Address, “Vital Statistics and the Conservation of Human Life”
Mr. Farquhar—Mr. Chairman, Ladies and Gentlemen: Yes, I have been interested in this subject for perhaps seventy years of the seventy-five years of my life. I am very much interested in the work done in Pennsylvania. I shall refer to that, as is proper in a man sent as a delegate to this Congress by the Governor, and I believe it is a good example to other communities.
Vital statistics are usually assumed to cover only the number of births and deaths occurring in a given territory within a given time, a subject not attractive to the general reader, but this address will be devoted more particularly to the objects for which and the agencies by which such statistics are assembled, which is far more important and interesting, especially as it includes the social questions they resolve for us. “It is sometimes said figures rule the world; but this at least is true, that they show how it is ruled.” To this saying of a wise man may be added that they also show how it might be or should be ruled; they best illustrate “philosophy teaching by example,” because most precise and definite in form of presentation. They are of most use when applied to the most important interests of mankind, and have no higher function than in bearing their part in safeguarding the nation’s health.
For its vital statistics the Federal Census Bureau has always had to depend on data collected by local agencies, and of the imperfection of those agencies, and especially the large territory for which there were none—no attempt to keep the official record of births and deaths, it has loudly complained. Notwithstanding the commendable efforts that have been made throughout the country to supply deficiencies by State legislation, so much remains yet to be done that a census report, as late as 1907, showed less than half the population of the country, and only a third of the States in number, within the registration area. But the movement has been forward, and it is gratifying to note that the most significant step in advance was made by Pennsylvania, in a law creating a state department of health and fixing its duties in 1905. Until then that commonwealth was said to have “the poorest registration of any of the Eastern States,” though its first law for the purpose had been passed fifty-four years earlier; but “it had in 1906, the first year of the operation of the new law, an effective registration of births and deaths practically as complete as that of any registration State in the country, and far superior to the majority.” The best point about the law of 1905, and its most significant difference from that of 1851, is that it is executed. Obedience is no longer optional, but compulsory. Authority under it is centralized in the hands of the Governor, Attorney-General and Commissioner of Health, and practically for most purposes in those of the Commissioner.
The total appropriations for work under this department since 1905 have been $9,286,080. The number employed by its various divisions is 3,625. Of this number there are 1,170, nearly one-third of the total force, who are local registrars in the vital statistics service.
With what is so large a force to occupy itself? The 1,170 registrars receive all birth and death certificates and issue all burial permits (to which registration is a prerequisite), and the bureau has also charge of marriage certificates, filed with it by the clerks of county courts. The medical inspection division establish quarantine under direction of the county inspectors, see to placarding houses and disinfecting them after cases of communicable disease, guard against the sale of milk from premises where any such diseases are found, and represent the department in co-operation with local health boards. Supervision of the medical inspection of schools forms also an important part of the duty of these officers, some 300,000 children having been examined during the past school year. At the free tuberculosis dispensaries, with which the department has provided the large centers of population, the indigent receive free medical advice and necessary supplies. The commissioner has supervision, by the act creating the health department, of all systems of public water supply and of public or private sewage disposal. Detailed plans must be filed with the department, and no new construction can be done until the Governor, the Attorney-General and the Commissioner have approved the plans. The biological products division distributes, through 656 stations in all parts of the commonwealth, free antitoxin to the poor. The stations are located as impartially as practicable.
What has been accomplished by all this equipment, discharging all these functions, cannot be completely told; a few figures may be given, with a result here and there, and the rest left to estimate of probability. For example, the statement that 6,724 patients were admitted to the Mont Alto Sanatorium in the four years 1907–1911 certainly indicates the magnitude of the problem, and the importance of giving it the best attention we can. It is perhaps a little more significant that 58,004 patients have been treated in the department’s tuberculosis dispensaries since they were organized. The activity of the sanitary engineering division is clearly shown in its recorded count that up to June, 1912, 40,447 private sources of stream pollution had been abated on notice from the department. One hundred and eleven modern sewage-disposal plants have been built or are in process of building, 306 municipal and private sewer systems are under construction in accordance with plans approved by the health department. Ninety-seven modern water filtration plants have been or soon will be constructed under State approval. It is worth while to connect with this fact another even more gratifying: the death rate from typhoid fever in Pennsylvania, which was, in 1906, 565 per million inhabitants, had fallen to 206 per million in 1911. As a final instance, the death rate from diphtheria, a little over 42 per cent. in untreated cases, has been reduced in the average of the 35,111 cases treated with antitoxin between 1905 and December, 1911, to 8.07 per cent., or less than one-fifth. Further, a certain district having been set apart for the trial of 5,000 units, instead of the usual 3,000, as an initial dose of diphtheria antitoxin, the death rate in that district has now shown a reduction to 4.22 per cent.
This story is not told for the mere satisfaction of praising our Keystone State or its faithful and capable public officers, though for that, too, it affords opportunity. Its function is to point a moral, to indicate a course of treatment of the subjects of vital statistics and public health, which, as Pennsylvania’s experience leads me to believe, may well be applied to a wider field than Pennsylvania. It is not by accident that the association of statistics of births and deaths and marriages, with a State office for the promotion of public health, has come into favor at the same time in so many parts of the country. The force of example is something, to be sure, as is also the circumstance that a physician is usually at hand, when a birth or death occurs, that he is apt to know what there is to tell about the occurrence, that he is apt to know how to report, and that the State health office is one to which a physician might naturally address himself. But more important than these considerations is the value of birth and death records in the conservation of the people’s health. From the greater or lesser number they show the favorable or adverse effects of accompanying conditions can be judged, and a conclusion reached as to how such conditions should be regulated. Nor could any condition be more important to regulate than those affecting health. The people’s health is its most precious asset. Dr. Wiley says he “would rather be a strong, vigorous man without a dollar than a sickly millionaire,” and thus indicates the pecuniary value of health to an individual. Multiplying that value by the number of the population, the amount becomes fairly appalling.
We have a department of agriculture expending vast sums—nearly fifty millions in the last decade—in improving the soil, improving the growth of vegetation, improving the health of animals, and no department to do anything to improve human health. We spend $700,000,000 a year for past and imagined future wars, and pay no attention to the 700,000 calculated above—a larger number dying every year, unnecessarily from disease, than bullets have slain since the continent was discovered. As we are reminded by Dr. Dixon, our Pennsylvania health commissioner, we are spending millions a year for the protection of our forests and water supply and other natural resources, but it is no credit to our intelligence that while guarding these material interests we allow man himself, without whom all else is worthless, to remain unguarded.
Yet it is a mistake to say that we do and have done nothing; what has been done is greatly to the credit of mankind, only it has not been enough. Jenner’s discovery and his application of it has left no excuse for smallpox anywhere. The president of the board of health in Mexico assured me that compulsory vaccination had freed his city of smallpox; and the Japanese health authorities, since their enforcement of compulsory vaccination, have ceased altogether to look upon the presence of smallpox as a source of danger. It is no longer a scourge in the Philippines and Cuba. Similar to the work of Lister in antiseptic surgery is that of Pasteur and Koch in various germ-diseases, of King and Carroll and Lazier in mosquito-transmission of infection. With the elimination of the Stegomyia mosquito, yellow fever is no longer dreaded; Havana and the gulf ports are as safe as anywhere; and the construction of the Panama Canal has become possible—as, but for the discoveries by Carroll and Lazier (or their rediscovery of Dr. King’s discovery) it never could have been.
From the brilliant successes attained in the directions just indicated, we seem to see that the most important thing for us is to know; we are to find our safety in knowledge. When we know that malaria is inoculated by the bite of the mosquito Anopheles, and yellow fever by the mosquito Stegomyia, that typhoid fever is fed to us, in a large proportion of cases, from the feet of the house-fly, that the fearful bubonic plague is inoculated by the bite of a flea infesting the rat, we have already traveled more than half way to deliverance. We can drive off the mosquito, or, by oiling the puddles, prevent her from hatching; we can “swat the fly,” or abate the manure-heaps and other filth from which it draws its unblest being; and, if we can not catch the flea, we can make war upon its host, the rat. If, as is computed, within the last 2,000 years 2,000,000,000 people have fallen victims to the bubonic plague, it is enough to justify wholesale enlistments in a grand rat-hunt.
Half a century ago people were afraid of night air, and closed their windows at night. It is hard to guess how many lives might have been saved by opening those windows. We are told that the average duration of human life has doubled in the last 200 years. Whatever gain there has been is due, more than anything else, to more knowledge.
The case of pure air as against contaminated air is but one way of putting the general case of cleanness against foulness. Bad air has the same vices that attach to dirt in other forms; one of the uses of more knowledge is to be able to detect dirt in all forms, however concealed or disguised; and another is to discover the best means of sweeping it away. Our ancestors used to drink water from pools and wells that were sinks of organic filth, to worship in churches built over an array of corpses in all stages of putrefaction, to wear the same suit of leather clothes, day and night, till they fell apart or the wearer outgrew them—all because they knew no better. They had no conception of the disgust with which such habits were to be regarded by a more educated posterity. Now the golden rule of health is “Wash you—make you clean!” It is not enough to make, or even to keep, the children’s faces clean; we must look no less to the cleanness of the lung passages, of the alimentary canal—yes, of mind and heart also.
Morally and esthetically, there is nothing in relation to which the duty to be clean is more stringent than the reproductive function. The source of the greatest work in all God’s creation, the human race, ought more than all else to be pure; and the necessary condition of our endowing the earth in coming ages with a better human race than it now has, or has ever had, is that we provide that coming race with the best kind of parentage. The quality of the next generation is determined by the quality of this generation; it will be in most respects as we make it, clean if brought forth in purity, foul if engendered in foulness. And the truth so strikingly evident in the moral and esthetical view is even more clear in the view we are here taking, that of the race’s health. To sexual impurity, by the testimony of the best physicians—the illustrious Dr. Osler for instance—more physical degeneration is due than to any other one cause. Dr. Prince A. Morrow, president of the Society of Sanitary and Moral Prophylaxis, estimates the number constantly ill from syphilis in this country—although that number has of late been considerably reduced—as still no less than 2,000,000. The syphilitic poison is communicated by inoculation—a contagion that has no danger for us so long as held at a respectful distance; and the essential point in guarding against it is to preserve that distance. Like the venom of the rattlesnake it is best known in a knowledge of its lurking places. It was first recognized in Europe, some time in the fifteenth century; and it came from the Orient, not of its own initiative, but because Europeans went after it and fetched it. Similarly now, a man does not have it unless he goes after it. There is nothing in the whole range of human disorders that shows more emphatically than this, the feebleness and inadequacy of the best possible cure as compared with prevention. Knowledge seems all that is needed for complete prevention; any young man, having more than the resolution and self-control of an infant or an idiot, ought to require nothing more than an elementary acquaintance with a few facts that should be at the command of every instructor of youth, to insure his leaving the syphilis and gonorrhea factory permanently alone. If their baleful function were made clearly known to those who most need to know it, the entrance door to every such temple of moral and physical ruin would carry to the eyes the sign that greeted those of Dante: “All hope abandon, ye who enter here”—a prospect whose unrelieved blackness looks even darker when contrasted with the brilliant glory of the hope relinquished. It is a law of our human constitution that the richest, deepest, keenest joys that life has for us are those that come from the contrast of two sexes. Even when that contrast is hostile, there seems to be some pleasure in it; but immeasurably more when it is an incident of ardent attraction. Byron in one of his earlier poems thus puts it:
“Devotion wafts the mind above,
But Heaven itself descends in love;
A feeling from the Godhead caught,
To wean from self each sordid thought;
A ray of Him who formed the whole;
A glory circling ’round the soul!”
It is too well known that the poet’s own loves, in after years, were not always of this ideal quality; but no one ever better set forth the exalted possibilities of the sex sentiment, to which the continuance of life on earth is due. But the worst, we are often reminded, is the corruption of the best, and it is another possibility of the same sentiment that it may urge a man to blast his whole future by incurring an incurable disease, and sadder yet—too often to involve others, tender and innocent lives, in his own condemnation. If more knowledge can ward off such a grisly fate, it is surely inhuman cruelty not to supply that knowledge, however disagreeable the duty may appear. When clearly seen as a duty it will be no longer disagreeable.
While making this call for more knowledge of vital truths primarily on account of the young men, since it is in the vast majority of cases the man who tempts, the man to whom the outcast woman owes her fall, it would be the wildest folly to stop with one-half of the rising generation. The future of the race is too dependent on its mothers to excuse or permit the neglect of any preparation of them for motherhood, which health in its fullest sense may demand.
Most of the great questions of health in its widest sense, of health as a public concern, resolve themselves into resisting the entrance of this or that species of bacterial germs into the body. The essential distinction between Mother Earth, that bringeth forth flowers and fruits, and grass for our herds, and dirt or filth, the especial opprobrium of the hygienist, is that the latter carries germs of bacteria. Cleanness, in the hygienic sense, is freedom from pathogenic germs; and when the doctors tell us that the marked improvement in health conditions recently observable in Germany and Switzerland, and pre-eminently in Sweden, is due to their exceptional attention to cleanliness, they use the term with particular reference to the provoking causes of preventable sickness. Not only is the death rate from the acute diseases in those lands rapidly falling off, but diseases of the chronic class are beginning to yield to the inculcation of better habits among the people.
We are by no means without instances in this country, of death rates reduced by preventive methods, as shown for young children in our largest cities after the introduction of pasteurized milk. Deaths have been thus spared for that peculiarly helpless class of sufferers, to the extent of fully 50 per cent. in some districts—in large measure through the well-directed activity of one public-spirited New York merchant. But we have much to do in other lines, and we have only begun to free ourselves of the typhoid fever incubus. As late as fourteen years ago there were 11,000 cases of that infection in the camp at Chattanooga, with 800 deaths. In the entire Spanish war the deaths of our soldiers from diseases, it was calculated, were thirteen times as many as from wounds in battle—the diseases mostly, like the Chattanooga typhoid, of the preventable kinds.
Loss of life by preventable accidents, on railways, in factories and mines, is too closely associated with that by diseases to be here omitted, though entitled to much fuller treatment than we can here afford. The deathroll from this cause is still disgracefully large in this country, far surpassing any country of Europe; but there are signs already of diminution. For instance, one steel factory, reporting 43 accidental deaths among 6,000 employes in 1906, showed only 12 fatalities in a payroll of 7,000 in 1909, safeguards having been introduced in the meantime. This instance is very good, so far as it goes, but we need to make much more progress in the same direction.
What we want is systematic effort, by some powerful consolidated agency, to promote the conservation of human life. We have no need to find fault with any of the organizations now engaged in furthering that end, several of which are doing good work. We may gratefully acknowledge the aid of the various medical societies, “regular” and “irregular”—though we take the liberty of wishing that they might fight the common enemy a little more and each other a little less. We may also welcome the assistance of the life insurance companies, notably the Equitable and the Metropolitan, whose managers clearly realize how their interests are involved. Whatever lengthens the average term of human life is a factor operating to increase their dividends and to reduce the cost of insurance to their policyholders. It is worth while to note, at this point, that the majority of life insurance officers are strong advocates of the formation of a national bureau or department of health.
Still more do we owe to the activities of State and municipal boards of health, which do more good because they have more power. Where properly supported they have done a great work, at obstructing the spread of epidemics by quarantines and other methods of isolation, at curing pollution of water supply, at instituting improved sewer systems, at bettering the general food supply by inspection of markets. You have just heard a condensed account of the activities of one of our best State health departments, that of Pennsylvania. You will infer from what that department has done in seven years what might be done by a national bureau or department, with powers and field of operation extending over the entire country.
The movement for a bureau or department of health, national in its scope, has been most actively advanced in Washington by Hon. Robert L. Owen, Senator from Oklahoma. His bills call for a department, and he gives strong reasons for the view that such an organization would, while that of a bureau would not, suffice for the national governmental activities in behalf of the public health. President Taft strongly urges a “Bureau of Public Health,” and plainly intimates a preference for the bureau plan. The “Committee of One Hundred on National Health,” formed by the Association for Advancement of Science, in 1906, with Prof. Irving Fisher as its president, originally contemplated a department whose head should be a member of the President’s cabinet, but it has in its recent publications adopted the alternative phrase “bureau or department,” which course is here followed, because there is manifestly nothing to gain by keeping up a contest on the point. The memorial prepared by the committee of one hundred proposes for a national department of health certain functions, as follows:
1. Administration—Including the national quarantine work, and whatever regulation of interstate commerce might affect human health, such as meat inspection and enforcing the food and drug act.
2. Co-operation—The work of assisting State, county and city health agencies, after some such fashion as the National Department of Agriculture co-operates with State agricultural colleges and institutions.
3. Research and Investigation—The work of obtaining needed scientific information concerning the cause and prevention of diseases that now shorten or impair human life; this would include a study of accidents, of poisonous manufacturing trades, of hygienic conditions in schools, etc., just as yellow fever was studied in Cuba, as the hookworm is now to be studied under private endowment, as the work of the Pasteur Institute was conducted under French government support.
4. Education—The work of supplying to the country scientifically established data on matters pertaining to health, such work as is done by the “publication division” in most of our governmental departments; thus rendering available for practical use the work of research and investigation. The countries in which is found the most rapid reduction of the death rate are just those (Sweden for example) in which the spread of a knowledge of hygiene is widest.
Of these functions the mere statement is a most powerful argument for the bureau or department suggested. It only remains to remove a few misunderstandings. One objection, for example, is powerful in many minds—that such a centralized office must necessarily be the organ of a particular medical school, and must so give that school—the one denominated “regular,” for example—an unfair advantage, unsuited to a government of liberty and equality. To this it may be frankly replied, that the primary objects of the new office being the four just stated (administration, co-operation, investigation, education), it would aim to collect and diffuse the greatest attainable amount of accurate knowledge on the subject of health; and that if it found a larger quantity of better knowledge in one school than in another, it would be false to its trust if it did not spread that knowledge accordingly. Personally, the writer finds it hard to believe that it could treat a school that taught the unreality of disease, or the surpassing value for all kinds of disorders, of drugs, of a narrow range of characteristics, on an exact equality with schools that deal with facts as they find them; but he heartily agrees that the citizen ought to enjoy the liberty of choosing his own medical advisers, so far as he does not endanger life or health by so choosing.
There are other objections to organized national work for health, many of them from a so-called National League for Medical Freedom, the most active workers in which have been shown to be interested in one or another kind of proprietary medicine, backed by some “mental healers,” and by associations of druggists who object to the “pure food and drugs act” of 1906. Several homœpathical State societies have repudiated that “league for freedom,” and have emphatically attested their approval of the proposed bureau or department of health; this, notwithstanding their well-understood grievances against “regular” practitioners. Some of the best informed among the osteopaths and the Christian Scientists are pronouncing similarly; and so, if the disavowals keep on, the League of Medical Freedom may soon be left with only those who seek freedom to dope their victims with drugs that enslave; stupefy them—infant and adult—with opium and thinly disguised alcohol, and generally to reverse the progress of a century. But, since it is estimated that $75,000,000 a year are expended by our fellow-citizens for patent medicines, it is easy enough to see how they must regard a national department which is to improve the sanitary conditions of the country, show people how to care for health, stop the sale of poisonous nostrums and impure foods, and end the career of opium under the name of “soothing syrup.” Their profits would be gone, and of course they disapprove and protest.
Altogether, the cause of a national bureau or department of health is commended, both by those who favor and those who oppose it. It could not ask better advocates than the distinguished men who heartily favor it, on the congressional or the collegiate stage; nor more suitable adversaries than those constituting the League for Medical Freedom.
President White—This is a most valuable paper, and it will be printed, together with the other papers and addresses of this convention. Every one should avail themselves of the opportunity to subscribe for this book, which costs one dollar.
I will now introduce to you the gentleman who kindly gave his hour to Mr. Farquhar. He is Mr. Reginald Pelham Bolton, of New York City, who will speak to you on “The Prevention of Elevator Accidents.”