COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX64073459 RA41 6 Sch5 A survey of the acti RECAP *bchneide/T- Oufv^ec/ cf> -flje. acti vi\ tea 6T muniQipcuL 'he.aJ lh cLljociy^ m ? Columbia ^IntbergttjQ intijeCitpofiBtetoPorfe \\ College of iJ&paician* anb burgeons r Reference Htfararp Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/surveyofactivitiOOschn SE21 January, 1916 A SURVEY OF THE ACTIVITIES OF MUNICIPAL HEALTH DEPARTMENTS IN THE UNITED STATES BY FRANZ SCHNEIDER, JR. SANITARIAN DEPARTMENT OF SURVEYS AND EXHIBITS RUSSELL SAGE FOUNDATION Department of Surveys and Exhibits Russell Sage Foundation 130 East Twenty-second Street, New York City Price 20 Cents . ■ SE21 January, 1916 A SURVEY OF THE ACTIVITIES OF MUNICIPAL HEALTH DEPARTMENTS IN THE UNITED STATES BY FRANZ SCHNEIDER, JR. SANITARIAN DEPARTMENT OF SURVEYS AND EXHIBITS RUSSELL SAGE FOUNDATION Department of Surveys and Exhibits Russell Sage Foundation 130 East Twenty-second Street, New York City A SURVEY OF THE ACTIVITIES OF MUNICIPAL HEALTH DEPARTMENTS IN THE UNITED STATES* The purpose of this investigation was to obtain an approximate idea of the status of health department work in the United States ; to examine the departments' programs and their financial resources, and to discover how great or small an advantage they were taking of their existing opportunities. Such an exposition of the condition of our local public health work should aid public health officials to secure increased appropriations and should serve as a basis for future measurements of public health progress. In scope the investigation was limited to cities having a popu- lation of 25,000 and over according to the census of 1910, and to twelve phases of work chosen as of special importance and in- terest. The location of the cities, of which there were 227, is shown in Figure 1 ; their distribution by state and group of states is given in Table 1. The investigation was carried on entirely by mail. On August 1, 191 3, letters were addressed to the health officers of the cities, requesting copies of their last two annual reports, their codes, and their financial statements. These letters also en- closed a questionaire covering the twelve subjects of inquiry; namely, appropriation (two questions), infant hygiene work, medical inspection of school children, laboratory service, health education and publicity, control of venereal diseases, housing regulation, dispensary service, tuberculosis work, industrial hygiene, and the number of privies. About one third of the de- partments answered this first letter; another third a second letter sent out three weeks after the first; and another fifth a third letter sent out a month after the second. Letters addressed * This paper was read, in preliminary form, before the Colorado Springs meeting of the American Public Health Association. In its present, final, form it is reprinted from the American Journal of Public Health; Vol. VI, No. 1; January, 1916. 3 ACTIVITIES OF MUNICIPAL HEALTH DEPARTMENTS IN U. S. to mayors and chambers of commerce brought in replies from 23 more cities, leaving only eight,* 3.5 per cent of the total, unheard from at the close of the canvass. Further correspondence was necessary because a considerable number of the replies were in- complete in some particular, and in the end it was not possible to secure complete information on all points from all the 219 TABLE I. — NUMBER OF CITIES OF 25,000 POPULATION AND OVER IN 1910 BY STATES AND STATE-GROUPS New England States 40 West North Central States Maine 2 Minnesota 3 New Hampshire 2 Iowa 8 Massachusetts 25 Nebraska 3 Rhode Island 4 Missouri 5 Connecticut 7 Kansas 3 Middle Atlantic States 55 East South Central States New York 21 Kentucky 4 New Jersey H Tennessee 4 Pennsylvania 20 Alabama 3 South Atlantic States 20 West South Central States Delaware 1 Arkansas 1 Maryland 1 Oklahoma 2 District of Columbia 1 Louisiana 2 Virginia 5 Texas 8 West Virginia 2 North Carolina 2 South Carolina 2 Mountain States 6 Georgia 4 Montana 1 Florida 2 Colorado Utah 3 2 East North Central States 48 Pacific States Michigan 9 Washington 3 Wisconsin 8 Oregon 1 Ohio 14 California 8 Indiana 5 Illinois 12 13 Total 227 cities reporting. The smallest number of cities giving satis- factory information in answer to any one of the questions regard- ing the department's program was 201 — in the case of the ques- tion regarding infant mortality. The fiscal year for which information from the majority of the ♦Columbia, S. C; Council Bluffs, la.; Holyoke, Mass.; Joplin, Mo. Knoxville, Tenn.; Newport, Ky.; Springfield, Mo.; Waco, Tex. ACTIVITIES OF MUNICIPAL HEALTH DEPARTMENTS IN U. S. cities was secured is the calendar year of 1913; in a few cases it varied slightly from this period and in a few cases the appro- priation figure for 191 2 had to be accepted. Such cases were, however, relatively rare and occurred in such distribution as not to vitiate any of the conclusions presented in this paper. The populations used in all computations are those for July 1, 1913, as estimated by the Bureau of the Census. While absolute accuracy cannot be claimed for the material contained in this paper, no effort has been spared to draw only conclusions for which the data is adequate, and it is confidently believed that the picture presented is a fair representation of conditions existing at the time of the investigation. Appropriation The first inquiry on the schedule related to the amount of the department's annual appropriation. This question was answered by 206 cities, representing a population of 29,488,321 ; the aggre- gate total appropriation being $13,155,547, giving a crude per capita figure of 44.6 cents. As this figure was sure to include many expenditures not common to all departments, and many of no special hygienic significance, a second question inquired what parts of the crude appropriation should be charged off for the following enterprises: hospitals and sanitoria; plumbing inspection; street cleaning; the removal or disposal of dead animals, refuse, garbage, or night soil; and any other unusual undertakings. Deducting these items, the remaining expenditure should represent with considerable accuracy the amount devoted to actual preventive measures, and should offer a fair basis for comparison between cities of different size and location. This corrected figure, which is the one discussed in this paper except where specifically stated to the contrary, aggregated $9,650,515, or 32.7 cents per capita. Excluding New York City, with its big appropriation of over three million dollars, the figure drops to 27.3 cents per capita. The facts regarding these appropria- tion figures for the grand divisions of states are shown in Table 2. The general tendency of the per capita appropriation to vary directly with the size of the city is shown in Table 3, which gives both the aggregate per capita — obtained by dividing the aggre- 5 ACTIVITIES OF MUNICIPAL HEALTH DEPARTMENTS IN U. S. gate appropriation by the aggregate population, and the average of the per capita figures of the individual cities. TABLE 2. — POPULATIONS AND HEALTH DEPARTMENT APPROPRIA- TIONS OF CITIES BY STATE-GROUPS Cities report- ing Aggregate population Appropriation Group of States Total amount " Cor- rected" amount Ratio of "cor- i rected" to total New England Middle Atlantic .... South Atlantic East North Central . . West North Central. East South Central . . West South Central . Mountain 39 55 17 44 17 8 9 5 12 3,344,302 11,541,623 1,853,087 6,716,947 1,850,371 852,073 838,263 462,943 2,028,712 $1,585,486 5,846,815 785,704 2,141,899 467,428 329,720 299,025 307,262 1,392,208 $938,775 4,716,305 601,280 1,655,739 358,381 267,440 230,187 164,203 718,205 59-2% 80.7 76.5 77-3 76.7 81. 1 77.0 53-4 51.6 Pacific Total 206 29,488,321 $13,155,547 $9,650,515 73-4% TABLE 3. — HEALTH DEPARTMENT APPROPRIATIONS a PER CAPITA IN CITIES BY SIZE-GROUPS Cities having population of Cities report- ing Aggregate population Aggregate appropri- ation Aggre- gate per capita Aver- age per capita Aver- age pop- ulation 300,000 and over. 300,000 and over excluding New York City 100,000 to 300,000 50,000 to 100,000 25,000 to 50,000 17 16 38 55 96 16,087,038 10,888,150 6,045,943 3,890,259 3,465,081 $6,486,979 3,477,033 1,688,959 790,014 684,563 40.3c 31-9 27.9 20.3 19.8 34.0c 32.6 26.7 19.6 19-3 946,296 680,509 159,104 70,732 36,095 All cities 206 29,488,321 $9,650,515 32.7c 21.9c H3,H7 All cities exclud- ing New York City 205 24,289,433 $6,640,569 27.3c 21. 8c 118,485 a "Corrected" appropriation The largest corrected figure was that of Seattle — $.98; the 6 ACTIVITIES OF MUNICIPAL HEALTH DEPARTMENTS IN U. S. smallest that of Clinton, Iowa, — three fourths of one cent. Others of the larger expenditures were Memphis, Tenn., $.93, Pittsburgh, Pa., $.61, Augusta, Ga., $.61, and New York City, $.58; among the smaller were Easton, Pa., $.02, Aurora, 111., and South Bend, Ind., $.03, Woonsocket, R. I., $.04, and Lewis- ton, Me., $.06. Such ridiculously small appropriations are by no means rare, and are to be found in almost any part of the country. The variation in liberality of the different sections of the country is brought out in Table 4, which shows the average per capita figure for the cities in the principal groups of states. TABLE 4. — HEALTH DEPARTMENT APPROPRIATIONS a PER CAPITA IN CITIES BY STATE-GROUPS Group of states New England Middle Atlantic South Atlantic East North Central . West North Central . East South Central . West South Central . Mountain Pacific Total . 206 Cities Average Average reporting population per capita 39 85,751 24.0c 55 209,848 19.0 17 109,005 34-4 44 152,658 15-2 17 108,845 15-4 8 106,509 32.2 9 93,HO 28.7 5 92,589 29.8 12 169,059 29.7 143,147 21.9c a "Corrected" appropriation It is evident that marked variations occur, and that these are out of all proportion to differences in size of the cities in the sev- eral groups of states. Relatively the largest appropriations are in the southeastern states; the smallest in the north central. That these differences are of real significance with regard to the strength of the health departments in different parts of the coun- try will become clearer in the light of the results of the other parts of the present investigation. Infant Mortality The third question on the schedule related to the department's efforts against infant mortality. Of 201 cities furnishing definite 7 ACTIVITIES OF MUNICIPAL HEALTH DEPARTMENTS IN U. S. replies, 137, or 68.2 per cent, attempted milk inspection; 89 of these also employed nurses or maintained baby welfare stations ; while 17 relied solely on private agencies. Forty-four per cent of the cities, in other words, possessed the essential features of a program for the prevention of the avoidable deaths of the new- born and very young; 8.5 per cent relied for such work solely on private agencies; while in 45 cities, or 22 per cent of the whole, no effort whatever was made, not even milk inspection. TABLE 5. INFANT HYGIENE WORK IN CITIES BY SIZE-GROUPS Cities having population of Cities report- ing Having "complete" program Making no effort Number Per cent Number Per cent 300,000 and over. . 100,000 to 300,000 . 50,000 to 100,000. 25,000 to 50,000. 18 39 50 94 17 27 21 24 94-4 69.2 42.0 25-5 3 11 3i 0.0 7-7 22.0 33-o All cities 201 89 44-3 45 22.4 The variations in the amount of interest shown in the saving of infant life by cities of different size are brought out in Table 5. It is plainly evident that the smaller cities are very neglectful in this regard; whereas 94 per cent of the cities over 300,000 TABLE 6. INFANT HYGIENE WORK IN CITIES BY STATE-GROUPS Group of states Cities reporting Average population Having " complete " program Number Per cent New England 35 53 17 46 18 7 11 5 9 89,283 215,615 112,298 H7,205 121,325 113,482 91,237 92,589 203,442 21 21 7 16 7 4 6 2 5 60.0 Middle Atlantic South Atlantic East North Central .... West North Central .... East South Central .... West South Central .... Mountain 39-6 41.2 34-8 38.9 57-i 54-5 40.0 55-6 Total 201 146,809 89 44-3 ACTIVITIES OF MUNICIPAL HEALTH DEPARTMENTS IN U. S. population had what may be called a complete program — milk inspection, and nurses and infant welfare stations to follow up births and educate mothers, only 26 per cent of the cities between 25,000 and 50,000 had initiated such work. Similarly not one of the first-named group of cities failed to do something; while 33 per cent of the smaller ones did nothing whatever. Table 6 brings out the differences in the activity with respect to this kind of work of health departments in different parts of the country. Here again it is interesting to note that the poorest showings are made by the North Central states, with New England and the South Central and Pacific states in the leading positions. Medical Inspection of School Children The fourth question, on medical inspection of school children, was in most cases easily and clearly answered. Of 211 cities reporting, 167, or 79 per cent, reported some such inspection; the work being in 103 instances under the school authorities as against 56 for the health department. Five cities reported the inspection in public schools under the school authorities with that in parochial or private schools under the health department, while three reported joint control by the two authorities. TABLE 7. — MEDICAL INSPECTION OF SCHOOL CHILDREN IN CITIES BY SIZE-GROUPS Cities having population of Cities reporting Having inspection Number Per cent 300,000 and over 100,000 to 300,000 50,000 to 100,000 18 39 52 102 18 37 40 72 100.0 94-9 76.9 25,000 to 50,000 70.6 All cities 211 167 79.1 Again the big cities lead, as is shown in Table 7, although in this case the showing of the smaller cities is better than in the case of infant hygiene work. All of the larger cities had inspec- tion systems, while even 71 per cent of the group of smallest cities 9 ACTIVITIES OF MUNICIPAL HEALTH DEPARTMENTS IN U. S. provided the service. The examination of school children is evidently one of the features of a public health program whose importance has something like general recognition. table 8. -MEDICAL INSPECTION OF SCHOOL CHILDREN IN CITIES BY STATE GROUPS Group of states New England Middle Atlantic South Atlantic East North Central. West North Central East South Central . West South Central Mountain Pacific Total Cities Average reporting population 37 87,129 53 215,097 19 104,780 47 144.739 19 129,357 9 98,890 IO 87,361 5 92,589 12 169,059 211 142,799 Having inspection Number 37 49 12 29 12 1 11 167 Per cent 1 00.0 92.5 63.2 61.7 63.2 88.9 80.0 20.0 91.7 79-i It is interesting to note that the provision for inspection is most complete in the New England and Middle Atlantic states, with the Pacific and South Central states following. The Mountain group is markedly the poorest off, while the showing of the North Central states is again relatively inferior. Laboratory Service The fifth question related to the department's laboratory facilities. The commoner laboratory diagnoses — for diphtheria, tuberculosis, and typhoid, were offered in 136, or 62 per cent of the 218 cities reporting. Of the other diseases gonorrhea was fairly often included, but syphilis less frequently. The replies regarding the examination of water, milk, and foods, showed that nearly three-fourths of the departments had facilities for chemical and bacteriological determinations. Once again the larger cities make the better showings, as may be seen from Table 9. In the group of largest cities all have well-rounded laboratories. Among the smaller cities it is inter- esting to note that their weakness is more pronounced with regard 10 ACTIVITIES OF MUNICIPAL HEALTH DEPARTMENTS IN U. S. TABLE 9. HEALTH DEPARTMENT LABORATORY SERVICE IN CITIES BY SIZE-GROUPS Cities having Cities report- ing Having diagnostic service Having bac- teriological service Having chemical service population of Num- ber Per cent Num- ber Per cent Num- ber Per cent 300,000 and over 100,000 to 300,000 50,000 to 100,000 25,000 to 50,000 18 40 57 103 218 18 33 34 5i 100. 82.5 59-6 49-5 62.4 18 33 42 62 100.0 82.5 73-7 60.2 18 36 39 63 156 100.0 90.0 68.4 61.2 All cities 136 155 71. 1 71.6 to facilities for laboratory diagnosis of communicable diseases than those for chemical and bacteriological examination of milk, water, and food, a circumstance which must be regarded as un- fortunate. table 10.- -HEALTH DEPARTMENT LABORATORY SERVICE IN CITIES BY STATE-GROUPS Having Havin gbac- Having Group of Cities report- Average popula- diagnostic service teriological service chemical service states ing tion Num- Per Num- Per Num- Per ber cent ber cent ber cent New England 39 85,751 24 61.5 28 71.8 27 69.2 Middle Atlantic 55 209,848 31 56.4 33 60.0 32 58.2 South Atlantic 19 104,780 16 84.2 16 84.2 15 78.9 East North Cen- tral 48 143,020 26 54-2 34 70.8 35 72.9 West North Central 19 129,357 10 52.6 13 68.4 14 73-7 East South Central 9 98,890 8 88.9 9 100.0 9 100.0 West South Central 12 89,226 8 66.7 9 75-o 9 75-o Mountain 5 92,589 2 40.0 2 40.0 4 80.0 Pacific 12 169,059 140,605 11 91.7 62.4 11 91.7 71. 1 11 91.7 Total 218 136 155 156 71.6 Table 10 shows the varying strength of health department laboratory service in the different parts of the country. The 11 ACTIVITIES OF MUNICIPAL HEALTH DEPARTMENTS IN U. S. South Eastern and Pacific states again make superior showings, while the Middle Atlantic, North Central, and Mountain states show perhaps the greatest opportunities for improvement. Publicity and Education Passing to efforts at health education and publicity, over one- fourth of 214 departments reported no effort whatever. The favorite medium for such endeavors when made was the news- paper, utilized to some degree or other in 88 instances. Fifty- three, or one-fourth, of the departments issued regular bulletins; 56 attempted lectures; while 51 distributed pamphlets or circu- lars. Table 11, giving the number and proportion of depart- ments having, on the one hand, regular bulletins and, on the other, doing nothing at all, gives an idea of the variation in value of efforts in this line by cities of different size. TABLE II. TWO TESTS OF HEALTH DEPARTMENT EFFORTS AT HEALTH EDUCATION AND PUBLICITY IN CITIES BY SIZE-GROUPS Cities having Cities report- ing Having regular bulletins Making no effort population of Num- ber Per cent Num- ber Per cent 300,000 and over 100,000 to 300,000 50,000 to 100,000 25,000 to 50,000 18 40 54 102 13 13 9 18 72.2 32.5 16.7 17.6 9 13 37 0.0 22.5 24.1 36.3 All cities 214 53 24.8 59 27.6 The story told is again the same; the larger cities have a higher percentage of regular bulletins and a lower percentage of departments making no effort. The indications with regard to the regular bulletin corresponds in a general way to those for other forms of publicity and education; cities having bulletins are more likely to carry on the other activities. The Pacific states lead in the two tests applied in Table 12, followed by the East South Central states. The Mountain states and New England are much in the rear; while the North Central states this time hold an intermediate position. Con- 12 ACTIVITIES OF MUNICIPAL HEALTH DEPARTMENTS IN U. S. TABLE 12. — TWO TESTS OF HEALTH DEPARTMENT EFFORTS AT HEALTH EDUCATION AND PUBLICITY IN CITIES BY STATE- GROUPS Having regular Making no Group of states Cities Average popula- bulletins effort report- ing tion Num- Per Num- Per ber cent ber cent New England 38 86,907 7 18.4 16 42.1 Middle Atlantic 54 212,784 11 20.4 17 3i-5 South Atlantic 18 106,853 5 27.8 6 33-3 East North Central 48 143,020 10 20.8 9 18.8 West North Central 19 129,357 6 31-6 4 21. 1 East South Central 9 98,890 3 33-3 1 11. 1 West South Central 11 89,181 3 27-3 1 9-i Mountain 5 92,589 1 20.0 4 80.0 Pacific 12 169,059 142,063 7 58.3 1 8-3 Total 214 53 24.8 59 27.6 siderable progress probably has been made in health department educational effort since the time this investigation was initiated, as this field is one of the more rapidly developing ones of health work; but certainly the opportunity for improvement existed throughout the country and on a large scale. Venereal Diseases Some interesting replies were received to the question as to what steps the department had taken toward control of the ve- nereal diseases. Twenty-eight cities reported some effort more aggressive than free laboratory diagnosis. In fourteen cities the problem was attacked along the line of case reporting ; seven requiring reports, five requesting them, two requiring them from institutions, and one making free laboratory diagnosis conditional on report of the case. Another line of attack was represented by the free laboratory diagnosis of gonorrhea and syphilis — the former being offered in 82 cities, the latter in 46. Four cities offered free dispensary treatment; three forced dangerous cases into hospitals; and two offered hospital care to indigents. Regu- lar inspections of prostitutes were made in eight cities — this type of effort in most instances being commented on as unsatisfactory 13 ACTIVITIES OF MUNICIPAL HEALTH DEPARTMENTS IN U. S. in results. Publicity and education, reported by three cities; placarding of houses of prostitution when considered necessary, reported by one city; and prohibition of employment of persons having venereal disease in food-handling places, also reported by one city ; completes a list of measures attempted which probably indicates certain of the ways in which health departments will endeavor to combat these highly important diseases in the future. Dispensaries and Outdoor Relief The replies to the question relating to the existence of city dispensaries and outdoor relief are worth analysis because of the opportunities possession of such service offers the health depart- ment in the way of locating and controlling otherwise undis- covered sources of infectious disease. Sixty-six of 211 cities reported a free dispensary service ; administration being in charge of the health department in 22 instances, the charity department in 18, city hospital in 10, a private organization receiving a city subsidy in seven, the county in six, and the police department in three instances. Fourteen cities reported district physicians working under the direction of the health department. TABLE 13. — REPORTS OF FREE DISPENSARY SERVICE IN CITIES BY SIZE-GROUPS Cities reporting Having service Cities having population of Number Per cent 300,000 and over 100,000 to 300,000 50,000 to 100,000 25,000 to 50,000 18 38 54 IOI 11 19 13 23 61. 1 50.0 24.1 22.8 All cities 211 66 3i-3 Table 13 makes it clear that the larger cities reported a mark- edly higher proportion of free dispensaries; while Table 14 shows the relative frequency of this service in different parts of the country. The Southern states again make the best showings; the North Central and Mountain states the poorest. 14 ACTIVITIES OF MUNICIPAL HEALTH DEPARTMENTS IN U. S. TABLE 14. REPORTS OF FREE DISPENSARY SERVICE IN CITIES BY STATE-GROUPS Group of states Cities reporting Average population Having service Number Per cent New England Middle Atlantic South Atlantic East North Central West North Central East South Central West South Central Mountain Pacific 39 53 19 47 18 9 9 5 12 85,751 215,611 104,780 145,066 121,325 98,890 93,542 92,589 169,059 142,123 14 16 8 11 4 4 5 1 3 35-9 30.2 42.1 23-4 22.2 44.4 55-6 20.0 25.0 Total 211 66 31.3 Tuberculosis Surely in these days one would expect the doctrine of tubercu- losis prevention to be widely spread, yet only 23.9 per cent of the cities reported a comprehensive program; 6.2 per cent fell a little short of such a program; 14.4 per cent reported no attempt whatever; while 55.5 per cent* were satisfied with mere frag- ments of a program. The phrase "comprehensive program" is used here to include compulsory reporting of cases, free laboratory diagnosis, investigation and visitation of reported cases by nurses or medical inspectors, free sanatorium facilities for those who need them, and disinfection after the termination or removal of a case. The variation in amount and value of anti-tuberculosis work in cities of different size is very striking, as may be seen from Table 15. Whereas 78 per cent of the cities over 300,000 popula- tion had comprehensive programs, only 12 per cent of the cities between 25,000 and 50,000 enter this class. Similarly, only 11 per cent of the larger cities fail to investigate the reported cases, as compared with 77 per cent for the smaller cities. Finally, none of the larger cities ignores the problem entirely as compared with nearly a fifth of the smaller cities which made no effort whatever. * Includes 6.7 per cent on account of Pennsylvania cities reporting state dispensary system. 15 ACTIVITIES OF MUNICIPAL HEALTH DEPARTMENTS IN U. S. TABLE 15. -HEALTH DEPARTMENT TUBERCULOSIS PROGRAMS IN CITIES BY SIZE-GROUPS Cities having population of Cities report- ing Having "compre- hensive" program No case investiga- tion No activity whatever Num- ber Per cent Num- ber Per cent Num- ber Per cent 300,000 and over 100,000 to 300,000 50,000 to 100,000 25,000 to 50,000 18 37 56 98 14 16 8 12 77-8 43-2 14-3 12.2 2 18 37 75 132 11. 1 48.6 66.1 76.5 63.2 4 8 18 0.0 10.8 14-3 18.4 All cities 209 50 23-9 30 14.4 TABLE l6. HEALTH DEPARTMENT TUBERCULOSIS PROGRAMS IN CITIES BY STATE-GROUPS Having prehei "com- No case in- No activity Cities Average lsive vestigation whatever Group of states report- ing popula- tion program Num- Per Num- Per Num- Per ber cent ber cent ber cent New England 38 87,268 14 36.8 22 57-9 5 13.2 Middle Atlantic 53 215,610 13 24-5 21 39-6 3 5-7 South Atlantic 18 108,574 5 27.8 12 66.7 4 22.2 East North Central 48 143,020 11 22.9 36 75-0 8 16.7 West North Central 17 126,155 2 11.8 13 76.5 4 23-5 East South Central 8 91,451 3 37-5 5 62.5 1 12.5 West South Central 10 93J59 00.0 10 1 00.0 3 30.0 Mountain 5 92,589 00.0 5 100.0 2 40.0 Pacific 12 169,059 142,883 2 16.7 8 66.7 00.0 Total 209 5o 23-9 132 63.2 30 14.4 In the regional analysis, given in Table 16, the West South Central and Mountain cities make the poorest showings of all, none of these reporting a comprehensive program and none in- vestigation of reported cases. These regions also furnish the highest proportions of cities absolutely ignoring the problem. 16 ACTIVITIES OF MUNICIPAL HEALTH DEPARTMENTS IN U. S. The showings of the eastern cities are manifestly the better, and probably reflect the extent and energy of the anti-tuberculosis campaigns carried on by private organizations in these districts. Other Hygienic Considerations Another branch of public hygiene receiving little attention in these cities is that relating to industry. Out of 217 cities, only 11, or 5.1 per cent, reported any effort. Four of these reported inspection systems; others reported lectures and bulletins, and co-operative efforts with labor unions. The larger cities re- ported a higher proportion of endeavor, the proportion ranging from 27.8 per cent for the cities of 300,000 population and over down to one per cent for cities of 25,000 to 50,000. The number of cities answering this question in the affirmative was too small to make their regional distribution of any significance. In considering the slight interest shown by our cities in industrial hygiene it must be remembered that this work is often, and prop- erly, delegated to the state industrial authorities; still it cannot be denied that with the present development of state effort there is ample opportunity for useful activity on the part of local health authorities. Another subject on which information was solicited was the existence of a "housing" code as distinguished from a "building" code. Of 209 cities 153 answered this question in the negative. The proportion of cities reported as having no regulations ranged from 22.2 per cent for cities over 300,000 population up to 86.1 per cent for cities between 25,000 and 50,000. The Pacific cities reported the highest proportion of regulations; the Mountain cities the lowest. The approximate number of dry closets and privy vaults, although not a direct test of the status of the health department's program, was considered of enough importance to justify the insertion of an inquiry on the questionaire. Of the total of 219 departments heard from during the entire investigation 25.6 per cent were unable to give even an approximate answer to this question. The aggregate population of the 163 cities that did furnish estimates was 25,595,415, the aggregate number of privies being 479,947, giving a ratio of 18.8 privies per 1,000 population. 17 ACTIVITIES OF MUNICIPAL HEALTH DEPARTMENTS IN U. S. The average of the privies per 1,000 population ratios of all these cities was somewhat higher — 33.8. In connection with these estimates the writer would draw attention to the fact that in his experience such estimates by local authorities of the number of wells and privies in their city err greatly on the side of under- statement. From the figures in hand it is probably in no wise extravagant to estimate a total of a million privies in our cities. table 17.- -PRIVIES AS ESTIMATED BY THE HEALTH AUTHORITIES IN CITIES BY SIZE-GROUPS Cities having population of Cities reporting Number of privies Average of per 1,000 population 300,000 and over 100,000 to 300,000 50,000 to 100,000 25,000 to 50,000 15 31 43 74 146,904 139,416 90,889 102,738 15-3 3i-3 3i-i 40.2 All cities 163 479,947 33-8 A glance at Table 17 makes it appear that the small cities are again relatively the worst. The large number of privies in the larger cities, however, shows that the country's privy problem is not restricted to the smaller cities. table 18.- -PRIVIES AS ESTIMATED BY HEALTH AUTHORITIES IN CITIES BY STATE-GROUPS Group of states Cities reporting Average population Number 1 f Aver 5*L r • • 101 per 1,000 01 privies 1 I- v 1 population New England Middle Atlantic South Atlantic East North Central West North Central East South Central West South Central Mountain Pacific 29 42 16 36 15 8 6 3 8 73,522 252,638 H5,297 175,975 137,134 97,023 60,071 124,063 138,345 8,566 114,812 47,385 142,100 64,390 43,094 21,500 19,000 19,100 5-9 24.7 5i. 1 48.3 30.4 77-4 55-9 63.0 18.5 Total 163 157,027 479,947 33-8 16 ACTIVITIES OF MUNICIPAL HEALTH DEPARTMENTS IN U. S. In the regional analysis New England appears far and away ahead, with the Pacific and Middle Atlantic states following. The Southern and Mountain cities have relatively the greatest number of privies, with the North Central states in an inter- mediate position. Summary and Conclusions What now are the conclusions to be drawn from these figures? We have seen that at the time of this investigation a fifth of the cities made no inspection of school children; over a third did not offer the ordinary laboratory diagnosis for the commoner com- municable diseases; over a fourth made no effort to educate in health matters; nearly three-fourths had no housing law; nine- teen-twentieths had no concern with the hygiene of industry; over six-sevenths had no program against the venereal diseases; over a half had no proper organization to combat infant mortal- ity; and less than a quarter had a coherent program against tuberculosis. Surely these facts argue for a surprising amount of neglected opportunity. And when we consider that this investi- gation made no effort to determine the efficiency of the work attempted, but only whether or not it was attempted ; and when, with the departments with which we are familiar in mind, we reflect on the partial thoroughness with which their slender staffs compel them to perform their work, the conclusion becomes in- evitable that public health work in this country is still in its infancy — certainly as far as application of established scientific methods is concerned. The striking correlation between the size of the city and the activity of the health department is another important result. Figure 2, which presents graphically the rankings with regard to the several subjects of investigation of the groups of different sized cities, shows that in every case the larger cities made the better showings, receiving relatively more money from the public treas- ury and carrying on larger and more intensive programs. It might be argued that this fact does not mean a better meeting of the public health problem by the larger cities — that conditions in the larger cities are so much worse that they are compelled to carry on more extensive health department work in order to keep 19 ACTIVITIES OF MUNICIPAL HEALTH DEPARTMENTS IN U. S. Cities having popu- lation of Ap- pro- pria- tion In- Laboratory service Edu- Dis- Infant tionof cation pen- mor- school Bac- and sary tality chil- terio- pub- ser- dren logical licity vice Tu- bercu- losis 300,000 and over 100 1 1 11 i i — ir 000 to 300,000 50,000 to 100,000 25,000 to 50,000 Fig. 2. — Ranking with Regard to Nine Tests of Health Department Activity of Cities by Size-groups. The darker shadings indicate inferior rankings. disease down to the level existing naturally in the smaller cities. Such an argument is, however, based entirely on assumption, and is in contradiction to such facts as that the rural death rate of New York state is now in excess of that of New York City, al- though the reverse was formerly the case. It seems to the writer that the direct indication is the more probable explanation of the facts; that is, that the inhabitants of the larger cities are receiv- ing better protection from preventable disease. Another striking result of the investigation is the variation in activity exhibited by health departments in different sections of the country. This is brought out graphically in Figure 3, which shows the standing of each group of states with regard to each of the points of investigation. The Southern and Pacific cities clearly out-rank the others; while the North Central and Mountain cities are markedly inferior. This result is perhaps less surprising than might at first appear if we will reflect on the fact that a good proportion of our very best health officers are located in the South. It is also certainly a fact that many of our northern departments, especially in the smaller places, are relics of other days, being in many instances mere nuisance abatement offices. One other point should receive all possible emphasis — the relation between these examples of municipal neglect and the scanty health department appropriations. What can we expect of a department in a city of 25,000 whose total appropriation is 20 ACTIVITIES OF MUNICIPAL HEALTH DEPARTMENTS IN U. S. but $200? And if the New York City department uses 58 cents per inhabitant per year and has to practice great care to make it go round, what can our average city do on only 22 cents? Again, do any real differences in local conditions require that Seattle spend 98 cents per inhabitant per year while Woonsocket may rest content with four cents? The answer is, of course, evident; our health departments now have new functions to perform which the public and, it is to be feared, many of the departments themselves do not appre- ciate. Far too many of our city health departments undertake far too little in proportion to their opportunities; on the other hand, all too few receive an anywhere near adequate appropri- ation. Under the circumstances one may re-emphasize the sug- gestion that there should be a minimum yearly per capita figure for a modern department — a kind of minimum wage. The sug- gestion is not new — having been made by Park in 191 1, the figure set by him ranging from 50 cents to one dollar according to the size of the city, and by the Committee on Activities of Municipal Health Departments of the American Public Health Association, Group of States East South Central Pacific South Atlantic West South Central New England Middle Atlantic East North Central West North Central Mountain In- spec- Laboratory service Infant Edu- cation Dis- pen- Ap- pria- mor- school Diag- Bac- Chem- and sary tality chil- terio- ical pub- ser- dren logical licity vice Tu- bercu- losis □ □^□□□□□LZD wz\\ — 11 — ii — 11 — 11 in^^ ^^ V///AV///AV///AV///AV//AV//A\ 1 \wm V///A\ II \v/z/i\^A^m^m V/A\ 1 ~^vm^^m£Ymm& BE^5ffi™El wmmft I — I I Fig. 3. — Ranking with Regard to Nine Tests of Health Department Activity of Cities by State-groups. White indicates that the group ranks among the highest three; cross-hatching that it ranks among the second three; black that it ranks among the lowest three. The groups are listed in the order of the sums of their rankings with regard to the nine tests. 21 ACTIVITIES OF MUNICIPAL HEALTH DEPARTMENTS IN U. S. its figure being 50 cents. Certainly fifty cents for real preventive measures would be an entirely reasonable figure, and in all prob- ability the time is not far distant when our cities will allow their health departments a dollar a head — an amount still moderate when compared with that spent for police or fire protection — and will realize a handsome profit on the investment. 22 RUSSELL SAGE FOUNDATION PUBLICATIONS The Pittsburgh Survey. Six volumes edited by Paul U. Kellogg. Price per set, postpaid, $10. The Pittsburgh District: Civic Frontage. $2.70. Wage-earning Pittsburgh. $2.72. Women and the Trades. By Elizabeth Beardsley Butler. $1.72. Work- Accidents and the Law. By Crystal Eastman. $1.72. The Steel Workers. By John A. Fitch. $1.73. Homestead: The Households of a Mill Town. By Margaret F. Bying- , ton. $1.70. West Side Studies. In two volumes. Boyhood and Lawlessness. The Neglected Girl. By Ruth S. True. $2.00. The Middle West Side. By Otho G. Cartwright. Mothers Who Must Earn. By Katharine Anthony. $2.00. Housing Reform. By Lawrence Veiller. $1.25. Carrying Out the City Plan. By Flavel Shurtleff. In collaboration with Frederick Law Olmsted. $2.00. Medical Inspection of Schools. By Luther Halsey Gulick, M.D., and Leonard P. Ayres, Ph.D. $1.50. Wider Use of the School Plant. By Clarence Arthur Perry. $1.25. Outdoor Relief in Missouri. By George A. Warfield. $1.00. The Almshouse. By Alexander Johnson. $1.25. San Francisco Relief Survey. $3.50. One Thousand Homeless Men. By Alice Willard Solenberger. $1.25. Social Work in Hospitals. By Ida M. Cannon, R.N. $1.50. Record Keeping for Child Helping Institutions. By Georgia G. Ralph. $1.50. Care and Education of Crippled Children in the United States. By Edith Reeves. $2.00. Prison Reform. By Chas. R. Henderson, F. B. Sanborn, F. H. Wines and Others. $2.67. Penal and Reformatory Institutions. By Charles R. Henderson and Others. $2.70. The Standard of Living Among Workingmen's Families in New York City. By Robert Coit Chapin, Ph.D. $2.00. Workingmen's Insurance in Europe. By Lee K. Frankel and Miles M. Dawson, with the co-operation of Louis I. Dublin. $2.70. Fatigue and Efficiency. By Josephine Goldmark. $2.00. The Longshoremen. By Charles B. Barnes. $2.00. Working Girls in Evening Schools. By Mary Van Kleeck. $1.50. Women in the Bookbinding Trade. By Mary Van Kleeck. $1.50. Artificial Flower Makers. By Mary Van Kleeck. $1.50. Handbook of Settlements. Edited by Robert A. Woods and Albert J. Kennedy. $1.50. SURVEY ASSOCIATES, INC. PUBLISHERS FOR THE RUSSELL SAGE FOUNDATION 105 EAST 22d STREET, NEW YORK Pamphlet Publications of the Department of Surveys and Exhibits, Russell Sage Foundation, New York City Prices indicated below are charged to help meet the cost of printing and mailing, and thus make possible a wider distribution of publications. SE i THE SOCIAL SURVEY, Paul U. Kellogg, Shelby M. Harrison, et al. 52 pp. 15 cts. SE 2 THE NEWBURGH SURVEY. 104 pp. 15 cts. SE 2c THE RELATION OF THE SOCIAL SURVEY TO THE PUBLIC HEALTH AUTHORITIES. Franz Schneider, Jr. 2 pp. 2 cts. THE TOPEKA IMPROVEMENT SURVEY; in four parts: SE 3 Public Health. 98 pp. 25 cts. SE 4 Delinquency and Corrections. 64 pp. 15 cts, SE 5 Municipal Administration. 43 pp. 15 cts. SE 6 Industrial Conditions. 56 pp. 15 cts. THE SPRINGFIELD (ILL.) SURVEY; in ten parts: SE 7 Public Schools. 152 pp. 25 cts. SE 8 Care of Mental Defectives, etc. 46 pp. 15 cts. SE 9 Recreation. 133 pp. 25 cts. SE 10 Housing. 24 pp. 15 cts. SE 11 The Charities of Springfield. 185 pp. 25 cts. SE 12 Industrial Conditions. 25 cts. SE 13 City and County Administration. 25 cts. SE 14 Public Health of Springfield. 159 pp. 25 cts. SE 15 Correctional System. 185 pp. 25 cts. SE 16 Springfield: The Survey Summed Up. 15 cts. SE 17 THE DISPROPORTION OF TAXATION IN PITTS- BURGH: Summary of findings of taxation inves- tigation of the Pittsburgh Survey. Shelby M. Harrison. 15 pp. 10 cts. SE 18 AN EFFECTIVE EXHIBITION OF A COMMUN- ITY SURVEY: A brief description of the Spring- field Survey Exhibition (reprint from the American City). 6 pp. 5 cts. SE 19 A SURVEY OF THE PUBLIC HEALTH SITU- ATION, ITHACA, N. Y. Franz Schneider, Jr. 34 pp. 20 cts. SE 20 DEPARTMENT OF SURVEYS AND EXHIBITS, RUSSELL SAGE FOUNDATION, Activities and Publications. 11 pp. SE 21 SURVEY OF THE ACTIVITIES OF MUNICIPAL HEALTH DEPARTMENTS IN THE UNITED STATES. Franz Schneider, Jr. 21 pp. 20 cts. SE 22 BIBLIOGRAPHY OF THE SOCIAL SURVEY. 16 pp. sets. *•■■+*■•■■■.;..•.■ ■:.. wm