What Is The Public Practice Of Medicine?

William H. Peters, M.D., Health Commissioner, Cincinnati, Ohio

A Presentation at the National Conference Of Social Work (Formerly National Conference of Charities and Correction),  Fifty-Third Annual Session Held In Cleveland, Ohio May 26-June 2, 1926 (pp.228-233)

Political control has been and still is one of the chief obstacles to effective public health administration in our country. What is best for the public health is not as a rule the motive inspiring appointments to positions in community public health service. All too frequently the position of health commissioner is the reward for political services rendered.

Too many men engaged in public health work lead a dual sort of life. They have a public conscience and a private one, and as a rule they are willing to subordinate their private conscience to what is best for the party. “Political expedience” should be listed as a contributory cause of death on thousands of death certificates signed tuberculosis, typhoid, diphtheria, etc.

Public health work is a highly specialized branch of medicine, and not until we eliminate political control and the indefinite tenure of office will men of outstanding ability be attracted to a public health career.

The adoption of a new appraisal form for use in measuring city health work by the Committee on Administrative Practice of the American Public Health Association is the culmination of a desire extending over a period of years to give health administrators an instrument to stimulate good public health practice. The conscientious and courageous use of the appraisal form by the health officer may be instrumental in overcoming the insecurity of tenure.

Here he has the opportunity of listing the public health assets of his city in terms that anyone may understand, thus revealing the strong and the weak points in his department. With public sentiment behind him, and the support of the press, the principles of standardization would go far in removing the uncertainties of political changes and influences. Forty-six activities are listed in the appraisal form under eleven main sections, as follows: vital statistics; control of communicable disease, venereal disease, and tuberculosis; prenatal health work; protection of the baby, the pre-school-age child, and the school child; sanitation; laboratory service and popular education. A score book, such as has been adopted, should serve as a fine stimulus for self-analysis by the health commissioner and city authorities.

We have applied the appraisal form in Cincinnati. We know of no other instrument that has been so helpful in conducting the health work of our city. As a result, standard methods of public health practice and record making have been adopted by the official and voluntary health organizations.

In a classical address which many of you may have heard last week at the American Health Congress, our esteemed friend, Dr. S. J. Crumbine, general executive of the American Child Health Association, ventured the suggestion, as a remedy for insecurity of tenure, that freedom from unjust political interference, as assured to chiefs of fire departments under the fire insurance rating plan, should be guaranteed for the health commissioner under a penalty of increased rates in industrial and life insurance.

Freedom from political domination is perhaps responsible more than any other single factor for the public health progress in Cincinnati. This change was brought about in I910, and with it came a reorganization of the health department, until now it parallels an ideal organization recommended by Dr. C. E. A. Winslow, chairman of the Committee on Municipal Health Department Practice of the American Public Health Association. The fact that the members of the Cincinnati Board of Health are appointed for ten years, and that only one member retires every two years, guarantees continuity of program and policy. This is a wise provision of our charter. All members of the health department are civil service appointees and devote their full time to public service.

It is not my purpose to burden this Conference with the details of our organization. We have a splendid foundation for a fine superstructure. Our chief complaint is the lack of funds, but each year gives a new encouragement. Our appropriation for the current year is $I76,620, or, at the rate of 43 cents per capita, a very meager sum for the health protection of 409,000 people living within the corporate limits of our city, embracing seventy-two square miles of area. In a survey which has just been completed we find that the per capita cost of public health administration in class 2 cities, that is, cities with a population between 250,000 and 500,000 inhabitants, is 59 cents. Next year we shall do better!

All of the bureau chiefs are technically trained men and women, but, as Dr. Crumbine has so aptly stated, alumni of “the school of experience.” Wherever possible we follow the district plan of one man or woman combining all of the functions of his bureau in a circumscribed area. The size of our districts shrink as we prosper. Under such an arrangement all duplication of time and effort are eliminated. Our people like the arrangement better. They are not overvisited.

Primarily we are interested in basic and fundamental things, such as the proper disposal of sewage; the purity of the water supply; a healthy environment for every citizen, no matter where he may be; wholesome food; complete registration of births and deaths; competent medical diagnosis for those who cannot afford to pay; sanitary isolation and hospitalization of communicable diseases; immunization as a matter of community prophylaxis; attendance of infants at instructive clinics; physical defects of school children, discovered and corrected; adequate laboratory facilities; and last, but not least, public health instruction.

We believe that the elimination of 22,000 outside vaults and catch basins during the last fourteen years has contributed tremendously to the health and comfort of our people, and that this too has played an important r6le in the prevention of typhoid fever and other intestinal disorders. Two hundred remain. Our slogan is, “A modern sanitary flush toilet for every home.”

About seven hundred homes must depend upon private water supplies. These are under constant supervision, and will be until city water is available. When it becomes necessary to chlorinate the water we do it, and the laboratory checks the inspection work. All steamboats stopping at our port are required to provide certified water. In cooperation with the United States Public Health Service we exercise constant supervision, collect samples of water, and examine them in our laboratory. Incidentally, our quota of typhoid fever, formerly from this source, has disappeared.

The Bureau of Sanitary Inspection is also concerned about public swimming pools, barber shops, public places of amusement, odorous trades, cleaning up unsightly places, flushing of sidewalks and gutters, vermin and rodent extermination, fly and mosquito control, and the thousand and one nuisances detrimental to health and comfort brought to our attention in citizens’ complaints.

If anyone wanted to start a riot, backed exclusively by the milk dealers of Cincinnati, the sure way to do it would be to try to eliminate pasteurization of milk. At present every drop of milk on the Cincinnati market is pasteurized at 145 degrees F. for thirty minutes, except certified milk, which constitutes a little over 1 per cent of the total supply. Through pasteurization, which became effective in 1915, milk dealers have eliminated waste and milk-born epidemics. Years ago drinking milk was like a lottery from which one drew an attack of typhoid fever, diphtheria, scarlet fever, or tuberculosis.

Forty thousand animals are slaughtered annually under municipal inspection. Abattoirs doing an interstate business are under control of the United States Bureau of Animal Industry. The standards for inspection are the same in both branches of the government. In addition, this bureau inspects all establishments in which food is manufactured, processed, held, or stored. Within a very short time a regulation will be in effect which provides for a rigorous inspection of all food establishments, a service charge, and a permit system. This is a consummation to which we have been looking forward for a long time.

It is the business of the registrar of vital statistics to elicit complete returns of birth and make accurate transcripts of all birth and death records for future reference. Much depends upon the complete and accurate registration of births and deaths. Certified copies of births and deaths, so necessary for the settlement of estates, proofs of citizenship, and passport purposes, are issued by this bureau. The registrar and his assistants also certify for approximately four thousand children applying annually for work certificates. For ten years or more we have made it our business to check every death in children under the age of ten against the birth records. This practice and surveys made by the Census Bureau indicate that our birth registration is close to 100 per cent. With us it is routine practice to check and reconcile deaths with reported cases of typhoid fever, diphtheria, scarlet fever, tuberculosis, and other communicable diseases.

Our district physicians are responsible for the medical treatment of the indigent, surveillance over communicable diseases, and the health of the child. We function in 119 public and parochial grade schools. During the summer infants and preschool-age children claim our attention. Our quota is thirteen doctors, one for every two wards of the city. Nutrition is the basis of our school work. We believe that we are striking at the root of the tree. Malnutrition is the arch enemy conspiring to keep the number of children susceptible to tuberculosis at full strength. All children are weighed and measured religiously, and those who are 10 per cent under weight for their height and age are examined very carefully.

We make no claim that our physical examination is complete in the sense that a positive diagnosis is recorded and confirmed by the usual diagnostic tests. This we leave entirely to the family physician or clinician. Our examination, however, is more than an inspection service. It leads to the discovery of serious abnormalities. If we may use Dr. William R. P. Emerson’s expression, it becomes our business to make undernourished children “free to gain” in weight by overcoming underlying causes. In the last five years 43 per cent of the undernourished children were restored to normalcy. In addition, the district physician examines all other children in the first, second, and third grades. One hundred per cent of the school population is vaccinated. This is our best defense against smallpox.

All of the usual provisions, such as open-air schools, lunchrooms, conservation of vision classes, dental clinics, and the like are found in Cincinnati. Glasses were provided for 1,600 children whose vision was found to be defective last year. This represents about a 50 per cent correction. One thousand sixty-two children had their tonsils removed. Fourteen hundred children were excluded from school on account of communicable diseases. These results give you some idea of the magnitude of our medical work and the far-reaching effect of the public health nursing service. We may lecture, exhibit posters, project moving pictures, and broadcast all of the splendid things to do, but the seed begins to grow when we speak in terms of Mary and John to Mary’s and John’s mother and father.

We spend approximately four hours every day in the schools for the health betterment of the pupils. This does not mean that we are in each school four hours every day. Some schools are visited daily, some three times a week, others not so often. The examination of children who are applicants for work certificates takes up a good part of the office time of the district physician. The purpose of the state law regulating work certificates, as you very well know, is to prevent child labor.

Good standard practice prevails to control communicable disease. Communicable diseases are well reported; an approved system of records is maintained, and a consultation service is furnished by the health department. In the appraisal form the ratios for reporting are fixed, a method of record keeping is suggested, and all of the control measures commonly accepted serve as reminders of good public health practice.

A new low diphtheria record was established last year in Cincinnati. Twenty-three deaths were recorded in 1923, nineteen in 1924, and fourteen in 1925, giving us a mortality rate of 5.6, 4.6, and 3.4 per 100,000 of the population for the three years. No city outranking us in population had lower rates. Antitoxin, the sovereign, is within the reach of all, and we are prepared to administer it on the spot if the family income is slender. We urge and recommend immunization against diphtheria with toxin-antitoxin. We have done much to popularize the procedure, and cheerfully do this work in child caring institutions when the trustees so request; but at large we believe that the task belongs to the medical profession.

Fifteen years ago tuberculosis was the principal cause of death in Cincinnati. The “Great White Plague” claimed an annual toll of a thousand lives. Now heart disease, influenza and pneumonia, cerebral hemorrhage, cancer, and Bright’s Disease lead in the order named. Last year the total number of deaths charged to tuberculosis was 478. Our colored people, who make up 9 per cent of the population, contributed 30 per cent of the deaths. We take no particular credit for this remarkable amelioration. So many factors enter the quotient.

In the control of communicable diseases we are inclined to believe that more can be gained by persuasion and immunization than by the prohibitions written in some of our sanitary codes. Harsh quarantines only encourage concealment; sanitary isolation of the patient is much better. What we need more than anything else is the cooperation of the parents.

In our curative work we aim to give the same treatment to the indigent as is ordinarily given by the private physician. Many of our cases are referred to us by the relief-giving agencies. The small volume of work in the last few years as compared to ten or twelve years ago is an indicator of general prosperity.

The health center is one of our very best assets. Here our poor people may come for examination, observation, advice, and treatment. The health center is a local clearing house for the municipal tuberculosis sanatorium, and the cooperation between both institutions is cordial. We have a thousand undernourished children under observation at the health center. It is from this group that the children are recruited for the Kroger Hill Camp, operated by the Anti-tuberculosis League. Last year 330 children enjoyed the benefits of camp life during the vacation period and came back with the roses in their cheeks.

We give good service to those who have venereal diseases. Women and children who are the innocent victims of infection come to us in large numbers.

Our laboratory is the keystone in the arch of public health administration, and what a splendid asset to our city! Here the family physician may submit specimens to confirm the diagnosis in suspected cases of diphtheria, typhoid fever, malaria, tuberculosis, and a host of other diseases. In the last two years, 18,802 examinations were made for the medical profession and the health center. Over forty-nine thousand samples of milk were analyzed chemically and bacteriologically, to be sure that our milk supply is of standard quality. Milk samples are examined for the number of bacteria, the proper percentage of butter fat and total solids, added water and preservatives. Nineteen hundred and fifty-three food samples were turned in by the food inspectors for evidence of adulteration and misbranding. In all, a grand total of 79,688 samples were tested, at a unit cost of 13 cents.

The Bureau of Public Health Nursing functions in all of the medical divisions. Instead of having, as we formerly did, special nurses for each type of service, one nurse does all of the work in a small circumscribed area. She gives advice and service to the expectant mother, the newborn infant, and the child of preschool age. She assists the doctor in his school work, sees that his instructions are carried out, and, if necessary, takes the poor children to the clinics and hospitals. She also assists in the clinics and visits in the home.

The public health nurse must be so well informed that she may be able to put her message into the simplest terms for the mother who is unlearned in the most elementary facts of hygienic living and be equally able to discuss the latest developments in public health with the most intelligent mother in her district.

Four separate chapters in the appraisal form, brief but to the point, outlining types of service relating to prenatal care, the infant, the preschool child, and the health of the school child, serve as an excellent reference for the health commissioner. All of the best scientific public health procedures are outlined in the appraisal form and should prove of real value to the health commissioner in helping him to develop a well-balanced program based upon relative values; to check up on the performance of his bureaus, and thus maintain the department at the highest point of efficiency; to secure funds for expansion by indicating where his organization falls short; to substitute group judgment for his own in time of controversy; and to secure the cooperation of local voluntary health organizations along the most effective lines.

Source: A Presentation at the National Conference Of Social Work (Formerly National Conference of Charities and Correction),  Fifty-Third Annual Session Held In Cleveland, Ohio May 26-June 2, 1926 (pp.228-233) — www.hti.umich.edu/n/ncosw/