bedside disinfection, with increased emphasis here on actual isolation of the patient. Discussion of the procedures now used in Ithaca may be found on pages 29-30; for the present it is sufficient to note that to continue the good record of the last few years the health department must have the active co-opera- tion of parents. It is to the advantage of all that cases be recognized as early as possible, that they be reported to the health department promptly, and that efficient isolation be maintained. TABLE A COMMUNICABLE DISEASES IN ITHACA, 1904-1913 Year Typhoid Fever Tuberci ilosis Pneumonia Diphth eria Cases Deaths Cases Deaths Cases Deaths Cases Deaths 1904 15 3 — 17 — 29 10 1905 30 1 10 18 — 16 5 1 1906 39 3 — 17 — 16 32 1 1907 13 — 20 — 13 173 8 1908 43 1 — 16 — 10 44 9 1909 92 4 12 12 — 10 21 4 1910 43 4 10 14 — 20 c 1911 40 2 24 14 23 20 8 1912 42 3 46 10 — 23 1 1913 32 2 62 9 — 25 1 1 Total 389 23 164 147 23 182 300 24 Scarlet Fever Meas les Influenza Whooping Cough Cases Deaths Cases Deaths Cases Deaths Cases Deaths 1904 3 1 368 4 2 5 — 1905 2 — — 3 — 1906 2 — — 1 — 1907 47 1 — — 4 — 1908 101 1 — — 6 ' — 1909 93 1 — — 2 — 1910 47 2 25 — 4 — 1911 28 1 361 4 — 5 31 1 1912 28 28 — 2 30 1 1913 12 21 — 5 — Total 363 793 37 81 15 Malaria Syphilis Paresis Locomotor ataxia Cases Deaths Deaths Deaths Deaths 1904 2000 [?] 1 1 1905 1000 [?] 10 1 1906 — 1 1 1907 — 1 1 190S — 1 1 1909 — 1910 — 2.0 1 1911 110 1 1912 — 1 2 2 1913 — 1 Total 3000 [?] 7 5 6 4 Tuberculosis Ithaca's tuberculosis problem is in many respects similar to its typhoid problem. A general decline in the mortality from this cause during the last ten years is evident from inspection of Table A. The rate per hundred thou- sand population averages 98 for the decade, which is low in comparison with most urban communities, and for 1913 it is only 58.7, an exceedingly low figure. The distribution of mortality throughout the city has not been uniform, as was seen from the table on page 8, the rate for the decade varying from 50 in Ward Five to 170 in Ward One. The disease has been most prevalent in the Inlet district. The table below, showing the distribution by ward of cases now in the register, gives the same general indication. The minor dif- ferences in the ward proportions as shown by the mortality figures and those for cases registered may mean that the present case investigation work is be- ing prosecuted more intensely in some parts of the city, or simply that preva- lence in the various districts has undergone a change. At all events, it is evident that certain parts of the city present serious tuberculosis problems, and that the usual restrictive measures are needed. TUBERCULOSIS CASES REGISTERED, BY WARD ITHACA, JANUARY, 1914 Ward City 140 100.0 9.1 16 Number Per cent Per 1,000 of cases of total population 40 28.6 14.9 13 9.3 5.0 27 19.3 9.5 26 18.5 7.4 34 24.3 8.9 Examination of Table A shows not only that the mortality from tuberculosis is on the decline, but that a great improvement in the reporting of the disease has taken place in tlhe last few years. This is undoubtedly a result of the work of the tuberculosis nurse. Ithaca's tuberculosis campaign started in Au- gust, 1911, when the Tuberculosis Committee, aided by an appropriation of $200 from city funds, opened a dispensary. No permanent staff was employed, however, and as people did not appear for treatment or advice, it seemed that the enterprise would fail. In November of the same year the present nurse was engaged on full time, and soon showed the wisdom of her appointment by quickly discovering cases and attracting them to the dispensary. The work in the first few months was largely in the hands of the Committee, but as the real need for the service became apparent, the city took it over and now em- ploys the nurse. At the present time the nurse seems to have the interest and co-opera- tion of patients and doctors, and a comprehensive program is under way. Two day clinics and one evening clinic, attended by three relays of four doctors, are held each week; patients are given record books, thermometers, and milk tickets, and their sleeping is supervised. A Saturday afternoon children's class was organized January 1, 1914, and a preventorium to build up weakly children has been incorporated. In addition the city and county maintain, at Taughannock Falls, the Edward Meany Sanatorium, an Institution with a ca- pacity of 17, which at the time of the survey was accommodating 15 Ithaca cases. Plans have been prepared for enlargement, which is certainly neces- sary to meet the proper demands of city and county. The nurse now has a waiting list of two or three cases, while the county cases go almost entirely without treatment. Altogether the city may be congratulated on having under way a well- rounded tuberculosis program. The reporting of cases seems excellent, there being at present 107 cases in the register. The needs of the situation are in the nature of amplification; a larger room for the clinic,* mere nursing service, and the enlargement of the sanatorium according to present plans. § Venereal Diseases Intensive investigation of the prevalence of the venereal diseases — syphilis, chanchroid, and gonorrhoea, was not possible in the time available for the sur- vey. It must not be concluded, however, that these diseases are relatively unimportant. As a matter of fact, if normally prevalent in Ithaca, they are among the most serious communicable maladies that afflict the community. Caused by specific micro-organisms, these diseases are infectious and preventa- ble. Rapid strides have been made in recent years in their laboratory diagno- sis and successful treatment, and useful prophylactics are at hand. Altogether they cause much suffering, loss of efficiency, and premature death in middle age. One of them, syphilis, is now regarded as the cause of the large ma- jority of cases of paresis and locomotor ataxia; and another, gonorrhoea, is responsible for much blindness and much sickness among women. * This need is now met. § The sanatorium has been enlarged and now accommodates 27. 17 Reliable information as to the prevalence of these diseases is difficult to obtain. Almost all the doctors and social workers know of cases, but exact figures are not available, as the community officially ignores the problem. One well-informed physician answered an inquiry on the subject in the fol- lowing words: "In reply to your letter of February 10, 1914 — I am not prepared to give you much information about venereal disease — not being a spec- ialist and simply knowing about what I consider is a small per cent of cases that are here. Most every doctor here treats these diseases — especially gonorrhoea of which I have treated exactly six (6) in tlhe past five (5) months. I have had two (2) cases of syphilis in the same period, one still here, one sent home. I am well aware that this is about half the number of cases seen last year by me — and I also know that this number multiplied by the number of doctors here would hardly give you an approximate number of the cases." We may note also that in the last decade, as is shown in Table A, five deaths have been recorded as due to syphilis, six to paresis, and four to locomotor ataxia; and it must be remembered that venereal diseases are seldom given as the cause of death when any other cause can be certified. On the whole, therefore, there is no reason for doubting that Ithaca, has her share of these diseases, for the restriction of which rational procedures exist ready to be applied once the community decides that the diseases shall be prevented. Oases should be reported to the health department, by number instead of name if so desired, free laboratory diagnosis should be offered phy- sicians (the presence of the University Laboratories is here a simplifying fac- tor), free treatment should be offered indigent sufferers,* and educational work should be carried on. The discovery and cure of infectious cases of venereal disease is one of the most important possibilities in a health department dis- pensary service, such as is suggested on page 30 of this report. At all events Ithaca should charge her health department with the study and prevention of these diseases. IV. SANITARY CONDITIONS Wells and Privies A careful enumeration of Ithaca's wells and privies was made possible through the co-operation of Professor W. F. Willcox and students from his class at the University. The city was divided into districts and a house-to- house convass made. As is generally the case, investigation proved the esti- mates of local persons to be very much short of the actual numbers. Thus some, of the city authorities estimated that there might be 200 private wells; as a matter of fact there proved to be 954. The distribution of the wells and privies is indicated in Maps 2 and 3 and in the tables below. * The Board of Health has since passed a resolution whereby indigent persons with syphilis may have prescriptions filled free. 18 PRIVATE WELLS, ITHACA, JANUARY, 1914 Ward Number 1 2 3 4 5 City 347 145 160 41 261 954 Per cent Per 1,000 of total population 36.4 129 15.2 56 16.8 56 4.3 12 27.3 69 100.0 62 MAP II. LOCATION OF WELLS, ITHACA, JANUARY, 1914 A house-to-house canvass by University students showed 954 wells still used in Ithaca. Note the preponderance in the Inlet district. Ward One has over ten times as many wells per 1,000 population as Ward Four. In a city, wells are to be regarded with suspicion. PRIVIES, ITHACA, JANUARY, 1914 Ward 1 2 3 4 5 City umber Per cent Per 1,000 of total population 303 46.2 113 83 12.7 32 123 18.8 43 28 4.3 8 118 18.0 31 655 100.0 42 19 Wells are evidently more numerous than -privies, although the latter are used by something like a fifth of the population. The distribution of both is very much the same — relatively more numerous on West Hill and in the lowlands around the Inlet. The remarkable correspondence between the distribution of Ithaca's wells and privies and her residual typhoid has already been pointed out (pages 10-11), and it is undoubtedly true that much of the correspondence partakes of the nature of cause and effect. To give the devil -his due, however, it must not be assumed that every insanitary privy or every polluted well is always infectious. Only when -portions of the discharges from persons with intestinal diseases reach these sanitary makeshifts is actual danger present. A community almost always contains, however, persons afflicted with these diseases, some of Whom are not inconvenienced thereby and show no symp- toms. Thus at some time or other, in the long run, a privy will receive in- fectious material, whereupon the danger becomes acute. The -potential dan- ger to the whole community is proportional, of course, to the number of op- portunities offered; -that is, the number of wells and privies existing. MAP III. LOCATION OP PRIVIES, ITHACA, JANUARY, 1914 The same canvass showed 655 privies. The health officer states that since that time 200 have been done away with. This policy certainly should be con- tinued, as the privy has no proper place in city life. Many of the wells in Ithaca undoubtedly furnish water of good character; some of them probably at all times; others at most times. A small per cent" of them, however, are undoubtedly always polluted. The point of the matter is that both wells and privies are sanitary makeshifts, and are country, rather than city, devices. In the city the opportunities for well pollution are enormously increased, as are the possibilities of fly infection from privies. As has been pointed out, many residents of Ithaca probably are prejudiced 20 against the city water supply on account of the typhoid epidemic of eleven years ago; but it must he reiterated here that cases are now reversed, and that the city water supply deserves to he trusted and wells to he regarded with suspicion. The defense for privies is weaker than that for wells. In places where sewers are in the street, privies absolutely should not be tolerated. This would mean in Ithaca the elimination of practically all privies on the east side of the Inlet. Some 200 privies were condemned in 1913, and this policy should be continued with vigor.* A large part of the city's privies can be DANGEROUS WELLS AND PRIVIES IN ITHACA The illustrations show typical Cliff Street well and privy. The privy was entirely open in the rear and was flooded by the water appearing in the foreground. Infectious matter deposited in such a privy has ample opportunity to reach new victims. The survey inspection showed 954 wells and 655 privies in Ithaca. eliminated in this way; while in other districts the sewer and water sys- tems should ibe extended, or privies should be required to be properly screened and otherwise made sanitary. A sewer on Cliff Street, where city water is already available, is certainly a necessity. It is stated that there are now (June 1915), less than 75 privies at places where it is possible to connect with a sewer. 21 Water Supply Ithaca's water supply is taken from Six Mile Creek, whose watershed is of rather small size and characterized by a quick run-off. In times of storm the creek water rapidly becomes very turbid, making its nitration a somewhat delicate matter. The territory drained is agricultural, containing a number of small towns which have no sewer systems. As a result of the typhoid epidemic of 1903 inspections were made of the water-shed, the obvious sources of pollution were removed, and nitration works of the rapid mechani- cal variety were installed. Typhoid fever has since that time, as we have seen, been "residual," or non-water j borne. The sanitary character of 'the water before and after treatment is in- dicated in the table below, compiled from reports on file in the city clerk's office. The indication is that the filters are receiving a water that is pretty uniformly objectionable and turning out one that is uniformly good. The colon bacillus, the typical intestinal organism which is almost always present in the raw water, has only appeared in the filtered effluent at rare intervals. BACTERIA PER CUBIC CENTIMETER IN ITHACA WATER, 1913 a Raw Water Filtered Water Month At 20° C. [ At 37° C. At 20° C. I At 37° C. Maximum at 37° C. January February March 5,950 2,390 17,400 1,790 490 1,760 80 62 207 15 17 32 42 (14 analyses) 130 (12 " ) 110 (13 " ) April May June -370 790 860 28 170 205 22 37 140 3 7 33 12 (12 " ) 35 (13 " ) 110 (13 " ) July August September 780 415 263 145 170 61 390 51 3 30 7 90 (13 " ) 38 (16 " ) 0(9 " ) October November December 600 2,530 360 240 770 60 40 450 23 12 185 q 60 ( 5 " ) 700 (4 ) 10 (4 ) It should be noted, however, that the filter plant is now operated at fu capacity fairly often, and that if a large fire should break out at such times the water would have to pass through unfiltered. Such a condition actually arose twice in the last three years. The filters have a designed capacity of 3,500,000 gallons a day and usually operate at the rate of about 2,500,000. At the same time it has been estimated that leakage and wastage in the distribu- tion system amount to 800,000 to 1,000,000 gallons a day, a loss which meter- Monthly average of counts by Nelson & Lauder, Binghamton, N. Y. All samples taken at filtration plant ; those of filtered water from the clear -water well. Samples iced and sent to Binghamton ; with one or two exceptions analyzed the same day as taken. Hypochlorite used for two months commencing the middle of August. 22 ing would do much to reduce. At all events, some provision should be made to allow for a much larger margin of safety as between consumption and capa- city. More liberal provision should also be made with regard to laboratory facilities at the plant and in the matter of superintendence.* In the event of disability of the present capable filter superintendent the city would be em- barrassed for lack of a competent understudy. The health officer's suggestion that such a person be provided is an excellent one. The lesson of 1903 — that the filter stands between the city and pos-sible epidemic — must not be forgotten; nor that the quick run-off of the water-shed, and the consequently changeable character of the creek water, demands careful supervision at the plant. The advisability of disinfecting the supply with chlorine subsequent to fil- tration is also suggested. During the fall of 1913 such disinfection was em- ployed to cover a temporary condition of filter inefficiency. Devices are now on the market by which the whole supply may be disinfected at very slight cost, and an extra margin of safety secured. The process is entirely harmless, and the chances of a failure in purification are rendered only one-quarter as great. It may be objected that disinfection tends to make filter operators care- less and that an overdose of chlorine, with resulting noticeable taste, would revive prejudice against the city water. With proper equipment such an occur- rence should be easily preventable, while efficiency of filtration may be main- tained, as at present, by analyzing samples of filtered water before the addition of the disinfectant. At the very least, an emergency disinfection apparatus, in good condition, should be available at all times. § Cornell University provides its own water supply, drawing on Beebe Lake. The supply is of the same general character as that of the city, and a similar filtration process is employed. In addition, this water is disinfected at all times. While figures as to the efficiency of the University plant were not readily available at the time of the survey, the general character of the plant and the freedom from disease of consumers of the water argue for the satis- factory quality of the latter. Sewerage and Sewage Disposal The city is now equipped with a fairly comprehensive system of sewers, the chief deficiencies being on the west side, especially on Humboldt and Cliff Streets. A description of the system, and of the sewage treatment works, may be found in Professor H. N. Ogden's report on sanitary conditions in Ithaca, f For the present purpose it is sufficient to note the extensive char- it is stated that this need is now met. § In the year subsequent to the writing of this paragraph arrangements were made so that Ithaca's water supply now has the added safeguard of chlorination. A number of water main extensions also have been made. 30th Annual Report of the New York State Department of Health, 1909, Volume 2, p. 780. 23 acter of the system, to urge that connection with, it be forced, and to sug- gest the construction of sewers on West Hill.* The treatment works consist of a large septic tank, located in the north- west part of the city near the point where Cascadilla Creek enters the Inlet. After passing slowly through the tank the sewage is discharged into the Inlet at a point nearby. The original method of pumping the sewage out into the lake has been entirely discontinued, and with the recent change in the Inlet channel the outfall no longer extends into the current, a cir- cumstance which is apt to cause local nuisance. It should be borne in mind that 'the present treatment in the septic tank is simply reduction and not purification. Solid material in the sewage is liquefied by such a pro- cess but the effluent is not rendered stable, i. e., unputrefiable, nor are the potential dangers from disease germs removed. While no great harm seems to have resulted from the discharge of the unpurified sewage into the Inlet, the city must bear in mind the possibility that purification may after all prove desirable or may at some time be commanded by state authorities. SANITARY CONDITIONS IN ITHACA West Hill, showing Hector Street above and Cliff Street below. Cliff Street has a water main but no sewer ; both streets have many wells and privies. Note the opportunity for pollution of Cliff Street wells by habitations above. V. CITY HEALTH DEPARTMENT Organization From what has already been said it is apparent that there is much to commend in the existing city health work. The board seems to have'^ acted with unusual intelligence, and the health officer with unusual con- scientiousness and energy. While the board system has in general fallen * A number of sewer extensions have been made. More than half, of Humboldt Street is now said to be sewered. 24 into disrepute, it must b'e admitted, that Ithaca does not seem to have suf- fered from this method of health department management. Possibly this is because the board has had among its members University professors with special knowledge of health work. It is perhaps an illuminating commentary on the board system that when an unusually intelligent board exists, as in Ithaca, it illustrates its capacity by giving the health officer a pretty free hand. Such has been the local state of affairs, and the results have been gratifying. Improvement can be secured, however, if not through changes in form of organization, at least through an increase in quantity of service provided. The health officer is at present employed on part time, and is engaged in the active practice of medicine.* In addition, 'he must act as his own con- tagious disease investigator, statistician, clerk and executive. These de- mands are, under the conditions, relatively greater than can be met with com- pleteness. As a result, the office must try to meet the more insistent needs and pass over matters that appear to be of minor importance. It is an arrangement which makes against good record keeping and the initiation of new work. The answer to this problem is, in most cities, the employment of a full- time health officer and the provision of proper clerical and nursing assistance. In Ithaca the question is Whether a full-time man could be obtained who would equal, in intelligence, energy, and knowledge of local conditions, the present health officer. Whatever solution is attempted the health officer should be given more assistance, probably best in the form of a public health nurse. Such a person would be useful in tuberculosis and other communica- ble disease work, in combating infant mortality, and in the keeping of suita- ble records. Financial Treatment The amount of work which a health department can do, or be expected to do, depends, of course, upon the amount of money it is allowed. Bricks cannot be made without straw, nor can effective disease prevention work be carried on without money. The expenditures of Ithaca's department for the last two years are as follows: EXPENDITURES OF THE BOARD OF HEALTH, ITHACA, 1912 AND 1913 Salaries 1912 1913 Health officer $1,000 $1,000 Sanitary inspector 420 420 Bacteriologist 250 240 Office clerk 180 180 Dairy and food inspector 612.50 $2,462.50 900 $2,740.00 * This is no longer true. The health officer now devotes all his time to public health work, partly as city health officer and partly as district supervisor for the State Department of Health. This arrangement offers many advantages. In addition the city now employs a full-time sanitary inspector. 25 Contagious Diseases City Hospital — care of patients... 1,144 227 Supplies and expenses 633.73 1,777.73 215.64 442.62 Miscellaneous Tuberculosis dispensary — salary and expenses 1,113.72 1,062.17 Registration fees 390.30 60.58 Mosquito work 201.99 241.85 Dairy scores, milk analyses, and expenses 202.25 Milk inspection and analyses.... 661.75 Postage, stationery, office ex- penses 41.15 1,949.41 68.60 2,094.95 Total $6,189.64 $5,277.59 The total expenditure for these two years gives an average yearly ex- penditure of about 38 cents for each inhabitant. This is, as health depart- ment appropriations go, a fairly liberal allowance; but is in no way ex- cessive, as recommendations for a minimum per capita expenditure have varied from 50 cents to $1.00. On the whole, however, the city is to be congratulated on the far-sighted policy which it has inaugurated, and it is to be hoped that this policy of reasonable health investment will be con- tinued and extended. Milk Inspection Among the commendable services which the local health department has initiated is that for the inspection of dairy farms and milk. An ar- rangement exists between the city and the College of Agriculture in Cornell University, whereby samples are examined in the University laboratories. The arrangement included, in the past, the scoring of dairy farms, but this work is now carried on by the city food inspector.* The results of the work are gratifying, as is indicated in the table below. RESULTS OF MILK EXAMINATIONS, ITHACA, 1907-1913* Year Number of samples Average bacterial count 1907-8 152 707,780 1908-9 150 370,760 1909-10 148 221,000 1910-11 179 187,000 1912 438 326,000 j£ 1913 822 347,300 * Since this sentence was written the old arrangement has been restored, dairy farms again being inspected by representatives of the University. B Figures furnished by Prof. W. A. Stocking, Jr. Counts on agar at 37° C and 48 hours. 26 . Not only is the general average distinctly good, but a very large pro- portion of the samples taken in 1913 gave a result meeting the require- ments of certified milk. This fact is brought out in the table below, 40 per cent of the samples giving counts of less than 10,000 per cubic centimeter, 66 per cent, counts under 50,000. RESULTS OF MILK EXAMINATIONS BY MONTH AND BACTERIAL CONTENT, ITHACA, 1913 a Number of samples total not counted 1 with counts Month below 10,000 1 10,000- 1 50,000 50,000- 100,000 100,000- 500,000 500,000- 1,000,000 over 1,000,000 Jan. Feb. Mar. Apr. 28 26 25 54 1 1 1 9 16 6 24 9 6 11 13 3 1 1 2 6 3 4 3 1 12 May June July Aug. 59 51 57 26 3 1 35 14 19 9 11 13 15 4 3 7 3 4 7 5 4 5 3 3 3 6 12 4 Sept. Oct. Nov. Dec. 42 118 127 108 16 3 15 37 67 40 6 35 26 36 3 20 11 12 2 13 17 11 7 2. 6 6 5 Total 721 26 291 184 68 75 23 54 Per cent 100.0 3.6 40.4 25.5 9.4 10.4 3.2 7.5 The counts, as might be expected, show a tendency to run up in the warm summer months, but the general showing is still good. The average count would be even better were it not for a small number of quite high counts, the presence of which indicates that the milk problem is not yet en- tirely solved. The increased effort should, in all probability, be along the line of more frequent dairy inspections, since the food inspector in the last year made 86 inspections, a number Which would not quite cover all the dairy farms once. The results of the farm inspections, made with the United States Department of Agriculture score card, is as follows: a Figures furnished by Prof. W. A. Stocking, Jr. Counts on agar at 37° C and 48 hours. 27 DAIRY SCORES, ITHACA, 1913 Figures furnished by city food inspector Scoring N umber of farms Per cent of total 90-100 2 2.3 80-90 16 18.6 70-80 35 40.7 60-70 25 29.1 50-60 7 8.1 40-50 1 1.2 Total 86 100.0 The showing is again good, as few very high scores are made with the government card, and as the latter is rather severe on the small farms — even when clean. One strong point in the present dairy inspection is the thorough physical examination given all cows each year. In 1913, of 1,419 cows examined 22 were condemned on account of local or general disease and were removed from the herds. Altogether the Ithaca milk supply is a good example of what can be accomplished by judicious inspection carried on without any great amount of agitation and with very little inconvenience to producers. Dairy farms and milk both show up well; about half the milk is sold in bottles; and about 15 per cent is pasteurized. A few bad spots exist, but they can be eliminated by the continuation of the present work with some amplification — such as more frequent dairy inspections. Pasteurization of this clean supply would provide an added safeguard, but the local situation presents peculiar difficul- ties in this connection, owing to the relatively large number of independent producer-dealers. A word of praise must be given the health department's initiation of a policy of useful milk publicity, a list of dealers with their dairy scores and milk counts for the summer of 1913 appearing in the Ithaca San- itary Bulletin, whose first issue appeared December 15, 1913. Food Inspection Since June 15, 1912, the health department has employed a part-time food inspector.* The duties of this official were at the start limited to the inspec- tion of meat markets, restaurants, and other places where food is handled or sold, but during 1913 they were extended to include the inspection of dairy farms. The nature and extent of the work is indicated below, the fig- ures being taken from the inspector's annual report. * Now discontinued, an arrangement having been made whereby the city's food in- spection is carried on by the Colleges of Agriculture and Veterinary Medicine of the University. 28 FOOD INSPECTION, ITHACA, 1913 Beeves inspected 718 Dairies condemned 3 Beeves condemned 28 Cows given physical examina- Entire carcasses condemned. . . 15 tion 1419 Separate carcasses condemned.. 18 Cows condemned 22 Hogs inspected 1034 Cows condemned for general dis- Hogs condemned 12 ease 14 Dairies inspected and scored. . . 83 Cows condemned for local disease 8 In addition to the work listed above, the inspector makes frequent visits to 14 markets, 17 restaurants, 19 student boarding houses, 8 bakeries, 3 fish markets, and a number of confectioneries. Perhaps one-tenth of the city's meat supply is locally slaughtered, in three slaughter houses. With the other demands on his time, the inspector is un- able to see these animals on the hoof, or to be present at the time of killing, thus having to be content with the less valuable examination of carcasses and entrails. Altogether the food inspector has more work to perform than his part-time employment allows; but it would appear that much useful work is being accomplished and it is obvious that the city can have more if it will pay the price. Control of Communicable Diseases Discussion has already been given to the procedures employed in the control of tuberculosis and typhoid fever and suggestions have been made looking toward a program for the control of venereal diseases. Considera- tion now will be given to the health department's routine efforts for the control of communicable diseases — certainly one of its most important func- tions. The present quarantine regulations for the common contagious diseases are commendable. In scarlet fever the health officer sees every case, except those among students, at the first notification and before release from quar- antine. In no case is the quarantine period less than three weeks, and the condition of the patient with regard to release is judged largely by the ap- pearance of the throat. In private houses quarantine is very strict, both the patient and his attendants being isolated from the general public. The same general rules are laid down for diphtheria, with the exception that two negative cultures from the throat are required before the patient is released. If a positive culture is secured, three days must elapse before the next culture may be taken. All cultures are taken by the health of- ficer. The use of milk tickets is forbidden in either disease and the milk- men are not allowed to leave bottles at the house in which the case exists. After quarantine is raised in scarlet fever, 10 days must elapse before the patient can mingle with other children; in diphtheria this period is seven days. Fumigation with formaldehyde, and what is more important, surface disinfection with liquids, are practiced at the termination of the case. 29 In measles, the child is excluded from school, as are all contacts who have not had the disease. The same procedure obtains in German measles and whooping cough. Reporting of cases in diphtheria and scarlet fever is stated to be slower than is desirable, as is the case with typhoid fever. Cases of these diseases seen by physicians are usually reported eventually, but for the best results it is exceedingly desirable that reports be prompt, and public opinion should require this. Tuberculosis is reported well, measles and whooping cough to a fair degree, and pneumonia and cancer not at all. Good facilities for laboratory diagnosis are available, due largely to the pres- ence of the University. Diphtheria cultures receive prompt attention, and free examinations of specimens also are made for tuberculosis, typhoid fever, rabies, and malaria. Free tetanus and diphtheria antitoxins are likewise dis- tributed. With the unusual laboratory facilities available it is suggested that arrangements be made for free examination of specimens for the organisms of gonorrhoea and syphilis, to include both microscopic examinations and blood tests for complement fixation. The present contagious disease hospital facilities at the old contagious disease annex are somewhat inadequate, and the hospital trustees propose to build a pavilion to the south of the city hospital to meet the need. As an alternative it has been suggested that alterations be made in the old con- tagious disease hospital. At all events this matter should be settled as quick- ly as practicable, so that the city may not be embarrassed in the face of an unexpected outbreak of contagion. This inadequacy in hospital facilities, which includes lack of provision for cases of smallpox, and the previously noted lack of adequate provision for the reinspection of quarantine and the supervision of typhoid cases are the most serious deficiencies in the city's service for restriction of the communi- cable diseases. It is suggested, however, that this service might be materially strengthened by a move in a new direction; that is, by the establishment of a health department dispensary.* The latter, conducted on modern lines, with a nurse to visit patients in their homes and to investigate their financial cir- cumstances, would offer better medical relief to the indigent and would help the health department in its work against infant mortality, tuberculosis, and the venereal and other communicable diseases. The sick poor are more will- ing to avail themselves of such a service as compared with the old style poor relief, while the health authorities' chances of discovering and eliminating centers of infection are greatly increased in its administration. Infant Mortality The mortality of infants in their first year of life is one of the most im- portant of all sources of mortality; it is especially important from the stand* point of prevention. In Ithaca 24 infants died during 1913 before reaching their first birthday. In the same year 276 were born, giving an infant death rate * The City Health Department now maintains a dispensary for tuberculosis and infant mortality. 30 of 87.0 per 1,000 births, a figure considerably lower than those of most urban communities. This does not mean, however, that preventable deaths do not occur among Ithaca's infants: it is entirely probable that such deaths do oc- cur in certain parts of the city, and that the usual baby-saving work would produce valuable results. Important causes of much of this infant sickness and death are intes- tinal infections, the overheating of infants during the hot summer weather, and improper feeding and general care. These are conditions that yield to educational procedures such as can be carried out by public health nurses and baby welfare stations. Midwives also need supervision. All these mat- ters should receive attention from Ithaca's health department, as this field assuredly offers one of the greatest opportunities for effective disease pre- ventive effort.* It is earnestly hoped that the brevity of the present discussion will not be taken as a measure of the relative importance of the subject. An inten- sive study of Ithaca's infant mortality by district, cause, and year, is not presented here simply for the reason that in the short time available for the survey it was impossible to gather the necessary data. Publicity and Education Another important field for her progress in which Ithaca may be praised is health education and publicity. Issue number one of the "Ithaca Sani- tary Bulletin" appeared on December 15, 1913. Not only is this a step in the right direction but it has been taken in the right way: the Bulletin is no meaningless list of more or less insignificant statistics, but gives a readable discussion of the city milk supply, with the scores and analytical results corresponding to the various dairymen, and several interesting notes on other sanitary subjects. Certainly this commendable innovation should be continued and developed. Plans for lectures and exhibits should also be considered; for modern public health work, after the more obvious menaces have been abated, must be to a large extent an educational campaign, and must have the appreciation, support, and co-operation of the public. Record Keeping Such favorable criticism cannot be given the present methods of col- lecting and preserving sanitary records and statistics. The register of tuber- culosis cases is in good order, but the records of other communicable dis- eases suffer from the limitations on the health officer's time and his lack of adequate clerical assistance. If such assistance is, as should be, furnished, the present records can be kept with greater completeness, and new ones, such as adequate case histories, can be kept which will be of much real value. In the more painstaking and detailed work necessary for the elimina- tion of "residual" sickness, careful record-keeping becomes of increased im- portance. * Since the preparation of this report the health department has opened an infant welfare station. 31 VI. SUMMARY AND CONCLUSIONS Ithaca's sanitary conditions and her general and specific death rates are, on the whole, better than the average. The big public sanitary improve* ments have been made, and the big excesses of preventable disease have dis- appeared. Her public health problem now consists in grappling with newly discovered opportunities, such as the restriction of venereal diseases and in- fant mortality; and in the elimination of the "residuals" of the other com- municable diseases. In mseting this problem some changes must be worked in the inanimate environment, such as the elimination of privies, and the extension of parts of the sewer and water systems; the main reliance, however, must be placed in an augmented health department, one that can discover the sources of in- fection promptly, and can prevent its spread. Such a program requires much closer supervision of infected individuals, and, therefore, increased and properly-qualified assistance for the health officer. The expense of such a program, when compared with that for public improvements, such as Ithaca has been forced to meet in the past, is fortunately not great. In accordance with the foregoing the following recommendations are of- fered: 1. That steps be taken to eliminate all privies where sewers and city water are available; and that owners of other privies be compelled to keep them in a sanitary manner; that is, so as to prevent pollution of the soil and the entrance of flies and other animals. 2. That the use of wells be discouraged, and that those in which there is evident opportunity for, or evidence of pollution, be condemned. 3. That sewers and city water be extended in a liberal manner, especial- ly to include certain districts west of the Inlet.* 4. That measures be taken to assure a larger margin of safety as be- tween water consumption and the capacity of the water filtration plant; that a more liberal laboratory equipment be provided at the plant; and that provi- sions be made to insure a high grade of supervision at all times. The de- sirability of securing the additional safeguard obtainable by chlorine disinfec- tion is also suggested. § 5. That additional assistance be furnished the health officer, probably best in the form of clerical service and a public health nurse, or nurses; this assistance to be utilized in the closer supervision of quarantine, and in work against infant mortality,! tuberculosis, and other communicable dis- eases. 6. That closer supervision be exercised over persons ill with typhoid fever, and that the power of removal be secured and exercised when neces- sary. * See note on page 24. § See note on page 23. t See note on page 30. 32 7. That the present work against tuberculosis be continued, supplemented by more nursing assistance, increased facilities for the dispensary, and in- creased accommodations at the sanatorium.* 8. That the health department initiate work against the venereal dis- eases, requiring reporting (by number instead of name if so desired), offer- ing free laboratory diagnosis, securing early free treatment for the indigent, and carrying on a campaign of educational publicity. 9. That the present work for milk inspection be continued on a some- what enlarged scale; and that more time be allotted to the work for food inspection. 10. That the health department's commendable start on health publicity and education be continued and extended. 11. That provision be made for the keeping, in the health department, of more complete records. * See note on page 17. 33 Survey Contributors Mr. Earl E. Atkinson Prof. L. H. Bailey Prof. P. Bedell Mrs. Mary E. Bell Dr. C. P. Biggs Dr. L. J. Bingham Mrs. H. T. Bull Prof. G. L. Bun- Mr. H. G. Carpenter Mrs. R. C. Carpenter Prof. I. P. Church Mr. J. M. Clapp Prof. J. H. Comstock Prof. C. L. Crandall Prof. T. F. Crane Dr. H. H. Crura Prof. L. M. Dennis Prof. A. B. Faust Federation of Women's Clubs Miss Mary S. Finch First Baptist. Church, Per Rev. R. T. Jones Prof. A. C. Gill Dean E. E. Haskell Prof. A. Hayes Prof. C. H. Hull Ithaca Business Men's Association Prof. H. S. Jacoby Mr. S. Jeffrey Prof. A. S. Johnson Prof. V. Karapetoff Mr. P. S. Livermore Mr. James Lynch Prof. J. McMahon Dr. H. E. Merriam Prof. E. G. Merritt Mr. J. T. Newman Miss M. M. Pitcher Mr. J. R. Robinson Mr. J. Rothschild Mr. C. T. Stagg Prof. J. H. Tanner Mr. C. E. Treman Mr. R. H. Treman Hon. A. D. White Misses Williams Prof. J. A. Winans Prof. E. H. Woodruff Prof. P. Work Prof. A. A. Young THE ATKINSON PRESS, ITHACA COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the library rules or by special arrangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE C28(842)M50 ScfcS EA448