II.—THE COST.
In order to establish a sure ground for estimate as to the economic drain of this disease upon this community, a concrete study of the cost of typhoid in six selected wards of Greater Pittsburgh was undertaken by the Pittsburgh Survey. The sections of the city chosen are fairly representative of living conditions among the wage-earning population. Wards 8 and 11, in what is commonly known as the Hill District, represent a congested quarter made up largely of Russian Jews, Austrians and Italians, with a considerable number of Americans and American Negroes. The residents of these two wards are chiefly employes of the small trades and the sweating and stogie industries, clerks, factory hands, common laborers, etc., who are rather below the average scale of earning capacity. They number about 22,000 for the two wards and among them there were forty-four per cent of the cases studied.
Wards 25, 26 and 27 are on the South Side. Their total population is about 33,000; mill hands, mostly of Slavic origin, occupy those parts of these wards bordering the Monongahela River, and a better-off class of Americans occupy the hilltops overlooking the river. The wards would, therefore, represent a rather uneven population, as based on nationality or wage scale, but were not a large factor in this study, as only eight per cent of the cases covered were found in these wards.
Ward 21, the other section selected, is in area one of the largest in the city, lying to the east in what is known as the Homewood District. The population of this ward is about 26,000, living mostly in good homes, with occasional poorer dwellings along the railroad and in some of the "runs." In the main, they represent a high wage or small salaried class. From this section, the other half of the cases studied, about forty-eight per cent was taken.
The period covered by the investigation was one year, beginning July 1, 1906, and ending June 30, 1907. The field work was done by Miss Anna B. Heldman, visiting nurse of the Columbian School Settlement, whose personal acquaintance with many of the families of the Hill District, and whose six or eight years' experience in caring for typhoid patients in this same neighborhood, enabled her to secure in detail many facts that might have escaped a person less familiar with the district or the families concerned.
An analysis of the cases thus studied, shows that there were either reported to the Pittsburgh Bureau of Health, or known to the investigator, but not reported, 433 cases of typhoid fever in wards 8 and 11, 94 in wards 25, 26, and 27, and 502 in ward 21—a total of 1,029 in these six wards within the one year studied. These cases occurred in 844 families. Miss Heldman, five months after the close of this year period, was able to locate but 338 of these families, the remainder having either moved out of the state, or been lost track of by people living in the neighborhood.
There were 2,045 individuals in these 338 families, or an average of 6.4 persons per family. Of this number, 448 individuals, or 22 per cent had typhoid fever within the year. Out of these 448 cases, there were 26 deaths and 422 recoveries, an exceptionally low percentage of deaths to cases.
Line representing 8,149 people who have died from typhoid fever in Pittsburgh since report of Filtration Commission in 1899 advising necessity of pure water. Standing in marching order, single file, four feet apart, they would make a procession six miles long.
Of the 448 patients, 187 were wage earners, contributing all or part of their earnings to the family income. As a result of their illness, these 187 wage earners lost 1,901 weeks' work, or 36.6 years. This averaged over ten weeks per patient, and represented an actual loss in wages of $23,573.15. In addition, other wage earners lost 322 weeks' work while caring for patients, thereby losing $3,326.50 in wages, and bringing the total of wages lost to $26,899.65.
The other large item of cost is that of expense for care and treatment of patients. Ninety cases were treated in hospitals for all or part of the time, as pay patients, half-charity, or full-charity cases. To meet these hospital expenses, $2,332.00 was paid to hospitals by full-pay patients themselves, and $1,834.50 was paid the hospitals by either individuals or charitable organizations for the care of half-pay patients, making the total cost of caring for 90 hospital patients $4,166.50. This is an understatement, because it omits the contribution of the hospitals themselves to the care of half-charity and full-charity patients. If figures were available, there should be added the amount represented by the difference in the money paid to hospitals and the actual cost of maintenance, presumably another $1,800.[11]
[11] Out of the 448 cases studied, twenty-four of the ninety cases treated in hospitals were as full charity patients and sixteen were taken as half charity cases; of the 358 cases treated at home, fifty received outside aid and ninety-six were compelled to incur a debt for all of their expenses, with no immediate prospects of being able to repay it. Moreover, many received sick benefits and others were a direct drain on the business interests of the city from the fact that their employers kept them on their pay-rolls during sickness, at half pay.
The expenses of the remaining 358 patients cared for in their homes amounted to $12,889.90 for doctors' bills, $1,965.50 for nurses, $2,640.60 for medicines and drugs; $1,810.10 for milk, $629.20 for ice, $861.50 for servants made necessary by the illness of those naturally caring for the home, and $1,204.45 for other expenses, of which the largest single item was the cost of a trip to Colorado and return at the doctor's orders, for a patient threatened with tuberculosis. The total of these expenses was $22,000.35.
The funeral expenses of the 26 patients who died, amounted to $3,186.00. It may be argued that sooner or later funeral expenses must inevitably be met, and that they should not, therefore, be charged against this account. Under the circumstances, however, these expenses were premature, and were directly chargeable to typhoid fever. Consequently, it has seemed fair from the point of view of this study, to include them. The grand total loss in wages and in expenses thus outlined was $56,252.50.
Further analysis shows that the average loss in wages per patient among the 187 wage earners was $126; that the average cost per patient in loss of wages and expenses for the 446 patients was $128; and that the average cost in loss of wages and expenses for each typhoid death among the 448 cases was $2,164.
Consider the losses in these wards in their bearing upon the city as a whole.
There were 5,421 cases of typhoid fever in Greater Pittsburgh in 1907. If the cost to each patient was $128, typhoid fever cost the city that year $693,888 in expenses and loss of wages alone. There were 622 deaths from typhoid fever in Greater Pittsburgh during the same period. If we put the value of these lives lost at so low a figure as $4,000, an additional loss of $2,448,000 was sustained. Or in round numbers $3,142,000 was the minimum economic loss to the community of Greater Pittsburgh, due to typhoid fever alone in the year 1907. This is a conservative estimate, in view of recent values placed on deaths from tuberculosis.[12] The two and a half million dollar death item might be doubled without overstating the case.
[12] Prof. Irving Fisher, of Yale, in a paper read at the International Congress on Tuberculosis in Washington last October, held that "the money cost of tuberculosis, including capitalized earning power lost by death, exceeds $8,000 per death." The average "expectation of life" lost through death from typhoid fever is not greatly different from that of tuberculosis.
When it is considered that typhoid fever has been almost constantly prevalent within the city limits, with practically no abatement, for the past thirty-five years, it requires only a little applied mathematics to calculate the probable enormity of the money loss to the community, through the ravages of this disease alone, year after year. Was it not time for it to stop? In the face of over a $3,000,000 loss last year, $5,450,000 was not more than the city could afford to pay for the filtration plant that is purifying the drinking water. Nor was it extravagance for the mayor and city councils to grant the superintendent of the Bureau of Health an increased staff of tenement house and milk inspectors, to make it possible to clean up other sources of infection, and hasten the time when typhoid fever in Pittsburgh shall constitute a no greater menace than in any other well-kept American city.
I have used the term "economic cost" of typhoid fever with reference to Pittsburgh families. The mere phrase carries with it no knowledge of all those family readjustments and inconveniences, the distress of mind and unalloyed misery that must be considered before we can form any adequate idea of what such sickness holds for a wage earning population. Were it necessary to measure the result of typhoid fever only in cold cash, it would be a relatively easy task. In the first place there are the thousand and one makeshifts and re-establishments that must be reckoned with in order to get a clear idea of what typhoid means to those poorer families, where, without the invasion of sickness, the business of getting bread is a constant struggle. In a family consisting of a man, wife and three children, the sixteen year old daughter, who had not been very strong, contracted typhoid. At the end of sixteen weeks in bed and thirty-two weeks out of work, she had developed a marked case of tuberculosis. Not being strong enough to go back to her former employment, she secured work in a bakery where she was subsequently seen coughing as she wrapped up bread for customers. The father of this girl, during her sickness, was keeping six cows on the premises and selling milk to customers living in the neighborhood.
The twenty-year-old wife of a Hungarian laborer had a six weeks' old baby when she came down with a slow case of the fever. She remained at home for a week with no one but herself to do the work and care for the baby. The husband, who did not realize the cause of her weakness, gave her a beating each day when he came home, because he thought her lazy. He made her carry up coal for the fires until she became so delirious that he could not keep her in the house. She was then sent to a hospital and the baby given to friends. The woman died in a week and the baby two weeks later.
A family of five, consisting of father, mother and three little children, cooked, ate and slept in one uncurtained room. The mother and four year old girl were taken sick at the same time. The girl occupied an Arbuckle coffee box, with a pillow and pillow-case for a mattress, and the man's overcoat was her only covering. The mother slept in the only bed, furnished with a mattress and one small comforter, and shared it at night with the father, the baby and their six year old girl, who lay across the foot of the bed. The girl was in danger of contracting pneumonia from exposure. A family of seven occupied a store and kitchen on the first floor and two rooms upstairs. A small bedroom was the only one which had a fireplace; and the entire family slept there; the mother (who had typhoid), in the only bed, and the father and five children in a row on the floor.
In another family, the six year old boy had the fever, and was found lying on an improvised bed, his little dog tied beside him. The mother had rested the ends of two boards in a china closet at one end of the kitchen, and on a chair at the other, so that she might care for the patient, do the cooking and attend to the baby at the same time. By this make-shift, the father was able to keep at his work.
One family, consisting of father, mother and five children, managed ordinarily with a bed for the parents, a child's bed for the eight year old girl, a two-third size bed for the eighteen and sixteen year old daughters, and a cot for the fourteen year and ten year old sons, one sleeping at each end. First the mother and one of the boys were taken sick, and during the early part of their illness, no one was disturbed. But within a month, and before the first two patients got well, the four other children came down with typhoid, making six in the family sick together. Then the father slept on the floor and the sick mother got out of her bed to give place to two of the children, she, herself, sleeping at the foot of the bed until one of the children became delirious. After that she moved to the foot of the two-thirds bed. In the day time she had no place to lie down, and sat all day in a chair until she became so weak that she could hardly walk. Occasionally she helped her husband who did the cooking and cared for the patients, by paring potatoes and doing other small work about the kitchen. No one had time to keep the kitchen sink clean, and the accumulation of vegetable matter became so filthy that it had to be reported to the Bureau of Health. With family income cut off, and with nothing saved, the family would have been penniless had it not been that the doctor made his bill moderate; the family was trusted for groceries, milk and ice; friends gave about twenty dollars in cash, and Columbian Settlement furnished bedding and the services of a visiting nurse. The mother did not fully recover for about six months. The father, who suffered a good deal from loss of sleep and exposure while caring for the patients, contracted a cold. This developed into a serious case of asthma from which he died.
To these and many similar families there were more serious results than the debts incurred. A school girl's unrecovered health, a stogie roller's reduced speed, a blacksmith's and a tailor's loss of strength, a case of tuberculosis developed, a boy become a truant, a family broken up and deserted, a baby's death,—all are of tremendous concern as items in the annual wear and tear of the city's potential resources. They are items of "economic cost" that cannot be handled by the statistical method. They are, after all, the real human finger marks that typhoid leaves when its clutches are loosened.
Such a showing, then, of actual economic and personal loss as this study of six Pittsburgh wards brought out, is offered as a final leverage to those who in other American cities may be endeavoring to dislodge inertia and clear their water supplies. This investigation of typhoid fever, however, as it was found in the households of the wage earners of Pittsburgh, had its immediate practical bearings. The sanitary facts it brought out showed unequivocally the necessity for ridding the city of other sources of infection at the same time that the water supply was cleared.
There was evidence that many of the after cases in the families studied, were due to conditions existing entirely apart from the water. Reports on housing conditions in Pittsburgh show that a favorable laboratory for the growth and dispersal of germs exists in the city's unsanitary dwellings. Insufficient water supply renders cleanliness almost impossible. Overcrowding means increased possibilities of infection through contact with food and drink in the combined family kitchen, pantry, dining-room, and bedroom. Pittsburgh's thousands of open privy vaults afford ideal conditions for the spread of disease by flies and other insects, and by personal contact. Such plague spots as Saw Mill Run, with its string of double-and triple-decker rear privy vaults discharging on the banks of a stream which are flushed off only when the water rises after a rain, afford further examples, deplorable and disgusting.
How much of the Pittsburgh typhoid has been due to direct contagion from such conditions as these, can only be inferred at the present writing. In line with the general question of contagion, and secondary cause, however, our data afford some clews. They show that in forty of the families studied, the first case was followed in from ten days to one or two months by other cases, seventy-six cases in all, in addition to the original forty. It shows further that in at least eighteen of these families, one or more of the following conditions existed: Family crowded into one or two rooms; home dirty and poorly kept; the person who cared for the patient also doing the family cooking; well and sick members of the family sleeping in the same room and often in the same bed; privy vaults in exceedingly bad condition, and often stopped up and overflowing with filth. In one family, consisting of man, wife, four children and three lodgers, crowded into two dirty rooms, a three year old boy was taken sick in October. The mother did the family cooking and cared for the patient. The cesspool in the yard which was in bad condition was used by two families. Another member of the family became ill November 3, and the mother came down on December 19. There were seven cases in this one courtyard within the year.
In another instance a man, wife, and nine children were living in three rooms. The sixteen year old son was taken sick on June 20 and was sent to the hospital. Then in July came the thirteen year old daughter for whom her mother cared at home. The mother also did the family cooking. The father, mother and eleven year old son all slept in the same room with the patient. All three of them followed within a month, and another son twelve years old, was taken sick in August.
In another family of eight, the sink in the kitchen and the toilet in the yard were in a very filthy condition. The mother and one son were taken sick in August. The sick and the well slept together in the crowded bedrooms. In November four more members of the family came down with the disease, on the sixth, ninth, eleventh and fifteenth, respectively.
Let the reader judge for himself whether or not, in the face of these facts, it can be expected that filtered water alone will solve the problem.
The Pittsburgh Typhoid Fever Commission is a recognition of these facts, and a recognition also from a national and scientific point of view, that probably never again in the history of any large American city will there be such a favorable laboratory in which to study the epidemiological facts of typhoid fever both before and after filtration. The commission was appointed in April, 1908, by Mayor Guthrie; is made possible by a grant from the Russell Sage Foundation, and by the co-operation of the bureaus of health and water, which offered the free use of their laboratories for analytical and administrative purposes. Dr. James F. Edwards is chairman, and the membership includes Dr. Dixon of the State Board of Health, Prof. Wm. T. Sedgwick of the Massachusetts Institute of Technology, and Dr. E. S. Rosenau, of the Public Health and Marine Hospital Service, who has been directing the elaborate governmental investigations into typhoid in the District of Columbia. The following report is made (January 1) by Dr. E. G. Matson, of the Pittsburgh Bureau of Health, executive officer of the committee.
The work of the commission to date has consisted of a minute investigation of all cases of typhoid which have appeared since May 1, 1908, including the sanitary condition of their living and working places. Investigations have also been made into neighborhoods where there appeared to be fewer cases than the average of the city, the milk supply, and the water supply, both public and private. It is remarkable that not even the smallest outbreak has been traced to milk. A particular feature of the study of water supply is that in connection with the acidity of the Monongahela and the eastern affluents of the Allegheny and its effect upon the sewage discharged by an enormous town population into them. So far typhoid has declined greatly in Pittsburgh since January, 1908, as compared with the average or even the minimum of previous years. This decline has naturally been a subject of great interest though it is too soon to give the results of investigations. We have ascertained that this decline has been shared by the towns on the lower Allegheny, which have hitherto been supposed to be the most important source of our epidemics. During November and December, which would represent the first months of the filtered water period, typhoid has been reported from the filtered water area at the rate of the most favorable American cities, and in Allegheny, which receives nearly the same water unfiltered, at about twice this rate.