Address, “Authority in Health Control”
Dr. Cofer—Mr. President, Ladies and Gentlemen: I do not think any invitation has ever been received with more satisfaction than the one for a representative of our service to appear before you. It was received with the greatest gratification.
The Public Health Service is absorbed in the work of health conservation and Surgeon-General Blue evinced the greatest interest in your invitation for him to send a representative to explain the scope of the work being performed and discuss the question of authority in connection therewith.
This topic is now receiving the consideration of many authorities on public health matters, and on this account one may approach the subject in a hopeful attitude. I say “hopeful” because public health as an institution is rapidly growing, and its practical value is becoming more and more manifest, and sanitary science is not now nearly so far in advance of its practical application as it was even a few years ago. The possibilities of sanitation in the general advancement are being made a part of all high ideals of government, so that it is not to be wondered at that the general government should be called upon to do its share. The difficulty lies in determining just what the government should do in aid of public health and just what should be left to the States and municipalities.
History furnishes no precedents for this Nation to follow. It is almost useless to seek a model for our guidance in some foreign country. A nation with our conditions of boundary and magnitude, with millions of immigrants coming to our shores from all parts of the earth, has its own salvation to work out in the public health as well as in many other problems. In other words, we must rely upon ourselves, whether we proceed in haste or by feeling our way step by step. There is a marked divergence of sentiment growing in regard to national health control. One is that the government should do far more than it is now doing towards the protection of the public health, another that too much is expected of the National Government, and that there is a tendency on the part of State governments to call upon the Federal Government for service which should be performed by the States themselves, but which service is asked for largely in the interest of economy. These widely differing ideas in regard to the apportionment of public health responsibility lead us to a consideration of the provisions of the Constitution of the United States relative to this matter. These provisions are contained in Section VIII, paragraphs I and 3:
Section VIII. The Congress shall have power—
Par. 1. To lay and collect taxes, duties, imposts and excises, to pay the debts and provide for the common defense and general welfare of the United States; but all duties, imposts and excises shall be uniform throughout the United States.
Par. 3. To regulate commerce with foreign nations and among the several States, and with the Indian tribes.
It has been held by some that the powers of the National Government, relating to public health, are restricted to paragraph 3, which gives the right to Congress to regulate commerce, and, in regulating commerce, to so regulate it as to prevent its being a carrier of disease. Others have held that under the general welfare clause, in paragraph 1, Congress has the right to legislate for the public health.
Should the latter interpretation be the correct one, Congress could establish the national health control over States and municipalities with regard to municipal and domestic sanitation, with all details as to house drainage, plumbing, sewerage, and disposal of garbage, water supply, ventilation, school houses and public buildings ventilation, examination of milk supply, food and drugs, disposal of the dead, disinfection of dwellings, etc. Would it be desirable for the National Government to have such authority? Would it be tolerated by the people? It is a fact that the American people have already decided this question when the old National Board of Health was abolished.
The National Board of Health was created by an act of Congress, approved March 3, 1879. Another act was approved June 2, 1879, clothing the board with certain quarantine powers, but this last act was limited to a period of four years, at the expiration of which time Congress declined to renew it. The National Board of Health, therefore, had an active existence from 1879 to 1883. The act establishing the board remained upon the statute books until February 15, 1893, when it was formally repealed by Congress.
To state the case concisely, the National Board of Health was not in accord with the spirit of American government, and the people rejected it. Now, what do the American people want? I will not attempt to answer this question, but will suggest that they want a general sanitary administration which is capable of steady development, and yet may be subject to such modifications as the changing conditions of our country may necessitate, a sanitary policy which can be made to expand until it will answer the public needs not only for the present but even for decades to come.
Its direct aim should be the ultimate intelligence and education of the average citizen in matters relating to his personal health, and the health of his commonwealth. No better plan for sanitary government appears at the present time than one modeled upon the structure of the general government itself. Broadly stated, this sanitary policy expects of each State a sanitary autonomy whose influence should be appreciated by every individual in every hamlet, however small, in its domain. It contemplates a State pride in the development of sanitation, a self-reliance and an unwillingness to surrender functions or call for aid from the general government excepting after the clearest convictions of propriety or necessity. This policy expects from the general government that since it controls commerce, both maritime and interstate, it will prevent commerce from conveying disease; that it will respect the sanitary institutions of the States; that it will have such organizations and establishments as properly belong to its sphere of action to supplement where States fail, and to enable it to wield its peculiar power when urgency demands.
As an apt illustration of this conception of authority in health control, let us consider the present activities of our Federal Public Health Service. These are as follows:
1. The prevention of the introduction of infectious and contagious diseases.
2. The sanitary regulation of foreign commerce.
3. The observance of international sanitary treaties.
4. The prevention of the spread of infectious and contagious diseases from one State to another through co-operation with State and municipal health authorities.
5. The collection and dissemination of sanitary information.
6. The conduct of scientific research in matters pertaining to the public health.
7. The enforcement of sanitation in Federal territory and in connection with Federal administrative affairs.
THE PREVENTION OF THE INTRODUCTION OF INFECTIOUS AND CONTAGIOUS DISEASES.
The chief national quarantine law is that approved February 15, 1893, amended and extended by acts of Congress approved August 12, 1894, March 2, 1901, and June 19, 1906.
Under these acts the maritime quarantine administration has become national, many state stations having been voluntarily surrendered to the Government, others supplanted by the General Government, because of failure to comply with government regulations, and others superseded by direct authority of law.
The diseases excluded from the country by the national quarantine establishment are cholera, yellow fever, smallpox, typhus fever, leprosy and plague.
Some quarantine stations are inspection stations only, but many are large institutions, comprised of hospitals, quarters, barracks for detention of crews and passengers, wharves and disinfecting machinery, and boarding vessels, all requiring good administrative ability on the part of the commanding officer, who must also be expert in the detection of disease.
When a ship from a foreign port arrives off a port of the United States, it is met by a quarantine officer for inspection under the national regulations. Fifty medical officers of the service are engaged in this work at forty-seven separate stations, extending along the Pacific, the Gulf and Atlantic coasts from Alaska to Portland, Me. Without the quarantine certificates given these officers and the bill of health obtained at the foreign port, the ship would not be allowed entry by the collector of customs and without his permit it would be unlawful for the ship to unload its cargo.
At a few ports, not more than three or four in number, this inspection is made by a State quarantine officer, a relic of the system which prevailed prior to 1893, when quarantine was considered a State rather than a National function. They are obliged, however, to enforce the National regulations, and are subject to inspection by the Federal officers, and if they fail or refuse to comply with the United States regulations the President is authorized to detail an officer of the Government for that purpose.
In addition to the diseases remanded by quarantine, others are excluded under laws relating to immigration, and for this purpose at the principal ports of entry there are also stationed seventy medical officers, who, during the past year, for example, examined more than 1,280,000 immigrants, certifying more than 30,000 of them on account of physical and mental defects. The immigration laws exclude persons afflicted with any loathsome or any dangerous contagious disease, or having mental or physical defects which may affect their ability to earn a living.
Humanity requires the treatment in hospital of immigrants arriving sick with ordinary as well as prohibitive diseases, and the large hospitals connected with the stations are under the professional conduct of service officers.
Although the immigration stations are under the control of commissioners attached to the Department of Commerce and Labor, nevertheless the medical officers are subject in their professional work to supervision by the Public Health Service, and their instructions as to the medical inspection of aliens are prepared by the Surgeon-General and approved by the Secretary of the Treasury.
THE SANITATION OF FOREIGN COMMERCE.
At certain foreign ports and at certain times, depending upon the presence of the various quarantinable diseases, either in the foreign ports of departure or in the country contiguous thereto, officers of the Public Health Service are detailed by the President to serve in the offices of the American consuls, to assist them in enforcing the quarantine regulations for foreign ports. These officers keep themselves informed of the prevalence of contagious disease in these cities and the surrounding country. They sign a bill of health which certifies that all the regulations required to be enforced at foreign ports on vessels leaving for the United States have been complied with.
This involves a knowledge of the point of origin of the freight and passengers, disinfection of material from an infected locality, the personal inspection of passengers, particularly steerage passengers, and their detention if necessary. The power of enforcement of these regulations lies in the above mentioned act of Congress approved February 15, 1893, which imposes a penalty of $5,000 upon any vessel from a foreign port seeking to enter a port of the United States without this consular bill of health. The consul can legally refuse a bill of health if the regulations are not complied with.
In this connection it may be said that officers of the Public Health Service are stationed constantly at such ports as Hongkong, Shanghai and Amboy, in China; Yokohama and Kobe in Japan; Salina Cruz, Manzanillo and Puerto Mexico in Mexico; Guayaquil, Ecuador; La Guaira, Venezuela, and Havana, Cuba. During the summer of 1911, on account of cholera conditions prevailing in Italy, Russia and France, there were officers of this service detailed in the offices of the American consul at Naples, Genoa, Palermo, Messina and Catania, in Italy, at Libau in Russia, and at Marseilles, France. In addition to this, officers were ordered to several other foreign ports of departure, there to confer with the American consular officers as to the enforcement of the regulations for foreign ports, and for the purpose of insuring uniformity of procedure.
The State Department has done much to assist in the quarantine and sanitary work in foreign ports, through the interest it has aroused in the said work on the part of its consular corps.
THE OBSERVANCE OF INTERNATIONAL SANITARY TREATIES.
These treaties or conventions establishing them have been ratified by the Senate of the United States, as well as by the other governments.
The International Sanitary Bureau of American Republics at Washington was founded by the International Conference of American States held in the City of Mexico in 1901. That conference also called for international sanitary conventions, which are now held every two years. Two have been held in Washington. The object of the conventions is to freely discuss all matters relating to the public health and particularly those which affect the American Republics, and the purpose of the international Sanitary Bureau is to encourage the execution of the resolutions or agreements decided upon by the conventions. The convention held in Washington in 1905 drew up a treaty with regard to the quarantine treatment of cholera, plague and yellow fever, which was signed ad referendum by the official delegates, and has been confirmed by practically all of the American Republics. At the meeting in Mexico in December, 1907, action was taken which has brought the International Sanitary Bureau at Washington into relations with the International Office of Public Hygiene at Paris.
The International Office of Public Hygiene at Paris was formally inaugurated December 9, 1907. It is the outgrowth of international sanitary conferences at Rome, Venice and Paris, with regard to the bubonic plague. The following governments are represented: Algeria, Argentina, Australia, Belgium, Bolivia, Brazil, British India, Bulgaria, Egypt, Canada, France, Great Britain, Holland, Italy, Mexico, Peru, Persia, Portugal, Roumania, Russia, Servia, Sweden, Spain, Switzerland, Tunis, Turkey and the United States.
Each of these governments has agreed to pay its pro rata of the expenses necessary to maintain the international office. The principal object of the office is to collect and bring to the knowledge of the participating States facts and documents of a general character relating to public health, especially as concerns infectious diseases—notably cholera, plague and yellow fever—as well as the measures taken to combat these diseases.
PREVENTION OF THE SPREAD OF INFECTIOUS AND CONTAGIOUS DISEASES.
These operations are conducted under two laws. One is the national quarantine act of 1893, already referred to, which contains practically the same provisions for interstate as for maritime quarantine. The other is the annual law passed by Congress appropriating an “epidemic fund” which contains a provision that it may be used in aid of State and local boards of health in the enforcement of their quarantine regulations, as well as those of the national service—to be used, however, only against certain specified epidemic diseases, viz., cholera, yellow fever, smallpox, typhus fever and bubonic plague.
Now, with these two laws in hand, and when the appearance of any of the above-named diseases in any State so require, the officers of the Public Health Service are at once upon the scene with the double object of seeing that the Treasury Interstate Quarantine Regulations are enforced by the State or local authorities and to offer aid, as authorized by law.
When aid is extended, the Government’s funds must be expended by its own officers, and the latter are therefore placed in charge and have the co-operation and assistance of the State or local authorities. They have, therefore, the support of the State and local laws and regulations, as well as those of the Federal Government. This is fortunate, since experience has shown the importance, in a Republic like ours, of local sympathy and support.
THE COLLECTION AND DISSEMINATION OF SANITARY INFORMATION.
The Public Health Bureau, through its Division of Sanitary Reports and Statistics, compiles and publishes each week a pamphlet called the Public Health Reports. It contains a statistical report from all cities in the United States of more than 10,000 inhabitants, and some others, giving the morbidity and mortality in each city with regard to twelve diseases and the total mortality from all diseases. It contains also a statement of the weekly mortality in some 120 foreign cities from thirteen communicable diseases. It gives special information concerning quarantinable diseases and sanitary measures in the United States and foreign countries. The foreign information is received through the United States consuls and service officers abroad.
Collective investigations are being made of the prevalence of pellagra, infantile paralysis and leprosy.
A compilation has been prepared of state laws bearing upon reporting diseases, with a view to increasing the collection of morbidity statistics and bringing about improved methods and greater uniformity in their collection.
CONDUCT OF SCIENTIFIC RESEARCH.
In the District of Columbia, in a commodious building, the Public Health Service has its hygienic laboratory, a research laboratory exclusively for public health investigations. It is conducted in four divisions, viz., bacteriology and pathology, chemistry, zoölogy and pharmacology. This organization brings under the same roof, and in intimate association, scientific workers in each of these several branches, interesting facts developed in one line of investigation being made freely known to the investigators in other lines of research.
Officers are detailed to receive instruction in this laboratory, thus enhancing the scientific attainments of the corps and giving opportunity for selection of those best qualified for permanent detail in research work. In this manner specialists have been and are being developed on various subjects, such as typhoid fever, pellagra, hookworm disease, infantile paralysis, scientific disinfection, etc.
Public Health Service officers may be found in the States investigating other diseases than those named in the epidemic law, viz., typhoid fever, infantile paralysis, cerebro-spinal meningitis, hookworm disease, malaria, pellagra, dengue fever, milk sickness, etc. These investigations are usually made at the request of State health authorities. The bureau at Washington, on receiving a request from a city or locality for expert aid, invariably refers the request to the State Board of Health before compliance.
The laws permitting these investigations are, first, the interstate section of the quarantine law of 1893; and second, the act of Congress approved March 3, 1901, providing a building for the hygienic laboratory for investigations of contagious and infectious diseases and matters relating to the public health. As the investigations require laboratory examinations, they come within this last named law and the appropriation which supports it.
In various States of the Union, there are thirteen establishments engaged in the production of vaccines, antitoxins and serums, which play so important a part in modern therapy. The variation in the potency and the occasional impurity of these products caused Congress to pass an act July 1, 1902, requiring a license for their manufacture for sale in interstate traffic.
ENFORCEMENT OF SANITATION IN FEDERAL TERRITORY.
In the Philippine Islands, where the government is by commission and a legislature, much work of value to the public health is performed in the bureau of science under the insular government. There are, however, in the several ports of the Philippines medical officers of the Public Health Service under appointment from the Treasury Department in Washington, engaged in the transactions of both incoming and outgoing quarantine. Two of these officers, in addition to their supervision of the national quarantine, are also director and assistant director, respectively, of the public health of all the Philippines.
In Hawaii you will also find medical officers conducting the national quarantine. They are also assisting the territorial health board in preventing the recurrence of plague by the extermination of rats and continuous bacteriological examination of those captured. One of these officers is the official sanitary adviser of the Governor of Hawaii, and is carrying on a campaign for the eradication of disease-bearing mosquitoes.
Here also may be observed the leprosy investigation station, also controlled by our officers, both on the island of Molokai, where hospital and other accommodations have been erected under the law of March 3, 1905, appropriating $100,000 for this purpose, and at the receiving station at Honolulu, where cases are seen in the earlier stages.
In Porto Rico public health officers are enforcing the United States quarantine regulations under the acts of Congress relating to Porto Rico and national quarantine. The campaign which has practically eradicated plague from San Juan is being conducted by the Federal Public Health Bureau.
In the Canal Zone you will find two commissioned officers enforcing quarantine regulations at Ancon on the Pacific and Colon on the Atlantic. These officers are loaned to the Isthmian Canal Commission. This is an important adjunct to the work of the canal, because it would be useless to clean the zone if fresh importations of disease were permitted.
I will now devote a few words to the Health Bureau organization in Washington by means of which all the functions or activities above described are administered under one head.
THE ORGANIZATION OF THE BUREAU OF PUBLIC HEALTH SERVICE.
The law which changed the name of the Marine Hospital Service and made it a Public Health Service was approved July 1, 1902. This law fixed the status of the officers, enlarged the hygienic laboratory and gave it an advisory board, provided for the conferences with the State and Territorial Boards of Health, provided for compilation and publication of statistics, and directed that the President should prescribe rules for the conduct of the service and the uniforms of its officers and employes.
It also provided for a Public Health and Marine Hospital Bureau at Washington.
By an act of the Congress approved August 14, 1912, the name of the Public Health and Marine Hospital Service was changed to Public Health Service. The public health functions and duties of the service were extended and certain changes were made in the salaries of the officers.
The Public Health Service is under the supervision of the Secretary of the Treasury, and is in charge of the Surgeon-General, who has six Assistant Surgeons-General in charge of the Bureau Divisions. These divisions are as follows:
1. Foreign and Insular Quarantine and Immigration.
2. Domestic (Interstate) Quarantine.
3. Personnel and Accounts.
4. Marine Hospitals and Relief.
5. Scientific Research and Sanitation.
6. Sanitary Reports and Statistics.
The above lengthy description of our present public health activities has been necessary not only in order to demonstrate their character, and scope, but also as an illustration of the variety of legal authority existing for the enactment on the part of the general Government of public health work.
This paper will not admit of the incorporation into it of the national laws relating to public health which are now operative, but a careful inspection of these laws will demonstrate that they will admit of such interpretation as would make possible an almost unlimited amplification of our present public health activities, the limit being only one of appropriations and officers.
Careful analysis of the present health laws and activities will also show that the Government is seeking to control nothing which any other public health organization would wish to control. The foundation of the national public health service is in the quarantine law of February 15, 1893, referred to above. The quarantine service is today almost entirely national, notwithstanding a local sentiment for State or municipal control, which exists in two or three cities only, and which it is believed is destined to a short tenure for the following reasons:
It must be admitted that maritime quarantine should be a national affair. It is a concomitant to commerce, over which under the Constitution the national government has absolute control, and it naturally belongs to that department of the government regulating commerce in other respects. In other words, it seems especially appropriate that quarantine should be one of the functions of the Treasury Department which registers, licenses and enrolls all merchant vessels of the United States, inspects the hulls, boilers and machinery of such vessels, determines the number of passengers which said vessels may carry and provides for the housing and rations of the crews.
Besides this, it carefully examines all pilots upon American vessels and determines upon granting them licenses. It enforces the navigation laws and aids vessels in distress by an efficient revenue cutter service. It also provides for the care of the sick of our merchant marine. Then why should it relegate to a State authority, or health officer of some small port, the one remaining act of surveillance over vessels, namely, the determination as to whether they may be admitted to entry from a sanitary standpoint? Why should it be left to a local appointee, responsible only to a mayor or governor, the power to determine whether all the people and the merchandise on vessels destined for all ports of the United States, shall be permitted to enter without detention; and why should it give this local officer power to detain such vessels; and further than that, why should such local officers desire that power?
In the same way, the other activities of the Public Health Service conflict in no way with the functions and prerogatives of the State and local boards of health. Therefore, the term “national health control” is a misnomer. The term “national health co-operation” would be much more descriptive of the conditions actually existing. The interstate health activities above described must of necessity be governmental functions. The duties and responsibilities connected with them could not be discharged by States with any degree of uniformity. Therefore, interstate commerce laws are considered as appropriate national enactments, and their operation encroaches upon no State or municipal rights.
It may be said with a feeling of conviction that the health control in the United States today is just exactly in accordance with the desires of the people. The people know that their State and municipal boards are being aided by the health activities of the national government rather than being encroached upon. In addition to this the Federal Public Health Service and the State and municipal boards are acting in harmony to the following ends: They are controlling commerce, in order that commerce may not be clogged, and where necessary they are laying the net of healthful restraint for purposes of good.
The government is receiving the good-will and co-operation of the State and local health authorities in its work of catching and throwing back the diseased persons who seek entrance to our shores in the great Waves of immigration. They stand together to check the merchant or the manufacturer when he is ready or willing to risk the lives of the people by furnishing improper or impure food or drug products. They stand together to frustrate the lawyer who seeks by illegal technicality in the behalf of an individual, or steamship company perhaps, to force a way around a sanitary barrier erected for the protection of the people at large. Again, the municipal, State and government health authorities are standing together to stimulate the knowledge of our legislators in public health needs and are combining their knowledge to insure reasonable appropriations for the carrying out of general public health projects.
The mission of the three classes of sanitarians above mentioned may go still further. It may go to the extent of prodding the conscience of the tardy doctor, and even to the sweeping aside of the sentimental obstructions which the unenlightened are able to put in the path of the conservation of life. There is ample law for present and probably for future needs, and the control of national health remains, after all, today where it has remained in the past, and where it always will remain, that is, with the American people, not solely with the government, nor with the State or municipal health agencies. Each of the great nations of the world has gone about the direction of its public health work in its own way, and always with the realization that the ideal is not necessarily the practical, and what is best today may be supplanted by better tomorrow.
To summarize the situation, we have today State boards of health in control of State sanitation, operating under proper and ample State law. We have municipal health organizations operating under their own legal authority, and finally we have the United States Public Health Service, operating under several laws, as stated before, more far-reaching in their scope than is indicated by the activities pursued under their authority. The people, apparently, are satisfied so far as the Public Health Service is concerned. When the people want anything more they will demand it, and if available appropriations will not admit of compliance with such requests they will be forthcoming. Therefore, I am at a loss to suggest what additional health legislation is necessary or desirable to be engrafted upon that already existing in this country, and I am unable to see the necessity for any different plan of organization so long as the people, in whose behalf the organization is being maintained, are satisfied.
In closing, I wish to say that I have endeavored simply to place various facts before this Congress, and while I do not pretend to have exhausted this branch of the subject, I fear that I can not say the same with regard to your patience.
President White here requested Dr. Henry Wallace, of Des Moines, Iowa, to take the Chair.