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grounds are under directors and assistants employed by
the board of education. Heretofore inadequate powers and
inadequate assistance for training or for research have
been given to the physical director.

The city superintendent of schools, in his report for the
year 1907, presented to the board of education in January,
1908, declares that the "present arrangements have been
inadequate. . . In only 248 schools — less than half the
total number — were any examinations for possible diseases
made. In these 248 schools not more than one third of the
pupils were examined. It is only a few months since any
examinations for physical defects were made outside of
the boroughs of Manhattan and The Bronx, and then only
on account of the New York Committee on the Physical
Welfare of School Children."

296



f!'



SCHOOL HYGIENE IN NEW YORK CITY 297

As is so often the case, it is difficult to decide the merits
of a method that has not been efficiently executed. The
department of health has not hitherto done its best in its
school relations. The commissioner of health, in a public
interview, expresses resentment at the strictures by the
school authorities. Yet in 1907 he permitted to accumu-
late an unexpended balance of ^33,000 specifically voted
for school inspectors, and repeatedly tried to have this
amount transferred to other purposes. The interest of the
Bureau of Municipal Research in municipal budgets that
tell for what purposes money is voted and then prevent
transfers without full publicity, preserved this particular
fund. Moreover, the discussion that prevented its diversion
from physical examinations strengthened the health depart-
ment's interest in this important responsibility. Neither
physicians nor nurses have been adequately supervised.
Instead of seeing that defects were removed, the depart-
ment of health sent out postal cards like the following :

"This Notice Does NOT Exclode Tblj ChUd From School"

DEPARTMENT OF HEALTH

THE QTY OF NEW YORK




T» r^ (S:<^. ^. 190 c,

•^ The parent or guardian of _

of _ . - _ _ attending P. S.-.-.-rT./

is hereby informed that a physical examination of this child seems to
show an abnormal condition of the._ .^^. ^^ j



Remarks .feS...(r:3fe*:t.«*:grfatrfM5=s-^.

Take this child to your family physician for treatment and advice.
Take this card with you to the family physician.

THOMAS DARLINGTON, M. D.,
HERMANN M. BIGGS, M. D., Commissioner o£ Health.

General Medical Officer

From 118,000 such notices sent out only 9600 replies
were -received, of which only one in twenty stated that
attention had actually been given the needy child. The



298 ENFORCING HEALTH RIGHTS

department had been satisfied with evidence that family
physicians had advised parents properly, as in the case of
the child above reported :

TAKE THIS CARD TO YOIR PHYSICIAN

The Pbysician in charge is requested to fill out and
forward this postal after he has examined this child.

I have this day examined..



of P. S b£21__and find the following condition:

and advised as follows : (Q^ie..t..„,.iti/~^ jf-. a*'<i^,^-^Y^ -»«»^ £r^va^



Date



At^



f,...ZfjJ..



For a candid, complete criticism of the medical exami-
nation work up to June, 1908, consult the report of the
Bureau of Municipal Research, presented to the Washing-
ton Congress of Public Education Associations in Octo-
ber, 1908, by Commissioner of Health, Dr. Darlington.
The bureau's study is entitled A Bureau of Child Hygiene,
and, in addition to the story of medical examination in
New York City schools, gives the blank forms adopted
for use in September, 1908. Important as are the facts
given in this study, its greatest value, its authors declare,
is in its account of " the method of intelligent self-criticism
and experiment which alone enables a public department
to keep its service abreast of public needs."

The Bureau of Municipal Research made its study for
the purpose of learning whether the disappointing results
emphasized by the school authorities were due to "dual
responsibility in the school — that of the board of educa-
tion and that of the department of health " — and to "lack of
power or inclination to compel parents to remedy defects,"



SCHOOL HYGIENE IN NEW YORK CITY 299



or to deficient administration of power and inclination
by health officials. Cooperating with school physicians
and nurses in three schools, 1442 children were examined,
of whom 1345, or 93.2 per cent, had 3458 defects that
needed treatment. The postal-card notice was followed
by an interview with the parent either at school or at
home. Only 4.2 per cent of the total number of parents
refused to act, 81 per cent secured or permitted treatment
for one or more defects,
while 1 5 per cent prom-
ised to take the proper
steps at the earliest
possible date. Three
fourths of the parents
acted after one personal
interview. "The net
average result of a day's
work by a nurse was the
actual treatment of over
five children, three of
them completely, and
two of them for one or
more defects," — sixty
cents per child !

Having established
the willingness — even
eagerness — of parents to do all in their power to remove
defects that handicapped their children, it was obviously the
duty of the health department so to organize its work that
it could insure the education of parents. The new Bureau
of Child Hygiene gives foremost place to instruction of par-
ents in care of babies, in needs of school children, and in the
importance of physical examination when enlisting in the
industrial army. Whether this work is well done is learned
by result tests applied at headquarters, where work done




A PHOTOGRAPH OF MOUTH BREATH-
ING MAY MAKE COMPULSION
UNNECESSARY



300 ENFORCING HEALTH RIGHTS

and results are reported daily and summarized weekly. No
longer will it be possible, without detection, for one phy-
sician to find only eye trouble and to neglect all other
defects ; for two inspectors examining different children in
the same school to report results differing by lOO per cent;
for physicians in different schools to find one i8 per cent,
another lOO per cent with defects; for two inspectors ex-
amining identical children to agree on 51 out of loi cases
of vision, on 49 out of 96 cases of adenoids, or 3 out of 10
cases of skin disease.

So conclusive were the results of follow-up work effi-
ciently supervised by the department of health, that school
officials are, for the present, inclined to waive the demand
for the transfer of physicians and nurses to the board of
education, and to substitute education for compulsion with
parents who obstinately refuse to take proper remedial
measures for their children when reported defective.

This present plan requires the entire working time of in-
spectors and nurses for school work. Thus New York has
for the present definitely abandoned the plan of having the
district inspection for contagious diseases done by school
physicians. The purpose of the change is not to reduce
danger of infection, which was negligible, but to increase the
probability of scientific attention to school children.

Before a final settlement is made for New York City
there should be tests showing what the school authorities
would do if physicians and nurses were subordinate to
them. It is conceivable that one physician working from
nine to five would accomplish more than six physicians
working the alleged three hours a day. So imperative are
the demands of school hygiene that it seems probable that
in New York and in other large cities school physicians,
whether paid by the board of health or the board of educa-
tion, must be expected to be at the service of school chil-
dren, subject to the call of school officers, during as many



SCHOOL HYGIENE IN NEW YORK CITY 30 1

hours of the day as teachers themselves must give. It is
even conceivable that effective use of the knowledge gained
by physical examinations of school children, and by those
responsible for school hygiene, will require evening office
hours or evening visits to hornes, and regular Saturday office
hours and Saturday visits by school physicians and nurses.
Finally, it must be expected that the programme for school
hygiene will need the special attention of physicians and
nurses during the summer months, and other vacation
periods when children and parents ahke have time to re-
ceive and to carry out their instructions.

One danger in New York City is that the board of edu-
cation, Hke the board of health, when compelled to choose
between so-called standard, necessary, traditional duty and
school hygiene, will sacrifice the latter. The school author-
ities, without any more funds and without physicians and
nurses, could already have made, had they desired, eye
tests and breathing tests sufficiently accurate to detect the
majority of children needing attention. The outcome of the
discussion as to the jurisdiction of the two boards will un-
doubtedly be to interest both in their joint responsibility for
children's welfare, and to increase the attention given by
both to the physical condition of the child when he presents
himself for registration as a wage earner.



CHAPTER XXIX

OFFICIAL MACHINERY FOR ENFORCING HEALTH
RIGHTS

The argument for getting things done presumes adequate
active machinery, official and private, for doing things that
schools are being urged to do. The chapter on Departments
of School Hygiene suggests local, county, state, and national
machinery necessary (i) to protect the child from injuries
due to school environment, school methods, and school
curriculum ; (2) to getting those things done for the child
at home and on the street, need for which is disclosed by
physical and vitality tests at school. It is unreasonable to
confine the school to the activities above outlined unless
health machinery, adequate to the demands placed upon it
by school and other community needs, is devised and kept
in order.

Generally speaking, adequate health machinery is al-
ready provided for by city charters and by the state laws
under which villages, townships, and counties are or-
ganized. Quite' as generally, however, machinery and
methods of adequate administration are undeveloped. How
much machinery has already been set to work by New
York City is shown by the accompanying chart. A use-
ful exercise for individuals or school classes wishing to
study health administration would be to chart in this way
the machinery actually at work in their locality, county,
and state. Even for New York it should be remembered
that this chart does not include national quarantine, the
state protection of the port, the stat*e dairy and health
commissions, or the state and national food inspection.

302



Tl/NCTIONAL ACTIVITIES

rN FECTlOUS JISEASESriHSPECTION AW P CONTROL
District inj-pection of all ihfectious Diseases

Dl.SI[MFECTIOW

VACCINATION

ATSMINI STHATIBN OT ANTITOXIN



TUBEHCULOJH CLI PtiCl



/ WSPECTION or /^Nir^^l-S



"DIAGNOSIS ; LA'Bo'RATeHY



rUWCTIONAL




13IYI.SI0N OF



'\ MftNrt/^TTIVW



{ I B'RooKi.YW
( •RtCHMONP ~



'pffQ-pUCTiON OT- VACCI'^g: t-ABCRATCTlV



"Reg-ulation of Infants Boa-r-d]n& Our

{JoiPlTALS CONT/>glOUS EVE BlSE^SES



GENEI'R/XL SANlTA"Ry CONDitjons:
INSTECTIO/V AN-D "F?EG-UL/\TlON

miTHlCT IN5-peCT<OM



1 NSPCCTION OT


LollGiNa Houses -^^


SHO-RE rwlPCCT-ioiy


"REMOVAl. OF"


OPFAL


ETC





SCHOOL AND fNFANT HYGIENE

MEDICAL SuPEffvrsiow OF School Children

EXAMIN/tTION FOH MeRCANHLE CtRTIFKATE5

SuMl^ff CAT^E of BA3IE&

SuPHTtV'^lON OF MlDWIVES




jDI V I S I O N



I -B-ffOINX

I a-RooKt-YN

I T?ICHWONP



Food ■ /NSTECTiow ahp corfpEM nat ion

(NyPECTION OF CBEAMEBIES AWD PAITyiCS

lNS"P£gTloiV OF fvULM T'o'R JAUE

INaTECTloN OT QTHETt "FooD-S^

CHEMKAL ANALYSIS' LABOHAT-ORY



"??£SEA"RCW tABo-RATOT^Y



"DlVlS/ON OF



I MANHATTA^
I 3T?ONX

I bttookUyw"
[ ouee./Y.$

I T^i CHIV10f>J J



Mo^'PitALS To'R jNFEcT/ouj Tnj£4i£ i: orpEHATieN
wii~i./^m> Ta'RK^'S and TjE.cE.-p-noN



KiNQSTori AVf/vue



TaBE7»CULOfl$ JAJVATol^lUM .OT-lJV/LLfi



"D1?l»ft LA30T* AToTlY



VITAL STATiSTiCS . MAINTENANCE or -ffECQ-B-PS




D/VISION OF



I /MANHATTAf



I BROw'jT"



/ I BTTOOKI-YW



I puE-Erv^



I •RicMrvioi*



CHART SHOWING HOW NEW YORK CITY'S .

Courtesy of E



STRAT/ON



G£N£7?AL ADMlNisrRATfOM



Ui


BlSEASeS


^^==


/chief \




Boated

OF
H E A LT H



DNT OF HEALTH EXERCISES ITS AUTHORITY
licipal Research



OFFICIAL MACHINERY 303

To get an idea of the vast amount of attention given to
health in New York City there should be added to this
chart the work of many departments other than the de-
partment of health. The building bureau, tenement-house
department, board of water supply, sewage commission,
street cleaning, public baths and comfort stations, the de-
partment of water, gas, and electricity, and finally the de-
partment of hygiene and physical training in the public
schools.

Five elements of adequate machinery are generally lost
sight of :

1. The voter.

2. The non voter, subject to health laws and often apt to violate
them.

3. The mayor, governor, or president who appoints health
officers.

4. The council, board of aldermen, legislature, or congress
that enacts health laws.

5. The police courts and the judiciary — police, circuit and
supreme — that decide whether society has suffered from violation
of law and what penalties should be inflicted for such violation.

Legislative bodies have hitherto slighted their responsi-
bilities toward public health. The chairman of a com-
mittee on public health of a state legislature was heard to
remark, " I asked for that committee because there isn't a
blooming thing to do." If voters, non voters, and health offi-
cials will follow the suggestion of this book to secure school
and health reports that will disclose community and health
needs, it will be increasingly difficult for legislators to refuse
funds necessary to efficient health administration.

To the courts tradition has required such deference
that one hesitates to find out in how far they have been
responsible in the past for the nonenforcement of health
laws. Yet nothing is more obstructive of sanitary prog-
ress than the failure of magistrates to enforce adequate



304 ENFORCING HEALTH RIGHTS

penalties for truancy, adulteration of milk, maintaining a
public nuisance, defiling the air with black smoke, offering
putrid meats for sale, running an unclean lodging house,
defying tenement-house or factory regulations, working
children under age and overtime, spitting in public places,
or failing to register transmissible diseases.^

The appointing officer cannot, of course, be held respon-
sible unless voters and nonvoters know in how far his ap-
pointees are inefficient, and in how far he himself has failed
to do his utmost to secure funds necessary to efficiency.
Too frequently appointments to health positions have been
made on political grounds, and catastrophes have been met
by blundering incapacity. The political appointee has been
made the scapegoat, and the appointing officer, whether
mayor, governor, or president, has regained public con-
fidence by replacing an old with a new incompetent.

In order to have health machinery work properly, the ap-
pointing officer should not be allowed to shift responsibility
for failure to his subordinates. For example, it was recently
found in New York City that while the tenement-house com-
missioner was being condemned for failing to enforce the
law, he had turned over to the corporation counsel, also ap-
pointed by the mayor, for prosecution ten thousand "viola-
tions " to which no attention whatever had been paid !

The voter, nonvoter, appointing officer, legislative officer,
and judicial officer determine the character and purpose
of machinery and are analogous to the surveyors, stock-
holders, directors, and constructors who provide railroads
with tracks and with running stock. The actual running
force of health department or railroad is what is meant
by its official machinery. What this machinery should be
depends, of course, upon the amount of business to be

1 The technic and principles of municipal engineering have been treated
in detail in Principles of Sanitary Science and the Public Health, by William
T. Sedgwick, and in Municipal Sanitation in the United States, by Charles
N. Chapin, M.D.



OFFICIAL MACHINERY



305



done, and differs with the size of the district and the
character of population to be served.

Local health machinery should guarantee protection
against the evils mentioned in preceding chapters. In
general, one man is better than three to execute, although
three rhay be better than one to legislate. Where small
communities do not wish to have the entire state sanitary
code rigidly administered, they can adopt New York's




FOR PUSH-CART FOOD, INSPECTION IS PARTICULARLY NEEDFUL

method of a legislative board of three members, headed
by an executive, whose business it is to act, not talk ; to
watch subordinates, and to enforce rigidly and continuously
ordinances passed by the board. The National Bureau of
Census places under the general heading Health and Sani-
tation the following activities : health administration, street
cleaning and refuse disposal, sewers and sewage disposal.
Sanitarians generally emphasize also the health significance
of efficient water service.



3o6 ENFORCING HEALTH RIGHTS

A community's health programme should be clearly out-
lined in the annual budget. Where health work is given
funds without specification of the kinds of work to be done,
serious evils may be overlooked and lesser evils permitted
to monopolize the energies of health officers. Again, after
money has been voted to prevent an evil, records should be
made of work done when done, and of money spent when
spent, so that any diversion will be promptly made known.
The best present guides to budget making, to educational
health reports, and to records that show efficiency or ineffi-
ciency of health administrators are the budget and report of
the department of health for New York City, and the story
of their evolution told in Making a Municipal Budget, by
the Bureau of Municipal Research.

To find out whether local machinery is adequate, the
reader must enumerate the things that need to be done
in his community, remembering that in all parts of the
United States to-day there are sanitary laws offering pro-
tection against dangers to health, excepting some dangers
not understood until recently, such as child labor, dan-
gerous trades, lack of safety devices. Adequate local pro-
tection, however, will not become permanent until adequate
state machinery is secured.

State health machinery should be of two kinds, — fact-
gathering and executive supervision through inspection.
The greatest service of state boards of health is to edu-
cate localities as to their own needs, using the experience
of all communities to teach each community in how far its
health administration menaces itself and its neighbors. In
addition to registration of contagious diseases, facts as
to deaths and births should be registered. State health
boards should " score " communities as dairies and milk
shops are now being scored by the National Bureau of
Animal Industries and several boards of health. When
communities persist in maintaining a public nuisance and



OFFICIAL MACHINERY



307



in failing to enforce health laws, state health machinery
should be made to accomplish by force what it has failed
to accomplish by education.

States alone can cope adequately with dangers to milk
and water sources and to food. The economic motive of
farmers has developed strong veterinary boards for the
protection of cattle. Similar executive precaution must




NATIONAL MACHINERY HAS STIMULATED LOCAL MILK
INSPECTION AND STATE DAIRY INSPECTION



soon be taken by cities for the protection of babies and
adults of the human species. It is far more economical to
insure clean dairies, clean water sources, and wholesome
manufactured foods by state inspectors than by' local in-
spectors. At present the task of obtaining clean milk and
clean water falls upon the few cities enlightened enough
and rich enough to finance the inspection of community
foods. Once tested, it would be very easy to prove that



3o8 ENFORCING HEALTH RIGHTS

properly supported state health authorities will save many
times the cost of their health work in addition to thou-
sands of lives.

County or district machinery is little known in America.
For that reason rural sanitary administration is neglected
and rural hospitals are lacking. In the British Isles rural
districts are given almost as careful inspection as are cities.
Houses may not be built below a certain standard of light-
ing, ventilation, and conveniences. Outbuildings must be
a safe distance from wells. Dairies must be kept clean.
Patients suffering from transmissible diseases may be re-
rnoved by force to hospitals. What is more to the point,
rural hospitals have proved that patients cared for by them
are far more apt to recover than patients cared for much
more expensively and less satisfactorily at home, while less
Hkely to pollute water and milk sources or otherwise to en-
danger health.

With national machinery the chapter on Vital Statistics
has already dealt. We shall undoubtedly soon have a
national board of health. Like the state boards, its first
function should be educative. In addition, however, there
are certain administrative functions where inefficiency
may result in serious losses to nation, state, and locality.
National quarantine, national inspection of meats, foods,
and drugs are administrative functions of vital con-
sequence to every citizen. Authorities are acquainted at
the 'present time with the fact that the sanitary adminis-
tration of the army and navy is unnecessarily and without
excuse wasteful of human energy and human life. In the
Spanish American War 14 soldiers died of disease for i
killed in battle ; in the Civil War 2 died of disease to i
killed in battle ; during the wars of the last 200 years
4 have died of disease for i killed in battle. Yet Japan
in her war with Russia, by using means known to the
United States Army in i860, gave health precedence over



OFFICIAL MACHINERY 309

everything else and lost but i man to disease for 4 killed
in battle. Diseases are still permitted to make havoc with
American commerce because the national government does
not apply to its own limits the standards whicb it has suc-
cessfully applied to Cuba and Panama.

" The Japanese invented nothing and had no peculiar
knowledge or skill ; they merely took occidental science
and used it. The remarkable thing is not what they did,
but that they were allowed to do it. It is a terrible thing
that Congress should choose to make one of its rare dis-
plays of economy in a matter where a few thousand dol-
lars saved means, in case our army should have anything
to do, not only the utterly needless and useless loss of
thousands of lives, but an enormous decrease of military
efficiency, and might, conceivably, make all the difference
between victory and defeat."



CHAPTER XXX



SCHOOL AND HEALTH REPORTS

For every school-teacher or school physician responsi-
ble for the welfare of children at school, there are fifty or
more parents responsible for the physical welfare of chil-
dren at home. Therefore it is all important for parents
to know how to read the index for their own children,
for their children's associates, and for their community.
School reports and health reports should tell clearly and
completely the story of the school child's physical needs.




NECESSARY TO EFFICIENT DEMOCRACY



It is impracticable at the present time to expect a large
number of men and women to be interested in the reports
published by school and health boards, for, with few excep-
tions, little effort is made to write these reports so that they
will interest the parent. Fortunately, a small number of
persons wishing to be intelligent can compel public officials
to ascertain the necessary facts and to give them to the
public. So backward is the reporting of public business

310



SCHOOL AND HEALTH REPORTS 311

that at the present time there is probably no service that
a citizen can render his community which would prove of
greater importance than to secure proper publicity from
health and school boards.

Generally speaking, these published reports fail to inter-



Online LibraryWilliam Harvey AllenCivics and health → online text (page 21 of 29)