Frederick Ludwig Hoffman.

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

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the service of the nation for directing the best development, utilization and conservation oi
all national resources, material; intellectual, manual and financial. Organizations and indi*
viduals, as well as the nation as a whole, should have the help of systematic expert knowledge
in bringing them up to their possibilities. A general and well-ordered application of the
results of scientific research to the problems of the individual, the organization, the nation,
and of the world would have incalculable effects. We are only beginning to apply organ-
ized knowledge in an organized way, but the desirability of increasingly doing this in the
near future is urged." (Science Monthly, May, 1918.)

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vented, by the gradual elimination of the conditions which undermine
health and shorten life, it is self-evident that priority of consideration
must be given to principles and methods of housing hygiene, school
hygiene, factory hygiene, etc., rather than to immunology and even
advanced bacteriology, which, though essential in a course on hygiene
and public health, are nevertheless of secondary importance to meas-
ures and means aiming specifically at the control of the environment
and the removal of conditions inimical to life and health.*

There is no provision in the Johns Hopkins School of Hygiene
and Public Health for race pathology, nor for tropical hygiene and
sanitation, two extremely important branches of public health admin-
istration, broadly conceived on principles of prevention, rather than on
those of quarantine and measures of correction after the fact. There
is also no provision for physical anthropology, as the very basis of all
that is required in modern health administration in connection with
the physical examination of school children and of applicants for
factory employment. The central thought throughout seems to be
the quarantine control of infectious diseases and highly specialized
branches of research work in connection therewith.

Nor is there adequate provision for sanitary engineering in the
accepted sense. Simply as an economic problem, the most effective and
satisfactory means of dealing with town and house refuse, sewage,
sewage disposal, water and water supplies, the disposal of the dead, etc.,
are all questions of the first importance in an effective health adminis-
tration, having for its main object the prevention of disease occurrence,
rather than the control of contagious and infectious diseases subse-
quent to outbreaks in epidemic form.

It is somewhat encouraging, however, to meet with a better
appreciation of the urgency of statistical knowledge and training in

* Of course, all of these subjects are of the first importance in the curriculum of medical
schools, preparing students for both the practice of medicine and the administration of
public health. The point raised here is that overemphasis is placed upon exceptionally
exacting branches of science, rather in the nature of research than in that of administrative
activities. The practical question as to the avoidance of infection is readily within the full
understanding of a person of average intelligence, if the facts are set forth with clearness,
as, for illustration, by Dr. Chas. V. Chapin in one of the Harvard "Health Talks"; but a
ftUl understanding, for practical purposes, of the whole question of infection and resistance
requires an amount of mental concentration and special aptitude quite outside of the posses-
sion of the average graduate in general medicine or public health. A superficial knowledge
of such subjects as the problem of virulence, inherited and acquired immunity, toxins and
antitoxins, etc.* is practically certain to lead to profound errors in public health adminis-
tration, as best illustrated by the experience gained during the recent influenza epidemic.
Since the course, at best, must be one of limited duration, it would seem that the education
of the future health administrator should be concentrated rather upon practical than upon
theoretical and upon non-medical rather than upon medical questions. There is much danger
of superficial knowledge of highly involved medical matters being made use of to give
ill-considered advice to the public, apparently demanded by urgent considerations. It would
seem best to leave such matters entirely within the realm of the medical profession, or with
those who as physiologists or pathologists, or otherwise, are concerned primarily with
bacteriology, immunity, and the related sciences.

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practical statistical analysis and interpretation. There is a lamentable
lack of qualified ability among public health officers in this respect,
although the use of statistical information has enormously increased
during recent years. It is to be hoped, however, that no attempt will
be made to introduce extensively the use of mathematics, although
provision for what is called the "advanced statistical theory" is made
in the curriculum of the Johns Hopkins School of Hygiene and Public
Health. Regardless of the exceptional value of the application of
mathematical principles to statistical analysis in connection with medi-
cal and public health problems for general purposes, such knowledge
and methods are more likely to prove a hindrance than a help. There
is only a limited field for actuarial mathematics and the new application
of statistical methods, such as have been brought forward by the
Galton Research Laboratory, etc. What is required, and most urgently
so, IS a better understanding of statistics in the more restricted sense,
and of the use of standardized methods of record-keeping, tabulation
and analysis. The same conclusion applies to more rational methods
of graphic presentation. At the present time practically every health
officer follows his own statistical ideas and there is in consequence a
deplorable want of uniformity and lack of comparability in the results.
The prerequisite technical and higher mathematical knowledge of a
course in "advanced statistical theory" is generally not within the
possession of the average applicant for admission to a School of
Hygiene and Public Health, nor is there more than a remote possibility
that such knowledge will ever be required for practical purposes
in the performance of actual administrative functions in the efficient
conduct of a Federal, State or municipal health service.*

PROPOSED NATIONAL AND LOCAL HEALTH CENTERS

The effective administration of public health depends in no small
measure upon the proper housing of the health administration. With
few exceptions the health organizations of the several States and

* As early as 1866 Dr. Wm. Parr, P. R. $., in his report on the cholera epidemic of
England, made use of the mathematical theory to subject the so-called "zymotic theory" to
a critical examination. In a similar manner, Sir Rontild Ross has applied mathematics to
malaria research. Perhaps the best known is the combined research work of Elderton and
Pearson in their essay on the "Relative Strength of Nurture and Nature" of the Galton
Laboratory for National Eugenics, a subject preceded by a more extended investigation of
the "Intensity of Natural Selection in Man/' by E. C. Snow, M. A. Highly specialized
research work of this nature must, however, be considered entirely outside of the practical
field of a large majority of health administrators, concerned with the solution of problems
of immediate public concern. The reqtiired preliminary training in higher mathematics will,
as a rule, be found entirely too exacting to leave the necessary time for serious and
sustained thought upon questions of administrative policy. In fact, it has been argued by
no less an authority than Sir Wm. Hamilton that training in higher mathematics may prove
harmful to intellectual and scientific pursuits of a more practical nature. The fact that
higher mathematics have been found useful in the furtherance of highly) specialized branches
of biology and eugenics is not an answer to the question as to which subjects in a course
on public health should be given priority for obvious reasons of public concern.

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municipalities are inadequately housed and frequently disgracefully
so. In numerous conspicuous cases the office conditions symbolize
official indifference to sanitation rather than rigid conformity to ideal
sanitary requirements. If modem civic pride insists upon the ade-
quate housing of general governmental activities, this attitude has
not as yet extended to the Health Department, although it is now
quite generally observed in the case of court houses and public
libraries. The progress which has been made in Federal buildings is
also suggestive of the direction to be followed in the future housing of
the Federal and local health administration. It would^ however, seem
decidedly preferable to assign to the health administration a separate
building, the exterior and the interior construction of which should
be in conformity to a thoroughly worked out plan of efficient co-
ordination of essential functions as obviously most advantageous to
the administration itself and the general public. The outside impression
should at once convey the idea of a temple of hygiene rather than
of any other branch of the Government, however important for
public purposes. Certainly in the case of the Federal Government there
is now the most urgent need for a new and thoroughly equipped as
well as efficiently coordinated separate building for the adequate
housing of the U. S. Public Health Service. A standard type
of architecture might be developed so as to accustom the public mind
to the idea that the public health administration as thus housed typifies
the ancient conception of a temple of hygiene or a house of health.
In the case of municipalities and counties such a building might
be constructed in a manner of providing not only for the central
organization of the health administration, but also on the one side,
first aid, dispensary, infirmary and hospital facilities, and on the other
the necessary office facilities for the r^stration of births, marriages
and deaths, the physical statistics of the growth and development of
the juvenile population, and finally for the records of diseases and other
data, as essential to a well coordinated plan of public health adminis-
tration. As thus conceived such a building would constitute the
health center of the community and it might easily be provided with
an auditorium for lectures on health and welfare contributory to the
health educational propaganda efforts of the local health administra-
tion. By combining the administrative health functions with other
essential auxiliary duties and health promoting efforts, the health
center could be made the radiating source of all local health activities,
both public and private, the thoroughly effective coordination of which
is never likely to be secured otherwise at the required minimum of
time, labor and expense.



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PUBLIC HEALTH LIBRARY, SANITARY INFORMATION
AND STATISTICS
Effective teaching methods depend in a large measure upon
adequate library facilities. There should be brought into existence
a great national Library of Public Health Information and Statistics,
including the graphic presentation of mortality and morbidity facts
not only for the United States, but for all important countries of the
world.* Such graphic illustrations should not, however, be limited
to mortality and morbidity, but an effort should be made to correlate
such information to climatological, pathological and other scientific
data useful for the purpose. At the present time a vast amount of
useful information is available only through general medical libraries
which cannot possibly meet highly specialized practical requirements.
In course of time there should be coordinated to such a library a
Museum of Public Health more or less in conformity to the principles
which govern in the arrangement and development of the American
Museum of Safety. The methods of health instruction require to be
made much more objective than is generally the case and special em-
phasis should be placed upon demonstrations of simple methods of
sanitary surveying as absolutely essential to the development of rational
plans of sanitary reforms. There is entirely too much reliance upon
book teaching and insufficient attention to the urgency of personal
contact with the actual facts of the sanitary and related sciences which
require to be dealt with in every-day lif6. It has been said that the
three fundamental ends of teaching are knowledge, power and skill.
To secure these ends in public health administration obviously neces-
sitates much more adequate teaching facilities and teaching methods of
a much higher standard than those available to the earnest and
conscientious student at the present time.

THE PROPER PLACE OF A FEDERAL HEALTH ADMINIS-
TRATION IN THE FEDERAL GOVERNMENT
The proper official status of a Federal Health Administration
would not seem to be a position in the Cabinet, but rather as an entirely
independent Federal department, responsible directly to the President.
Every position in the Cabinet is primarily political in its nature and
for purposes of administrative guidance and control under our form of

* On the occasion of; the Panama-Pacific Exposition, San Francisco, 1915, The Prudential
Insurance Company of America made an exhibit of mortality facts, presented by a large
number of charts, descriptive in part of the Geographical and Race Pathology of the West-
ern Hemisphere. The exhibit has since been made a permanent one, together with other
charts of mortality tendencies from particular diseases, the relation of height and weight to
the mortality from specified causes, the influence of family history, etc., at The Prudential's
Home Office, No. 9 Bank Street, Newark, N. J. Descriptive publications are available on
request

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government and responsibility on a partisan basis. The introduction
of politics into a Federal Health Administration would be lamentable
and lead in the end with practical certainty to the defeat of even the best
conceived measures of reform. The remarkable success of the U. S,
Public Health Service has its origin in the fact that throughout
its entire history of more than a hundred years, first as the Marine Hos-
pital Service and subsequently as the U. S. Public Health Service,
the organization, broadly speaking, has been kept entirely out of
politics. If it has been found practically feasible to administer and con-
trol the interstate railways through the Interstate Commerce Commis-
sion, directly responsible only to the President, it should not be difficult
to bring about a corresponding organization on the part of a Federal
Health Administration concerned exclusively with the public welfare
and with nothing else. By a mere accident of early circumstances the
Marine Hospital Service was placed in the Treasury Department, but
it should require no argument to sustain the point of view that the
enormous interests involved in an effective public health administration
even through the U. S. Public Health Service as at present organized
can not be adequately met by a Cabinet officer concerned primarily
and chiefly with questions of public finance. It is, therefore, to be
hoped that in the event of a complete reorganization of all Federal
health agencies the new organization will be placed on the basis of a
separate administrative function directly responsible only to Congress
and the President.

THE DUTY OF THE NATION IN RELATION TO HEALTH
AND PHYSICAL WELL-BEING
In the inspiring words of the late William Edward Hartpole
Lecky,

"To raise the level of national health is one of the surest ways of
raising the level of national happiness, and in estimating the value of
different pleasures, many which, considered in themselves, might appear to
rank low upon the scale, will rank high, if in addition to the immediate
and transient enjoyment they procure, they contribute to form a strong and
healthy body. No branch of legislation is more really valuable than that
which is occupied with the health of the people, whether it takes the form
of encouraging the means by which remedies may be discovered and
diffused, or of extirpating by combined efforts particular diseases, or of
securing that the mass of labor in the community should, as far as possible,
be carried on under sound sanitary conditions."

The achievement of this ideal demands a decidedly more effective
health administration, attainable only, however, upon new and broader

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conceptions, scientific as well as practical, than those which underlie
our Federal and State health organizations of to-day.

The foregoing observations and conclusions are briefly restated
in the following recommendations for a plan of action urgently called
for by the highest considerations of national and State welfare.

First. The President of the United States should be prevailed
upon to appoint a select ccmunittee of experts on sanitation and public
health to prepare a plan for a Federal Health Administration inclusive
of all the healtii interests and health promoting activities of the
Government, to replace the existing Public Health Service, the inade-
quacy and restricted function of which are clearly recognized by all
who are thoroughly f am^iar with the facts.

Second. The committee should have power to associate with
itself in an advisory capacity experts recommended by national health
organizations and health promoting activities directly interested in
and thoroughly familiar with the facts and considerations involved
in the proposed plan of a Federal Health Administration.

Third. A sufficient appropriation should be made available to the
committee for general expenses and the technical inquiries called for
in its judgment in the furtherance of its plans. The members of the
committee, however, should serve without compensation, but they
should be reimbursed for their traveling and secretarial expenses.

Fourth. The work of the committee should in broad outlines be
subject to instructions from the President prepared by the Surgeon-
General of the U. S. Public Health Service, the Surgeon-General
of the Army and the Surgeon-General of the Navy, separately or
jointly, as the President may deem advisable. The committee, how-
ever, should also from the outset act in thorough cooperation with the
American Public Health Association, the National Conference of State
and Territorial Boards of Health, the American Medical Associatiwi,
and all other health promoting public activities willing to assist by
expert counsel in the working out of the details of the proposed plan
of a Federal Health Administration.

Fifth. Aside from the general instructions concerned chiefly with
questions and problems of an administrative nature, the committee
should concern itself with the practical feasibility of the inclusion in
a new plan of Federal Health Administration of (a) the systematic
physical examination and medical supervision of children and young
persons below the age of majority, (b) the systematic collection,
tabulation and analysis of the sickness data derived from general
medical practice and institutional experience, (c) .the establishment of

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a limited or restricted State Medical Service, free from every taint
of poor-relief or the recognized disadvantages of poor-law adminis-
tration. The inclusion of the foregoing three principles would neces-
sarily be largely limited to a reorganized system of State Health Admin-
istration based in all essentials upon a model Federal law.*

Sixth. The committee should inquire into and report upon the
extremely important question of adequate Federal financial aid in
support of local sanitary activities possibly inclusive of associated
health promoting activities more or less in conformity to the basic
principles of the States Relations Service applicable to agricultural
education, interstate highway construction, etc.

Seventh. The committee should report upon the more or less
involved legal aspects of the proposed Federal Health Administration
and the implied possibilities of conflict of Federal and State authorities.
In the event that the committee should deem it necessary it should be
at liberty to recommend the adoption of a Constitutional amendment
under which the required powers in matters of health and physical
welfare would be granted to the Federal Government, possibly to be
concurrently exercised under both Federal and State jurisdiction.

Eighth. If approved by the President the recommendations of
the committee, with their report and exhibits, should be transmitted
to the Senate Committee on Health and National Quarantine for the
purpose of a public hearing and a full opportunity for a public con-
sideration of every question involved in a measure than which no
legislation of recent times is more likely to affect so vitally the present
and future welfare of the American people.

*0f special value in this connection is the plan of organization of the U. S. Public
Health Service, issued in 1915. The plan is slightly out of date, but useful for the purpose
of emphasizing the numerous functions and subdivisions of the service as carried on at
the present time. Of exceptional importance for the present purpose are "Some Notes on
Medical Education in England/' by Sir George Newman, Chief Medical Officer of the
Board of Education and Medical Assessor of the Universities Branch of the Board, issued
as a Parliamentary Paper in 1918. This publication emphasizes the functions of the
medical practitioner and the changed conditions of medical practice. It contains a discus-
sion in detail of the modern requirements in medical education and concludes with observa-
tions on preventive medicine, the place of research in medical schools and the study of
medicine after graduation. Particularly suggestive is the statement that "both the science
and art of medicine suffer from the embarrassment of ever growing and expanding themes,
and of the infinite number and variety of idiosyncrasies, heredities, and circumstances
Roveming health and disease in the individual."



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APPENDIX A

Standard form for Physical and Medical Examinations Recommended by the
Ck>mmittee on Race in Relation to Disease of the National Research Ck>uncU





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Online LibraryFrederick Ludwig HoffmanA plan for a more effective federal and state health administration → online text (page 9 of 10)