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and total solids, added water and preservatives. Nineteen hundred and fiftythree food samples were turned in by the food inspectors for evidence of adulteration and misbranding. In all, a grand total of 79,688 samples were tested, at a unit cost of 13 cents.

The Bureau of Public Health Nursing functions in all of the medical divisions. Instead of having, as we formerly did, special nurses for each type of service, one nurse does all of the work in a small circumscribed area. She gives advice and service to the expectant mother, the newborn infant, and the child of preschool age. She assists the doctor in his school work, sees that his instructions are carried out, and, if necessary, takes the poor children to the clinics and hospitals. She also assists in the clinics and visits in the home.

The public health nurse must be so well informed that she may be able to put her message into the simplest terms for the mother who is unlearned in the most elementary facts of hygienic living and be equally able to discuss the latest developments in public health with the most intelligent mother in her district.

Four separate chapters in the appraisal form, brief but to the point, outlining types of service relating to prenatal care, the infant, the preschool child, and the health of the school child, serve as an excellent reference for the health commissioner. All of the best scientific public health procedures are outlined in the appraisal form and should prove of real value to the health commissioner in helping him to develop a well-balanced program based upon relative values; to check up on the performance of his bureaus, and thus maintain the department at the highest point of efficiency; to secure funds for expansion by indicating where his organization falls short; to substitute group judgment for his own in time of controversy; and to secure the cooperation of local voluntary health organizations along the most effective lines.

THE COMMUNITY AND PUBLIC HEALTH
LESSONS FROM THE HEALTH SURVEYS OF 186 CITIES

W. F. Walker, Field Director, Committee on Administrative
Practice, American Public Health Association,
New York

I am expected to bring to you the lessons which cities and national organizations may learn from the health surveys of all cities over 40,000 which were made by the American Child Health Association, the American Public Health Association, and the United States Public Health Service in 1924. This subject, then, will be treated in two divisions: first, briefly, a few of the outstanding conditions which were found, and second, the use which has already been made of the material thus gathered in formulating broad policies for the prosecution of health work over the country as well as instances of specific results in individual cities and states.

As the cities for survey purposes were divided into two groups, those over 70,000 and those between 40,000 and 70,000, and as it has been impossible to tabulate all information for the entire group, it will be necessary in certain instances to discriminate and make references which will not apply to both groups.

The expenditure for health services is an item which should claim a considerable portion of our attention. It is a matter which we hear frequently quoted as an Index to the quality of work and the efficiency of the service, both because of large expenditures or because they are unusually low. A midwestern city has recently claimed first place among industrial cities in health activities, and points with pride to an official expenditure by the health department of about 25 cents per capita. Expenditures by health demonstrations run as high as $2.50 to $3.00 per capita, which is several times the average figure for similar communities. The span of these figures would be materially decreased if they were made to cover the same items. When considering expenditures for health purposes, comparative costs are meaningless without a clear statement of the items which are included in the public health program.

In the cities of over 70,000 in 1923 it was found that the average expenditures for health purposes by official agencies, exclusive of expenditures for hospitalization of acute communicable diseases, tuberculosis, and venereal diseases, was 83 cents per capita. This figure would be considerably increased, possibly doubled, if the expenditures of private agencies were added. The encouraging part of this picture is that the official expenditure has increased nearly 20 cents per capita since 1919. The range of expenditures in this group of cities was from 67 cents per capita, in cities from 70,000 to 100,000, to $1.02 per capita in cities from 250,000 to 500,000. While if we consider the maximum spent in each activity by any city the total expenditure would amount to $1.95 per capita, which approaches the expenditures recommended by the so-called model plans for city health work.

Our lesson from this part of the study is that, due to wide variation in what is included by city accounting systems in their public health expenditures, the lack of information concerning voluntary agencies, and the like, we cannot consider the expenditure alone as even a rough index of the adequacy of health services. The upward trend in average expenditures, however, is indicative of what we may expect in the future.

Considering the personnel of health departments, we too frequently find the effects of inadequate finances reflected in part-time service and untrained staff. Only 60 per cent of the health officers of these 186 cities devote full time to their official duties. And when it is considered that the average salary of these fulltime men is but a little over $4,000, while the part-time officer receives $3,000, it is little wonder that the position does not appeal to highly trained and efficient individuals.

The situation with regard to the rest of the staff is only slightly different. Laboratory workers, sanitary engineers, and nurses to some extent have been

trained for the work which they have to do, but the majority of health department personnel are graduates only of the elementary school of experience, and in general have stumbled quite by accident into the public health field.

If we would provide even a minimum of health service to all of our 110,000,ooo people, the shortage of trained personnel is estimated at from 10,000 to 17,ooo workers of all types. It is, then, of importance that not only sanitarians but educators and all those interested in public welfare give careful thought to the need for making this field sufficiently interesting to attract trained personnel for the perpetuation and extension of the service.

Most of us, I believe, if questioned, would declare that more public health services are performed by private than official agencies. These surveys revealed that such was not the case. Among the eighty-six smaller cities from 40,000 to 70,000, 57 per cent of the activities were administered by the health department, of which II per cent is in conjunction with other organizations; 18 per cent, by other official agencies, of which 3 per cent is in conjunction with other organizations; 16 per cent, by private agencies; and 9 per cent were as yet untouched. Referring to the census of public health nurses made by the National Organization for Public Health Nursing in 1924, we find that 47 per cent of all of the public health nursing service of the country is paid for by public funds alone, an additional 28 per cent is financed jointly by public and private means, and 25 per cent, by private funds alone.

The pendulum seems to be swinging from the voluntary, or private, to the official agency in the public health field. We have long set this as a desirable end, but many have been pessimistic as to its accomplishment. They have seen private agencies jealously hang onto work which they had initiated, even when public officials properly responsible for the service were prepared and ready to take it over.

These surveys indicate a definite need for the voluntary agency to assist and encourage the public officials to undertake and do those things of proved worth which properly are community functions. The aggressive steps in community organization for a united health program under the health department may well be taken by those organizations banded together in a community chest or a council of social agencies.

To tell in detail of the findings, the ups and downs in communicable disease control, child welfare, and the like, is not the purpose of this meeting. It should deal with larger things which may influence trends of public health work throughout the country, and without doubt the greatest result and lesson from the surveys is the idea that health department practice, in cities at least, can be measured with sufficient accuracy and,detail to permit of intelligent comparison. And intelligent comparison is the first step toward reasonable standardization. From the material gathered in these surveys there has been developed an appraisal form for city health work. This appraisal form is essentially a classified list of activities common to the public health practice of most cities. It lists

the items which are necessary for the proper handling of vital statistics; it likewise enumerates in logical sequence the more important steps to be taken in the control of communicable diseases, tuberculosis, and the venereal diseases. In the same way the fundamentals of a child health program, including maternity, infancy, preschool, and school service are set forth. And so on through the major public health activities.

Each of the 117 items of public health service which are listed call for a definite standard of service. For example, 4,000 nursing visits per 1,000 live births, or 5,000 visits in behalf of tuberculous cases per 100 deaths from that disease. Against each item thus enumerated, with its standard of service, is set a relative value which group judgment has agreed to as being approximately and temporarily correct. In developing the appraisal form no attempt has been made to cover all of the variations of practice which were found in the field, but rather to take those accepted practices of proved worth, to develop standards for them on the basis of the extent to which they were found employed in the field, and to use them as samples of the health work of a community.

The standards set for each item of activity do not represent the ideal far beyond the reach of the average city, but rather they are standards which represent the extent of service which is already rendered by 25 per cent of cities. The relative values assigned different activities are not indications of their absolute worth. They are expressions of the relation between the 117 items enumerated in the appraisal form as they apply to conditions found in cities in the United States at present. For example, nothing transcends in value a pure water supply for the city that is in the throes of a serious epidemic of typhoid fever from a water-borne source. However, of the 186 cities studied, only three or four had failed to recognize long before this the necessity of safe water, and these few were engaged in legislative and administrative programs which would accomplish this result. Naturally, then, the quality of the domestic supply can be taken for granted and emphasis be placed upon the extent of distribution. The relative value, therefore, of this item is accordingly very much lower than it would have been twenty-five years ago.

We have, then, a standard method of appraisal of public health activities, official and unofficial, in a community, which appraisal furnishes an accurate picture of the adequacy of the service to meet the needs of the city, and which will become a base line from which progress in future years can be measured.

But beyond this there are other uses of an appraisal. Merely as a uniform method of recording activities at a given time it would not be worth the effort to develop it, but its use, first, in scoring the information obtained in the 186 cities surveyed, and second, in interesting communities in the results of such a detailed and tedious thing as a survey, has shown it to have tremendous possibilities for the improvement of public health practices. It is not a measure of the activities and efficiency of the health department or health officer alone; it is

a measure of the degree of tangible support which a community has given its public health services.

The securing of adequate appropriations to carry on health work and the building up of a staff of trained personnel is not entirely the responsibility of a health officer. The community must believe in public health work. It must encourage its health officer and its appropriating body to invest wisely and adequately in public health protection. It has been found, in cities where it has been tried, that an appraisal is a means of translating public health statements into the universal language of the street. The mayor, the secretary of the chamber of commerce, and the man of the street, the "middle-brow," so called, will readily understand and appreciate a statement that the city is doing but 60 or 75 per cent of what can reasonably be expected in the matter of public health service. No city wishes to be known as lagging behind in its official interest in health work.

The instrument is now at hand for determining with all necessary accuracy the latitude and longitude of your ship of health, and by repeated observation you can note the progress along a predetermined course, or "whither you are drifting."

I am inclined to the opinion that the lack of interest in official public health work on the part of the commercial element of the city has been largely due to the lack of uniform plans and definite methods of expression. It has been found in cities where appraisals have been made that business interests have become suddenly awakened to the advantage of supporting the plan for organization and improvement of health work which naturally resulted from the appraisal.

Among the first acts of Dr. Louis I. Harris, health commissioner of New York City, upon taking office the first of this year, was the request made to the American Public Health Association for an appraisal of the health activities, first of his department, and later of the entire city, to be used as a basis for planning his administration and to mark a zero from which progress could be measured. The private health and social agencies of the community, the public health committee of the Academy of Medicine, and the New York Tuberculosis and Health Association recognized the wisdom of this procedure and are participating in the study and bearing the financial burden.

A private organization can probably render no greater service to its community than to organize and support from time to time an appraisal of its community health services on this basis. In fact, community chest organizations might well consider the facts and relations brought out in an appraisal before alloting its funds.

Dr. Rawlings, director of public health of the state of Illinois, recognized the potential values of such studies for the cities of his state and caused a detailed appraisal of small cities in Iliinois to be conducted this spring. In a bulletin of the Illinois state health department just issued, which I commend to each of you, Dr. Rawlings states:

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