When this summary was undertaken the department planned to bring to the attention of city governments, health officers, the medical profession, commercial interests, and the volunteer health agencies the facts as to the actual and comparative standings of each health activity in these cities, in the belief that they would serve as a stimulus to meeting the shortcomings of local health programs and in pointing out activities in which different cities excelled. Those of you who have state-wide interests will find this report a refreshing analysis which has a happy faculty of going directly to the heart of things and pointing unerringly at the deficiencies of the service in each city. In conclusion, the lessons which we have learned from these surveys are: first, that the expenditures for the public health work in the country are increasing, and that the advance guards of communities in different activities are spending, officially and unofficially, sums which approach very closely the sums set up in the plans for health organization which have been promulgated in recent years; second, that the training and compensation of health personnel in communities is not commensurate with the responsibilities placed upon them; third, that the responsibility for making this field of service sufficiently interesting to attract recruits rests to a large extent upon the public, and sanitarians generally should use every effort to acquaint the public with the obstacles which must be overcome in order to make the field more attractive; fourth, that the private agency, as an operating agent in the field of public health, is rapidly being replaced with the public agencies and private funds thereby released for a larger service, that of guiding the health developments of the city, furnishing financial and moral support to the services officially rendered; fifth, that a method for the appraisal of city health work has been devised which gives an accurate picture of the health services in the city and provides a basis for a program upon which all interested agencies can safely unite. THE EFFECT OF NEGRO MIGRATION ON COMMUNITY H. L. Rockwood, M.D., Cleveland To fill the gap in the supply of common labor caused by the restrictions of war and of immigration laws, the American Negro has responded to the call of industry from northern industrial cities. In response to this call Cleveland has received during the past decade additional colored citizens sufficient in number to increase fourfold the colored population, which had been fairly constant in ratio of whites to blacks during the entire twenty years preceding. In both 1900 and 1910 the census returns show approximately 1 per cent of the total population of Cleveland as colored. At present the percentage of colored is approximately 5 per cent. In the total estimated population of 960,000, the number of colored is slightly over 50,000. This, however, does not truly picture the situation as regards the settle ment in Cleveland of an increasing number of Negroes from the South, as fully 90 per cent of the colored population occupies a small sector of the city known as the Central Avenue District and adjacent territory to the east of this district which in the aggregate contains not over 25 per cent of the total population of the city. This district, comprising the territory just stated, with an area of about IO square miles, is estimated as containing 240,000 persons, of whom 45,000 are colored. This indicates a ratio of 230 colored to every 1,000 white in this region, with a population density per acre of 35 or 40, whereas the population density per acre for the entire city is 21. Congestion and overcrowding, wherever found, regardless of color, race, or creed, are so constant a factor, and so important in their effects on hygienic living, that no discussion of the effects on community health of Negro migration should be undertaken without due consideration to the part which overcrowding may play in health conditions quite apart from the migratory activities of the colored group. When poverty also is present with overcrowding, these two social evils, from the local standpoint, far outweigh in their influence on community health the question of color. The foreign-born, the native white, immigrants, or natives are adversely affected as regards health by the presence of overcrowding and of poverty, and in direct proportion to degree. Groups of the population so affected tend to become liabilities rather than assets to the health of the community in which they live according to the extent of poverty and overcrowding which exists among their numbers. It is apparent, then, that no mere comparison of morbidity and mortality statistics as related to whites and blacks in the same community is a reasonable method or a fair method of illustrating the effects on health of the migration of such a group as the colored group unless like conditions prevail among the total population. With ample evidence available of the presence of both overcrowding and of poverty among the Negroes who have migrated to Cleveland within the past ten years, and without entering into a discussion of the causes of these evils, which are fairly well understood, it is sufficient to say that both poverty and overcrowding occur among the colored population to an extent greater than that among the total population, and on this account other methods of investigation must be employed than that of relying solely upon a comparison of vital statistics of whites with those of blacks in determining the specific effects of Negro migration upon the public health. With a fairly constant colored population of approximately 1 per cent prior to 1915, it seems equitable to compare the vital statistics among the colored population for the years 1910-14, inclusive, before the influx of southern Negroes began, with the vital statistics of the same group for the years 1920-24, when this migration has been at its height and the percentage of colored population has reached 5 per cent. Such a comparison of total mortality rates among the colored in Cleveland is made in Table I, which follows, showing the total deaths among the colored in each of the two-year periods, the principal causes of death among Negroes, listed by number of deaths and by the mortality rates based on 100,000 Negro population, together with data showing the percentage of increase or decrease in these mortality rates in 1920-24 as compared with 1910-14. A second table is also submitted (Table II) which gives the estimated 5-year mortality rates for the period 1920-24 for the white and colored population in these principal causes of death among the colored listed in the table comparing the two 5-year periods. Table II also shows the total or combined mortality rates for the city of Cleveland for the 5-year period 1920-24 in the same principal causes of death among Negroes. A study of the data furnished in these tables will give most of the detail regarding the effect of Negro migration upon community life in so far as fatal diseases are concerned. As regards morbidity rates but little information is available beyond a general conclusion that among the migratory colored people coming to Cleveland there exist very few diseases not often fatal which have an effect upon the community life beyond that which would be considered a normal condition of affairs. In fact, among the colored school children a recent investigation has shown that absenteeism on account of illness among colored children in the public schools is relatively less frequent than among white children. In venereal diseases, however, there has been noted a definite increase in the proportion of colored attending the out-patient departments of hospitals maintaining such clinics during recent years, and investigation over a considerable period of time seems to indicate that 40 per cent of patients attending such venereal disease clinics are colored at the present time. Returning to the consideration of the fatal diseases and those which cause the greatest effect upon community health, a consideration of the tables submitted leads to the following conclusions: First, the total mortality rates among Negroes have not increased as a result of Negro migration. Second, among diseases prevalent or predominant in the wage-earning group and among young adults, a marked increase among the colored population has occurred during the past five years in some instances, and in other instances, such as tuberculosis, while no great increase has occurred, there has been no decrease among Negroes in these diseases, as has been generally the case in the total population. Third, the chief immediate effect upon the public health of Negro migration has been to increase the health hazards of the entire population to such communicable diseases as tuberculosis because of the much higher rate of incidence of this disease among the colored population. It is generally agreed that tuberculosis is largely spread by infectious material from those already infected. Tuberculosis is also a disease which requires a long period of invalidism for cure or for its fatal termination in the great majority of cases. The effect of the Negro migration has been to bring into Cleveland a 360 per cent increase in a population group which, both before and after the migration, shows mortality rates from tuberculosis over 300 per cent greater than similar rates among the entire population. Among the entire population tuberculosis deaths, during the 5-year *Total mortality by principal causes of death among Negroes, Cleveland, Ohio, in the two 5-year periods, 1910-14, inclusive, and 1920-24, inclusive, with estimated mortality rates for each period and the percentage of increase or decrease in rates for 1920-24, inclusive, for each principal cause. period 1920-24, numbered 4,115, of which 883 were among the colored. This is 21 per cent of all tuberculosis deaths occurring in the city. In the years 1924 and 1925 over 28 per cent of all tuberculosis deaths have been among Negroes. Nevertheless, in the comparison of mortality rates of the two 5-year periods, 1910-14, inclusive, before migration began, and 1920-24, inclusive, the increase of mortality rates in tuberculosis for the second period among Negroes has not * Estimated 5-year mortality rates, 1920-24, inclusive, Cleveland, Ohio, for white and colored population by principal causes of death among the colored population. exceeded 1 per cent. The same increase of health hazards for the entire community arises, of course, in connection with any other communicable disease which has a greater incidence among the migratory group. Fourth, another marked immediate effect upon the public health has been the increase in deaths due to external violence, excluding suicides and acute poisoning. In deaths due to external violence, the mortality rate per 100,000 among |