The community health problem

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HEALTH SCIENCES STANDARD

HX64073823 RA425 B932 1 920 The community health

Chapter I

The public health problem of today is a community problem. It is no longer possible to separate the health of the individual from the health of the community at large. Conditions of work, play, education, food supplies and transportation, which were at one time largely the personal concern of the individual have today become community problems and must be solved as such. The health of the individual, influenced largely by man's environment, presents a similar problem.

THE RESPONSIBILITY FOE SICKNESS

Responsibility for accident and disease is no longer con- Bidered merely as a personal problem, it is a community problem as well. Just as we insist that every American shall have the benefits of public education so should we insist upon the inherent right of every American to the possession of a body free from the handicap of preventable disease.

The causes of disease are found in individual, industrial and community conditions, many of which are under public supervision. These conditions must be studied and corrected by the community before any appreciable decrease in preventable disease can be attained. For example, in order to protect the growing child from infection with bovine tuberculosis the state health authorities may inspect and condemn infected cattle hundreds of miles away — cows which neither the child, nor hit parents, nor even his physician have ever Been. The community recognizes its responsibility in the case of bovine tuberculosis but in the case of human tuberculosis the responsibility is less clearly defined. Some communities make fairly adequate provision for the care of the tuberculous, others undertake the care of charity cases only and some make little or no provision for the treatment of patients suffering from this disease.

Until comparatively recently the problem of public health has been almost entirely one of prevention in the case of acute infectious disease. Small-pox, typhus and plague have been all but completely wiped out. Scarlet fever and diphtheria have been greatly diminished. During the last few years there has been a praiseworthy stimulation of interest in the prevention of disease, with a consequent steady progression toward better health. The movement at present is, notwithstanding the rapid progress already made or, possibly because of the very rapid growth of the movement, somewhat inco-ordinate and characterized by a certain amount of duplication of effort and waste of energy which is, from the nature of things, unavoidable during the early stage of a movement of this sort.

DISABILITY DISCOVERED BY THE DEAFT

Examination of the records of nearly five million drafted men has focused attention upon the fact that there is in the United States a health problem which has been ^nerally disregarded, Kot entirely so, because during recent years many exhaustive health surveys have brought to light a tremendous amount of untreated illness, but such statistics have been read by comparatively few and have not made the same impression upon the popular imagination as have the more striking figures which resulted from the draft board examinations.

There is in every community, if we accept the figures of the Surgeon-General, a comparatively large amount of preventable disease among young men between the ages of 18 and 31. The figures vary somewhat in different parts of the country and there is a variation between the urban and rural population, but the figures taken as a whole represent an approximately accurate cross section of the country.

The following figures furnished by the Surgeon-General* of the TJ. S. Army, indicate the percentage of disability found in the examination of approximately 5,000,000 drafted men:

SOME IMPORTANT DEFECTS REVEALED BY THE DRAFT

Per Cent.

1. Defects of feet (flat-foot 11 per cent.) 13.

2. Venereal disease —

During first period of draft 2.9

In later period of draft 5.7

4. Defective vision (largely errors of refraction) . . 3.5

5. Defective physical development, including under-

weight and under-height 3.5

6. Organic diseases of the heart 3.

7. Deformities or loss of extremities 3.

9. Hypertrophy of tonsils 2.33

10. Defective and deficient teeth 1.33

11. Mental deficiency 1.25

12. Otitis media (purulent) 1.

14. Goitre (simple and exophthalmic) 0.75

15. Deformities of the hand 0.75

According to figures obtained from various sources the number of men disqualified for military service was found to vary between 21 and 34 per cent., depending upon the

•Ireland, Merritte W. ; Physical & Hygienic Benefits of Military Training as Demonstrated by the War. Journal A. M. A., Vol. 74; No. 18, Feb. 21, 1920.

statistics quoted. The records of the Surgeon-General showthat 39 per cent, had some form of disability. Other records show a slightly higher figure. Suffice it to say that approximately one-third of the young men of the country were physically unable to perform full military duty. In the later examinations 14,5 per cent, were rejected by local boards as unfit for service and about 7 per cent, were rejected by military boards after having been sent to camp. Only fifty-three per cent, were accepted as fully meeting the military standard with no defects recorded.

If preventable illness (and physical disability which results from preventable illness) is found to such a great extent among young men during a period when the highest degree of physical development is expected, is it not natural to suppose that preventable illness exists in a proportionate amount in other members of the community ?

This number errs on the side of conservatism for in the haste of mobilization many minor disabilities were overlooked and many men were taken into the Army as ''physically fit" only to be found disqualified at a later date. It is safe to say that over one-half of the young men of military age show some form of physical defect.*

SICKNESS SURVEYS

So much for the military. Without attempting to determine whether adequate treatment had been available for the average drafted man and whether such treatment might have modified the findings, let us examine the status of the civilian population. In general, no such complete figures are available for civilians, but in recent years a number of health surveys have been carried out in various parts of the country with most striking results, which indicated that general conditions were at least as bad as those discovered in the draft.

*A report published in tlie Journal of the American Medical Association (April 10, 1920), states that according to recent figures only 25 per cent, of the drafted men were qualified according to pre-war standards.

Jnst what is a health survey and how is it carried out? As ordinarily understood a health survey is the examination of the health conditions in a given conununity especially with reference to disability due to injury and disease. In some cases only meagre details are furnished and include only a report of those seriously ill and unable to work. In other surveys every member of the community is carefully examined and a notation made of non-disabling conditions such as defective teeth, adenoids, varicose veins, and other similar conditions. As a consequence of the varying conditions under which health surveys are carried out, it is very difficult to compare figures given in different surveys without clearly understanding the methods adopted by the examiners.

Surveys are made difficult because of the fact that most adults object to a physical examination by a physician unless they are seriously ill. There are those who resent what they consider to be an intrusion into their private affairs and others who, while not actively antagonistic, show little inclination to supply information required to complete the survey.

For this reason, and others which are self evident, it has been much easier to make a health survey among children of school age than among either infants or adults. Consequently we are much better informed as regards the health conditions of children of school age than of other members of society. After making due allowance for those children who are crippled or too iU to attend school, the results of so-called "school examinations'* offer reasonably accurate figures upon which to base an estimate of the general health of the community.

EXAMINATION'S OF SCHOOL GHILDEEN

For some years ITew York State has had a fairly comprehensive law requiring the examination of school children. During the year 1918 over 700,000 school children were examined and over 500,000 were found to have physical defects. In New York City defects were found in 77 per cent, of the children examined. In rural districts and villages the percentages were somewhat lower. The New York State Reconstruction Commission, in discussing these findings, suggests that the smaller percentages in rural communities are due to "the varying degree of thoroughness in examinations."

PHYSICAL CONDITION OF SCHOOL CHILDEEN 1918

720,176 Children Examined in N. Y. State

Defects

Vision

Hearing

Teeth

Enlarged or Diseased Tonsils.

Breathing

Nutrition

Lungs

Total Number of Defective Children

New York

City Number

Cities and Villages Number

23,362

15,692

1,214

2,511

161,686

63,925

33,475

29,756

26,168

10,203

35,225

4,578

Rural Schools Number

18,591

4,699

70,561

42,202

17,455

3,859

190,898

(77%)

138,093 (57%)

177,063 (63%)

During recent years the Bureau of Child Hygiene of New York City has made a careful study of the subject of mal-nutrition in school children.* Ignorance of the nutritive value of foods, the high cost of food, carelessness in its preparation, and the use of food substitutes all play a part in the causation of mal-nutrition. Many cases were found to be secondary to physical defects such as enlarged tonsils, defective teeth, etc. In a nutritive survey of school children an arbitrary standard, known as the Dumferline Scale, has been adopted for convenience of classification. This consists of four classes as follows :

Excellent — the child is well nourished. Good — ^nutrition falls short of excellent. The child requires supervision — ^borderline. Nutrition seriously impaired — ^requires medical

Class 1.

Class 2.

Class 3.

Class 4. treatment.

•Report of the Poblic Bealth Committee on Reconetrnctlon. Xork State, Oct. 24, 1919.

New

THE HEALTH OF THE COMMUmTY 9

During 1918 nearly 200,000 school children were examined and graded for nutrition with the following result:

EXAMINATION OF SCHOOL CHILDEEN, 1918

City of New York

Public Parochial

Schools Schools Total

It is estimated that the number of children in Class 4 has increased during 1919, since the cost of milk and butter has risen so high that many families have economized by cutting down on the daily supply, substituting other less nutritious foods.

Of the children requiring medical treatment probably only a comparatively small number actually are receiving medical attention. Some are under the care of private physicians and others are being treated by weKare associations and dispensaries, but a large number are neglected and will continue to be neglected unless treatment is insisted upon by school authorities or by welfare organizations.

COMMUNITY HEALTH SUEVETS

^iaong adults there are few surveys which indicate physical disability with the same amount of detail as is found in the draft board and school reports. As has been noted, adults are apt to object to physical examination and consequently most of the surveys include only personal statements as to actual disability.

In six surveys made by the Metropolitan Life Insurance Company covering a total of 637,000 persons holding policies,

10 THE COMMUNITY HEALTH PKOBLEM

it was found that there were 13,114, or 1.9 per cent., who were suffering from an illness severe enough to prevent them from going to work. In addition to this number about 1200 were fiick but were still able to work. No attempt was made to discover those suffering from light illness and non-incapacitating disability. In the Chelsea survey the figures were 1.5 per cent, sick, and 1.4 per cent, disabled. In North Carolina the fi^gures were 2.85 per cent, sick, and 2.3 per cent, disabled.

Information as to adult sick rates may be secured in another way, that is, by considering the number of days sick per year for each member as shown by the records of sickness and death benefit societies. Such records compiled by the Bureau of Labor Statistics show that, for all ages, there was a disability rate (per insured person) of 6.6 days per year. This figure is approximately 5 days per year for insured persona under 35 years of age and gradually increases to 15 days per year for members 70 and over.

In time of epidemic the amount of sickness may be greatly increased. During the epidemic of influenza in 1918 it was shown that in a total of 148,245 persons canvassed* in various parts of the United States, 43,580 suffered from an attack of influenza. This is a case rate of 29.4 per cent.

FEAMINGHAM HEALTH DEMONSTRATION

In the Framingham Community Health and Tuberculosis Demonstration a careful health survey was made of the entire community.** Every individual who would permit examination was systematically examined by a physician trained in this work. In all, 4,473 persons were examined during a period of several days.

Minor ailments such as colds and defective teeth were included with the result that 3,456 or 77 per cent, were found to show physical disability of some sort. This is an enormous

•Animal Eeport U. S. Public Health Service, Washington, 1919. ** Armstrong, Donald B. : Framingham Monograph No. 4; Community Bealtb Station, Framingham, Mass., November, 1918.

figure, and, as miglit be expected, represents largely ''minor ills/' These may be classified as follows:

MIX02 ILLS IX EXAMINATION OF 4,473 PEESONS

Defective teeth 1,006

Enlarged tonsils 563

Colds, coryza, etc 132

Glandular system 277

Miscellaneous 100

2,443

Of the major ills there was a total number of 1,113 of which 96 were pulmonary tuberculosis. The number seriously ill represented 25 per cent, of the total examined.

The result of these examinations shows the large amount of illness usually disregarded. In this same group a census taken before the examinations showed only 6.2 per cent, who reported any illness. Compare this number with 77 per cent, as found by the medical examinations or even with 25 per cent, which represented those having "major ills."

Of the total number of affections found, both minor and serious. Doctor Armstrong estimates that 61 per cent, are either "theoretically preventable or easily remediable," while about 15 per cent, are non-preventable. The balance are classed as "doubtfully preventable."

HEALTH IN THE ASMT

If we turn now to the report of the Surgeon-General, IT. S. Army, for 1918, we find that among picked men (remember a large number were not accepted for the Army because of physical disabilities) there is always a fairly constant sick rate. This is called the non-effective rate, meaning thereby that among a given number of men a certain number per hundred are "non-effective" or unfit for dutv. The non-effective rate for 1917 among enlisted men was 22.21 per 1,000 in the United States. In Europe it was slightly less and in the Philippines considerably more. Over a series of years the Army non-effective rate runs pretty regularly between 2 aiid 3 per cent. There are several factors which tend to make the rate lower in the Army than in civilian life, chief of which is the fact that soldiers are carefully picked young men presumably able to do full duty when enlisted. In addition, when soldiers develop chronic diseases they are discharged so that such diseases as tuberculosis and chronic nephritis play a comparatively small part in the non-efEective rates.

THE SICK IN THE COMMUNITY

If the figures already given are carefully considered it will be seen that while there is abundant evidence of illness in a given community, it is rather difficult to state exactly any figure which would fairly represent the total number requiring treatment at any one time, but by a consideration of the facts we may judge rather closely the number seriously ill.

If we start, for example, with a consideration of those who ! are too ill to work we will find that, excluding the number who have a permanent disability imsuitable for treatment — such as an amputated leg or deformed hand — there is a fairly definitely fixed percentage which represents those incapacitated. This figure is as a rule between 2 and 3 per cent. At times it may drop below this figure and during epidemics it may rise as high as eight or ten per cent, or even higher.

Of this 2 per cent, probably at least one-half should be under hospital treatment so that in any given community there should be at least one hospital bed for every hundred persons. As a matter of fact this number is very conservative, it being claimed by many that two hospital beds for every hundred persons is the least number consistent with adequate treatment. In military camps where there are no accommodations for "home treatment" this number should be increased to at least 5 per cent, in time of peace and considerably more during war.

In addition to those unable to work because of illness there is a certain percentage who feel the effects of illness but continue to work (among these are cases of chronic heart disease, tuberculosis, kidney disease, chronic bronchitis and many minor ailments). This is usually estimated as about 2 to 4 per cent,, so that the figure for the total acknowledged iUness will usually average pretty close to 6 per cent.* That is to say, that if one physician should undertake the care of a typical community of a thousand persons he would have about 60 patients at all times. This does not mean that such a physician would see 60 patients a day. Many would be at work, reporting for treatment weekly or monthly, or possibly even less frequently.

If we accept the figure of 6 per cent, as representmg the number in a community who admit illness and acknowledge the necessity for treatment, we still have a considerable discrepancy between this figure and the figures obtained from the draft boards, school surveys and the Framingham survey quoted above. Part of the discrepancy is due to those who Buffer from a permanent disability such as a deformed hand or amputated finger and do not consider that they are ill; part is due to the ignorance of the symptoms of disease ; and a large part is due to minor ills which for economic reasons have been untreated and are consequently disregarded.

However the exact percentage of sickness in a given locality is of less importance than is the fact that, in each and every community, there are constantly found some persons seriously sick, some iU but not incapacitated, and a large number of others suffering from minor ills of more or less consequence. The efficiency of the methods adopted in dealing with these conditions has a direct, influence on the social and economic life of the community.

Every community should examine closely into the preparation it makes for care of its citizens' health. Do the sick receive adequate treatment ? Are there sufficient hospital beds ?

•In Dr. Armstrong's health census the number who said they were sick represented 6.6 per cent, of the total surveyed.

Are proper measures being taken to educate the mother in the care of her child and is every effort being made to decrease preventable disease and to diminish remediable ills?

It is not enough to increase wages and to expect the individual to secure medical treatment. Every patient suffering from an infectious disease is a menace to his neighbors, and every case of disability is an economic drain on the community as a whole. Education of the medical profession has decreased illness but not sufficiently to wipe out certain easily preventable diseases ; public education has not, up to the present, sufficiently influenced physical health

Neither increased wealth nor advances in medical science will develop the full resources of the youth of the nation unless directed by a well-planned concerted effort to apply the lessons taught by medical science to the every-day problems of public health.

CHAPTEE II SICKNESS AS A CAUSE OF POVERTY

In the straggle between capital and labor the pecuniary rewards of the workman have steadily increased, and this was true even before the World War upset all pre-war standards. The recent rapid increase of wages combined with a diminished supply of labor has tended to decrease the ordinary evidences of povert}'. Bread-lines are strikingly short ; municipal lodging houses have few guests; and unemployment is at the minimum rate for many years.

There is, however, still considerable poverty due to disease. The increased income has not, as might be expected, been hoarded against the proverbial rainy day but has been expended for luxuries of a temporary character. The workman receiving an unprecedented high wage is living better than ever before. More automobiles, more phonographs, and more fine clothes have been purchased by wage earners than ever before. Moving picture theatres are flourishing, candy and Boda-water is sold in enormous quantities, and silk has become the daily raiment of the skilled worker. This is perhaps as it should be. Certainly labor has waited a long time for the coming of the day of high wages and is entitled to a few of the luxuries of life, but it is certain that the average wage earner is not saving any considerable portion of his wage as an insurance against loss due to illness. There is today, in every large city, an enormous number of persons entirely dependent upon charit}' as a direct result of sickness and there will be more when the present boom begins to diminish, and still more when really hard times arrive.

Prosperity during and after the war tended in one way to decrease poverty due to physical disability. In every community there is always a certain number of crippled and subnormal individuals who are unable to secure any sort of remunerative employment during periods when supply of labor exceeds the demand. In the prosperity which followed the World "War most of these individuals secured employment at a living wage. Others, however, who are actually too ill to work are less fortunate. The increased cost of living and the diminished purchasing power of the dollar makes their plight doubly difficult and throws an increased burden upon the resources of charity. When sickness occurs it is found that the cost of medicine has increased, medical attention is considerably more expensive than during the pre-war period and rents and household expenses have more than doubled.

So that we find that, even with high wages, illness of the bread-winner of the family, for an extended period, often results in economic distress. This is true in the case of the wage earner so frequently as to be considered the rule. Those who are especially wasteful are almost immediately plunged into poverty; those who have greater means do not feel the pinch of want until later; while a few of the more provident may pass through a fairly long illness without actual distress.

Edward T. Devine of the Charity Organization Society of New York City says in his book "Misery and its Causes": "111 health is perhaps the most constant of the attendants of poverty. It has been customary to say that 25 per cent, of the distress known to charitable societies is due to sickness. An inquiry into the physical condition of the members of the families that ask for aid, without taking any other complication into account, clearly indicates that whether it be the first cause or merely a complication from the effect of other causes, physical disability is at any rate a very serious disabling condition at the time of application of three-fourths — not onefourth — of all the families that come under the care of the Charity Organization Society."

Sickness acts as a double cause of poverty. There is, first the direct loss due to the cessation of regular income and,

SICKNESS AS A CAUSE OF POVERTY 17

second, the loss of savings due to expenses for doctors' and nurses* fees and for medical supplies.

The loss due to idleness has been estimated to be equal to an average of nine days' wages per year. The Pennsylvania Health Insurance Commission estimated that in that state alone employees are losing more than $39,000,,000 annually because of sickness. In the Kensington Survey the wage loss was reported in 367 cases and averaged $78.53 per case. In only a smaU percentage of employees are wages continued during sickness, probably not more than five or six per cent. Illness may act further to increase poverty through its results. Frequently after an attack of rheumatism or typhoid or other disease, the body is left so shattered from the effects of the illness, that the former occupation is beyond the strength of the individual. Consequently a new and lighter occupation must be chosen which results in diminished earning power.

The expenditure for sickness varies considerably in different families and in various localities. Many of the poorer families spend as much, or more, for patent medicines (self -medication) as they do for medicines prescribed by physicians. In a number of families studied in Philadelphia, the average expenditure for this purpose was over $5.00 a year. In a survey by the United States Bureau of Labor Statistics the expenditures for medical relief of families with varying

income was studied with the following findings ;

YEABLY EXPENDITUEES FOE SICKNESS

Washington, D. C, 1916

Income

Number

of Families

Yearly Expenditures

Under $600

Colored....

Colored ....

Colored. . . .

Colored ....

Colored ....

Colored ....

65 45 19

235 115 118

198 191

922 692 230

$12.01

12.83 10.03

20.84

$900-$1,200

25.52 16.20

40.19

$1 200-11,500

42.31 32.84

42.42

Over Sl,500

43.16 28.95

58.71

Average, all incomes

69.57 35.21

37.75 43.59 20.19

This of course does not include the free treatment at charitable institutions, snch as hospitals and dispensaries, which would amount to considerably more. Therefore it is safe to say that medical attention and medical supplies cost each family at least $40 per year under conditions such as exist in large cities. In rural districts it is possible that the expenditure is a little less.

Though this expenditure is not large, it should, if it were expended scientifically and efficiently, purchase a fairly satisfactory medical service. However, under our present system

SICKNESS AS A CAUSE OF POVERTY 19

the money is to a large extent not well spent. In the first place it is spent almost entirely after illness has occnrred. Only a smaU amount is devoted to the prevention of disease. Compared with the amount spent for the cure of illness the community spends only a comparatively insignificant amount for prevention, possibly from one to three dollars,* per capita, yearly in cities and very much less in most rural communities. In the next place the care of illness is left largely to the patient himself. When he decides he needs medicine he proceeds to buy patent medicine; when he thinks he needs a doctor he secures the services of one, if he can afford the expense, only when he is convinced that there is no other alternative. In many cases this is too late to secure the best results. The physician, being paid to cure disease and not to prevent it, devotes most of his energies to curative medicine and very little to prevention.

The experience of the Rockefeller Foundation in certain southern communities has thrown considerable light upon this point. In certain cases they have found that by expenditures directed toward the prevention of malaria they were able to reduce malaria almost to the vanishing point and this at a cost of less than had previously been spent for treatment of the disease.

In an experiment carried on by the Foundation in Arkansas an attempt was made to rid four towns in the state of malarial infections by means of well recognized measures for the extermination of the mosquito. Pools were drained or filled, sluggish streams were ditched and oil was applied to surface water which could not be otherwise dealt with. In other words the attempt was made to make these towns unhealthy places for the disease-carrying mosquito.

The results were measured by the number of visits made by

physicians to patients suffering from malaria. In 1916, before

the experiment, the number of calls made in the town of Ham-

•The expenditures of the New York City Department of Health Is about 65 cents per capita. This amonnt is increased by State and FederaJ expenditures and by voluntary donations.

20 THE COMIVIUNITY HEALTH PROBLEM

burg, Arkansas, was 2,312; in 1917, the year of the experiment, the calls dropped to 259, and in 1918 to 59.*

In this town of only a few over a thousand inhabitants the per capita cost of the conquest of malaria was $1.45 in 1917 and 44 cents in 1918.

Similar results could not be secured in every community, but there are many towns and villages in the United States where comparable results might be obtained.

The element of charity in free medical treatment, whether provided from the public purse or by charitable organizations, has prevented a certain portion of the community from accepting free treatment even when it is offered. There is a certain portion of the population, perilously near the poverty line which resents the implication that it is unable to pay for medical care. This follows closely on the experience of the early days of education. The "free school" was for the very poor, the pay school for the well-to-do and nothing for the middle class. Many children were denied the benefits of education because their parents refused to send them to the free school. It is the same today with regard to medical care. Free medical care is available to a limited extent but self respecting wage earners often prefer to do without treatment rather than to deprive others who may be more in need of help.

It is easy to determine for yourself the effect of prolonged illness as a cause of poverty and want. Examine a given number of wage earners, say twenty or thirty, and find out how many of them could stand the financial strain of a disability lasting six months or longer. Such a disability might easily occur as a result of a broken thigh or an attack of nephritis and yet only a few have enough money in bank to begin to pay the necessary expenses of such a long illness. Yet scattered over the entire population such a period of disability occurs comparatively seldom and could be easily met by some form of insurance.