Community Civics and Rural Life

by Arthur William Dunn

CHAPTER XX

THE COMMUNITY'S HEALTH

PHYSICAL DEFECTS AND THE NATIONAL DEFENSE

There is nothing else that concerns the community or the nation so much as the health of its citizens. Of more than three million men between the ages of 21 and 31 examined for military service in 1918, only about 65 per cent were passed as physically fit to fight for their country. [Footnote: Public Health Reports, U. S. Public Health Service, vol. 34, No. 13, p. 633 (March 28, 1919).]

The remaining 35 per cent were either totally unfit for any kind of service, or were capable only of the less strenuous activities connected with warfare. Most of the defects found could have been remedied, or prevented altogether, if proper care had been taken in earlier years.

PHYSICAL DEFECTS AND THE NATION'S INDUSTRY

The nation loses by this physical unfitness in other ways than in fighting power. Investigations have shown that wage earners lose from their work an average of from six to nine days each year on account of sickness.

[Footnote 2: Public Health Reports, U. S. Public Health Service, vol. 34, No. 16, pp. 777-782 (April 18, 1919).]

The cost to the individual in loss of wages, doctors' bills, and otherwise, is a serious matter, to say nothing of the absolute want to which it reduces many families and the suffering entailed. In addition to this, the country loses the wage earner's production. Sometimes death brings to the family permanent loss of income, and to the nation complete loss of the product of the wage earner's work. The nation spends large sums of money every year in providing for dependent families and individuals.

If each of the 38 million wage earners in the United States in 1910 lost 6 days from work in a year, how many days' work would the nation lose? How many years of work would this amount to?

At $2.50 a day (is this a high wage?) how much would be lost in wages in a year?

Get information regarding the cost of a long case of sickness, such as typhoid fever, in some family of your acquaintance (perhaps your own), including doctor's bills, medicines, time lost from work, etc.

What would such expense mean to a family living on as low wages as those mentioned on page 167?

EDUCATION AND PHYSICAL DEFECTS

Moreover, the nation loses a great deal (how much cannot be calculated) from the physical unfitness of many who keep on working, but who are not fully efficient because of bodily defects or ailments. We see the results of this even in school. Pupils who lag behind their mates in their studies are often suffering from physical defects of which their teachers, and even they themselves, may be unaware. It may be that they are ill-nourished, or that they have defective vision, or hearing, or teeth, or that they sleep in poorly ventilated rooms. The community does not get its money's worth from its schools if its children are not in physical condition to profit by them. In a similar manner earning and productive power are reduced.

PHYSICAL UNFITNESS IN RURAL COMMUNITIES

It has usually been assumed that the people in rural districts are more healthy than those who live in cities; but it has been found that there is as much physical unfitness there as elsewhere. It is true that the records of the war department seem to show fewer men rejected in rural districts as totally unfit for any kind of military service; but evidence of other kinds has been collected that indicates that some kinds of disease, at least, and many physical defects are more prevalent in the country than in the city. In THE LURE OF THE LAND, Dr. Harvey Wiley makes a comparison of the death rate from certain diseases in a few states where the figures are available for both city and country.

[Footnote: Dr. Harvey Wiley, THE LURE OF THE LAND, Chapter VIII,
"Health on the Farm," pp. 53-60.]

RURAL AND CITY SCHOOL CHILDREN COMPARED

Studies have been made of the comparative health of city and rural school children, which show results in favor of the former. Of 330,179 children examined in New York City 70 percent were found defective, while of 294,427 examined in 1831 rural districts of Pennsylvania 75 per cent were defective. The preceding chart shows the comparative prevalence of health defects among city and country children.

Investigate the following:

Meaning of "vital statistics." Importance of vital statistics to your community. Where recorded for your county or town. What the vital statistics of your community for the last year show.

Causes of deaths in your community for the last year. The percentage of these deaths that were "preventable." Increase or decrease of death rate in your community during recent years, in your state.

The nature of the prevailing sicknesses in your community during the last year. Per cent of these that were contagious. List of contagious diseases in the order of their prevalence.

Quarantine regulations in your community against contagious diseases. Extent to which they are observed. Who is responsible for their observance? For their enforcement?

Observe condition of sidewalks and other public places with respect to expectoration. Is there a law on the subject in your community'? Is it observed or enforced? Who is responsible? Dangers from expectoration.

Medical inspection in the schools of your county, town, and state. If any, its results. Kinds of defects most commonly found. How is it conducted? Who sends the inspectors? To what extent the homes of the community cooperate with the schools in getting results from medical inspection.

BETTER CONDITIONS IN CITIES DUE TO ORGANIZED TEAM WORK

We may well ask why ill health and physical defects seem to be more prevalent in rural communities than in cities. The answer probably is, simply, that in cities they are PREVENTED more effectively. The chart on page 313 shows that while the death rate in New York City was 20.6 per thousand in 1900, it had declined to 14 per thousand in 1914; while that in the rural districts of New York State remained practically the same during these years (15.5 per thousand in 1900, 15.3 in 1914).

This indicates that health conditions in the city were originally much worse than in the country. They were rapidly improved by organization for health protection. There is not the occasion, in rural communities, for the elaborate health-protecting organization that is now found in all large cities, because the people in rural communities are not so completely dependent upon one another nor at the mercy of conditions over which, as individuals, they have no control. And yet even in rural communities physical well-being depends largely upon organized team work.

SCHOOLS AS AN AGENCY FOR HEALTH CONSERVATION

Cities have used their school organization to combat physical defects and weaknesses of pupils, and that is why they make a better showing than rural communities in such matters as those shown in the table on page 312. Removing such defects from young people means a stronger and more efficient adult population ten or twenty years from now; for these defects are often the causes of more serious illness in later years. The table on page 299, Chapter XIX, shows how much behind cities rural communities have been in the use of their school organization for this purpose. The encouraging thing is, however, that rural communities are beginning to find the means to use their schools in this way. The way has been opened by school consolidation (p. 295), by the grouping of all the small and isolated schools of a county under a central county administration (p. 294), by aid from the state, both in money and in supervision, and by cooperation from the national government.

HEALTH EDUCATION FOR ADULTS IN CITIES

Cities have extended their health-educational work to the adult population. This takes place in part through the schools also. Instruction given to children is of course taken home by them. Visiting nurses employed by the schools visit the homes. Classes for mothers are conducted at the school in the afternoon or evening. But more than this, city boards of health, often in cooperation with the school authorities, conduct educational campaigns by means of literature distributed to the homes through school children, by means of evening lectures and moving pictures, and through the newspapers.

AGENCIES FOR HEALTH EDUCATION IN RURAL COMMUNITIES

Means are not wanting for similar work in rural communities. The homes may be reached by the right kind of instruction in the schools. The classes or clubs for women conducted by women county agents may be, and often are, used as means of health instruction. Public meetings at the "community center" at the schoolhouse may be devoted at times to public health problems, with lectures, moving pictures, and discussions. The local newspapers always afford a channel through which to get matters of this kind before the people. Local and state boards of health, the United States Department of Agriculture, and the Public Health Service may and do use these and other agencies to reach the people.

RESPONSIBILITY OF THE HOME

No matter how much machinery for cooperation we may have in our community, like that described above, it cannot help much unless every family and every citizen cooperates intelligently.

In a large city, a small group of men, constituting the city council, may inaugurate measures which will accomplish sanitary improvements at thousands of homes; but for the accomplishment of sanitary improvements at 1000 farm homes at least 1000 persons … must be convinced that the sanitary measures are needed, become informed how to apply them, and be willing to put them into operation.

[Footnote: RURAL SANITATION, by L. L. Lumsden, Public Health
Bulletin No. 94, United States Public Health Service, p. 10.]

THE IMPORTANCE OF PURE AIR

Pure air is essential to good health. It is not always easy to get in the crowded living and working conditions of cities. There it is necessary to regulate these conditions by law, and factories and tenements are inspected to see that they are properly ventilated and not overcrowded. In rural communities there is less excuse for bad air, and the responsibility for it rests more directly upon the individual, as illustrated on page 112, Chapter X.

BAD AIR AND THE SPREAD OF DISEASE

It might seem that it is nobody's business but our own how we live in our homes or at our work. But bad air lessens vitality and nurtures disease. This reduces productive power. Moreover, colds, influenza, and tuberculosis (of which more than a million people are constantly sick in the United States), all of which are nourished in bad air, may be spread by contact, or by food handled by those who are sick. People who live in bad air at home mingle with others at church, in moving picture theaters, at school, in the courtroom, and in other public meeting places, which are themselves often poorly ventilated. It is strange that court rooms, where justice is administered, schools where children are prepared for life, and churches where people worship, are so often badly ventilated.

Report on the following:

Is your schoolroom well ventilated? How do you know? What effect does poor ventilation have upon your feelings and your work?

If the law requires school attendance, why should it also require good ventilation of the school?

If the ventilation of your school is not good, what may you do about it? Who is responsible for it?

Observe and report upon the ventilation of the court rooms, moving picture theaters, churches, and other meeting places in your community.

PURE WATER AND HEALTH

Cities go to great expense to get an abundant pure-water supply. It is of the greatest importance in community sanitation Impure water is one of the chief sources of typhoid fever and other diseases of the intestines. About 400,000 persons have typhoid fever every year in the United States, and 30,000 are killed by it; and it is unnecessary. We have from three to five times as much typhoid as many European countries have, and for no other reason than that we are negligent.

PURE FOOD AND HEALTH

Pure, clean, wholesome food is equally essential. We need not dwell upon the importance of the right kinds of food and well- cooked food. Much illness is caused by "spoiled" foods. Disease germs may be carried by food as well as by water. Tuberculosis may be carried by milk, either from diseased cattle, or from victims of the disease who handle the milk at some point in its progress from the dairy farm to the home. The death rate among babies is appalling, especially in cities, because of the use of milk containing germs of intestinal diseases. Typhoid fever may be contracted from milk, green vegetables, and oysters from beds contaminated with sewage.

The food supply of cities passes through many hands before it reaches the consumer. At almost every point it is protected by regulations and inspection. Most of it, however, comes originally from the farm which is beyond the control of the city authorities. The producers and handlers of food products in rural districts therefore owe it not only to themselves but also to their city neighbors to exercise every possible precaution against the spread of disease. Such precautions consist in cleanliness in handling and storing milk, butter, and meats; in the cleansing of milk receptacles with pure water; in the proper location and construction of wells; in protecting springs from surface drainage; in sanitary disposal of sewage and other wastes from the household; in protection of food against flies.

SANITATION IN CITIES

In cities a great deal of attention is given to sanitation. Sewage is carried off by public sewers. Householders are required to place garbage in sanitary cans, whence it is collected and disposed of in such a way as not to pollute the soil. Ashes and refuse are carried away from homes and shops, and the streets are cleaned daily. In rural communities such matters are left almost entirely to the householder.

FLIES AS DISEASE CARRIERS

Exposed garbage, improperly built outdoor toilets, and stable manure are breeding places of flies; and flies are notorious carriers of disease. Yet, out of more than 3000 homes in one county in Indiana only 31 made provision to prevent stable manure from breeding flies, and the same was true of only 1 out of more than 2000 homes in a county in North Carolina, and only 86 out of nearly 5000 homes in an Alabama county.

DANGER FROM MOSQUITOES

Malaria is widespread in the United States and imposes a heavy toll upon the nation's health. It is carried from one victim to another by a certain kind of mosquito, of which it is comparatively easy to get rid by proper drainage of breeding places, by treating the surface of pools with kerosene, by screening, and by seeing to it that rain barrels are covered and that tin cans and other receptacles of water are not left lying around. But flies and mosquitoes do not stop with fences, nor do they recognize city or county boundaries. Hence, individual effort without community cooperation is likely to be useless.

POLLUTED SOIL AND HOOKWORM DISEASE

The terrible hookworm disease so prevalent in our southern states is caused by a minute worm that infests soil polluted with sewage. It penetrates the soles of the feet of those who go barefoot and the palms of the hands of those who work in the soils, finds its way through the blood to the intestines, and thence to the soil again. An investigation in 770 counties in 11 states where hookworm disease is prevalent showed that out of 287,606 farm homes only six tenths of one per cent disposed of their sewage in such a way as to prevent soil pollution.

Out of 305 homes in a little community in Mississippi, only 4 properly disposed of sewage. When the first investigations were made, there were 407 cases of hookworm disease out of 1002 residents. Besides, there had been recently 12 cases of tuberculosis, 47 of typhoid fever, 184 of malaria, and 384 of dysentery.

Safe methods of disposing of sewage were introduced, houses were screened, an artesian well was bored for a public water supply, and the community cleaned up generally. After these improvements the various diseases almost entirely disappeared. Similar results were obtained in 99 other communities in the southern states.

[Footnote: Report of the Rockefeller Foundation, 1917, pp. 136- 138.]

Topics for investigation:

The water supply of farms in your locality. Any recent improvements.

The public water supply (if any) of your community. Its sources. Method of purification. Quality of water. How the people know it is pure or impure. Public or private ownership of the supply. Cost to the householder.

Extent to which the families represented in your class depend upon private wells. How many have had their well water examined to test its purity. How to proceed to have water tested. Who tests it? Who pays for the test? (If possible, visit the laboratory where the tests are made.)

Number of cases of typhoid fever in your community, now or during last year. How the information can be obtained. Is the information likely to be accurate? Whose business is it to keep a record? Why should a record be kept? Why should it be made public?

Causes of typhoid in your community. Are they preventable? How?
Observance of quarantine against typhoid.

How may wells become polluted? Give cases of which you may know.
Study diagram on page 314.

Methods of sewage disposal in your community. Laws on the subject.
Can you suggest improvements?

Regulation of milk production and handling in your community: on the farms where it is produced; in the hands of dealers and distributors; in the home. Who make these regulations?

Outline on a map the area from which your community is supplied with milk. Show on a map cities that are supplied by your county with dairy products, garden vegetables, meats, etc.

Clean-up campaigns in your community.

Progress and methods of fly and mosquito extermination in your community.

The work of the Rockefeller Foundation for the extermination of hookworm disease (see references).

Hospitals that serve your community. Where located. By whom supported (private, city or town, county, state).

NATIONAL CONTROL OF HEALTH CONSERVATION

Health protection, like education, has been considered primarily the duty of the state. But many conditions affecting health have arisen that the state cannot completely control. Chiefly under the power given to it by the Constitution to regulate foreign and interstate commerce (p. 451), Congress has passed many laws that protect health, placing their enforcement in the hands of the several departments of the national government.

HEALTH WORK OF THE DEPARTMENT OF AGRICULTURE

The Department of Agriculture conducts much public health work, through its home demonstration agents, its Office of Rural Engineering, which deals with problems of farm water supply and rural sanitation, its Bureau of Entomology which wages war against flies and other disease-carrying insects, and its Bureau of Animal Industry which inspects cattle, meats, and dairy products. The Department of Agriculture also administers the Food and Drugs Act, the purpose of which is to secure purity of food products and to require that they and medicinal drugs shall be labeled in such a way as to show what they contain. Fraudulent and harmful "cures" and "patent medicines" may thus be exposed.

THE PUBLIC HEALTH SERVICE

The United States Public Health Service investigates diseases and health conditions and the means of controlling them. It has given considerable attention to rural sanitation. It issues reports and other publications of great value to the citizen, some of them being listed at the end of this chapter. It has representatives in all important foreign ports, inspects all ships that enter American harbors, and holds them in quarantine until they and their passengers are given a clean bill of health. Cholera and other dangerous diseases have thus been prevented from gaining a foothold on American soil.

HEALTH WORK OF OTHER DEPARTMENTS

The War Department has also waged a relentless warfare against disease, not only in the army itself, but also in the Panama Canal Zone, Cuba, Porto Rico, the Philippines, and other regions occupied by the army. The Department of Labor seeks to improve the physical conditions of labor for both men and women, and its Children's Bureau is charged with a study of all matters pertaining to the welfare of children. In the Department of the Interior the Census Bureau collects national vital statistics; the Bureau of Mines has done valuable work for the prevention of accidents in mines and mining industries; and the Bureau of Education seeks to promote physical education, instruction in home economics, and education in the home relating to the care of children.

STATE RESPONSIBILITY FOR HEALTH PROTECTION

A very large part of the duty of health protection must, however, remain with the states. Every state has its department of health, headed by a state board of health, or a commissioner of health, or both. These departments differ greatly in their organization and in the extent and effectiveness of their work.

NEW YORK STATE ORGANIZATION

One of the best organized state departments of health is that of New York. Among its most important features are (1) a PUBLIC HEALTH COUNCIL which has power to establish a state-wide SANITARY CODE; (2) the concentration of all administrative power in the hands of a single state COMMISSIONER OF HEALTH, who has a staff of experts to direct special lines of health work; and (3) a well- organized scheme of cooperation between the state department and local health authorities.

LOCAL ORGANIZATION FOR HEALTH PROTECTION

The absence or weakness of local organization for health protection has been one of the obstacles to progress in physical well-being in the United States. Driven by an appalling death rate and frequent epidemics, our large cities have developed health departments which in many cases have proved very effective. But in smaller communities, while health departments or health officers usually exist, the organization has for the most part been very ineffective. The people themselves have not been sufficiently aroused to their needs and to methods of meeting them. New York and Massachusetts are among the most progressive states in this matter. Each local community in these states (town, village, or small city) has its board of health and health officer; but these communities are grouped into HEALTH DISTRICTS (8 in Massachusetts, 20 in New York), each district being in charge of a health officer appointed by the state commissioner or board of health. In New York the district health officer, who is there called the SANITARY SUPERVISOR, has the following duties:

To keep informed regarding the work of each local health officer within his sanitary district.

To aid the local health officers in making health surveys of the community under their control.

To aid each local health officer in the performance of his duties, particularly on the appearance of contagious diseases.

To hold conferences of local health officers.

To study the causes of excessive death rates.

To promote efficient registration of births and deaths.

To inspect all labor camps and to enforce in them all public health regulations.

To inspect Indian reservations and to enforce all provisions of the sanitary code in them.

To secure the cooperation of medical organizations for the improvement of the public health.

To promote the information of the public in matters pertaining to the public health.

EXAMPLE OF NORTH CAROLINA

Another type of local health organization and of cooperation between local and state authorities for health protection and promotion has been developed in North Carolina, where 85 per cent of the population is rural. Here the county has been taken as the unit of local organization. Health conditions had been very bad in this state, hookworm disease, tuberculosis, malaria, and other diseases being prevalent. The state board of health, assisted by the Rockefeller Sanitary Commission (see above, page 320, and references below), began an investigation and an educational campaign among the people, with the result that many of the counties of the state now have an organization for health cooperation unsurpassed, perhaps, in any other state. Each county has a health department, which is controlled jointly by the state board of health and a county board of health. The county board of health consists of the mayor of the county seat, the chairman of the board of county commissioners, the county superintendent of schools, and two physicians of the county elected by the other three members. The work of the health department is directed by a county health officer, who is appointed by the state board of health of which he is also a member. He has a staff of trained assistants.

In this plan note the cooperation between state and local communities, between town and county officials, and between the school authorities and the health organization. Note, also, the leadership of specialists in health matters.

Topics for investigation:

Organization of the department of health in your community (both county and town): the board of health; the executive health officer or officers; the kinds of work done.

Amount of money spent by your local health department for all purposes and for each purpose separately. Compare with the amounts spent for roads, for schools, and for other work of the local government.

The interest shown by the people in your community in public health matters.

Some of the more important health problems of your community.

The leadership in your community in health matters.

Cooperation between the state government and your local government in health matters.

The more important local and state laws relating to health in your community.

Organization of your state department of health.

Local health problems that need state control.

State health problems that need local cooperation.

The operation of the Food and Drugs Act in your community.

The work of the Public Health Service.

The extermination of yellow fever in the United States.

The fight against the bubonic plague in California.

The work of the War Department to maintain the health of the soldiers during the recent war. Volunteer agencies that cooperated in this work.

Work done in your community for the promotion of health by the
Department of Agriculture and the United States Public Health
Service.

The work of the Children's Bureau of the Department of Labor.

The inspection of immigrants.

READINGS

Reports of local and state boards of health.

Publications of state agricultural college relating to public health.

Publications of the United States Public Health Service,
Washington. The following are illustrative:

Federal Public Health Administration: Its Development and Present
Status. Reprint No. 112, U. S. Pub. Health Reports, 1913.

Public Health Reports. Issued weekly.

Rural Sanitation, Pub. Health Bulletin No. 94, 1918.

Health Insurance, Pub. Health Reports, vol, 34, No. 16, 1919.

The Nation's Physical Fitness, Pub. Health Reports, vol. 34, No. 13, 1919.

Good Water for Farm Homes, Pub. Health Bulletin No. 70, 1915.

Typhoid Fever: Its Causation and Prevention, Pub. Health Bulletin
No. 69, 1915.

Public Health Almanac (for current year).

What the Farmer Can Do to Prevent Malaria, Pub. Health Reports,
No. 11, Supplement, 1914.

Fighting Trim: The Importance of Right Living. Supplement No. 5,
Pub. Health Reports, 1913.

The Transmission of Disease by Flies, Supplement No. 29, Pub.
Health Reports, 1916.

The Citizen and Public Health, Supplement No. 4, Pub. Health
Reports, 1913.

The Department of Agriculture publications contain material relating to public health. For example:

Health Laws, Year Book, 1913, pp. 125-134.

Animal Disease and Our Food Supply, Year Book, 1915, pp. 159-172.

Public Abattoirs in New Zealand and Australia, Year Book, 1914, pp. 433-436.

Meat Inspection Service of the U. S. Department of Agriculture,
Year Book 1916, pp. 77-98.

Sewage Disposal on the Farm, Year Book, 1916, pp. 347-374.

Clean Water and How to Get It on the Farm, Year Book, 1914, pp. 139-156.

Dunn, THE COMMUNITY AND THE CITIZEN, Chapter IX.

Beard, C. A., AMERICAN CITY GOVERNMENT, pp. 261-282.

Among the Bulletins of the United States Bureau of Education treating of health matters are the following:

1910, No. 5, American schoolhouses.

1913. No. 44, Organized health work in schools. No. 48, School hygiene. No. 52, Sanitary schoolhouses.

1914, No. 10, Physical growth and school progress. No. 17, Sanitary survey of the schools of Orange County, Va. No. 20, The rural school and hookworm disease.

1915, No. 4, The health of school children. No. 21, Schoolhouse sanitation. No. 50, Health of school children.

1917, No. 50, Physical education in secondary schools.

1919, No. 2, Standardization of medical inspection facilities. No. 65, The eyesight of school children.

Publications of the Children's Bureau, Department of Labor.

See, for example, Rural Children in Selected Counties of North Carolina, Rural Child Welfare Series No. 2, and Baby-Saving Campaigns. A Preliminary Report on What American Cities are Doing to Prevent Infant Mortality, Bureau Publication No. 3. See list of publications issued by the Bureau.

In LESSONS IN COMMUNITY AND NATIONAL LIFE:

Series B: Lesson 14, The United States Public Health Service.

Series C: Lesson 19, How the city cares for health.

Reports of the Rockefeller Foundation, 61 Broadway, New York City.