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 The Full-Time Health Officer and 
 Rural Hygiene 
 
 Address delivered at the 
 
 CoNPERBNCE OF State Heai^th Officers 
 
 Louisville, Ky., December 8, 1913 
 
 BY 
 
 LOUIS L DUBLIN, Ph.D., Statistician 
 
 Metropolitan Life Insurance Company, New York 
 
 1913 
 

The Full-Time Health Officer and Rural Hygiene 
 
 The State of Kentucky presents a condition of lively interest 
 to the student of health and sanitation. As a State, it is among 
 the most typically American in the country. According to the 
 1910 Census, it had a population of 2,290,000, of whom about 
 98 per cent, were native born. You have, therefore, no serious 
 problems of assimilating the foreigner in your midst as we have 
 in the East. The State of New York, for example, has 30 per 
 cent, of its total population foreign born, many of whom have 
 ■ come here more or less recently from Southern or Eastern Europe. 
 Furthermore, over 75 per cent, of your population live in rural 
 territory or in small communities of less than twenty-five hundred 
 inhabitants. Your population is, therefore, homogeneous. You 
 live in the country and are free from congestion and those other 
 unfavorable conditions of industrial and urban life which make the 
 health problems of many of our States so acute. 
 
 The situation in Kentucky is interesting in another respect. 
 You have upon your statute-books a good health law which 
 provides the necessary machinery for your health work. You 
 have also a model law for the registration of births and deaths, 
 and you have been admitted to the Registration Area. In other 
 words, you have what to a stranger like myself would appear 
 to be a very favorable condition for efficient health adminis- 
 tration; namely, a population not too large, of good native stock, 
 thoroughly imbued with American ideals, and adequate statutory 
 provision to make your sanitary control both sure and efficient. 
 
 It is, therefore, not surprising that health experts look to 
 Kentucky for an encouraging example. They are anxious to 
 learn whether you are ready to take full advantage of your fine 
 opportunities; whether you will make continuous advances in 
 health conditions, and, perhaps, be able to solve for other States 
 some of the vexing problems of rural hygiene. Not only are 
 
 1 
 
your own best interests involved in the success or failure of your 
 endeavors, but the success of health work in other places is at 
 stake. Other communities will be guided by your results when 
 providing for the protection of their people. 
 
 Permit me to review the essential features of your Health 
 Law: 
 
 In the main, your administration is based on the county as 
 the unit of organization. The county boards of health are each 
 clothed with responsibility in their several jurisdictions. They 
 have power to establish and execute sanitary regulations for the 
 control of disease; to establish quarantine and erect hospitals 
 for the treatment of communicable diseases. The county boards 
 must, moreover, report to the State board at least every three 
 months on the incidence of communicable diseases and on the 
 general sanitary condition of the county. Each county board 
 acts through an executive secretary, who is the health officer of 
 the county. He receives compensation from the county, and 
 holds office at the pleasure of the local board. Apart from the 
 officers of the State board and a few local health officers in each 
 of the larger cities, the county health officers hold the key to the 
 situation in your State; upon their efficiency and loyalty depends 
 the health progress of Kentucky. 
 
 Kentucky has 119 counties, the population ranging from 
 about 4,000 in Robertson County to 263,000 in Jefferson County. 
 A large number of your counties have much the same land area, 
 with a population density of about 57 inhabitants per square 
 mile, or an average of a little under 20,000 per county. This 
 makes a favorable unit for the administration of rural health 
 work, and you are to be congratulated upon your natural advan- 
 tages of geographical distribution. The one question that arises 
 in my mind, however, is this: To what extent are your local 
 county organizations fighting machines for vigorous adminis- 
 tration? "Wliat provisions have you made for getting the work 
 done that must be done? To what extent is your county health 
 officer a live public health executive, giving all his time and 
 energy to the public service? In the last analysis, this is the 
 one great question which you must face squarely and answer. 
 
 The problem that I am here considering is not a new one. 
 Other States have addressed themselves to it, and to-day it is 
 agreed that the work of the local health officer must measure 
 up to certain standards. I propose to review some of these 
 
 2 
 
standards, not because you are not familiar with them, but rather 
 for the sake of emphasis. In this way, we may examine our 
 problem comprehensively and draw the necessary conclusions. 
 
 1. The county health officer must be a full-time official; that 
 is essential. In certain States the county unit has not been 
 closely followed, and where the county is too small or too sparsely 
 settled to permit the services of a full-time official, a few counties 
 have been merged for health purposes. In every instance, how- 
 ever, the full time of a competent person is obtained and the 
 geographical arrangement is modified to suit. I do not know 
 to what extent your distribution of population in certain of the 
 smaller counties calls for a similar arrangement, or whether your 
 laws would permit of such a merging of county lines ; but, whether 
 they do or not, the principle is clear. The health officer must 
 be one whose sole interest is in the community, to the exclusion 
 of private interest, be it his own or that of private individuals 
 or groups. The occasion should no longer arise when a health 
 officer may be tempted by personal considerations to neglect 
 the clear dictates of commimity needs. You know only too 
 well how often the part-time health officer who has a private 
 practice to maintain, must choose between the performance of 
 public duty and the loss of his practice. This situation should 
 not arise. He should never find it necessary to compete with 
 those whom it is his sworn duty to supervise. 
 
 2. The county health officer should be well trained in the 
 modern science of sanitation and public health. The average 
 practising physician is not well enough equipped, as a rule, to 
 administer a progressive health office. The protection of the 
 public health, as now conceived, is a science with its own data 
 and formulae. The larger medical schools, such as those at 
 Harvard and at the University of Michigan, for example, have 
 organized special post-graduate courses leading to the degree of 
 Doctor of Public Health. It will be a great day in American 
 public health affairs when medical officers will, as a class, qualify 
 by study in such post-graduate courses for their arduous duties. 
 But experience is also a good school, and the health officers here 
 assembled have been trained in the severest of schools. Ulti- 
 mately, provision will undoubtedly be made in your State for the 
 exclusive appointment of holders of the Diploma in Public Health. 
 May I suggest that you direct your energies toward your personal 
 
 3 
 
improvement, through study, to quaHfy for the distinctive degree 
 of your profession ? 
 
 3. The tenure of office of the health officer should be co- 
 extensive with his efficient service. The successful health officer 
 is made, not bom. With a proper background of training, ever}^ 
 year of added experience makes him a more useful servant of 
 the State. The health officer should, therefore, be assured of a 
 continuous tenure of office. He should in no way be a pawn in 
 the political game. A period of six to eight years has been sug- 
 gested as a sufficient term. Health officers who have made good 
 should then be considered for reappointment, although the State 
 may reserve the right to dismiss in shorter time those who are 
 incompetent or neglectful of their duties. There is no better 
 reason for removing good health officers than there is for changing 
 other public servants whose work is necessarily continuous, and 
 who, in the first instance, are properly chosen. 
 
 In view of these requirements it should hardly be necessar>' 
 to point out that health officers must be reasonably compensated 
 for their services. We have already assumed that the man 
 chosen for the place is the one in a hundred best qualified by 
 training. Surely, if his full time is required, his compensation 
 must be sufficient to attract him and to keep him in the service 
 without inflicting any hardship upon him or his family. It 
 is folly to set high standards and to make them impossible of 
 attainment because of inadequate compensation or uncertainty 
 of tenure. Health laws may as well not exist if they are not 
 properly enforced because of inadequate appropriations. A 
 county health officer, having in his safekeeping 20,000 lives, 
 cannot maintain himself on an annual allowance of a few hundred 
 dollars. It is not for me to determine what you shall pay, but 
 your salaries must be adequate to attract able men and to maintain 
 them in a state of comfort consistent with their important duties. 
 
 I say this guardedly. I am one of those who believe in govern- 
 mental economy. I have always urged that the efficiency tests 
 which have been introduced into modem business must also be 
 applied to the expenditure of public funds. It is because of this 
 very conviction that I maintain that communities must tax 
 themselves liberally to support high standards of health adminis- 
 tration; for it is the best economy in the end. The chief assets 
 of a community are the life and the health of its citizens. We are 
 realizing more and more that life and health are within our control. 
 
 4 
 
Changes in century-old conditions are being brought about every- 
 where and the marvels of modern medicine are visible on all sides. 
 
 Permit me to point out more definitely the character of the 
 return that awaits you on your investment in full-time health 
 oflBcers. In spite of the fact that yours is a rtu-al State, you are 
 by no means free from the ravages of tuberculosis. In the year 
 1911, 5,293 deaths from this disease were reported in your State, 
 which is equivalent to a rate of 229.3 per hundred thousand. In 
 the Registration States, which include the centers of congeston, 
 the rate was 155.6 per hundred thousand. A clear duty is there- 
 fore at your door, namely, to reduce your tuberculosis mortality. 
 This would be the first task of a full-time health officer. If 
 in five years the rate from this disease be reduced to what it is 
 in the Registration Area to-day, about 1,700 lives will be saved 
 annually for the State of Kentucky. The victims are largely 
 men and women in their prime, whose money value to the State 
 would be enough to compensate for the cost of the additional 
 health work. 
 
 Your typhoid problem is equally urgent. In 1911, your 
 death rate from this disease was 46.3 per hundred thousand, as 
 against 20.4 in the Registration States. In this respect your 
 experience is parallel to that of other rural communities, and 
 clearly indicates the many sanitary dangers incident to life in the 
 country. Typhoid fever is always, to the health engineer, an 
 unerring signal directing him toward polluted water supplies, 
 infected food products, and unsupervised typhoid carriers. These 
 are a constant menace to the entire State through their effect on 
 milk and other food supplies. All of these sources of typhoid 
 infection, including the disposal of dangerous waste products, 
 lend themselves to the concerted efforts of modem sanitary science. 
 Indeed, no disease has shown such a ready response to control as 
 this preventable filth disease. What is every one's concern is no 
 one's. The full-time health officer, supported enthusiastically by 
 his community, would, in the course of his first administration, 
 earn many times his cost in reducing sickness and death from this 
 cause alone. 
 
 The full-time health officer would, of course, participate in 
 other lines of activity. The influence of his work would soon 
 become manifest in reduced rates of sickness and death for the 
 other preventable diseases. The records put at my disposal 
 show that, in 1912, 39.5 per cent, of all your deaths were of this 
 
 5 
 
character. In other words, about 12,000 deaths occurred in the 
 course of the year which could have been controlled and perhaps 
 indefinitely postponed if proper sanitary facilities had been at 
 work during the past few years. In no one respect, however, 
 would the service of the full-time health officer be more con- 
 structive and remimerative to a community than in this active 
 participation in what we now call "Child Hygiene." In the 
 larger cities throughout the country this phase of health adminis- 
 tration is becoming permanently established. In New York, 
 where I am best acquainted with its results, there is no division 
 of the health department which has aroused greater enthusiasm 
 among experts than the Division of Child Hygiene. It would be a 
 function of the full-time county health officer to work in co- 
 operation with the school authorities of his community, and to see 
 that each child in his jurisdiction is examined at least once annually. 
 It is during the period of child life that the foundation is laid for 
 the physique which will determine largely the usefulness and 
 longevity of the future citizen. If there were no better excuse 
 than the need for some local authority to cany^ on intelligent and 
 modern child hygiene work in each community, you would be 
 justified in appointing a full-time health officer for this purpose. 
 
 The full-time health officer would also be of great service 
 as the representative of the State health board in overseeing the 
 registration of births, deaths and the occurrence of communicable 
 diseases in each county. Fortunately, the health law of Kentucky 
 clearly provides for the reporting of epidemic and communicable 
 diseases to the local boards of health. Your county health officers 
 are, moreover, under obligation by law to see that all the cases 
 are registered, and in turn to notify the vState office. In spite of 
 the importance of this work, it is clear that without adequate 
 administrative supervision, it is sure to be neglected. The reports 
 of your county health officers compel me to believe that this is 
 the condition of morbidity registration at the present time in 
 your State, except, perhaps, in the larger cities where tuberculosis 
 and typhoid fever are carefully handled. The morbidity reports 
 of your county health officers are extremely vague and indefinite. 
 With full-time health officers to do this important work scientific- 
 ally and effectively, the State would not be deprived, as it is at 
 present, of a most useful agency of sanitation. 
 
 An examination of your annual reports has raised a number of 
 other questions in my mind which I submit frankly for your atten- 
 
 6 
 
tion and discussion. I have already remarked that your death rate 
 from tuberculosis is relatively high; for pulmonary tuberculosis 
 alone your figure for 1911 was 200.4 per hundred thousand, or 15.2 
 per cent, of the total deaths for the year. In the Registration 
 States the corresponding figures are 134.7 per hundred thousand 
 and 9.7 per cent, of the total deaths. In other words, you have a 
 high tuberculosis rate coupled with a low general death rate. 
 As you know, the death rate from tuberculosis presents a fairly 
 constant relation of about 10 per cent, to the total deaths in 
 most communities where satisfactory registration conditions 
 prevail. In view of this fact, two questions arise, namely, either 
 your tuberculosis rate is inordinately high, or, what is perhaps 
 more likely, you are not registering a considerable number of 
 your actual deaths. A death rate of 200 per hundred thousand 
 from pulmonary tuberculosis should ordinarily show a general 
 death rate of about 20 per thousand, and not 13, as your reports 
 indicate. In this connection, I need hardly point out how valu- 
 able full-time health officers would be to your State health de- 
 partment and to your Legislature, in putting at their disposal a 
 complete accounting of all the occurrence of disease and death 
 which come under their jurisdiction. You would thus be in a 
 position to see annually what your added expenditures for health 
 work had accomplished in the conservation of health and life. 
 
 It was proposed by Dr. Heizer, your State Registrar of Vital 
 Statistics, that I also discuss the economic saving that would 
 accrue to your State through the employment of full-time health 
 officers in the lowered cost of life insurance. I believe that 
 this is the least interesting phase of the discussion. Insurance 
 costs are naturally dependent upon the death rates the com- 
 panies experience. If your new programme results, as it should, 
 in reduced death rates, certain appreciable savings will undoubtedly 
 be experienced by the companies operating in Kentucky. It 
 has been the constant policy of insurance companies to keep in 
 close touch with the life and health conditions prevailing in their 
 territory, and in every case to accommodate their rates to the 
 changing mortality. Life insurance is the one essential commodity 
 in modem life the cost of which has not risen during the last 
 twenty years. Further reductions will undoubtedly follow in 
 the wake of improved living standards. Indeed, the history of 
 insurance is the best index of the constant increase in the average 
 span of life which has been observed during the last century. 
 
 7 
 
There is still one other source of communal gain which goes 
 hand in hand with high health standards. I refer to the added 
 commercial value of locations in which good health conditions 
 prevail. vSuch communities have added attractiveness for pur- 
 poses of residence and industrial development. Persons who 
 contemplate a change of residence are naturally attracted to places 
 where they can be assured of a good water supply and other 
 safeguards to health. Nowadays, industrial concerns are located 
 only where a large nuniber of employees can be housed with 
 safety. As a result of these things, land values rise and an impetus 
 is given to the general prosperity of the community. 
 
 In closing, let me once more urge upon you that life and 
 health are both largely purchasable. It is only in the present 
 day and generation that we realize the full significance of the 
 situation, and feel the obligation that it places upon us. It lies 
 with us whether our communities shall rise up in their strength 
 to work and accomplish their full possibilities, or whether we 
 shall continue to pay a constant tribute with human life through 
 our indifference and neglect. Public health is no longer an 
 indi\ndual matter. We must protect ourselves by keeping watch 
 over all. This is the new order of living, and a new public health 
 with rigid standards and methods has come to stay. The full- 
 time health oflicer is the keystone in the arch of the new public 
 health service. You are at a crucial point in your health ad- 
 ministration. I am sure that you will take good counsel and 
 that your decision will be a source of inspiration to other com- 
 munities who have not as yet seen the light. 
 
S!61 
 
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