Progress of public health as it relates to the child

Critical Review PROGI%ESS O F P U B L I C H E A L T H A S I T R E L A T E S TO T H E C H I L D HAROLD C. STUART, M.D. BOSTON, ~V~ASS. MORTALITY AND MORBIDITY H E p i c t u r e p r e s e n t e d b y m o r t a l i t y s t a t i s t i c s i n the U n i t e d S t a t e s f o r 1934 is s o m e w h a t less s a t i s f a c t o r y t h a n f o r 1933 or 1932, b u t r a t e s were i n g e n e r a l b e l o w t h o s e for 1931 a n d p r e v i o u s years. P r e l i m i n a r y figures m a d e a v a i l a b l e b y t h e U n i t e d S t a t e s P u b l i c H e a l t h S e r v i c e ~ show a c o m b i n e d i n f a n t m o r t a l i t y r a t e of 58 f o r 1934 as comp a r e d w i t h 56 f o r 1933, 57 f o r 1932, 61 f o r 1931, a n d 62 for 1930. R a t e s f o r d i a r r h e a a n d e n t e r i t i s i n c h i l d r e n u n d e r two y e a r s of age w e r e s l i g h t l y h i g h e r t h a n i n t h e p r e c e d i n g two y e a r s b u t still m u c h h-,wer t h a n i n 1931 or 1930. D e a t h s f r o m p n e u m o n i a were i n c r e a s e d over the two p r e c e d i n g years, b u t the r a t e s f o r i n f l u e n z a a n d t u b e r culosis s h o w e d a m a r k e d decline. T h e r a t e s f o r d i p h t h e r i a , s c a r l e t fever, t y p h o i d f e v e r , a n d p o l i o m y e l i t i s w e r e all f a v o r a b l e . T h e t w o most striking increases were in the rates for measles a n d wh o o p in g cough, b o t h of w h i c h r a t e s w e r e m u c h h i g h e r t h a n i n a n y r e c e n t y e a r . The a c t u a l r a t e s f o r these diseases i n the t w e n t y - f i v e states h a v i n g ' 1934 figures a v a i l a b l e are s h o w n i n T a b l e I f o r each of the p a s t five years. These are p o p u ] a t i o n r a t e s - - a g e d i s t r i b u t i o n s are n o t y e t available. TABLE I

T

~I0g~ALITY FR0iVf CEI%TAnq CAUSES IN ~I'H~ 2 5 ~I~ATES, OF TtIE UNITED 8TAT'ES W I T H

AW~.ILABLE DA~A BY YEAI~ 1930-1934• , (Population July 1, 1934--80~813,000; Live Bir%hs~ 1934--1,499,000) D~A~HS

.

1934 . .

.1933.

.

3932

1931

58.0 I s6,0 [ 57.0 I 61.0 Maternal mortality / 5.4 I 5.6 [ 5.9 I 6.2 Per ~00,000 Population 11.1 Diarrhea and enteritis (under i0.0 10.3 14.0 2 yr.) Measles 4.2 1.6 1.5 2.5 Whooping cough 5.] 3.2 4.1 3.5 Scarlet ~ever 2.0 2.0 2.1 2.1 Diphtheria 2.9 2.7 3.8 4,1 Acute anterior poliomyelitis 0.6 0.6 0.7 1.9 Meningoeoccus meningitis 0.8 1.0 1.3 2.1 Influenza 23.7 15.2 27.5 24.8 Pneumonia, all forms 69.3 78.2 77.1 81.7 Tuberculosis, all forms 54.3 56.6 60.0 64.7 *Figures taken from Public I~Iealth Reports, U.S. Public Health Service, April 26, 1935. The states included ~.re Alabama, California, Connecticut,

Pe~" 1,000 Births Total Live' infant mortality

1930

I 62.0 I

6.2 17.8

2.9 4.2 1.9

4.6 ].1 3.1 18.5 83.0 68.0 50: No. 17. District of

Columbia, Georgia, Idaho, Indiana., Iowa, Kansas, Louisiana, IV[aryland, lYIiehigan, lY!innesota, lYs ]Nebraska, New Jersey, New York, Ohio, Pennsylvania, l~hode Island, South Dakota, Tennessee, Virginia, West Virginia, and Wisconsin. (Mississippi, Illinois, and North Carolina are also included in some of the rates.)

839

840

THE

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PEDIATRICS

D i p h t h e r i a death rates for tile c o u n t r y as a whole have not declined as r a p i d l y in the past four years as results in those states actively pressing for preschool child immunization have shown to be possible. This fact explains the selection of diphtheria p r e v e n t i o n by the Committee of State and Provincial H e a l t h Authorities of N o r t h America as the subject f o r special emphasis in 1Viay D a y health activities this year. A n o t h e r incentive to renewed efforts t o w a r d securing a population immunized against this disease comes f r o m the simplification of p r o c e d u r e incident to the p e r f e c t i o n of alum-precipitated toxoid. The adoption of this agent as the one of choice for public health purposes seems to be generally f a v o r e d at the present time. Its safety and effectiveness, used in a single injection of 1 c.c. (7.5 to. 10.0 units) have a p p a r e n t l y been a d e q u a t e l y demonstrated. 2-s As to the incidence of reportable illnesses, measles and whooping cough were unusually prevalent t h r o u g h o u t the country, accounting' for the high specific death rates a l r e a d y r e f e r r e d to and probably also to a degree for the higher pneumonia rate. Poliomyelitis showed a high incidence in the Pacific and Mountain states, but the genera] picture t h r o u g h o u t the country was not altered. Influenza remained generally inactive t h r o u g h o u t the year, but 1935 opened with a mild wave of a c t i v i t y in progress. Scarlet f e v e r also had not been prevalent but was generally on the increase at the beginning of 1935. Exclusive of d a t a on reportable diSeaSeS which, being communicable, tend to v a r y Jn incidence, from y e a r to year', and in contrast to the large mass of statistical data available on m o r t a l i t y rates, there have n e v e r been available any adequate data on the incidence of illness f r o m different causes and among different age groups. B a r r i n g a few local studies such as those in Hagerstown, Md., v e r y few investigations have been made of morbidity. Collins 7 has recently published extensive figures collected by the United States Public H e a l t h Service on the n u m b e r and t y p e of illnesses occurring within a given y e a r among' 9,000 families visited every two to f o u r months, resident in 130 loeaIities in eighteen different states and c o m p r i s i n g 39,185 individuals. A comparison of the incidence of illness d i s c o v e r e d in t h i s w a y m a y be made with the m o r t a l i t y rates for corresponding states to' give a rough picture of the expected f a t a l i t y from different conditions at different ages. F o r example, at all ages collectively, r e s p i r a t o r y diseases iu this s t u d y represented the same proportion of all illnesses, as t h e y r e p r e s e n t e d of all deaths in the corresponding states, but they constituted a much h i g h e r p r o p o r t i o n of illnesses than deaths at each age subdivision of childhood. I t appears that illness rates, are highest u n d e r five y e a r s and next between five and ten years of age, whereas death rates are h~gber a f t e r fifty-five years than u n d e r five and are e x t r e m e l y low between five and ten years. The f a t a l i t y of il]ness is h i g h e r a f t e r fifty-five years t h a n at any earlier age. ~~ In the years before m a t u r i t y , however, the general f a t a l i t y of illness is highest u n d e r five years and lowest between five and ten years. Such studies, if conducted at r e g u l a r intervals, would give valuable infoTmation as to the changing prevalence and severity of different diseases, and offer a rough measure of tb.c progress made in the prevention or modification of each. *In this comparison deaths under one year are averaged into the first five. statements would not apply if the first year were considered separately.

These

CRITICAL

EFFECT

OF

DEPRESSION

Ol'q T H E

841

REVIEW

I-IEAL,TI-I A N D

GROWTI~

Ol~1 C H I L D R E I ~

Eliot reviewed the l i t e r a t u r e on this subject in this series of critical reviews last year. s F a r t h e r evidence has been amassed during the y e a r pointing to h i g h e r illness rates a m o n g the i n d i g e n t t h a n a m o n g the general p o p u l a t i o n ; a n d one such r e p o r t 9 indicates, t h a t these r a t e s are higher in those families m a d e poor b y the depression t h a n in those p r e v i o u s l y a c c u s t o m e d to a low s t a n d a r d of living. I t has always been possible to d e m o n s t r a t e higher illness rates, h i g h e r mortality, a n d p o o r e r s t a n d a r d s of g r o w t h a m o n g tile low income classes t h a n a m o n g the well-to-do; a n d as the p r o p o r t i o n of the p o p u l a t i o n in the l o w e r income b r a c k e t s increases, it is reasonable to assume, t h a t the health and g r o w t h of c e r t a i n children are being a d v e r s e l y affected. A comparison of large g r o u p s including all classes t o d a y w i t h similar g r o u p s d u r i n g prosperous, years, however, need not d e m o n s t r a t e these effects. The general t r e n d t o w a r d b e t t e r hygiene and n u t r i t i o n operatiilg w i t h the m a j o r i t y of children m a y m a s k the adverse influences u p o n the children of the u n e m p l o y e d or poorly employed, who are still in the minority. A c t u a l l y m a n y investigators h a v e been unable to demons t r a t e any mass evidence of r e t a r d a t i o n of g r o w t h a m o n g large g r o u p s of children a f t e r five y e a r s of continuing severe economic stringency. F o r example, P a l m e r '~~ has m a d e a comparison of a n n u a l weight gains of e l e m e n t a r y school children in H a g e r s t o w n , Md;, in two p e r i o d s : the first, 1921-1927 and the second, 1933-1934. I I e f o u n d t h a t the increments, while on the a v e r a g e definitely smaller for each g r a d e in the l a t t e r period, w e r e not smaller t h a n occurred in single p r o s p e r o u s years. H e r e also the gains w e r e s t r i k i n g l y smaller f o r the children oF." persons receiving aid t h a n f o r those not so situated, but this difference was no w i d e r than between similar g r o u p s in prosperous years. N e w m a n ~ also r e p o r t s similar findings in G r e a t B r i t a i n ; namely, t h a t the depression has not m e a s u r a b l y increased the a m o u n t of illness or m a l n u t r i t i o n or the n u m b e r of deaths a m o n g c h i l d r e n - - q u o t i n g f r o m his r e p o r t : " . . . t h e general health and n u t r i t i o n of the population of E n g l a n d and Wales, t a k e n as a whole, was well m a i n t a i n e d in 1933 . . . there can be no question t h a t the n u t r i t i o n of the English people is better t o d a y t h a n at a n y past period of which we have record. 9 . . This c i r c u m s t a n c e is due to the increased care and devotion of the mothers and teachers, to m a n i f o l d f o r m s of v o l u n t a r y service, a n d to the public provision of insurance benefit, school feeding and medical s u p e r v i s i o n . " W e are, therefore, not w a r r a n t e d in being too complacent, but there is nevertheless justification f o r real satisfaction in the net results of c o m m u n i t y efforts to p r o v i d e f o r the physical needs o~. children. PUBLIC

I-IEALTH S E R V I C E S

I n the first review in this series ~2 it was p o i n t e d out t h a t changes incident to the depression h a d not only i n t e r r u p t e d progress in the d e v e l o p m e n t of state, municipal, and p r i v a t e services for' the betterm e n t of child health, but h a d a c t u a l l y caused serious interference w i t h the activities of those a l r e a d y established in m a n y p a r t s of the country. In the second r e v i e w s the changes incident to the depression w e r e dealt with in more detail, and it was made evident t h a t the facilities f o r m e e t i n g the health a n d medical needs of children in large sections of the c o u n t r y w e r e f a r f r o m adequate. A p p r o p r i a t i o n s and expen-

842

THE

J O U R N A L OF P E D I A T R I C S

ditures for child health activities in a majority of the slates were shown to have experienced a f u r t h e r decline. In some states reduclions in budgets or actual elimination of appropriations were shown to have seriously handicapped maternal and child health work. More recently ~a it has been shown that health departments in general mainrained their appropriations through 1931, that some reductions occurred in 1932, but that the most drastic reductions, occurred in 1933. This latter report estimated that the further cuts occurring in 1.934 had reduced budgets to near the level of 1923. It has become apparent to those seriously eoncerned with these changes thai, although joint action by public health, medieal and welfare groups ean undoubtedly prevent further inroads into essential health services, financial limitations are bound to restrict the expans.ion of health activities for some time to come. A healthy emphasis has therefore become apparent upon the reexamination of programs, upon the demonstration of usefulness of procedures, and upon the selection of those of greatest value. Bishop TM has summarized the outstanding trends in public health administration today and mentions among others the following: greater emphasis en the technical excellenee of service and specificity of methods; increasing emphasis on special training of public health personnel; specificity of objectives and planning programs with subsequent analysis of results in view; and increasing appreciation of the fundamental importance of the state government in the public healt:h program, with increasing interest on the part of the state health department in local health programs, especially in organization to meet rural health needs. It has still more recently become apparent that the federal government is prepared to acknowledge its share of' responsibility for securing at least a min inmm of health service for mothers and children in all parts of the United States. The provisions of' the "Social Security B i l l " now before Congress are considered in mere detail below. The point of interest in this connection is that federal appropriations for maternal and child health, for the crippled child, and for general public heaIth services are made prominent and continuing features of this legislation. R U R A L P U B L I C H E A L T b l SERVICES

The "Social Security B i l l " just referred to makes frequent and specific reference to the intent of Congress, through this legislation, to provide or strengthen public health services in rural communities, and all public health literature is filled with discussions, of rural problems, especially those relating to the provision of adequate maternal and infant care. Rural communities have on the whole never received more than rudimentary public health services, and these largely from untrained personnel. Some of the p r o g r e s s that ihad been made in improving these conditions has recently been wiped out. During the year 1933 alone, health services with a full-time health officer in charge were discontinued in fifty-five rural units and were being newly established in only four. 1~ As of Dee. 31, 1933, approximately fifteen millions out of the fifty-five millions comprising the rural population of the United States were served by such health officers. Even within full-time organizations child health services are very limited, and in communities without full-time health officers these activities are often

CRITICAL

843

REVIEW

totally lacking, a~ In general, child health services are highly developed only in units in which the state, the United States Public Health Service or some foundation has aided in organization, administration, and finance. I'UBLIC

IIEALTII

CONDITIONS

IN

FOREIGN

COUNTRIES

While considering conditions in this country and before discussing pending" legislation which if passed would materially alter' conditions., it has seemed desirable to review briefly the major trends in certain foreign countries. There is. such a wide variety of' conditions present in different eonntries as to defy descriptive summary, but foreign experiments which have a bearing on our own problems may be brought to attention. In the main the actual content of services and t h e procedures adopted have followed American lines, but they have been carried out in different ways and with varying em.phasis. There has apparently been a greater tendency to combine social and health activities and a more predominant participation of govermnent in medical services. As a result, the protection of the public health and the m e d i c a l care of the sick have been less. distinctly separated. Bolt 17 has recently sketched in outline present-day conditions and trends in certain European countries and has shown that the trend in Europe. is decidedly in the direction of public control of tile administration of all child health and welfare agencies. He finds an amazing interest in the health and well-being of mothers, and children in all European countries and more ample provision for' health services, despite desperate economic and governmental conditions. In England " T h e Children an.d Young Persons Act of 1 9 3 2 ' " h a s f u r t h e r consolidated the regulations relating to the health of mothers, prospective mothers, and children, and under the "National Health Insurance Acts," prenatal and obstetric care and certain other maternity benefits are afforded all classes in tile population. Through grants-in-aid the central goverm~tent has done much to stimulate better local conditions. A recent project of far-reaching importance, which is given f u r t h e r consideration below, is that of extensive slum c]earance and the construction by the government of low rental, small houses in the outskirts of cities. England has also made enviable progress in developing full-time public health units under specially trained health officers. Bolt credits France with leadership in providing adequately for illegitimate children and their mothers and in provisions for the care of tuberculous children. Germany appears to have been interested primarily in centralizing control of child health agencies already developed under local g'uidanee, and regimenting them according to the dictates of national policy. This policy is fortunately directed toward the maintenance of the home and maternal care. Hence health services are organized for the family as a unit. Matemhal and infant health centers are found Ln practically alI the important cities of Germany. There are, for example, forty-six consultation tenters, for expectant mothers in Berlin alone. In Italy the eentrat government is furthering the development of health services through the National Institution for the Protection

844

THE

JOURNAL

OF P E D I A T R I C S

of Motherhood and Infancy, b u t in general, emphasis on preventive medicine has lagged. It is hoped t h a t the new Institute of Hygiene and Public H e a l t h in Rome will stimulate interest in this work. I t a l y has recently greatly extended the protection afforded working mothers t h r o u g h a decree 18 which provides f o r compulsory leave of absence f r o m w o r k before and after confinement, o p p o r t u n i t y for nursing, insurance benefits, and investigation of m a t e r n a l deaths. Sweden's system of m a t e r n i t y benefits is an example of social insurance supplemented b y national t r e a s u r y contributions. Uninsured women with low incomes receive cash benefits f o r t h i r t y days at the time of confinement, while insured industrial workers receive these f o r fifty-six days. and in addition free midwife attendance, or' hospital care if needed. Application must be made sixty days before the expected confinement, so t h a t some p r e n a t a l care and plans for a d e q u a t e delivery can be arranged. This system also allows for subsequent enrollment of the child in child health centers. I t is most difficult to appraise the value of health services from written reports. The plan m a y a p p e a r excellent on paper, b u t much depends upon the quality of work done, especially upon the training and ability of personnel, and one cannot make an estimate of these without close observation of work in progress. W h e n political considerations dominate, the reporting evaluation is even more difficult. One even questions w h e t h e r the reports of foreign visitors who acquire their information from hasty p r e a r r a n g e d inspections or conversations with officials are really indicative of actual conditions. Reports from Soviet Russia relating to the progress of child health work bring all these questions vividly to mind. The observations of Newsholme, however, are of great interest. 19 Child health activities in Soviet l~ussia have advanced f r o m almost negligible levels to most extensive proportions under governmental auspices d u r i n g recent years. This progress has. been greatly facilit a t e d by the virtual t r a n s f e r of the care and control of children from parents to the state and the increased concentration of infants and children in public nurseries, schools and camps. It has gone hand in h a n d with welfare legislation affecting the economic and social status of women d u r i n g pregnancy, the availability of medical care and the e x t e n t of health education. It has obviously been r e t a r d e d b y the dearth of a d e q u a t e l y trained physicians and nurses. To show the r a p i d i t y of change, there were in the towns of R.S.F.S.R. ~ in 1932, 263,000 beds in creches as against 34,000 five years previously, and there were in villages in the same y e a r 329,000 p e r m a n e n t and 3,500,00C seasonal beds as against 2,500 p e r m a n e n t and 101,000 seasonal beds five years earlier. Creches house infants from two months to three years, sometimes to five years of age, while t h e i r mothers w o r k in industry. H e a l t h service is provided in connection with these, as well as in connection with kindergartens, which care for children from the ages of t h r e e to seven years, and schools and camps, which care for older children. F r e e attendance at infant consultation centers is also generally p r o v i d e d and is often made a eondition of the m o t h e r ' s receiving m a t e r n i t y benefits. Newsholme states that the training, hygiene, and precautions against infection in the creches are intelligent, and " t h e quality of the provisions made f o r the hygienic and *Russian Socialist Federated

Soviet Republics.

CRITICAL REVIEW

8zi5

medical care of i n f a n t s b e a r s comparison with a n y similar a r r a n g e merits in w e s t e r n countries, and in q u a n t i t y it is v a s t l y g r e a t e r . " ' There is in ]~ussia no separation between clinical and p r e v e n t i v e medicine because both institutional and domiciliary care h a v e b e e n socialized. There is r e p o r t e d to be close cooperation between home, medical attendance, and the health work in creches and consultation centers. Care of maternity in Soviet Russia is of special interest because of the a t t e n t i o n which this subject deserves a n d is receiving in the United States. A b o u t 90 per cent of births in cities in Russia are now in institutions, new m a t e r n i t y hospitals h a v i n g been p r o v i d e d on a liberal scale. Special consultation centers for p r e g n a n t w o m e n have also been established in all l a r g e cities. I n r u r a l areas, however, only a b o u t 20 p e r cent of deliveries are in institutions. Since the g r e a t m a j o r i t y of women in these areas are d e p e n d e n t u p o n midwives or relatives; the g o v e r n m e n t has recognized the u r g e n t need f o r m o r e a d e q u a t e l y t r a i n e d midwives b y p r o v i d i n g a n u m b e r of t r a i n i n g centers. I n s u r ance provides w o m e n in i n d u s t r y with extensive m a t e r n i t y benefits, including full w a g e s d u r i n g absence f r o m w o r k due to p r e g n a n c y and confinement, and m o n e y allowances d u r i n g the n u r s i n g period. I n f a n t m o r t a l i t y was r e p o r t e d f o r E u r o p e a n Russia as 275 deaths per 1,000 live births in 1913, 186 in 1927, a n d 141 in ]930. The r a t e f o r Moscow was ]30.9 and f o r Leningrad, 14].0 in 1929. The birth r a t e in these cities in the same y e a r was 22 and 22.1 r e s p e c t i v e l y ; this despite the f a c t t h a t in Moscow r e c o r d e d abortions were 61 p e r cent in excess of n o r m a l births. .Abortions were estimated to be ten times as n u m e r o u s in 1929 as they w e r e in 1922. N e w s h o l m e ' s description of medical education ~mder the new regime and experience with r e g i m e n t a t i o n of medical services elsewhere lead one to be s o m e w h a t skeptical as to the present q u a l i t y of the various, medical services described. One cannot doubt, however, t h a t present conditions r e p r e s e n t real progress. T h e r e woul.d seem to be little d o u b t t h a t A m e r i c a has in recent y e a r s made more p r o g r e s s in the s t u d y of the child, especially of his. health and medical needs, t h a n has any other country. W e u n d o u b t e d l y h a v e more physicians a n d other w o r k e r s well equipped as specialists in the care of children. This review of activities in f o r e i g n countries raises the question as to w h e t h e r we have as seriously f a e e d the p r o b l e m of m a k i n g p r e v e n t i v e health services, as well as medical services, available to all classes in all communities. W i t h f a r f e w e r resources and g r e a t e r handicaps, as to a d e q u a e y of t r a i n e d personnel, it would seem t h a t other countries h a v e been a t t e m p t i n g to do m o r e to assure a m i n i m u m of health protection to all. These considerations give point to the plans of o u r f e d e r a l g o v e r n m e n t f o r promoting' m a t e r n a l and child health a n d f o r general public health protection, as embodied in the p r e s e n t revision of the " S o c i a l S e c u r i t y Bill.'" TIIE SOCIAL SECUIClTY BILL The H o u s e of R.epresentatives has r e c e n t l y passed the so-called " S o cial Security B i l l " (H.R. 7260) and at the present writing this bill is a w a i t i n g consideration b y the Senate F i n a n c e Committee. This is an omnibus bill providing" the means f o r protection a g a i n s t a v a r i e t y of social hazards, a n u m b e r of which have indirect b e a r i n g on child health, but we are h e r e concerned p r i m a r i l y with those provisions f o r

846

THE

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direct m a t e r n a l and child health and public health services. Title V of this bill, " G r a n t s to States f o r Maternal and Child W e l f a r e , " is divided into five parts. P a r t 1, " M a t e r n a l and Child H e a l t h Services, ~' makes an annual a p p r o p r i a t i o n of $3,800,000 for p a y m e n t s to states to c a r r y out suitable plans f o r such services. T w e n t y thousand dollars is g r a n t e d directly to each State and $1,800,000. apportioned on the basis of p r o p o r t i o n of live births in each state. Only such portmn of these allotments shall be paid to each state as does not exceed one-half of the total sum expended b y the state exclusively for carrying out the accepted plans. An additional $980,000 m a y be allotted by the S e c r e t a r y of L a b o r without r e g a r d to the amount of state contributions on the basis of financial need. This equalization f u n d takes into account the g r e a t e r need of health services where resources are least adequate. Receipt of these sums is made dependent upon suitable administration, supervision, reports, cooperation with medical, nursing, and welfare groups, etc. P a r t 2 of Title V, " S e r v i c e s for Crippled C h i l d r e n , " appropriates a sum of $2,850,000 a n n u a l l y to enable " e a c h state to extend and improve (especially in rural areas and in areas suffering" from severe economic distress) . . . services for locating crippled children, and f o r providing medical, surgical, corrective, and other services and care, . . . " This sum is to be allotted, $20,000 to each state and the r e m a i n d e r according to need, b u t in this case the a m o u n t paid shall not exceed one-half of the total sum expended. P a r t 3, " C h i l d W e l f a r e S e r v i c e s , " appropriates. $1,500,000 for cooperation with state public welfare agencies, $10,000 to each state and the balance on the basis of rural population. P a r t 4 increases the present grants for vocational rehabilitation, and P a r t 5 provides $425,000 " f o r all necessary expenses of the Children's B u r e a u in administering the provisions of this t i t l e . " Oddly enough this provision for administration is made for one y e a r only, whereas the title to be administered provides continuing" services. Title VI of the " S o e i a l Security A c t , " entitled " P u b l i c H e a l t h W o r k , " appropriates $8,000,000 f o r " a s s i s t i n g states, counties, health districts, and other political subdivisions of tile states in establishing and maintaining adequate public health services, including the training of personne~ . . . " The p r i m a r y purpose of this title is to secure for a f a r larger proportion of the counties a full-time public health organization, qua,lifted to provide the essential services. The amount allotted in this ease is determined by population, special health problems, and financial needs; matching with local funds is not required. An additional $2,000,000 is provided for e x p e n d i t u r e by the Public H e a l t h Service for investigation of disease and problems of sanitation, ete. Thus a total of about $17,000,000 is a p p r o p r i a t e d annually for health services, $7,000,000 u n d e r Title V for maternal and child health and care of crippled children to be administered b y the Children % Bureau, and $10,000,000 u n d e r Title VI to be administered by the United States Public H e a l t h Service for general public health enterprises. Consideration is given in the bill to the uneven development of these serviees in different parts of the country, and especially to their general inadequacy in r u r a l communities. I t is also recognized that those eomraunities least able to finance improvements are, in general, those most in need of strengthening their facilities. No consistent principle i s

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followed, however, as to the amount of local participation in carrying the costs of necessary services required under the different sections of the bill. It is provided that the bulk of the fnnds shall be spent locally under the direction of th.e states, with considerable latitude as to programs and services, but that certain standards shall be required by the federal agency. The House of Delegates of the American Medical Association in special session went on record 2~ as opposed to the administration of any health service by a lay bureau and specifically deplored and protested those sections of the "Social Security Act'" (the original bill S. 1130) " . . . which place in the Children% Bureau of the Department of Labor the responsibility for the administration of funds for these purposes" (medical services for crippled children and for the preservation of child health and maternal health). However, at the Senate ]~'inance Committee hearings on this original bill a large number of physicians, prominent in the field of pediatrics, recorded their approval of these health provisions.. The organization of the federal government is such that the division of administrative responsibility between the two departments seems to be, entirely logical and most certain to secure well-planned and supervised service. The assistant director of the Children's Bureau and the acting director of the Division of Maternal and Child Health are pediatricians, with outstanding records of accomplishment and with the confidence of the profession. Title V will most certainly be administered by this Bureau in close cooperation with, and in m a n y instances be applied through, the health units operated under Title VI by the Public Health Service. Some m a y seriously question the desirability of the federal government's further participation in local services which the Social Security Act obviously provides, and many are concerned as to the economic implications of some of th~ other titles of this bill. The appropriations under Titles V and VI for health work are, however, relatively small. The health conditions in one section of the country are of vital concern to all others; and the problems in some sections are far more difficult than in others; a small equalization fund therefore seems warranted. Furthermore, the federal government can make available expert advice and general information which local communities are often not in a position to secure for themselves. There is every indication that both federal departments administering the health provisions under discussion will grant the widest local autonomy consistent with the maintenance of a high quality of work and a suitably trained and qualified personnel. ~ I~OUSllq~3

Relatively little attention has been given in the past by public health authorities in this country to the effect of bad housing conditions upon child health, except so far as they concern water supply, s e w a g e and garbage disposal, or adequate cubic feet of air space. It has been noted that in England health authorities have been placing great emphasis upon slum clearance and low-rent suburban residence building as a public health measure of importance. Other countries in Europe * T h e a c t a s a t prescott w r i t t e n u n f o r t u n a t e l y w i t h o l d s f r o m t h e C h i l d r e n ' s B u r e a u a n y a d m i n i s t r a t i v e c o n t r o l o v e r t h e selection, t e n u r e of office, a n d c o m p e n s a t i o n of p e r s o n n e l s e c u r e d u n d e r t h e s e g r a n t s ( T i t l e u See. 5 0 3 ) .

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h a v e been giving adequate housing considerable attention, and the aeeomplishments of V i e n n a are of special interest. 21 A new interest in this s u b j e c t has recently been developing in this country, p r i m a r i l y as a result of the search f o r useful ioublie w o r k s projects. H e a l t h officers h a v e begun" to realize the possibilities f o r i m p r o v i n g public health t h r o u g h e n c o u r a g e m e n t of slum clearance campaigns, and a n u m b e r of studies on the relation of housing to health have a p p e a r e d in public h e a l t h journals. I t is. not difficult to d e m o n s t r a t e a s t r i k i n g correlation b e t w e e n residence in slum areas 22 and a b n o r m a l l y high m o r b i d i t y and m o r t a l i t y rates, b u t it is r a t h e r difficult to d e m o n s t r a t e t h a t these relationships. are due to the housing conditions, p e r se, and not. to r e g u l a r l y asso.crated conditions such as race, ignorance, p o v e r t y , and overcrowding. H e a l t h authorities have not felt certain t h a t without, changing these other conditions, m e r e t r a n s f e r e n c e of families f r o m d i l a p i d a t e d slum buildings, to m o d e r n tenements, would m a t e r i a l l y i m p r o v e health conditions, l%ecent studies ~a do suggest, however, t h a t the condition of the house itself a n d its immediate s u r r o u n d i n g s are of real i m p o r t a n c e and t h a t the t r a n s f e r e n c e of families f r o m condemned buildings to m o d e r n low-cost s t r u c t u r e s results in an i m m e d i a t e and definite imp r o v e m e n t in m o r t a l i t y a n d m o r b i d i t y rates. T h e r e are of course aee o m p a n y i n g changes in living conditions which are inevitable and which m a y explain the i m p r o v e m e n t , but these desirable changes are not easily secured without the housing p r o g r a m . PAI~TICIPATION

01~ P R A C T I C I N G

PHYSICIANS

During' the late twenties there was evident in m a n y communities a determination on the p a r t of public health authorities to achieve certain goals, as f o r example, the immunization of the child population o.r the examination of the preschool children, b y reliance upon publicly sapported agencies. This policy was n e v e r prosecuted to. the: po.int of serving adequately the child population or of closing a f r u i t f u l field to the private practitioner, as the White House Conference survey ~ clearly demonstrated. I t was nevertheless carried beyond the stage o.f demonstration and offered to m a n y who. might better have turned to. their personal physicians. The economic difficulties of the early thirties have operated to correct this trend. The restriction of public health funds has in m a n y instances fo.reed the. health officer' to relinquish routine services and to. look upon himself as a champion and p r o m o t e r o.f these services r a t h e r t h a n their provider. On the other hand, economic conditio.ns and the low incidence of illness have made preventive health procedures seem more w o r t h y of cultivation to p r a c t i c i n g physicians. The same forces have, however, increased the proportion of those unable to p a y for preventive procedures. As a result, there have been m a n y evidences of cooperation between d e p a r t m e n t s of health and local medical societies in w o r k directed t o w a r d the establishment of m o r e satisfactory relations, and especially t o w a r d a g r e a t e r p a r t i c i p a t i o n by p r i v a t e p r a c t i t i o n e r s in b r o a d h e a l t h m o v e m e n t s . A n article b y the B u r e a u of Medical Economies of the A m e r i c a n Medical Association 2~ discusses a n u m b e r of local m o v e m e n t s and indicates t h e i r wide divergence in m e t h o d b u t t h e i r common purpose. Space does not p e r m i t a consideration of the effects u p o n child health services of the various plans now in operation, or the direction

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o~ trends in different communities. So far as they strengthen the ties between the personal physician and the family, and increase rather titan diminish the acceptance of the important health procedures, these changes may be accounted evidences of progress. REFERENCES 1. Pnb]ic ttealth Reports, U. S. Pub]ie Health Service 50: No. 17, April 26, 1935. 2. Baker, J. ~., and Gill, D. G.: Precipltated Toxoid as an Immunizing Agent Against Diphtheria, Am. J. Pub. Health 24: 22, 1934. 3. McGinnes, G. F., Stebblns, E. L., and Hart, C. D.: Experience With Alum Precipitated Toxoid in Virginia and Observations on the Reaction Following I t s Use, Am. J. Pub. Health 24: 1141, 1934. 4. Harrison, W. T. : Some Observations on the Use of Alum Precipitated Diphtheria Toxoid, Am. J. Pub. Health 25: 298, 1935. 5. Williams, ~Iuntington: The City Health Oificer Looks at Diphtheria Prevention, Am. J. Pub. Health 25: 425, 1935. 6. Volk, V. I(.: Diphtheria Immunization by One Injection, Am. J. Pub. H e a l t h 25: 430, 1935. 7. Collins, Selwyn D. : A General View of the Causes of Illness and Death at Specified Age% Pub. Health Rep. 50: 237, 1935. 8. Eliot, Martha M.: Child ~Iealth, 1933-1934, J. PEDIA~. 4: 817, 1934. 9. Perrott, G. St. J , and Collins, Selwyn D.: Sickness Among the "Depression Poor," Am. J. Pub. Health 24: 101, 1934. 10. Palmer, Carroll E.: Further Studies on Growth and the Economic Depression, Pub. /-Iealth ~ep. 49: 1462~ 1934. 11. Newman, Sir George: ICeport on tim Health of the School Child, Ministry of Health, Great ]3ritain, December, 1934. 12. Stuart, Harold C.: Progress of Public Health as I t Relates to the Child, J . PEDI&T: 2: 756, 1933. 13. Report of Special Subcommittee on Cnrrent Practices of Health Departments, Committee on Administrative Practice, American Public Health Association, Am. J. Pub. H e a l t h 25: 347, 1935. 14. Bishop, E . L . : Modern Trends in Public /{ealth Administration, Am. J. Pub. Health 24: 591, 1934. 15. Extent of Rural Health Service in the United States, Pub. Health Rep. 49: 1469, 1934. 16. A Study of Rural Public Health Service, Report of Subcommittee on Rural Public Health Work, Committee on Administrative Practice, American Public Health Association, Allen W. ~veeman, editor, New York Cit L 1933, published by the Commonwealth Fund. 17. Bolt, Richard A.: Child Health Conditions in Europe, Am. J. Pub. Health 24: 951, 1934. 18. Recent Child Welfare Developments in Foreign Countries, Children's Bureau, U. S. Department of Labor, Washington, D. C, Release of August, 1934. 19. Newsholme, Sir Arthur, and Kingsbury, John A.: Red Medicine--Socialized Health in Soviet Russi% Garden City, 1933, Doubleday, Doran and Company,

Inc. 20. Report of Special Reference Committee, Proceedings of the Special Session, J. A. M. A. 104: 751, 1935. 21. Hardy, Charles O., and Ruczynski, Robert R.: The Housing Program of the City of u Washington, D. C., 1 9 3 4 / T h e Brookings Institution. 22. Gengenb~ch, F. P.: I n f a n t and Maternal Mortality in Denver, J. PEDI&T. 1: 719, 1932. 23. Some Facts on the Relation Between Housing and Hea]th, Pub. Health Rep. 49: 1307, 1934. 24. Health Protection for the Preschool Child, P a r t I I (A White House Conference Report), New York City, 1932, D. Appleton-Century Company. 25. Medical Society Plans, American Medical Association Bulletin 29: 145. 1934.