entirely unventilated, securing their air and light only from adjoining rooms. The first tenement house law under which such unventilated rooms were outlawed was secured by the social agencies of New York City. At that time onehalf to two-thirds of the rooms were totally dark, until, in 1879, the legislation was secured providing for the light shaft, and twenty years later a bill was presented and passed, over the strenuous objection of the landlords, providing for the admission of light in every room in the tenement.

Probably the greatest advance in sanitary science in the housing field for the past half-century is a direct result of the work of the housing agencies in New York. The modern disposal of waste, the provision for draining, the whole development for sanitary plumbing can be traced directly to those courageous and highly unpopular crusaders for decent housing for the poor in New York City. To be sure, it is true that the homes of the tenement dwellers of New York City are still a disgraceful blot upon modern civilization, but it is nevertheless a far cry from the unspeakable and miserable conditions of those tenements sixty years ago.

Infant Mortality.—Sixty years ago there was literally a slaughter of the innocents in New York City. Out of 2,500 children born alive, death took nearly one-third of the total number before their first birthday. In 1925 we had an infant death-rate of 65 per 1,000 births, as compared with the infant death-rate of 333 in 1866. If the death-rate of 1866 had continued we would have had 42,390 deaths, as against 8,315 which actually occurred. Fifty years ago there was no child health work in New York City; in fact, the Society for the Prevention of Cruelty to Animals was organized many years prior to the Society for the Prevention of Cruelty to Children.

While it is impossible to give a chronological account of the development of infant welfare work, we do know that the impetus for this work came largely from private social groups. In 1873 the New York Diet Kitchen Association was founded to distribute nourishing food to the sick among the very poor. Twenty years later Mr. Nathan Straus founded his famous pasteurized milk laboratories, where any baby who needed milk could obtain a daily supply. This was followed by similar stations established by social agencies in every part of the city, and finally by the organization of the division of child hygiene in the department of health itself. Social agencies have ever insisted upon the direct relationship of poverty to infant mortality, and through the exhaustive studies of the federal Children's Bureau, in a number of cities, proved this point conclusively. We know now that for a variety of reasons the babies of the poor die in greater numbers than the babies of the well-to-do. Mothers living in miserable tenements with inadequate medical and nursing facilities lose children for no other reason than their poverty. In no field, perhaps, has as much pressure been brought to bear upon public authorities by social workers to give adequate health service to any single group as has been the influence on the care of infants. They have demanded the establishment of facilities for the preven

tion of infant mortality, and no little credit is due them for the winning fight now carried on in every city in the country for the lives of babies.

Tuberculosis.-The tuberculosis movement, too, is a shining example of the influence of social work on public health. In this field particularly we find outstanding individuals like the Bowditches, Trudeau, Biggs, and Loomis, who were the real pioneers and whose ideas were capitalized by social groups. With this movement there has developed a technique and phase of public health which provides a wholly new chapter in preventive medicine. There has developed the dominant motive in the present-day public health program, namely, the education of the individual in the practices of personal hygiene. The discovery and application of the use of popular health education was made by the pioneers of the tuberculosis movement, who were aided from the beginning by the social agencies of this country. The actual provision for adequate sanatorium clinical and nursing care has come about very largely through the interests of social agencies in the care of tuberculous families under their control. The history of tuberculosis is one of the social agencies' interest in, and the fostering of, facilities for the care and prevention of tuberculosis.

The history of public health and the influence of social work upon it cannot be related adequately in terms of agencies, because it has been written by individuals through whom social movements of this or any other character are largely influenced. The first approach to sanitation in the modern public health movement was urged by the aggressive and pugnacious secretary of the Poor Law Commission of England, who from the first saw the connection between poverty and disease, as well as the preventability of much of this disease. The famous report of the sanitary condition of the laboring population in Great Britain was Chadwick's outstanding work, which resulted in the appointment of special commissions on health for all the large towns in England. There directly resulted from this the first intelligent handling of water supply and sewage disposal throughout the modern world.

Homer Folks, attracted from his pleasant studies of the Romance languages at Harvard into the field of social work, has become probably the most influential single individual in the promotion of adequate health facilities in New York State. As secretary of the State Charities Aid Association he has taken the leadership in the promotion of public health in New York since 1893. He was instrumental in founding the Craig Colony for Epileptics, the establishment of the first state hospital for consumptives, and for the reorganization of the state health department into one of the most effective units in this country. He helped reorganize the health machinery of Cuba. In 1902 he organized the first municipal hospital for consumptives in the United States, and under his leadership has developed the whole machinery for tuberculosis prevention in New York State. Lee Frankel, trained in the family case work field, has, as director of the welfare department of the Metropolitan Life Insurance Company, inaugurated a health educational campaign among policyholders that leads the world in health edu

cation. Through his influence was organized one of the finest tuberculosis sanatoria in America for the care of employees of the Metropolitan Life Insurance Company. He conceived the idea of the now famous Framingham Health and Tuberculosis Demonstration. He has been active in the development of the social hygiene movement, and has been president of, and for many years active in, the American Public Health Association. These and many others have been the champions of public health in the field of social work. They have helped to organize the forces of the community to fight disease, and to them and to hundreds of social workers in as many communities the public health movement owes much for its tremendous advances.

Haven Emerson has recently drawn some invidious comparisons between some branches of social work and public health on the score of the latter's willingness to measure their results in terms of careful research and statistical analysis. Nearly a million dollars will be spent this year in experimental work in health demonstrations in half a dozen communities for the specific purpose of determining the values of various administrative practices. With no preconceived idea of methods to be followed in the several fields of health, they will test their value on the basis of criteria worked out by the best statisticians in the country. Why should there not be organized "social welfare demonstrations," the purpose of which would be not only to analyze the social work of a community, but to set up adequate experimental machinery to try out on a scientific basis the theories expounded for years by social workers?

In still another field it seems to me public health has far outstripped most of the fields of social service, and that is in the technical standards of administration. Precise and well-recognized standards have been developed in prenatal and infant welfare work, in the medical inspection of school children, in tuberculosis, venereal disease, and other fields. Many of the activities of social work might well examine the history and procedure by which these technical standards have been attained.

But the burden of this paper is to explain again that the fields of social work and public health are inseparable, and no artificial boundaries can separate them. Social work is interwoven in the whole fabric of the public health movement, and has directly influenced it at every point. No phase of community effort has made such remarkable progress. It has probably had more direct influence on the decrease in poverty than all the other forces of social work combined. Made possible by the scientists, it has been put into practice in every community in the land, largely through the humanitarian impulses organized and directed by the social agencies of the nation.

WHAT IS THE PUBLIC PRACTICE OF MEDICINE?

William H. Peters, M.D., Health Commissioner, Cincinnati

Political control has been and still is one of the chief obstacles to effective public health administration in our country. What is best for the public health is not as a rule the motive inspiring appointments to positions in community public health service. All too frequently the position of health commissioner is the reward for political services rendered.

Too many men engaged in public health work lead a dual sort of life. They have a public conscience and a private one, and as a rule they are willing to subordinate their private conscience to what is best for the party. "Political expedience" should be listed as a contributory cause of death on thousands of death certificates signed tuberculosis, typhoid, diphtheria, etc.

Public health work is a highly specialized branch of medicine, and not until we eliminate political control and the indefinite tenure of office will men of outstanding ability be attracted to a public health career.

The adoption of a new appraisal form for use in measuring city health work by the Committee on Administrative Practice of the American Public Health Association is the culmination of a desire extending over a period of years to give health administrators an instrument to stimulate good public health practice. The conscientious and courageous use of the appraisal form by the health officer may be instrumental in overcoming the insecurity of tenure

Here he has the opportunity of listing the public health assets of his city in terms that anyone may understand, thus revealing the strong and the weak points in his department. With public sentiment behind him, and the support of the press, the principles of standardization would go far in removing the uncertainties of political changes and influences. Forty-six activities are listed in the appraisal form under eleven main sections, as follows: vital statistics; control of communicable disease, venereal disease, and tuberculosis; prenatal health work; protection of the baby, the pre-school-age child, and the school child; sanitation; laboratory service and popular education. A score book, such as has been adopted, should serve as a fine stimulus for self-analysis by the health commissioner and city authorities.

We have applied the appraisal form in Cincinnati. We know of no other instrument that has been so helpful in conducting the health work of our city. As a result, standard methods of public health practice and record making have been adopted by the official and voluntary health organizations.

In a classical address which many of you may have heard last week at the American Health Congress, our esteemed friend, Dr. S. J. Crumbine, general executive of the American Child Health Association, ventured the suggestion, as a remedy for insecurity of tenure, that freedom from unjust political interference, as assured to chiefs of fire departments under the fire insurance rating

plan, should be guaranteed for the health commissioner under a penalty of increased rates in industrial and life insurance.

Freedom from political domination is perhaps responsible more than any other single factor for the public health progress in Cincinnati. This change was brought about in 1910, and with it came a reorganization of the health department, until now it parallels an ideal organization recommended by Dr. C. E. A. Winslow, chairman of the Committee on Municipal Health Department Practice of the American Public Health Association. The fact that the members of the Cincinnati Board of Health are appointed for ten years, and that only one member retires every two years, guarantees continuity of program and policy. This is a wise provision of our charter. All members of the health department are civil service appointees and devote their full time to public service.

It is not my purpose to burden this Conference with the details of our organization. We have a splendid foundation for a fine superstructure. Our chief complaint is the lack of funds, but each year gives a new encouragement. Our appropriation for the current year is $176,620, or, at the rate of 43 cents per capita, a very meager sum for the health protection of 409,000 people living within the corporate limits of our city, embracing seventy-two square miles of area. In a survey which has just been completed we find that the per capita cost of public health administration in class 2 cities, that is, cities with a population between 250,000 and 500,000 inhabitants, is 59 cents. Next year we shall do better!

All of the bureau chiefs are technically trained men and women, but, as Dr. Crumbine has so aptly stated, alumni of "the school of experience." Wherever possible we follow the district plan of one man or woman combining all of the functions of his bureau in a circumscribed area. The size of our districts shrink as we prosper. Under such an arrangement all duplication of time and effort are eliminated. Our people like the arrangement better. They are not overvisited.

Primarily we are interested in basic and fundamental things, such as the proper disposal of sewage; the purity of the water supply; a healthy environment for every citizen, no matter where he may be; wholesome food; complete registration of births and deaths; competent medical diagnosis for those who cannot afford to pay; sanitary isolation and hospitalization of communicable diseases; immunization as a matter of community prophylaxis; attendance of infants at instructive clinics; physical defects of school children, discovered and corrected; adequate laboratory facilities; and last, but not least, public health instruction.

We believe that the elimination of 22,000 outside vaults and catch basins during the last fourteen years has contributed tremendously to the health and comfort of our people, and that this too has played an important rôle in the prevention of typhoid fever and other intestinal disorders. Two hundred remain. Our slogan is, "A modern sanitary flush toilet for every home."