“A few words on this subject may describe much. State of cleanliness of the individual, slovenly condition, dust and dirt, foulness of air noticed on first entering, condition of children, of kitchen sink, etc., should be noticed, and good or bad features recorded. In the poorer districts not a few families will be found in which the cleanliness, considering the surroundings, is quite laudable. Of particular importance are amount of daylight, ventilation, care of bathroom and toilet, garbage, whether windows are kept open at night.”
On the basis of these returns we have classified the families as indicated, but each inspector was governed to a certain extent by the average cleanliness of her district, and it is difficult to compare the cleanest tenement with any of the districts of well-to-do individuals. We will therefore probably find it more profitable and more nearly accurate to combine the groups and classify them only as “clean” and “dirty.”
| TABLE VIII. | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Relationship between cleanliness and number of cases in family. | ||||||||||
| (Clean families were invaded less frequently and had solitary cases more often than did dirty households.) | ||||||||||
| Very clean. | ||||||||||
| (47.62 per cent. had none.) | ||||||||||
| Cases in families. | Total families. | ’18. | Per cent. | ’20. | Per cent. | Both. | Per cent. | Total. | Per cent. | |
| 1 | 124 | 72 | 15.65 | 50 | 10.87 | 8 | 1.74 | 460 | 26.96 | |
| 2 | 53 | 41 | 8.91 | 27 | 5.87 | 15 | 3.25 | 11.52 | } 25.42 | |
| 3 | 37 | 33 | 7.17 | 13 | 2.82 | 9 | 1.95 | 8.04 | ||
| 4 | 18 | 16 | 3.48 | 8 | 1.74 | 6 | 1.30 | 3.91 | ||
| 5 | 4 | 3 | 0.65 | 2 | 0.43 | 1 | 0.21 | 0.87 | ||
| 6 | 3 | 3 | 0.65 | 0 | 0.0 | 0 | 0.0 | 0.65 | ||
| 7 | 2 | 2 | 0.43 | 1 | 0.21 | 1 | 0.21 | 0.43 | ||
| 8 | 0 | 0 | 0 | 0 | ||||||
| Clean. | ||||||||||
| (41.52 per cent. had none.) | ||||||||||
| Cases. | Families. | ’18. | Per cent. | ’20. | Per cent. | Both. | Per cent. | Total. | Per cent. | |
| 1 | 301 | 212 | 18.45 | 120 | 10.44 | 31 | 2.70 | 1149 | 26.19 | |
| 2 | 177 | 143 | 12.45 | 91 | 7.92 | 57 | 4.96 | 15.40 | } 32.29 | |
| 3 | 101 | 83 | 7.22 | 52 | 4.53 | 34 | 2.96 | 8.79 | ||
| 4 | 52 | 47 | 4.09 | 20 | 1.74 | 15 | 1.26 | 4.53 | ||
| 5 | 30 | 29 | 2.52 | 17 | 1.48 | 16 | 1.22 | 2.61 | ||
| 6 | 8 | 7 | 0.61 | 3 | 0.26 | 2 | 0.17 | 0.70 | ||
| 7 | 3 | 3 | 0.26 | 0 | 0.0 | 0 | 0.0 | 0.26 | ||
| 8 | 0 | 0 | 0 | 0 | ||||||
| Dirty. | ||||||||||
| (36.89 per cent. had none.) | ||||||||||
| Cases in families. | Total families. | ’18. | Per cent. | ’20. | Per cent. | Both. | Per cent. | Total. | Per cent. | |
| 1 | 79 | 59 | 17.40 | 36 | 10.62 | 16 | 4.72 | 339 | 23.30 | |
| 2 | 58 | 48 | 14.16 | 29 | 8.55 | 19 | 5.61 | 17.11 | } 39.81 | |
| 3 | 37 | 31 | 9.14 | 22 | 6.49 | 17 | 5.01 | 10.91 | ||
| 4 | 26 | 22 | 6.49 | 12 | 3.54 | 8 | 2.36 | 7.67 | ||
| 5 | 6 | 5 | 1.79 | 4 | 1.18 | 3 | 0.94 | 1.77 | ||
| 6 | 7 | 7 | 2.06 | 4 | 1.18 | 4 | 1.18 | 2.06 | ||
| 7 | 0 | 0 | 0 | 0 | ||||||
| 8 | 1 | 0 | 0.0 | 1 | 0.29 | 0 | 0.0 | 0.29 | ||
| Very dirty. | ||||||||||
| (39.26 per cent. had none.) | ||||||||||
| 1 | 22 | 16 | 14.95 | 8 | 7.47 | 2 | 1.85 | 107 | 20.56 | |
| 2 | 11 | 8 | 7.47 | 6 | 5.10 | 3 | 2.80 | 10.28 | } 40.18 | |
| 3 | 14 | 12 | 11.21 | 10 | 9.35 | 7 | 6.54 | 13.08 | ||
| 4 | 7 | 5 | 4.67 | 4 | 3.73 | 2 | 1.85 | 6.54 | ||
| 5 | 6 | 6 | 5.10 | 1 | 0.93 | 0 | 0.0 | 5.61 | ||
| 6 | 3 | 3 | 2.80 | 2 | 1.85 | 2 | 1.85 | 2.80 | ||
| 7 | 2 | 2 | 1.85 | 0 | 0.0 | 0 | 0.0 | 1.87 | ||
| 8 | 0 | 0 | 0 | 0 | ||||||
But even without combining in this way, the table shows us that for both years 27 per cent. of the very clean families, 26 per cent. of the clean, 23 per cent. of the dirty and 21 per cent. of the very dirty, had but one case, while 25 per cent. of the very clean, 32 per cent. of the clean, 40 per cent. of the dirty, and 40 per cent. of the very dirty, had multiple cases.
The cleaner the family the less is the likelihood of multiple cases.
It is rather difficult to find concrete examples of the influence of domestic habits and environment in the 1918 pandemic. The remarkably high incidence among the natives of India and among the American Indians might by some be attributed to unfavorable environment. Lynch and Cumming obtained records from a large number of institutions and from business concerns having their own records, and discovered that the influenza incidence was higher in those institutions where dish washing was done manually than in those in which mechanical washing was performed. They appear to conclude that the difference in the two methods of washing dishes was the cause for the greater incidence in influenza, thus bearing out their theory of the propagation of influenza chiefly through eating utensils. On the contrary it is possible that the presence of the mechanical washer is an indication of advanced methods, greater care in the kitchen, and better hygiene probably not only in the kitchen and dining room, but throughout the institution.
Economic status.—Although in our survey information has been obtained regarding the economic status of the various families we would not stress this phase of our subject. Obviously the amount of money an individual has in his bank will not directly influence the amount of influenza he will have in his home. As nearly an accurate classification by wealth is by the separation into the districts, Districts I and III being very poor, District II poor, Districts IV and V moderate, and VI well-to-do. From Chart XXVI we see no definite relationship between influenza incidence and economic status.
Dr. Niven has had similar experiences. He remarks that the disease does not appear to have affected especially any class or section of the community. Rich and poor suffered alike. Inquiry in some towns shows that the epidemic not infrequently started in the well-to-do districts and only later involved the poorer and less prosperous areas.
We cannot state with any degree of accuracy in what section of Boston the 1920 recurrence first began. The sections studied are for relatively small portions of the city, and it is possible or probable that the original increase was in some area outside of our districts. In the districts studied the earliest increase in reported cases was from the section of the city known as Dorchester (Districts IV and V), where there was some increase in December, 1919. The latest definite increase was in the Irish district of South Boston. Geographically these two areas are quite near. The relative insusceptibility of the Irish population is probably a much more important factor in the difference.
Frost found after classifying the white population canvassed in Little Rock and San Antonio according to economic status, and adjusting the incidence rate in each group to a uniform sex and age distribution, that the ratios of incidence in each economic group to incidence in total white population did show an increase with increasing poverty. “Notwithstanding that the classification according to economic status is a very loose one, based solely on the judgment of inspectors with widely different standards, a considerably higher incidence is shown in the lower as compared to the higher economic group.”