Frederick Ludwig Hoffman.

A plan for a more effective federal and state health administration online

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fertile Santa Cruz and Santa Catalina. The normal range in tempera-
ture is from 12** below zero to. a maximum of 120° and more in the
Death Valley. The range in rainfall is from 3 inches in the extremely
arid region of the south to a maximum normal of 113 inches per annum
in the extreme north. At San Diego the sun shines nearly every day
throughout the year, but at ^ureka the number of days with sunshine is
only about 100. Wide variations are met with in wind velocity and the
frequency of fogs. Seismic disturbances are common in some sec-
tions, and the State has the unique distinction of having the only active
volcano in the United States.

California has practically every variety of soil from the most
fertile to the absolutely unproductive. In the area immediately
adjacent to San Francisco fifty different types of soil have been clearly
differentiated, from the fertile sandy loam and adobe to dune sands,
tidal marsh and river wash. Even more varied are the soil conditions
in the great Sacramento Valley, the extreme length of which is approxi-
mately 150 miles. Seventy-three soil types have been identified in
this area, ranging from widely varying loams and clays to tidal marsh,
muck and peat. The relation of such soil variations to health and
longevity and to special disease prevalence has thus far been only
approximately determined and hardly to much practical purpose. The
same conclusion applies to the wide range in the quality of surface
and ground waters, although a large amount of useful information has
been brought together on this subject in the water supply investigations
of the U. S. Geological Survey. The same department has also
issued a valuable report on the Springs of California, which emphasizes
what is practically as yet an almost undeveloped natural resource of
the utmost value in the more scientific treatment of disease.

The health promoting value of the California desert regions has
not been made the subject of a thorough investigation. The extraor-
dinary results attained in certain localities, as for illustration, at
Indio, in the Colorado Desert, are suggestive of much more far-reach-
ing beneficial results when the more or less involved facts of
physiography, climate, geology, soils, etc., are better understood. As
encouraging evidences of progress, attention may be directed to the
reports of the Bureau of Soils on the Indio area and of the U. S.
Geological Survey on the Ground Waters of the Indio area, with a
sketch of the Colorado Desert and a supplementary report on "Some
Desert Watering Places in Southeastern California and Southwestern
Nevada," by Walter C. Mendenhall, Washington, 1909.

Aside from the important physical factors which more or less
determine the' health of the State, there is an equally wide range in

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the racial distribution of the population and its social and economic
conditions. In some sections certain racial elements predominate,
such as the Portuguese, the Mexican, the native Indian, the Chinese,
the Japanese and even the East Indians and Koreans. All of these
races have their own special obscure mortality problems and excep-
tional disease predisposition or resistance, as to which additional
information would be of real value in the more scientific practice of
medicine.

The range in the industries of California is extraordinary and
inclusive of practically every important occupation involving special
industrial hazards, such as the mining of eVery variety of metal, from
gold and lead to copper and quicksilver, and of the non-metallic sub-
stances, from salt and borax to cement. There is every variety of
lumbering, from the sugar pine forests of the high Sierras to the giant
redwoods of the northern coast counties, with all the subsidiary wood-
working industries, from ship-building to the manufacture of matches.
The smelting industries are thoroughly representative, with all their
peculiar problems of dust and fume control, not only of immediate
concern to the employees, but also to the population at large living in
areas adjacent to smelting plants. The Selby Conmiission may here
be referred to as an excellent illustration of the scientific resources
available to the Government when utilized on a thoroughly well-
considered plan of cooperation with private interests.

The agricultural and horticultural development throughout the
State includes every variety of local conditions, artificially modified
where necessary by extensive systems of drainage and irrigation. No
other section of the United States illustrates in such a remarkable
manner the soundness of the conclusions advanced by the late Prof.
George P. Marsh, in his treatise on "The Earth as Modified by
Human Action," and from another viewpoint by Elsworth Huntington,
in "Civilization and Climate.*' Only those who are familiar with the
truly enormous natural obstacles to be overcome in eflfective methods
of drainage and irrigation can realize the true significance of the new
mortality problems which result from defects which at the outset are
relatively insignificant, but which may prove serious in their ultimate
influences on the life and health of the people. No other diseases better
illustrate the force of this observation than malaria and typhoid fever.

California presents every contrast of riches and poverty and of
physical well-being and chronic ill-health. For many years the State
has attracted invalids from other sections, particularly those afflicted
with tuberculosis and other chronic respiratory diseases. No other

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disease, unless it be leprosy, manifests more cleariy certain important
interstate aspects of Federal Health Administration. The investiga-
tions which have been made by Dr. Sweet of the U. S. Public
Health Service on the problem of the indigent tuberculous patient in
the Southwest may be referred to as evidence of an increasing interest
on the part of both the Federal and the State health authorities in a
problem .the national importance of which has heretofore not been
recognized.

In no other State, therefore, it would seem, are the conditions
more ideal than in California to justify the undertaking of a thoroughly
reorganized State Health Administration on the basis of new principles
and inclusive of new functions essential to the attainment of decidedly
better results. No State is more progressive and more willing to
meet the required expense to attain the highest ideals in the proper
sphere and function of every branch of the State government. Cali-
fornia has three great universities, adequate medical schools and
clinical facilities, and numerous well-managed public institutions, all
useful for the purpose of sustaining a thoroughly well-worked-out
plan for a modernized health administration such as is here proposed.

How much has been achieved within a comparatively short period
of time is best illustrated by the gratifying success of the State Land
Colony at Durham, which in practically all the details of its adminis-
tration rests upon the scientific advisory assistance of the University
of California. This work which has been carried forward to such a
successful termination by Prof. Elwood Mead, the distinguished
authority on irrigation, gives every promise of serving as a model to
other sections of the country, even though the plan may not prove
feasible of universal adoption. What has thus been achieved in the
realm of agriculture should be equally possible in connection with efforts
to improve health and physical well-being. It is to be hoped that the
executive officers of the State Land Colony will see their way clear to
initiate a practical method of health supervision, including physical
examinations, medical assistance and institutional treatment in con-
formity to all the knowledge available on these subjects at the present
time. If this suggestion could be adopted the State Land Colony would
only carry into further practical execution the method so successfully
worked out in behalf of the students of the University of California,
who for more than six years past have been under qualified medical
supervision, which has been provided for at minimum expense, and
without the pretense of social insurance, including all that must be
considered essential to reasonable medical or surgical needs.

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STATE HEALTH ADMINISTRATION IN NEW MEXICO
The State of New Mexico may serve as another illustration. At
the present time it may safely be asserted that the State is not only
without a State health organization, but not one of the principal cities
or larger communities has a thoroughly satisfactory local health board.
The registration of deaths is not enforced. The people of the State
of New Mexico are of right entitled to a progressive health policy.
The health of this State is not merely a matter of local but of national
concern as well, as best illustrated during the recent epidemic of in-
fluenza, on the one hand, and the problem of the interstate migration
of tuberculous invalids, on the other. There are numerous special
problems, such as the effect of altitude on health and its relation to the
treatment of certain diseases, the proper and more effective use of
medicinal springs, the morbidity and mortality of the Indian popula-
tion, the special sanitary problems of the Mexican element, etc. None
of these are receiving proper consideration at the present time. The
State can not possibly hope to attract new residents proportionately
to the practically unlimited opportunities for further economic develop-
ment unless evidence is forthcoming of a well-considered State policy
of a health administration more or less in conformity to the outline
presented on the present occasion. The efforts which have been made
by the New Mexico Public Health Association are deserving of the
most liberal encouragement on the part of both the State authorities
and the public at large.*

THE ADVISORY PUBLIC HEALTH COUNCIL
As essential to such a plan of complete reorganization it would
seem that provision should be made in the case of the Federal Health
Administration as well as in those of the several States, for an advisory
council, rigorously limited to suitable expert ability. Such a council is
urgently insisted upon in the proposed plan for a Ministry of Health
for Great Britain. It has been recommended by the British Medical
Association that such a council "should be appointed by the minister
from nominations made by bodies recognized as having a special claim

*A special report has recently been prepared on public health administration in New
Mexico* by Dr. J. W. Kerr, Surgeon U. S. Public Health Service. This report is an admir-
able presentation of suggestions more or less in conformity to present-day conceptions of
public health administration, as chiefly conditioned by restricted police powers of the state.
The report, however, includes suggestions for the investigation and control of diseases;
the need for diagnostic laboratories, the sanitation of schools, public health engineering and
public health educational work. The report concludes with the recommendation for the
financial support of a State department of health limited to $22,900, or on the basis of the
present probable population of New Mexico equivalent to 5c. per capita. If the Stote of
New Mexico were to begin with twice the sum, or, say, $50,000 per annum, for the purpose
of an adequate and really effective health administration, the resulting benefits to the
people of New Mexico would be many times the amount suggested as a minimum by Dr. Kerr.

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to representation. This claim should be based not on any sup-
ported vested interests, but on the ability of the bodies concerned
to give expert advice on the subjects to be considered and
to keep the minister in living touch with those bodies and
classes of persons on whose cooperation the success of the new
ministry would depend." Applied to the problem under discus-
sion this would mean that the Federal health administrator, of the
State health administrator, would attach to his office a body of experts
recommended by associated activities, such, for illustration, as the
American Public Health Association, the American Red Cross, the
National Tuberculosis Association, the National Safety Council, the
National Committee on Malaria, the American Association for the
Study and Prevention of Infant Mortality, etc. Since the advisory
services through the council would be individual rather than collective
in the majority of cases in which such advice would be required, the
membership of the council might be made relatively large. There
should, of course, be representatives of the American Medical Associa-
tion, the American College of Surgeons, the American Dental Associa-
tion, the Mental Hygiene Association, the Social Hygiene Association,
the Association of Pharmacists, The International Health Board,
etc. There might even be representatives of related public
activities, such, for illustration, as the American Statistical Associa-
tion, the American Actuarial Society, the Association of Life Insur-
ance Presidents, the U. S. Chamber of Commerce, the Association of
Industrial Physicians, the National Industrial Conference Board, the
National Association for School Hygiene, etc. Assistance might
also be drawn from the membership of the different sections of the
American Association for the Advancement of Science, the American
Anthropological Association, etc. The spirit of active cooperation
and the willingness to render voluntary services are so thoroughly
diffused throughout this country that it may safely be held that
whatever voluntary assistance would be required by the Federal or
State health aclministration in the directions indicated would be forth-
coming without any difficulty whatever.

TEACHING METHODS IN PUBLIC HEALTH
Of the foremost importance, however, is the establishment of a
thoroughly well-organized School of Hygiene and Public Health,
independent of, or in connection with, a large university providing
abundant facilities for research work. Such a school should not be
made to rest upon exclusively medical considerations. The new
science of Public Health is essentially non-medical in its major

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function of disease prevention and control. The problems of sanitary
law and administration are almost exclusively non-medical, except
in so far as medical considerations amplify local powers, such, for
illustration, as those of qtMuantine officers, inspectors of nuisances,
contrcrf of midwives, protection of infant Kfe, enqJoyment of children,
etc. In all of these matters l^;al, social and econopiic considerations
take priority over those that are medical. The same conclusicm
applies to the supremely important question of a wholesome and
abundant water supply, which is primarily an engineering problem.
The determination of impurities or the required methods of mechani-
cal or chemical purification, as well as the chemical and bacteriological
examination of the water itself, all lie outside of the plan and scope
of medical service, even in the broadest sense of the word. Equally
conclusive are the facts regarding air, ventilation and heating. The
ascertainment of the composition and physical properties of air, of
air impurities and the making of air examinations, as well as the
ascertainment of the quantity of air required for ventilation and the
best methods by which the necessary quantity of air can be supplied,
are primarily engineering questions, the practical solution of which
has become a recognized branch of sanitary science. Even in such
a restricted field as dust phthisis, the major portion of the required
research work is non-medical. The most useful contributions which
have been made to problems of ventilation and heating are those of
mechanical engineers, rather than those of medical men.*

In the immense field of food control and the enforcement of
laws against food adulteration, etc., the responsibility in the main rests

*Por illustration, the report of the Departmental Committee appointed to inquire into
the yentilation of factories and workshops is signed by Prof. John Scott Haldane and Mr.
Edward H. Osborne, neither of whom, as far as known, is an active member of the medical
profession. The reports of this committee rank as the most useful contribution to a subject
which is of the utmost practical importance to persons employed under conditions which give
rise to atmospheric pollution. The investigations of the commission included such widely
different employments as clothing factories, boot and shoe making, laundries, bread and
confectionery making, printing, file-cutting, textile factories, etc Practically all the technical
problems involved in the control of dust and the removal of fumes are non-medical and
depend for their ultimate solution upon engineering considerations. It may be said In this
connection that Mr. E. H. Osborne is the engineering adviser to the Chief Inspector of
Factories and that if Mr. John Scott Haldane is a member of the medical profession, he
was probably not appointed to the committee on that ground, but because of his preeminence
in other fields of exacting scientific research. It may also be suggested to those who are
interested in this question that a collection of illustrations of the methods of dust extraction
has been compiled by Commander Sir liamilton P. Freer-Smith, R. N., and published as
a Parliamentary paper in 1906 (C D. 3223). It ^s also suggestive that the Commission
on Ventilation of the Sute of New York, of which Prof. C E. A. Winslow was the
chairman and Prof. Frederick S. Lee an important member, included, as far as known,
only a single member of the medical profession, Dr. John Alexander Miller, the distinguished
author of an important paper on "The Effect of Changes in Atmospheric Conditions upon
the Upper Respiratory Tract." The work of Dr. Miller in this and other fields is an admirable
illustration of the practical services which members of the medical profession, if othmrwist
quaKfied, can render the cause of improved ventilation and dust control in factories and
workshops.

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upon chemists and bacteriologists and not upon members of the
medical profession. The same conclusion applies to the supervision
of beverages, including the use or the abuse of alcohol. One of the
most important recent investigations of the psychological effects of
alcohol is the work of Raymond Dodge and Francis G. Benedict,
experts in nutrition and psychological research, but, not as far as
known, men of any experience whatever in the practice of medicine
as a healing art.

Such subjects as clothing, exercise, soil, housing, schools and
hospitals are largely problems outside of the field of medical practice.*
While all of these questions have important medical aspects, the
governing principles of right public action are in the main non-
medical, or determined by other spdcial physical, social and economic
considerations. In the successful solution of each and all of these,
medical men have in the psl^t and are certain in the future to render
much valuable and, in fact, indispensable aid, but it is held that
for administrative purposes non-medical, scientific and business ability
are more urgently needed for the attainment of urgently required
practical health and general sanitary reforms.

Finally, such problems as scavengering and street cleaning, sewage
and sewage disposal, and the disposal of the dead are largely non-med-
ical, and so much so. that it would seem a wrongful waste of opportu-
nity on the part of a medical practitioner to give much time and thought
to problems obviously essentially of an engineering or otherwise non-
medical character. The same conclusion applies to the supervision and
control of offensive trades or dangerous occupations, which within
recent years have become centralized in the public administration of
factory inspection on the one hand and safety engineering on the other.

With these facts in mind, it would, therefore, seem that a thor-
oughly efficient modem School of Hygiene and Public Health should
rest upon different fundamental principles and a differently conceived
plan of cooperation and coordination than the recently established
School of Hygiene and Public Health of Johns Hopkins University. The

*This obsenration, of course, must not be carried too far. Important contributions have
been made to the scientific study of the effects of clothing upon health by members of the
medical profession, and even more so, of course, to the larger problem of physical exercise.
Among recent contributions, reference may be made to a paper on "The Influence of Clothing
on the Surface Temperature of Infants," by Drs. McClure and Sauer, of Chicago, con-
tributed to the American Journal of Diseases of Children, This paper presents an admirable
analysis of temperature observations, etc., concluding with the statement that "At a room
temperature of about SI** C an infant clothed in the manner above described and under the
conditions of our observations, approaches very closely the point where a heat loss by
conduction and radiation is no longer possible. Our experiments indicate that such a state
of affairs may be fraught with danger to the organism." Of value also is a rather interest-
ing volume on "Dangers in Neckwear," by Dr. Walter G. Walford, London, 1917, including
observations on the thyroid as affected by neck pressure; the importance of neck-room in
growing children; the reasons why small ailments are often the beginning of a serious
breakdown; etc

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Johns Hopkins School provides, it is true, courses leading to the degree
of Doctor of Science in Hygiene and of Bachelor of Science in
Hygiene, but the general implication is that priority 6f consideration
is given to medical subjects as a prerequisite of graduation, leading
to the degree of Doctor of Public Health. As yet, merely in the
preliminary stage of organization, it is to be hoped that in its future
development the School of Hygiene and Public Health will be made
to rest upon a much broader plan of organized thought * than is at
present the case, for though the teaching of effective methods of
sanitary administration is paramount, it is given merely incidental
consideration in the curriculum at the present time. The object rather
seems to be to add a relatively small measure of public health educa-
tion to a large amount of previous medical education, much^ if not
most of which, is absolutely useless for. all public health purposes.
There is no adequate provision for the teaching of sanitary law and
public health administration in its hygienic, as well as in its medico-
legal and more general aspects. There is also inadequate provision
for the teaching of the principles and practice of ventilation and heating
and .of illuminating engineering, than which perhaps no branches of
modern public health administration are of greater immediate practical
importance. Considering the fact that an ever-increasing number of
men and women are employed indoors and at occupations involving
more or less physical and physiological strain, the question of adequacy
of air and ventilation, freedom from exposure to injurious industrial
dusts, proper methods of lighting and heating, are all paramount
questions of public health administration. It would, therefore, not
seem sufficient to include such important subjects as these under the
general term of "physiological hygiene," and in any event the more
practical engineering aspects of these particular branches of public
health administration should be more clearly emphasized.

There should also be advanced teaching in all that has reference
to town planning and housing. If diseases are to be effectively pre-

♦The most important recent publication on this subject is a treatise on "The Organiza-
tion of Thought" by A. N. Whitehead, F. R. S., Philadelphia, J. B. Lippincott & Co.. 1917.
The work is an indictment of modern methods of technical education and a convincing plea
for drastic educational reforms. In the words of P. G. Nutting: "Especially in a time
of crisis like the present, national welfare depends upon the greatest possible development
and utilization of all its resources, particularly those of strength and skill. New experts
should be constantly selected and trained. All the highest expert knowledge should be at


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Online LibraryFrederick Ludwig HoffmanA plan for a more effective federal and state health administration → online text (page 8 of 10)