[9]. However bad certain factory conditions may be, these of themselves cannot produce tuberculosis any more than they can produce scarlet fever or diphtheria. The disease itself must be brought into the factory by a carrier—someone who is himself infected.
Outside-the-home supervision is the next logical step in the anti-tuberculosis campaign. But valuable as this would be, from the point of view of the general health, it cannot be done until the community is prepared to care for all who would undoubtedly suffer as a result. Some patients, of course, would not lose their situations, but the majority would be turned adrift without a moment’s hesitation. These the community must take charge of. Therefore, before we can supervise tuberculosis beyond the boundaries of the home, we must have ample hospital facilities. Hospital accommodation must be so extensive, so complete, and so excellent that institutional care can be given to all who need it.
In this way, the community will be relieved automatically of a vast amount of danger. Patients will either seek institutional care, or, if they continue at work, will do so under conditions which do not jeopardize other people. For the reaction from the first intense phthisiphobia will be a demand for carefulness on the part of the consumptive, and sane toleration of him.
The one objection to this policy of supervision and publicity is the seeming interference with the personal liberty of the individual, but to curtail the liberty of the patient to transmit a communicable disease, is to increase the liberty of hundreds to escape it. There should be no question as to which has the superior claim.
CHAPTER XIX
Municipal Control—The Danger of “Political” Control—“Politics” in the Co-operating Divisions—Results in Baltimore—Tuberculosis and Poverty.
Municipal Control. Tuberculosis is a communicable disease in which the patient himself must be relied upon to protect the community. We depend upon him for whatever protection he chooses to give, and whether this is much or little is determined by his circumstances, temperament, and environment. Whenever his ability or good-will breaks down, we are at his mercy. We may try to overcome his ignorance by education; to substitute ethical for unethical standards, and in a more or less unsatisfactory way to reconstruct his immediate surroundings. But the success of these efforts depends, in the last analysis, upon the patient himself. The public is exposed to a communicable disease, the control of which lies with the transmitter.
For this reason, a disease which may be contracted by a neighbour becomes as much his affair as it is that of the patient or possessor. Should the interests of the two conflict, it is obvious that we must have some impartial arbiter to decide between them. At such a point—the right of one person to transmit, of another to acquire an infectious disease—the matter becomes one of public as well as private concern. The arbiter between these two interests should be the Health Department of a community, and the control of all infectious diseases should be placed completely under the municipality.
In the first chapters of this book, we considered the special nurse as supported by a group of private individuals, in connection with some privately maintained association. Social experiments frequently begin in this way; when their value is proved, it should be the aim of the promoters to transfer this special work to the department of the municipality in which it belongs. Upon looking over the various municipal departments, we realize that much of what is now freely recognized to be municipal work, was originally carried on through private enterprise and initiative. This is the case with school nursing, playground work, juvenile court and probation work; which in many cities has passed through the stage of private enterprise and become firmly incorporated into the city machinery. In all public health nursing, the aim of the founders should be, first to prove its worth to the community, and then make the community (municipality) assume full charge of it as soon as possible. It is particularly necessary to transfer tuberculosis work from private to municipal control.
The Danger of “Political” Control. The question of doing this, however, is often a matter of great concern to the founders. They are usually deeply interested in the work, and have maintained it upon a basis of efficiency, in spite of many obstacles. They fear, and often rightly, that to transfer it to the municipality will be to transfer it from the basis of efficiency in its own line, to the basis of politics, and they dread that sinister condition known as “political control.” And yet the administration of public affairs is not necessarily “political” in the bad sense of the term. On the contrary, municipal control may, and in many cities does mean, that work is conducted with the force, authority, and financial backing of a great department, such as the Health Department. Under such conditions, it can attain a far greater degree of efficiency than could ever have been reached through private administration. Under municipal control, it is possible to have a large staff of nurses and pay them good salaries—which latter always means a wide choice of applicants. It is also possible to establish many and well equipped dispensaries, in charge of salaried, qualified physicians. Money will be forthcoming for all necessary expenses connected with the development and extension of the work—in short, the financial handicap will be removed, and the work can go forward with increased facilities, enlarged opportunities, and heightened dignity and authority.