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Cross for the use of the nurses and the sanitary inspectors, and the city bought one for the use of the doctor. One of the first things done was to inoculate the people with typhoid serum free of charge; other physicians in the city offered their services in helping inoculate, and in a short time over 6,000 people were inoculated.
Each case of typhoid fever in the city was visited by one of the nurses, and before each patient was released from quarantine a specimen of stool was examined by the bacteriologist to be sure that he or she was not a typhoid germ carrier. For over two months the doctor and the nurses were on the go; working hours were not counted, visits were made night and day, but results began to show; new cases were dwindling—only a few new ones a day, where a month before it was nothing to have 10 or 12 in one day. Since October only five cases have been reported; two of them had just come to town and the others had not been inoculated.
In September smallpox broke out. Steps were immediately taken to prevent an epidemic. The order went out that all school children in the city not having a certificate of vaccination must be vaccinated or stay out of school for 25 days. Doctors and nurses went to the schools and vaccinated, free of charge; the result was that 94 per cent of the school children were vaccinated, and a large per cent of grown people. The same preventatives are taken when any other contagious disease is reported.
Every child in the schools of city and county has been examined and a history of the diseases they have had is kept in the office; also a record of any defects, and notification cards of these are sent to their parents, so that they may be treated by their family physicians. Every home in the county outside of the city has been visited by United States Public Health Service nurses, giving instructions on health and the care of babies. All sanitary conditions of the zone are looked after.
Rapidity an Important Principle
The organization and workings of this unit are typical of those throughout the country. The zone proper comprises five miles about each camp, but in some places, where it has been requested by the local authorities, whole counties have been included in the area thus administered, and local boards of health, county and state funds, chambers of commerce, men's and women's clubs, all have contributed to the salaries of the nurses needed.
On account of the tremendous increase in population over normal times, it has been necessary to correlate the work of the public health nurses in these zones and to drop much of the usual bedside care, in order to cover the immense amount of instructive work that has to be done. The conviction that this is no time to waste a minute underlies the plans for reorganization which has been recommended in the various extra-cantonment zones which have been visted. On a recent tour of inspection in one of the cantonment zones, it was recommended that a combination of various existing agencies, under the direction of the United States Public Health Service be inaugurated, the following being a brief outline of the general plan submitted:
That the city be laid out in small districts, with a nurse assigned to do all the nursing work in each district; that the supervisors of the various existing associations be retained as specialists to train the nurses and to advise in difficult cases; that the funds now made available for nurses' salaries by the separate associations be applied for the same number of nurses for work under the new plan; and that the present directing bodies, such as the district nurse association, remain in existence as advisory boards.
This generalization of nursing work, wherever possible, has been effected as being the most economical use of the nurses' time and efforts. It will provide a more intensive nursing service, because it will double the number of patients a nurse can visit, will increase by 50 per cent the number of cases of disease reported, will enable disease to be recognized and treated in its early stages, will facilitate the isolation of patients before they are able to infect others, will keep people well by educational work, will protect the civilian population, and in that way the soldier—for a great proportion of the epidemics among the soldiers can be traced directly to the community in or near which the camp is situated. This plan will mean less besides nursing, but the nurses can teach others to do the simple things for which trained service is not required. It will reduce the number of special nurses, but special supervision will make up this lack. This war, with its mobolization of soldiers in great centers, with its demand for highest human efficiency delivered promptly at the fighting front, with its requirement for great numbers of nurses drawn into military service, presents an emergency which must be met by emergency measures. This plan has already been put into successful operation in a number of other cities and cantonment zones.
Value of the Service
Hundreds of American soldiers have died and hundreds of others have been brought down by preventable diseases, contracted in the preparation and training of soldiers who were unable to embark at the appointed time on account of sickness, and this form of organization would give the greatest protection to the men in training and preclude as far as possible the increment of military loss due to preventable sickness. How appalling this military, economic and human loss has been in the past was very clearly shown in statements made by Dr. Louis Livingston Seaman, in testimony which he gave recently before the Committee on Military Affairs of the House of representatives. Dr. Seaman has been in eight different wars, on every continent of the world, for the sole purpose of studying military sanitation and the prevention of disease in armies. He gave, among others, the following statements and figures:
It must never be forgotten that in every great campaign an army faces two enemies—the armed forces of the opposing foe with his various machines for human destruction, who is met at intervals in open battle, and the hidden foe always found lurking in every camp, the grim specter ever present, that gathers its victims while the soldier slumbers in hospitals, in barracks, or in bivouac— the far greater and silent form, disease. Of these enemies, the history of warfare for centuries has proven that in prolonged campaigns the first or open enemy kills 20 per cent of the total mortality in the conflict, while the second or silent enemy kills 80 per cent. In other words, out of every 100 men who fall in war, 20 die from bullets or wounds, while 80 perish from disease, most of which is preventable. This dreadful and unnecessary sacrifice of life, especially in conflicts between the Anglo-Saxon races, is the most ghastly proposition of modern war. In the five months of the Porto Rican campaign in the late Spanish-American War, 262 men died from disease, while only three were killed by bullets. In the mobilization camps of the United States during that war 26,649 men died of preventable diseases without one of them leaving the country or seeing the firing line. * * * * In this army of 170,000 there were 158,000 hospital admissions, or 90 per cent, although three-fourths of the men never left the camps of their native land.
Perhaps the most significant new piece of work has been the establishment of venereal clinics. This has followed the successful work done along these lines in some of our large hospitals during the past five or six years. Such clinics, to treat venereal disease in the civilian population, is the logical concomitant of the efforts being put forth to make and keep our troops the cleanest body of men that have ever gone into battle.
Surely these figures and facts carry their own convincing argument for the adoption of such means of protection for the men in cantonments as have been proved efficacious by the test of experience.
VENEREAL DISEASES AND CLINICS FOR CIVILIANS NEAR MILITARY CAMPS
Ann Doyle, R. N., Supervising Nurse, Division of Venereal Diseases, U. S. Public Health Service
Immediately following the declaration of war and the establishment of cantonments by the War Department, the President, by executive order, charged the Public Health Service with the task of rendering the extra-cantonment zones safe for the soldiers.
When the first draft figures became available, the incidence of venereal disease was noted to be alarming. This accentuated the knowledge gained by the experience the army had just had with the troops on the Mexican border. It became apparent that something very definite must be done to control and prevent venereal disease. To accomplish this end clinics for the treatment of venereal diseases were opened in the extra cantonment zones. These clinics were supported jointly by the American Red Cross and the U. S. Public Health Service, and designated U. S. Government clinics. In charge of these clinics were syphilogists, genito-urinary specialists, bacteriologists, and nurses.
Close co-operation was established with the law enforcement division of the Commission on Training Camp Activities, and extensive advertising was carried on through the newspapers, through trade journals, stickers in the pay envelopes of men employed in large industries, ship yards, munition factories, etc., as well as talks given by the medical officers and the nurses to groups of people wherever possible. The clinics were located in the business sections of the cities readily available for all classes of people. The work of the clinics has proved to be very effective in the education of the venereally infected, and their preparation, through treatment, to return to society. . As the majority of these clinics are in cities where there has never been such care available before, they soon become crowded with patients.
Three classes of patients have received treatment. First: Persons taken in raids and brought to the clinic on charges of disorderly conduct for examination to ascertain whether or not they are infected. Second: Cases coming under coercion; in other words, people who have been under suspicion are warned that if they do not present themselves for examination and treatment, if necessary, they will be brought in by the police. Third: Voluntary cases. These include persons who have read the advertisements and who have been advised through the talks given at the various meetings; or persons sent in by the various agencies, such as the visiting nurse association, the infant welfare nurses, etc.
An analysis of the figures does not indicate that the problem of prostitution has been really solved, as few known prostitutes attend voluntarily, and for the most part these have been found to be only slightly infectious. The great problem of clandestine prostitution is as yet only partly touched. There is the greatest need for more workers in this field, workers who understand the problems of venereal disease, are trained in sex hygiene education, and who will be able to interpret to various types of mentalities the problem of prevention of venereal disease.
The social aspects of these diseases have received the attention which we, as public health nurses, have long felt would never come. Attached to many of these U. S. government clinics are social service departments conducted by socially trained public health nurses whose business it is to ascertain the moral, economic, and social reasons for the infection of each person applying for treatment.
The responsibilities of the nurse in the government clinic social service departments are many. She has constantly before her first, the duty of protecting the military forces from disease, second, the protection of the community, and third, the protection of the individual and his family. She must aid in ascertaining the source of infection; she must aid in the rounding up of contacts, for the venereal diseases have their epidemiology just as other communicable diseases have epidemiology, and contacts and carriers of venereal diseases require just as careful attention as do contacts and carriers of meningitis, etc. The final disposition or "post quarantine" stage of the venereal diseases is of utmost importance. Especially is this true of women infected with gonorrhea. Here the nurse must use exceptional judgment, for like carriers of typhoid or dysentary, carriers of the gonococcus are a constant source of danger.?
The detention hospitals, maintained by the states, cities, or counties, the Red Cross in conjunction with the U. S. Public Health Service, provide for the early, radical care these diseases require, segregate the carriers thus preventing the spread of infection, and at the same time detain these people long enough so that a plan for their future living may be made.
Section 13 of the Selective Act made it unlawful for any person to practice prostitution, fornication, etc., within a certain radius of a military establishment. Many of the patients brought in by the police authorities and under coercion are guilty of violation of this act. Plans are being made to have such offenders placed on Government farms and in Government reformatories.
Effort is being made to secure proper legislation for the prevention and control of venereal disease. The "State Board of Health Regulation for the Prevention of Venereal Disease" (Public Health Service reports, Volume 33, No. 13, March 29, 1918,) are comprehensive and practical. We are hoping that most of the new legislation will be based upon these suggestions. As the work goes on the enormity of the problem becomes apparent, and the U. S. Public Health Service is contemplating a very definite program for the future of this work. It is hoped that this campaign, started for the protection of the military forces, will become a nation-wide movement for the protection of every citizen— man, woman, and child, black and white—in this country.
HOUSING—ITS RELATION TO SOCIAL WORK
There never was a time when social work was more important. There never was a time when housing was more important, and its relation to social work so clearly recognized. The war has enlarged the field of social work immeasurably. It has also suddenly brought to light the relation of housing to all classes of people, to industry, to government employes, to the very winning of the war. The appropriation by Congress of $60,000,000 for housing, following a hold-up of ship building and munitions making, due to lack of housing facilities, is the strongest word that can be spoken in regard to this subject. Until the war is won, everything we do is estimated according to its relation to the war. But social workers, whose work has been made heavier and harder by the war, must be looking ahead to the days of reconstruction, after the war, when the excitement is over, the tension is relaxed, when the men come home. President Wilson has said that this war is to make the world a fit and safe place to live in. The social worker's job is also to make the world a fit and safe place to live in. That is also the job of the housing worker, and it will never be a fit and safe place to live in until "all the homes of all the people" are safe—until every little child is safe in its own home.
The purpose of this paper is to establish the true and correct relation of housing to social work. There seems to be no relation, in most