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 11 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 meas· ured. 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:

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
HEALTH IN CLEVELAND

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