detailed from the commissioned corps of the Public Health Service of the Treasury Department.

This system of contract service whereby one government agency, which has the trained personnel and equipment, undertakes to operate in its own field on behalf of another bureau which is perhaps only interested casually in the specialty, as public health, also solves the problem or the objection which may arise, that there may be other units as important as health. Thus, the Indian is said to be a unit, and his entire social, economic, educational, and hygienic problems are so interrelated that they must all be administered by a single agency. The Indian Medical Service, comprising some two hundred physicians, has not been noted for its efficiency in the past. This service should be attached to a central federal health agency for purposes of selection, training, and scientific direction, and then detailed to the Commissioner of Indian Affairs for purposes of administrative direction. This procedure would be somewhat analogous to that already in effect by which the Public Health Service details officers to the commissioner of immigration in order to make the medical examinations of aliens. As a matter of fact, the Secretary of the Interior has recently requested the Surgeon General of the Public Health Service to assist in the reorganization of the Indian Medical Service.

When a central federal health agency is mentioned, the question at once arises as to whether the ideal would be a secretary of health in the cabinet. Fifteen years ago there was a determined agitation for a national bureau of health with such a secretary. While most of the great nations of the world, such as Great Britain, France, Germany, and others have established ministries of health, a department of health with a secretary in the president's cabinet is still only an ideal in the United States. Health yields in importance to no other branch of government, but its administration can be taken care of adequately without the necessity of having a place in the cabinet. Public health is a technical subject. Under the prevailing system of selecting cabinet officials it is at least questionable whether a sanitarian would be chosen for such a secretaryship, if there were one, and it is certain that there would be changes at fairly frequent intervals. All things considered, a new department is not necessary, and it might be further remarked as a very practical matter that Congress has shown much reluctance even to consider increasing the number of cabinet officers. Thus such a well-supported movement as that for a department of education has so far been unsuccessful.

While a secretary is not essential, an assistant secretary for public health would be desirable. It does not matter particularly in what department the federal central health agency is placed. At present, some kind of health work is done in all ten of the departments, as well as by a number of the independent establishments. The chief health bureau is the Public Health Service, which, for historical reasons only, is in the Treasury Department. Another important health agency, the Children's Bureau, is in the Department of Labor, while the

enforcement of the federal food and drugs act comes under the Bureau of Chemistry in the Department of Agriculture. Vital Statistics, the bookkeeping of public health, are collected and compiled in the Department of Commerce by the Bureau of the Census. School hygiene is in the Interior Department and nutritional research in the Department of Agriculture. The most significant problem is to assemble certain of the bureaus and activities; where they are to go is secondary.

To be specific, an ideal arrangement of federal health activities would consist of an assistant secretary for public health in any appropriate department and the nucleus for the central federal health arrangement would obviously be the Public Health Service. To it should be transferred the Division of Vital Statistics from the Department of Commerce; St. Elizabeth's Hospital, the government hospital for the insane, from the Department of the Interior; certain nutritional research now performed by the Bureau of Chemistry and the Bureau of Home Economics of the Department of Agriculture; and the medical division of the Office of Indian Affairs in the manner already outlined. The Children's Bureau should likewise come under the jurisdiction of the assistant secretary for health.

Scientific personnel should be detailed from this central public health agency to the Division of School Hygiene of the Bureau of Education (Interior Department); Bureau of Labor Statistics (Labor Department); and to the Bureau of Animal Industry, Bureau of Dairying, and the Extension Service (all in the Department of Agriculture); in addition to the details already authorized by law, which include the Bureau of Mines, Consular Service of the State Department, Bureau of Immigration, Coast Guard, Bureau of Chemistry, and the Alaska Division of the Bureau of Education, these details being made by the Public Health Service.

The problem of personnel would be an important one in an ideal arrangement. At present the Public Health Service has a corps of between two and three hundred commissioned medical officers and a much larger group of non-commissioned scientists, including physicians, sanitary engineers, dentists, chemists, and other sanitarians. There is no commissioned personnel in any of the other bureaus which should be brought together to form the central federal health agency. The status of the entire personnel should be equalized. The commissioned corps of the Public Health Service is not the best model, as it is a distinctly military system, though the bureau is essentially a civil one. Instead, the recent system adopted for the Foreign Service of the State Department, setting up grades and making promotions and advances a matter of merit and service, and establishing a career basis for the foreign department, would be an excellent model. The medical corps of the Public Health Service was founded n 1870, while the corps of the Foreign Service was created in 1923, and the latter is said to have taken many of its features from the former. Be that as it may, it also managed to omit some of the undersirable ones. Putting the entire person

nel of a central federal health agency on some such basis as this would provide the best system for efficient operation.

This arrangement as outlined is the ideal one. It is also probably practical, though it may have to be attained gradually. Thus, there is now pending before Congress a bill (HR. 10125), known as the Parker bill, which would authorize the president to transfer by executive order any executive agency engaged in public health work to the Public Health Service, and also order the assignment of scientific personnel from the Service to other bureaus which might be doing health work. This measure specifically exempts the Army, Navy, and Veterans' Bureau from such transfer. The Surgeon General would likewise be authorized to send officers to educational and other institutions for scientific purposes. The bill, furthermore, would provide for giving a commissioned status to sanitary engineers, dentists, and other scientists in the Public Health Service, so that they would be on a par with medical officers and enjoy all of the same privileges. The measure was drafted in consultation with the Surgeon General and has been agreed upon as sound by representatives of the leading health organizations, and considerable effort has been made to secure its favorable consideration. It is reported, however, that the Parker bill has failed to receive the approval of the Director of the Budget, though it is difficult to see any legitimate reason why he should not sanction the bill. If it had secured his approval, it might be a law today, as it was introduced on March 8, and is known to be favorably considered by Congress generally.

Sooner or later public health will attain to its proper position in government and will be accorded the same recognition which has been given to other branches of government which are no more important. The ideal which we have outlined is not very far away. Unlike some ideals, it is also, we believe, a practical scheme. When it has been achieved, the opportunities for improving our national vitality will be immeasurably enhanced.

FEDERAL SUBSIDIES TO THE STATES WITH SPECIAL
REFERENCE TO HEALTH

Richard Arthur Bolt, M.D., Assistant Professor of Child Hygiene,
University of California, Berkeley

The United States at the present moment is once more approaching the crest of a wave of pronounced individualism. Our insistent demands for personal liberty, states' rights, and national isolation are significant symptoms of an American individualism which expresses itself in no uncertain manner. We are becoming daily more engrossed in our own creature comforts and stimulations. The well-being of our neighbors at home or abroad is of secondary consideration. This is exemplified by the present disregard for law and order; by

the self-sufficiency of the bootlegger and his well-to-do customer, and by a moral supineness on the part of the so-called "best people" as to possible outcomes.

Nationally our individualism is exhibited in attempts of a number of the states to thwart ratification of the Child Labor amendment, to restore alcohol to a respectable place in society, and to erect such barriers to our entrance into the World Court as to restrict its usefulness. The withdrawal of adequate support from our missionary endeavors and the increasing difficulty of raising the full quota for our community chests throughout the country also indicate the trend of the times. These phases of reaction, however, cannot be regarded as permanent. The modern world is so closely knit and interdependent that we are forced to take an interest in our neighbors if for no other reason than that of self-preservation.

Federal subsidies themselves are a confession of the weakness of state selfsufficiency. They have been in vogue since the beginning of our government and are today more firmly intrenched than ever before. Our history records that while the federal government from its inception has allowed considerable latitude to the states and guaranteed them certain privileges under the Constitution, it has nevertheless taken definite steps to establish supervision over many matters having to do with the common defense and the general welfare. The methods employed to secure this supervision have been made possible through the taxing power of Congress and a broad interpretation of what constitutes general welfare. The operation of choice was the painless device of federal grants-in-aid to the states. From small beginnings and in an unobtrusive manner the system of federal subsidies has gradually expanded until the central government has gained a considerable amount of supervision over certain state funds for designated purposes.

The Supreme Court of the United States has made no definite pronouncement as to what specific measures should fall under the welfare clause of the Constitution. The nearest approach to such a decision was in the case of the Sheppard-Towner Act for the Promotion of the Welfare and Hygiene of Maternity and Infancy, when the Court decided that the test cases brought before it were not judicable, leaving the constitutional issues involved still undecided. The Supreme Court has scrupulously avoided poaching upon the preserves of Congress as to its spending power or the right to designate the purposes for which funds should be spent for the general welfare. For enlightenment along this line we must go to the precedents set by Congress in its welfare legislation and to the opinions of the presidents as set forth in state papers. A careful study of these reveals that, on the whole, the principles underlying federal grants-inaid for education, protection, and health have never seriously been threatened. On the contrary, there has been an ever widening extension of such federal grants to the states for education, good roads, social betterment, and agricultural improvement.

The federal Constitution makes no specific provisions for the public health.

This has been left almost entirely to the states, as a part of their police power. As Tobey says, "the control of the public health is therefore primarily a state matter, but many of the clauses of the federal Constitution affect the way in which this power may be exercised." Legislation affecting the public health has been passed by Congress under the blanket of the welfare clause of the Constitution and made effective through federal grants-in-aid. Practically all of the state measures dependent upon federal subsidies are more or less related to the public health, e.g., state education, vocational rehabilitation, agricultural extension, control of venereal disease, hygiene of maternity and infancy, etc. Even if some of the measures do not appear to bear directly upon the public health, their social, economic, and industrial implications force us to consider them as closely correlated with health.

The extension of federal subsidies as a means of guiding the states in their welfare legislation has, in fact, been inevitable. This has arisen mainly out of the blindness, inability, or unwillingness of some of the states to make provisions for welfare measures which have been demonstrated in the more progressive states to be of value for all the people. We have in this country, as Corwin well states, "a federal system with a national government at its center." We cannot long preserve a United States unless the benefits-social, economic, educational and health enjoyed by the few are gradually extended to the many. The United States, therefore, cannot tolerate with impunity conditions in any of the states which foster illiteracy, violence, immorality, or enfeebled health. While making due allowance for local peculiarities, certain minimum standards must obtain, and these the federal government has undertaken to secure through the system of grants-in-aid to the states.

The state is a complex organism, and no state can survive in isolation. Massachusetts, for example, is dependent upon the cotton fields of the South for raw material, upon the great Middle West for a large part of its food supply, and upon the Far West for its cattle and hides. Anything, therefore, which affects the health and productive capacity of the people in these distant parts may seriously affect the welfare of the people of Massachusetts. New York City has piled up its wealth on account of the mines, the wheatfields, the fruit orchards, the cattle ranches, the oil wells, and the railroads supported by the labor of workers in all parts of the country. Its strategic position as a worldport enhances its wealth. We as a people, regardless of state lines, are bound together by railroads, post roads, highways, telegraph, telephone, and radio. Epidemics may spread rapidly from state to state. Poor professional training in one state may jeopardize the health of mothers and children in states across the continent. Socially and economically, the whole country is so interdependent that the welfare of one state may condition the welfare of all. While this I James A. Tobey, Public Health Law, p. 18.

Edward S. Corwin, "The Spending Power of Congress-Apropos the Maternity Act," Harvard Law Review (March, 1923), XXXVI, No. 5, pp. 548–82.