Public health movement
ER Kt Lt'< _„<..-rv Of f)UBUC HEAV-TH UB^^ The PjLiblic Health Movement PHILADELPHIA American Academy of Political and Social Science 1911 Copyright, 191 1, by The American Academy of Political and Social Science. All rights reserved. CONTENTS PART I THE GENERAL PROBLEM PAGE HEALTH NEEDS AND CIVIC ACTION 3 William H. Allen, Pli.D., Director, Bureau of Municipal Research, New York. HOUSING AND HEALTH 13 Lawrence Veiller, Secretary, National Housing Association, New York. SCIENTIFIC RESEARCH BY THE PUBLIC HEALTH SERVICE.. 26 J. W. Kerr, M.D., Bureau of Public Health and Marine-Hospital Service, Washington, D. C. THE CENSUS AND THE PUBLIC HEALTH MOVEMENT 42 Cressy L. Wilbur, Chief Statistician of Vital Statistics, Bureau of the Census, Washington, D. C. SOURCES OF INFORMATION UPON THE PUBLIC HEALTH MOVEMENT 61 Robert Emmet Chaddock, Ph.D., Assistant Professor of Eco- nomics, University of Pennsylvania. WORK OF THE COMMITTEE OF ONE HUNDRED ON NATIONAL HEALTH 77 Wm. Jay Schieffelin, Ph.D., Chairman of the Executive Com- mittee of Committee of One Hundred on National Health. PUBLIC HEALTH MOVEMENT ON THE PACIFIC COAST 87 Sarah I. Shuey, M.D., Oakland, Cal. PROTECTING PUBLIC HEALTH IN PENNSYLVANIA 95 Samuel G. Dixon, M.D., LL.D. Commissioner of Health, Com- monwealth of Pennsylvania. HEALTH PROBLEMS OF THE INDIANS 103 Joseph A. Murphy, M.D., Medical Supervisor, United States Indian Service. HEALTH PROBLEMS OF THE NEGROES 110 John A. Kenney, M.D., Tuskegee Institute, Alabama. 235507 iv Contents PART II DISEASE CARRIERS -THE CONTROL OF CAUSES PAGE ; THE RURAL HEALTH MOVEMENT 123 Ch. Warden Stiles, Ph.D., Professor of Zoology, United States Public Health and Marine-Hospital Service. SANITATION IN RURAL COMMUNITIES 127 Charles E. North, M.D., New York. TROPICAL DISEASES AND HEALTH IN THE UNITED STATES 150 John M. Swan, M.D., Medical Director of The Glen Springs; Secretary of the American Society of Tropical Medicine, Watkins, N. Y. THE HOUSE FLY AS A CARRIER OF DISEASE 168 Edward Hatch, Jr., Chairman, Fly Fighting Committee, American Civic Association, New York. THE MOSQUITO CAMPAIGN AS A SANITARY MEASURE 180 John B. Smith, Sc.D., State Entomologist of New Jersey. CLEAN MILK AND PUBLIC HEALTH 192 Jesse D. Burks, Ph.D., Director, Bureau of Municipal Research of Philadelphia. VENTILATION AND PUBLIC HEALTH 207 D. D. Kimball, of Richard D. Kimball Company, Mechanical and Electrical Engineers, New York. PART III ELIMINATION OF DISEASES— PHYSICAL CARE OF INDIVIDUALS SOCIAL SERVICE WORK IN HOSPITALS 223 Richard C. Cabot, M.D., Boston, Mass. MOUTH HYGIENE AND ITS RELATION TO HEALTH 228 Arthur H. Merritt, D.D.S., New York. THE PHYSICAL CARE OF CHILDREN 243 Walter S. Cornell, M.D., Neurologist to the Division of School Inspection, Department of Public Health and Charities, Philadelphia. WHAT AMERICAN CITIES ARE DOING FOR THE HEALTH OF SCHOOL CHILDREN 250 Leonard P. Ayres, Russell Sage Foundation, New York. Contents PAGE THE ELIMINATION OF FEEBLE-MINDEDNESS 261 Henry Herbert Goddard, Ph.D., The Training School, Vine- land, N. J. PREVENTION OF INFANTILE BLINDNESS 273 Charles F. F. Campbell, General Secretary, Pennsylvania Asso- ciation for the Blind; Editor, "Outlook for the Blind," Pittsburg, Pa. THE WARFARE AGAINST INFANT MORTALITY 288 S. W. Newmayer, M.D., in charge of Child Hygiene, Depart- ment of Public Healtt and Charities, Philadelphia. PART ONE The General Problem (I) HEALTH NEEDS AND CIVIC ACTION By William H. Allen, Ph.D., Director Bureau of Municipal Research, New York City. Of $ii2,cxx),ooo requested last year in 4400 appeals to one New York philanthropist, $1,075,000 was asked for various co- operative health purposes. Of this total, only $45,000, or less than one-half of one per cent.^ was asked for preventive or edu- cational health work. The rest was for hospitals, dispensaries, clinics, etc. Of $163,000,000 in public benefactions last year, $19,100,000 was for health purposes. Of this not one dollar was for teaching laymen or governmental officials how to use knowledge already possessed, while $6,800,000 was for finding facts not yet known about cancer, hookworm, etc., and $12,200,000 for hospitals and medical colleges. When John S. Kennedy's will provided for public benefac- tions of $32,000,000, not one dollar was given in a way that indicated an interest in preventive health work, or in what we speak of as the "health movement." The only part of his gift of which he could have been certain that any fraction would be applied to preventive and educational health measures was the $750,000 for the New York School of Philanthropy, where in the treatment of social and civic subjects, considerations of private and public health are given emphasis. Among the world-famous gifts of Mr. Rockefeller and Mr. Carnegie, which together total nearly $350,000,000, not one dollar has been given specifically for furthering the administrative use of health knowledge already possessed, whether by experts or by the public, and less than $10,000,000 is known to have been given for hospitals and medical research. What does it mean to the "health movement" that, while hospitals received last year in wills and in large gifts over $10,- 000,000, the National Committee of One Hundred could not raise $10,000 to show the need for a National Bureau of Health? Is it not really true, as might seem from the figures, that rich (247) 4 ** THe Annals of the American Academy men and women prefer to spend their money on curing a handful rather than on protecting a townful, or on training a few medical students rather than on training a nation? Is a not-yet-found germ of disease more alluring to a philanthropist than a not- yet-found method of getting communities to kill the infinitely more important and more famous germs already understood, and to apply for all of us the lazvs already knoiini to the favored few? No. They give from misinformation, not from choice. The gap between what we know and what we get done — between obvious opportunities for large giving and the actual large giving for health purposes — is one helpful index to the present status of the "health movement" in the United States. It is not true, as one is apt to imagine when reading a list of health activities — of beginnings such as are described in this volume — that a nation has been won over to a full appreciation of its health problems. True, subjects that were considered im- possible for use in the magazines and newspapers ten years ago are given prominent places with profuse illustrations. True, as the physician has lost his monopoly on knoweldge of health laws, the layman has found health stories and health work absorbing. True, our bill-boards, street cars, magazines and newspapers, aflford innumerable evidences that huge factories have been built and stores started to cater to the new appreciation of health laws — e. g.y vacuum cleaners, incinerators, sanitary drinking fountains, sanitary underwear, ventilated shoe-soles, disinfectants, "spotless town" soaps, health cereals, etc. Yet we are barely beginning, and cannot go much farther without giving new direction to two forms of private benefaction: (i) money gifts by rich men and women; and (2) thought gifts by those who most influence private giving and public spending. If private giving had none but positive influence, we could afford to disregard it, for its volume is small when compared with health work done through taxes. But private giving has also negative, obstructive, deflecting, inhibiting influences on those who read of it. In fact, its thought and feeling product is vastly more significant than its cure or relief product. For example, when John D. Rockefeller said to the world, "There will never be money enough to do the world's uplift work," he started in motion forces and doubts and compromises that will do vastly (248) Health Needs and Civic Action 5 more harm to the South than the hookworm. On the other hand, by a statement in his autobiography that there is money and to spare to do the world's uplift work, the world's most intelligent giver on a large scale would have done more good than millions for health or medical education. Therefore, it behooves us who are enthusiastic over the immeasurable strides recently made by the "health movement" to consider the direction of our thinking about the work that remains to be done. Let us take up some of the alternatives confronting rich men and women, and the still richer communities of taxpayers who are confronted with the same facts as are rich men and women, to illustrate some of the misconceptions now current. The medical examination and inspection of school children has "arrived." Newspapers and magazines have given miles of space to describing the benefits to school children from having their physical defects discovered and from being constantly pro- tected against the spread of transmissible diseases. Taking one hundred readers of The Annals at random, probably ninety of them will be under the impression that certainly the greater num- ber of twenty million school children are now enjoying the bene- fits of these advanced methods so widely heralded. The actual condition, so far as state laws are concerned, is that medical pro- tection to school children is provided for in but ten States. Even in New York State itself at the present writing the educational and health officials are under the impression that this is not a good year to introduce a bill providing for physical examination of all children in all schools. The only place in the country where children in private and parochial schools, as well as in public schools, are by law assured the benefit of medical inspection and examination is in the city of Indianapolis. It is true that in al- most all of the larger cities there is now a nominal effort to discover physical defects. It is also true, unfortunately, that with few exceptions, the discovery of the physical defects goes no farther than the statistical records of the board of education or the board of health. In New York City, which, because of the large figures necessary to describe its experience, is responsible for the greater part of the publicity on this subject, the city superintendent re- ports that for the last school year but a little more than one-third (249) 6 The Annals of the American Academy of those in the schools were examined at all, and of 264,425 defects found, only 113,278 were remedied. To get this total of defects remedied, the health inspectors advise tooth brushes as treatment- for defective teeth. Except as money and time are spent in getting done what now everybody knows ought to be done for all children in all schools — laws compelling examination, school nurses for exami- nation, school physicians for diagnosis, house-to-house instruc- tion of parents, harnessing hospitals, philanthropists and health departments to preventive and educational work, establishment of clinics, constant comparison of work attempted with work done, hygiene instruction and hygiene practice at school, which will stop manufacturing defects at their source and give the chil- dren right habits — it will be generations before the majority of our children will have these health rights which most of us now take for granted they possess. The money which will build one hospital in Chicago would get all schools in the country under this legitimate load. The story of the "dental awakening" affords another illustra- tion of the need for constant challenge of our expenditures for health. Men have been pouring millions upon millions into hos- pitals. It is now admitted that many of these millions have been worse than wasted, because dental knowledge has not been ap- plied within hospital and dispensary walls. So much more is now being done by dentists than was done five years ago to enlist the layman's co-operation and to emphasize the dentist's social mission, that even among dentists themselves the im- pression is gaining currency that the world is aroused to the need for dental care. Many a city, however, has had the ex- perience of New York: (i) Physical examination of school chil- dren without proper examination of the teeth ; (2) Piling up records of defective teeth with almost negligible facilities for securing treatment; (3) Permitting children's teeth to be ex- tracted when they should be repaired and cleaned ; (4) Heralding one or two dental clinics as evidence that dental needs have been recognized; (5) Promise of wholesale co-operation between dentists and public schools with practically no examinations or treatments of children. The $2,000,000 given for dental clinics and instruction in dentistry in Boston could be so used as to (250) Health Needs and Civic Action 7 give a nation clean teeth and habits that will preserve clean teeth. Would it be worth while? The crusade against infant mortality has finally come down to the simple proposition of what the mother knows and does for her baby. The only agency in any community equipped to do lOO per cent, of the educational work that is required to equip mothers to save their own babies is the city or state govern- ment. Those most interested in saving babies have the choice of spending time and money in getting done lOO per cent, of the educational work for lOO per cent, of the mothers who need it, or diverting public attention and private funds to the main- tenance of a few, nurses or a few milk stations, or, worse still, a few babies' hospitals. A\'hen confronted with this choice in Hoboken, Mrs. Robert L. The National Children's Bureau adds its testimony and, in my judgment, its warning to those who are investing energy or money in promoting health campaigns. It would have been just as easy to interest Theodore Roosevelt in the possibilities of the United States Bureau of Education, United States Bureau of Census, and a United States Bureau of Health, as in a special not-yet-existing Children's Bureau. The same energy that tried to arouse a country to the need for an additional agency, with an income of $30,000 or $40,000 a year, could have organized and galvanized these other already existing agencies, in touch with a half-million teachers, fifty state and colonial superintendents of education, fifty state and colonial departments of health, all the city bureaus of vital statistics, etc. We social workers can hardly hope to divert the millions upon millions of private philanthropy that now pour into curative institutions over into preventive work, if we ourselves fail to see that our greatest problem, like our greatest opportunity, is in making existing agencies efficient, and in getting done what we all know ought to be done in ways that we know it should be done. It is one of the anomalies of present-day reform, and even present-day health work, that we undervalue the potential service of the newspaper, except when we want to make appeals for our own work. The Healthgrams of Chicago's health officer. Dr. William A. Evans, could, if generally known and generally imi- tated, do more for nation-wide promotion of health than a thou- sand hospitals. Why will we go on believing it is worth while for private philanthropists to work in a few spots a part of the time, while permitting newspapers, street railways or billboards to advertise, all of the time to all of the people, various nostrums which aggravate disease and manufacture misconceptions on which disease thrive? In two New York Sunday papers one issue printed 2y columns of advertising more potent for evil than (252) Health Needs and Civic Action 9 2y cases of smallpox equally flagrant. Have you ever compared the amount spent in your city by private philanthropy to fight tuberculosis with the amount spent by quacks to advertise quack medicines for these same tuberculous neighbors? Take, for instance, the campaign against infant mortality. It w^ould be an interesting study to note on w^hat days of last year the newspapers of your city printed facts about saving babies. Were these newspaper items and editorials addressed to the mothers who have the babies, or to the men and women who have the money to support private work? Did they relate to 100 per cent, of the babies, or to one per cent, or to 10 per cent, cared for in different private institutions? Was the maximum atten- tion given in the summertime when babies could be saved, or in wintertime when the annual reports of child-saving institu- tions were published? In New York City, at the height of the infant mortality of last summer, toward the end of June and early in July, day after day, hundreds of thousands of citizens, including practically all mothers of young babies, read shouting headlines to the effect that there was no hope for reducing infant deaths because the hot wave would last another week. Private agencies, instead of coming "square back" to the mothers through these same welcome sources of information, utilized the torrid wave to state their own need for funds. The health department itself finally accepted the co-operation of the newspapers, and day after day told the New York public that babies died because the milk was warm or unclean, and not because the weather was hot or baby was hot. In my judgment, we cannot go much farther in our health crusades without more funds for making such effective use of the newspapers as has characterized the crusades for legislation against the white plague and child labor. Propaganda for more laws or more hospitals makes news more easily than propaganda for the enforcement of laws already obtained, and the effective use of hospitals and health agencies already established. Here energy and money must be spent in getting facts about the non-enforcement of child labor and other laws, and the administrative remedies for the non-enforcement of our child labor, factory, truancy, compulsory education laws, etc. Just as we are never going to have dentists enough to do the repair work for a nation with unclean teeth, so we are never (253) lO The Annals of the American Academy going to have private agencies enough to undo the evils of in- efficient administration by public officials and employes v^ho are working for good or evil every day in the year w^ith the mo- mentum of lOO per cent, of their communities. Clean streets are more deadly enemies to tuberculosis than are hospitals and dis- pensaries. Efficient state and local departments of health can do more to check transmissible diseases than state and local pri- vate organizations. Getting loo per cent, of us "under the load" by placing our official representatives under that load, with methods that do efficient routine work, is a duty imposed upon all of us by the growing interest in health laws. As Superintend- ent Young illustrated by opening Chicago's school windows, it is infinitely more important to give lOO per cent, of our school children proper ventilation than to start open-air classes for the anaemic and tuberculous. The only time in the year when our communities attempt to picture lOO per cent, of their health opportunity and health needs is when they are preparing their local or state budgets. The only document that pretends to outline lOO per cent, of a community's health needs is the budget estimate. The only document that pretends to describe loo per cent, of what a community proposes to do next year for promotion of health is the city budget. Yet to a degree that is astounding, when one considers public re- sponsiveness to the "health movement," budget estimates, budget hearings, budget making and budget possibilities are still un- known lands to health crusaders. Still more of a stranger is interest in the after-budget fulfill- ment of before-budget pledges. From one end of the country to the other are illustrations in almost every city, that getting money voted for a health purpose is by no means the same thing as getting money used for that health purpose. In October, 1909, at a taxpayers' hearing on the budget for the year 1910, the need for a comprehensive fight against tuber- culosis was presented with a skill and with authority siich as were probably never before equalled in any public hearing in any American city. All the money was voted that such famous ex- perts in the fight against tuberculosis as Robert W. DeForest, Abraham Jacobi, Simon Flexner, Woods Hutchinson, etc., de- clared was needed. Public schools, Bellevue and allied hospitals, (254) Health Needs and Civic Action il and the health department, received all the money asked for the tuberculosis campaign. Yet with two months' full notice that the money would be available January i, 1910, not one of these agencies was ready on January ist to begin to spend the money as planned, and not one of these agencies had spent the money as planned by December 31, 1910. The health department al- lowed $4727 in January, $2590 in February and $9875 by July 31st to lapse for want of organization and direction. Instead of twenty out-door school rooms, the board of education equipped but three and used but two. (Those wishing information on bud- get making and budget estimates, budget hearing and after-bud- get records and accounts that will disclose the truth about after- budget uses of appropriations, are referred to the Herman A. Metz National Fund for Promoting Efficient Municipal Account- ing and Reporting, 261 Broadway, New York.) Utilization of health knowledge already known requires at- tention now more than the discovery of facts heretofore con- cealed. With almost negligible exceptions, we can stamp out diseases common to man without knowing one more fact regard- ing medicine. The great problem of the next few years is to show medical men themselves and philanthropists who like to give money for training medical men and medical research that the supreme need is for administrative use of medical knowledge already in hand. An investigation by the Carnegie Foundation for the Ad- vancement of Teaching has given the physician's halo and that of the medical college a pretty severe tilt. Hundreds of thou- sands of readers, who, until that report, felt that medical schools were distributors of health knowledge, were made to see that what the country needs even more than physicians are men and women who can teach to what a very great extent physicians are unnecessary. For example, after working for a couple of years, the Rbckefeller Fund seems to have proved conclusively that the cure for the hookworm requires chiefly the application of a few elementary principles of cleanliness. The great problem in the South seems to be, not to find germs, analyze them and discover means for killing them, but to give the Southern farmer and small town modern standards of cleanliness and modern local and state machinery for applying modern sanitary methods everywhere. (255) 12 The Annals of the American Academy Likewise the union of Columbia University and the Presby- terian Hospital for the bedside training of medical men raises a question whether an additional step must not soon be taken to supplement bedside instruction with sewer-side instruction, un- clean milkshop-side instruction, unclean home-side instruction, uninformed mothers-side instruction, unlighted tenement-side in- struction, unventilated factory-side instruction, etc. It is not true that a cause is always advanced when every- body comes to see the necessity for promoting- it, and when everybody talks about it. Oftentimes consciousness of social need acts like a drug, putting the public to sleep instead of open- ing its eyes, unless supplemented by administrative acts which harness public conscience and public intelligence to efficient daily routine work. Immediately after hearing of the Slocum disaster — the burn- ing of several hundred women and children on an excursion boat on the Hudson River — I telephoned to Sea Breeze to ask about our fire protection for several hundred mothers and children on fresh-air outings, and for forty children suffering from bone tuberculosis. Fire drills were started at once, and upon my first visit I asked to see one. The promptness, efficiency, pleasure and order that characterized that fire drill were a joy. There was just one defect — nobody had been detailed to turn on the water. Had there actually been a fire, it is not inconceivable that build- ings would have been entirely empty or several lives lost before dis- covering it was nobody's business to turn on the water. This is the condition of a great number of our health cru- sades at the present time. The public is convinced, everybody knows that water puts out fire, everybody knows that there must be organization, but in too many instances^ even when we have our fire drill organized, we have not yet arranged for turning on the water and keeping it on until the fire is out. Social workers and the philanthropists and officials they try to influence can pay biggest dividends these next few years by seeing and taking the administrative steps necessary to utilize, every day in the year, the knowledge they already possess through the only agencies zvhich belong to all of us, which make mistakes or advance steps in the name of all of us, — our city, county, state and national governments. (256) HOUSING AND HEALTH By Lawrence Veiller, Secretary, National Housing Association, New York. Dirt and disease have gone hand in hand too long. As modern surgery owes its rapid strides to the discovery of asepsis and the banishment of dirt from the operating room, so modern medicine is about to come into its own through the banishment of dirt from our communal life. The slum, the mother of disease, is now doomed. Its end is in sight. From ocean to ocean, throughout the land, there is a newly awakened consciousness of our past folly and a slowly dawning perception of our in- herent right to decent conditions of living. We have paid dear for our slums, and have given hostages to fortune, leaving a heavy debt for posterity to liquidate. No one has even attempted to estimate the cost to the nation of our bad housing conditions, because it is an impossible task. Who can say of the vast army of the unemployed, how large a portion of the industrially inefficient are so because of lowered physical vitality caused by disadvantageous living conditions? To what extent is the forbidding atmosphere of so many homes an ele- ment in the problem of inebriety? Of the burdens which the State is called upon to bear in the support of almshouses for the dependent, hospitals for the sick, asylums for the insane, prisons and reformatories for the criminal, what portion can fairly be attributed to adverse early environment? Despite our vaunted civilization, our material prosperity, our increasing love and appreciation of things artistic, our greatly improved architecture, our musical development, our mastery of the mechanical world, our readiness of invention, our diffusion of education, our higher standards of liberty, in a word, our greatly increased culture, we are still in some respects "barbarous America." From the past no word comes to us of the slums of ancient Tyre or Sardis or of noble Athens — only a faint breath from decadent Rome, to tell us that the worst they had did not approach the evils of present-day America. (257) 14 The Annals of the American Academy In the great majority of our cities we are still in that rudi- mentary state of sanitary knowledge where we know no better than to surround ourselves with the vilest elements of human waste, which we allow to remain near the homes of the poor for long periods of time, turning living places which should be gardens of delight and centers of sweet repose into nothing more nor less than disease factories, whose daily output is literally disease and death. We still suffer to remain in large numbers even in the crowded quarters of our cities, where the poor are huddled close together, and where disease spreads quickly, thou- sands of vile privies, vaults, sinks, cesspools, outdoor closets, "sanitary conveniences," so-called. No one knows how many thousands of these there are, but the city where they are not present in large numbers is exceptional. Even New York, with its four and three-quarter millions of people, had 7000 of them up to a few years ago. Baltimore still has 70,000 earth closets, and through all her existence has had no system of public sewers, but only now is installing one. St. Louis can still show 12,000 privy vaults, Philadelphia and Chicago have literally hundreds of thousands of outdoor closets, and many privies and cess- pools. Indianapolis, Milwaukee, Pittsburg, Cleveland, Cincin- nati, Nashville, Birmingham — all have to admit the presence of these ancient evils by the thousands. The list might be added to indefinitely. Hardly a city in America is free from this blight. That such conditions could prevail among the cultured, well- to-do, progressive people of America to such degree is unthink- able. That people of intelligence and wealth would continue to live in such surroundings is not to be believed. And, of course, they do not. These conditions are to be found only among the homes of the poor — in our slums, in those foreign colonies which we have allowed to spring up in the various sections of our cities, "empires within an empire," segregated from American institu- tions, isolated communities feeling but slightly the touch of democracy — "social Saharas," as they have been aptly called. Just because these evils have been removed from our immediate sight we have foolishly fancied ourselves secure, and have believed that they do not touch us. But the "mighty miasmatic breath blown from the slums" penetrates all parts of the town. No home is (258) Housing and Health 15 exempt, no person secure. Disease, no respecter of persons, visits all alike. The so'rdidness of it all, the degrading baseness of it, un- fortunately is withheld from the eyes of most of us.. What it means to the people who have to live in the midst of it we can but faintly conceive. Let us frankly admit that these conditions result in imposing upon the great mass of our working people habits of life that are more compatible with the life of animals than with that of human beings. What it must mean in its effect on the standards of decency, of modesty, of morality even, of young girls growing into womanhood, I leave to the reader's imagination. The effect upon health is direct and intimate. To the de- bilitating influence of the noisome odors in the hot summer weather may be traced much of the illness of the poor; to such influences are largely traceable their lowered vitality and inability to readily resist disease. The connection is even more direct; myriads of flies swarm throughout the hot months, feed on the contents of the vaults, and then proceed to infect the food supply of the people in the neighboring stores, in the kitchens where food is preparing — and with their dangerous burden crawl upon the faces and bodies of the sleeping infants in the homes of the poor. Nor do they stop there — even the homes of the rich are not exempt from the dangers of the typhoid fly. That conditions such as these should grow up in a young community like America, without our becoming conscious of them, is not strange, but the time is rapidly passing when we can longer plead ignorance and extreme youth as excuses for our failure to act. Few cities have as yet dealt effectively with this situation, but, fortunately, the number which have awakened to the sig- nificance of these conditions is constantly increasing. We are rapidly passing out of the stage where the repre- sentative men of a community with whispers discuss these evils and in subdued tones deprecate their ventilation on the ground that it is "bad for business" and will "hurt the city's fair fame." Far-seeing men realize that any such ostrich-like policy but post- pones the evil day, that the continued tolerance of the conditions in the long run injures the city and that a low death rate and a (259) i6 The Annals of the American Academy well-earned reputation as "a city of homes" is one of the best assets a city can have. Such men realize that frank, open- minded discussion of health needs is a prerequisite to their cure. Diagnosis must precede treatment. In many cities groups of business men, chambers of commerce, etc., are themselves actively taking hold of these problems. They are abandoning the policy of concealment and working tkat there may be noth- ing to conceal. Strangely enough, democracy itself seems to be an obstacle to sanitary progress. It is a disconcerting and startling dis- covery to make, but the evidence is unmistakable. In those cities where the "workingman owns his own home," where there are miles and miles of small one-story and two-story houses, the sanitary authorities will tell you that they have the greatest difficulty in meeting health needs, in securing adequate appro- priations, in enforcing higher standards. A low tax rate becomes in such communities a fetich of sinister effect. Where the com- munity is made up to a predominant degree of working people, many of whom "own" their own homes by the payment of but $2'5 or $50, as is frequently the case, the tax rate becomes directly felt to a degree that cannot be appreciated in other communities where the burden of high taxes is more widely distributed and is frequently disguised in the form of rent and increased prices of commodities. In such cities every public expenditure is viewed with the closest scrutiny — public officials, who owe their office to popular vote, are loath to pursue any course of action that will impose upon the electorate at large additional expense. Bond issues for needed public improvements, for installing a system of public sewers, for example, or for alley improvement, are often voted only with great difficulty. The small property owner, with limited resources, stagger- ing frequently under burdens which he should never have placed on his own shoulders, lured by "land hunger," and sometimes by the hunger to be a landlord, is the greatest obstacle to progress. Burdened as he is, limited in his intelligence, his own standard of living low, his knowledge of sanitary science practically nil, it is not strange that he should not place the welfare of the com- munity above that of self-interest, and should not divorce in his (260) Housing and Health 17 consideration of public questions, their effect on his own pocket from their vakie to his neighbors and to posterity. The low standards of living of such a man are further ob- stacles to sanitary advance. Living himself under sordid sur- roundings, content with the conditions that he has known from early childhood, he can see no reason for the new "fads and fancies" which the health authorities would compel him to pro- vide for his tenants. If vaults are good enough for him, they are quite good enough for his tenants, whom he considers as social and industrial inferiors. The false cry for "economy" which now is so popular, and which is usually a cry for false economy, threatens to wreck our institutions. Its appeal to the taxpayer is immediate and satis- factory. His materialistic sense is gratified, and he cares little if it means a serious setback to the sanitary and social progress of the community. It will take the country years to recover from its present hysterical outbreak in this direction. It will be a long time, I fear, before we return to a sane realization that with our advancing standards of civilization, the increased burdens imposed by unrestricted immigration, and our constantly enlarging conceptions of governmental functions, ex- penses of government must necessarily increase from year to year. New sources of revenue must be developed, due economy should be practiced, waste eliminated so far as practicable, but retrenchment in public expenditures should never be made at the expense of the health of the community. It is due largely to the conditions just described that we have as yet in no city dealt effectively with our alley problem. The alley is both a blessing and a curse. As a means of letting light and air into the interior of city blocks that would otherwise be without it, it is a distinct gain. And the few cities that have no alleys feel their misfortune in this regard most keenly. The small, pocketed back yards, shut away from the free current of air, are unknown in the city with alleys. The alley is generally however, an evil. As a minor street, hidden away at the rear of everything, it becomes the dumping ground for all the cast-off material of humanity. Here will be found collected, in all stages cf picturesque disorder and sordid squalor, all of the unpleasant things of our material existence. (261) l8 The Annals of the American Academy The privies generally are close to it. Piles of manure, those pest factories which breed uncontrolled the typhoid fly by myriads, frequently overflow into it. Uncollected garbage, in the hot summer months, lies there in decaying heaps. Surface water, slops, wash-tub emptyings, leakage from privies and from stables cover the surface with slime. Old paper, tin cans, rub- bish and refuse of every kind are everywhere; huge rats, living and dead, add to the general horror. In many cases, these are the playgrounds of the children of the working people. In some they are the only approach to their homes, the sole outlook upon life they get from the windows of their dwelling places. And we wonder at the improvidence of the poor, at their inebriety, at their shiftlessness ! We are surprised at the burdens which the State has to bear in the sup- port of the defective and delinquent. Unpaved, as most alleys are, the cleaning often is a difficult problem. This difficulty is greatly enhanced by the fact that in most cities the city itself assumes no responsibility for their cleanliness, but looks to the abutting property owner to perform this function. The result is what might be expected. We years ago passed beyond that stage of our development where we imposed on private citizens the responsibility for cleaning the streets in front of their houses, but we still, in many cities, fool- ishly expect them to clean the streets in the rear. In few cities are the alleys policed or lighted at night. They become often, therefore, the haunt of criminals, and naturally lend themselves to practices which shun the light. All of these evil conditions are well recognized in most of our cities, but the same causes that have tended to perpetuate the evils of the privy vault have been operative here as well. The small property owner, to whose wishes the elected public official is sensitive, objects to assessments for paving the alleys. He sees no "benefit," in the financial sense, to his property, and he is unwilling, as a rule, to be asked to pay for an improvement which, from his point of view, does not "improve," and which he thinks too good for the class of people from whom he draws his revenues. The alley, if it is to remain, must be treated as a street. It must be paved ; it must be cleaned at regular intervals, that is, (262) Housing and Health 19 kept clean, not made clean; it must be lighted and it must be policed. Before any of these things can be done the city must officially assume responsibility for it; where it does not already own the fee, the owners must dedicate it to the city. The cry for "economy" and the desire to keep down the tax rate operate against the carrying out of these measures. If the alleys are to be cleaned by the city as often as the streets are cleaned, the cost of street cleaning will increase at least fifty per cent. So, if they are lighted and policed, the city's yearly expense will be similarly increased. But it is a false economy that stands in the way of carrying out these greatly needed reforms. It is saving at the spigot and wasting at the bung-hole. We are paying the cost now, in fact, but in indirect and less obvious ways. It will cost the city more for police, but less for police courts and jails; more for street cleaning, but less for hospitals and relief. It is better economy to keep people well than to get them well, to prevent crime than to punish it. The cost must be paid one way or another. If we refuse to pay it in treasure now, we must pay it in both blood and treasure in the end. The filth and squalor which surround the homes of the poor in so many of our cities may be traced to similar causes. From the very nature of things, the working people cannot be expected to hire carts and cart away the refuse which accumulates. Nor is there much likelihood of the average landlord doing this under the conditions of our ordinary urban existence. This is a function of the municipality, and, if the city neglects it, the responsibility must be placed where it belongs, upon the city officials who are so benighted that they do not see the short- sightedness of their policy, and upon the citizens who are so penurious that they prefer to tolerate the evil conditions rather than increase the cost of government. There are few cities in America to-day where the garbage is collected with sufficient frequency or regularity. And the city which collects rubbish, ashes and other waste is as yet the exception rather than the rule. Tuberculosis, that sinister terror of former years, is thought by many to be about to vanish from us, but sober vision indicates that it will be many years before we see it disappear. Although it would seem that no one could have escaped learning the im- (263) 20 The Annals of the American Academy perative necessity of fresh air and sunlight, yet, notwithstanding that we have been taught that tuberculosis is a "house disease," that in dark, unventilated rooms it thrives and flourishes, and that the germs cannot live in strong sunlight, yet in how few cities is the speculative builder restrained from adding new dark rooms to swell the present number. In growing Western cities, where space is plentiful and land is cheap, new tenement houses are built with half the rooms dark — it is easier to do it that way. And, as a nation, we normally choose the easiest way. In no city. East or West, have we so far progressed as to prohibit in our private dwellings and our public buildings rooms without direct outside light and air. Everywhere, irrespective of land values, one encounters an intense, individualistic desire to cover over an undue amount of the lot, and occupy, if possible, every foot of land. In our houses on wheels, the railroad cars and trolleys, where disease spreads most easily and rapidly, we have just be- gun to enforce standards of ventilation ; one might almost say we have hardly commenced it. In our public buildings we are still in the dark ages; our court houses, our municipal and state buildings, our schools and churches, our workshops, our theaters and the moving picture shows, where so many hundreds of thou- sands of people congregate nightly, proper ventilation is the ex- ception rather than the rule. We have a long and difficult campaign of education ahead of us before we can approach reasonable health standards in this regard. Most people do not want fresh air in their homes or elsewhere. It is not only "night air" that is dreaded, but all fresh air. Let a man open a window in a railroad train, or trolley car, or even at a convention of physicians or sanitarians, and see what happens. How quickly some one closes it who cannot stand "the draft." All the ignorance in this regard cannot be charged to the "great unwashed." Viewing these conditions, it seems premature, at least, to talk of establishing "garden cities" and "zone systems." These highly desirable ideals, so successfully carried out in the Old World, must wait until we can bring ourselves to attend to the elementary principles of sanitation and the rudimentary prin- ciples of community living. It is as if the doctor attending a (264) Housing and Health 2i patient desperately ill with typhoid or pneumonia were to con- cern himself before the crisis of the disease had passed with the patient's diet during the convalescent stage. We have not yet reached the convalescent stage, but are still battling for the patient's life. 