Popular Science Monthly/Volume 74/March 1909/The Work of Boards of Health
|THE WORK OF BOARDS OF HEALTH|
By Dr. GEORGE A. SOPER
NEW YORK CITY
THE spirit of the laws by which matters of public health are administered rests upon the theory which underlies all forms of government, that is, that the state has the power to compel the ignorant, the selfish, the careless and the vicious to so regulate their lives and property that they shall not be a source of danger to others. It is an expression of the idea that the interests of no man can exceed the interests of his fellows. The welfare of the many is the supreme law.
Extraordinary powers have from early times been vested in the authorities charged with administering sanitary laws. The highest courts have declared that the administration of public health laws is fundamentally important and entitled to the support of the police power of the state. Public health authorities are in effect police officers charged with a special jurisdiction over the conditions which cause, aggravate or predispose to disease. In the exercise of their remarkable powers health authorities may restrain persons from contact with others, they may enter upon and even destroy private property and may exercise supervisory jurisdiction over trades and occupations.
Many years ago, the almost autocratic power enjoyed by health authorities was much more necessary than it is at present, for the highly contagious diseases have, through the operation of health laws, better personal and household hygiene and municipal sanitary works, been relegated to a comparatively unimportant place as a cause of death. Epidemics of high mortality and vast extent rarely take place in civilized countries to-day, and the need of a prompt, decisive exercise of great authority in this direction is consequently less often necessary than formerly.
At the same time, a new class of duties is growing upon health authorities. Some of these duties are plainly within the proper functions of health boards, while others appear to be less so. Among the obviously proper duties referred to are vaccination, the manufacture and distribution of antitoxin, the control of methods of sewage disposal and the sanitary management of milk and water supplies. Of less obvious appropriateness is the regulation by boards of health of such matters as the discharge of excessive quantities of smoke into the atmosphere of cities, the suppression of street noises, the hygienic care of the food, clothing, exercises and amusements of school children. It is probable that these matters should be made the subject of regulation in the public interest, but should the board of health be the instrument chosen to regulate them?
Obviously some limit should be placed upon the exercise of the power possessed by boards of health when questions not strictly germane to the sanitary welfare of the public are concerned. If no such limit is placed, it is difficult to understand where the activities of boards of health are to cease. Almost every act and occupation and nearly every feature of city life may be construed as having some bearing upon public health and welfare. Before a board of health sets out upon a campaign of more esthetic than sanitary value it should be certain that all its simple and essential duties are being efficiently discharged. There is often much inconsistency in public health work.
So extensive and so numerous are the conditions of modern civilization which certainly affect health, that boards of health generally do not pretend to cover them all. For example, the construction and maintenance of public water supplies and sewerage systems, although undertaken by the public at the public expense, are not conducted by health authorities but by private corporations or special municipal departments. Likewise the collection and disposal of garbage, and even the cleaning of privies, is often done by other than public health authorities.
There is something incongruous about a board of health conducting a crusade against smoke and noise and at the same time allowing the streets to be filthy with dirt and dust and offensive with accumulations of fermenting garbage. Again a great deal of the attention of health boards is occupied with alleged private nuisances which affect comfort but not health. The history of every city is a record of more and more strict regulations to minimize the unpleasant as well as the unsanitary conditions of household life.
The work of boards of health has been, on the whole, very decidedly for the advancement of the general welfare. The great reduction in the general death rate and the more wholesome and agreeable conditions of living of to-day as compared with those of a generation ago, bear ample testimony to this success. If it be objected that other factors have been at work to improve the sanitary conditions of cities, it must be answered that much of the inspiration for this other work has come from health authorities. It should never be forgotten that it is sanitation which has made the growth of cities possible.
Having thus briefly referred to the scope and bearing of public health work we may pass to a consideration of the relation of city, state and nation in protecting the public health.
The authority exercised by public health boards is derivable from the state. In the United States the management of the internal affairs of each separate state is left, for the most part, to the state concerned. Municipal charters are obtained from the state governments and in these charters the power to regulate conditions affecting public health are specifically granted. Cities and towns thus owe responsibility to the state governments and are answerable to them to a greater or less extent, depending upon local circumstances. In Massachusetts local boards of health are comparatively independent of the state authority, while in New York the state department of health is a central body to which the local boards of health are closely tributary.
State health authorities are in no case responsible or answerable to the general government. There is no national board of health.
In the management of health matters the smallest unit of responsibility is a municipal health officer or municipal board of health; the largest the state health officer or board of health. Whether municipal or state, the functions of health authorities are very much the same. The main differences arise from the differences in area over which the authorities are required to exercise supervision. Local boards have charge of the conditions which occur in the several localities in a state; they take cognizance of individual houses and of persons. The ultimate units over which state boards exercise jurisdiction are municipalities.
It is the first duty of all health boards to collect vital statistics, to collate them in tabular form, and to interpret these data so as to show the state of the public health. Local boards of health collect reports of deaths and of contagious and other diseases from physicians, interpret these data, for the benefit of the districts in which they apply, and then forward them to the state authorities. The state authorities so obtain a knowledge of the health in various sections of the state and are so enabled to judge the relative healthfulness of the different localities. An excessive prevalence of disease in one place can thus be promptly detected.
The methods of collecting vital statistics are often unsatisfactory and the results frequently deceptive. It may be remarked in passing that vital statistics are to-day available for only a part of the people of the United States, except during years when this government makes a census enumeration. The census returns are themselves unsatisfactory. In this respect the United States government is behind nearly every civilized country in Europe. The fault lies with our municipal and state governments.
In interpreting death rates careful account must be taken of the marriage and birth rates, total population, migrations of population, and other factors; and it would be well for boards of health to charge themselves with collating as well as collecting these vital statistics, in a more intelligent manner.
When the evidence of vital statistics indicates the presence of an unsanitary condition through an excessive prevalence of some communicable disease, investigations are commonly made to determine the nature of the difficulty. This is often a troublesome and uncertain task. But when the difficulty is once discovered it is usually a simple matter to prescribe the remedy.
In very recent years sanitary investigations have been made much more definite and effective by the applications of bacteriology, chemistry and pathology, and a new class of professional men has been developed for laboratory and field work of the highest and best order. These persons we may call sanitarians or, better, hygienists.
The second main branch of public health work is the suppression of communicable diseases. Suppressive measures include the establishment of quarantine, the isolation of patients, disinfection, vaccination and the management of epidemics. Contrary to the custom of twenty years ago, all the best work in these directions to-day is based upon a scientific knowledge of what we may call the natural history of disease. In all these matters of control the dictum of the health authority is supreme. It can be resisted only through intervention by the courts.
The third main branch of public health work is the abatement of nuisances. The practical work of suppressing unsanitary conditions is done by health authorities by recourse to special statutes and local regulations made by the authorities themselves and termed "sanitary ordinances" or "sanitary codes." Offenders against these laws and regulations are brought before proper magistrates and fined. A board of health exercises the unique function of both making and enforcing the law.
It may be extremely difficult to determine what does and what does not constitute a nuisance. For practical purposes it is often considered that anything which is detrimental to health or which threatens danger to persons or property may be considered and dealt with as a nuisance.
Interesting work for the suppression of disease lies in educating the public, the medical profession and the health authorities as to the causes of and means of preventing the transmission of disease germs. This is one of the newest and most successful branches of public health work which has been undertaken for many years. It is based on the fact that people are not careless in sanitary matters because of a wilful or vicious design against the public welfare; they err through ignorance. By educating the less fortunate concerning the ways in which diseases are transmitted and showing how they can be prevented, substantial benefit results.
This educational work is carried on by the daily papers, the medical papers, special bulletins and magazines, by lectures, by clinics, by congresses and, to some extent, by schools. Sanitary societies and public health associations deserve special credit for good work in arousing the public to the need of better public health work.
At the same time it is regrettable that arguments have been made and movements have been initiated in the name of public health which have had no foundation in fact or scientific principle. The cause of public health has always been a favorite theme alike for the charlatan and the statesman.
By the remarkable advance in that composite body of knowledge known as sanitary science much of the quackery of fraud and the deceptions of ignorance are being dispelled from public health work, and we may confidently look forward to the time when persons who have had adequate training and experience in this direction will be looked upon as the proper sanitary teachers.
In the campaign of sanitary education which is going on it is a deplorable fact that the universities and colleges of the United States are singularly backward. With a few notable exceptions, there is scarcely a school for higher education in the United States where a competent knowledge of hygiene can be obtained. In spite of the fact that man} of the largest and most prominent universities have had severe experiences with typhoid they have been exceedingly slow in providing proper facilities for the teaching of hygiene. One of the greatest needs of to-day is the want of competent teaching for health officers, physicians, engineers and others, who may wish to obtain a complete and practical knowledge of their profession. In the absence of suitable facilities for the education of health officers the United States is decidedly behind European countries.
In the management of communicable diseases the principles of isolation, disinfection and vaccination, have been referred to. It remains to mention the help that may be afforded by the establishment of laboratories for the diagnosis of suspected cases of communicable diseases. Laboratories where examinations may be made of sputum, blood, urine, stools and other pathological specimens, are one of the newest developments in public health work, but they have been in operation sufficiently long to make them seem indispensable. By their means early and obscure cases of tuberculosis, typhoid fever, diphtheria and other too common preventable diseases may be discovered, and with a precision and promptness generally impossible in private medical practise. Along with pathological work of municipal public health laboratories facilities are often provided for the analysis of water, milk, food and drugs. Any citizen may send specimens to these laboratories for examination, and is entitled to a report without charge.
Every board of health should have the benefit of laboratory assistance of this kind. Municipal boards in large cities can afford to maintain them, but for the small city and village other provision must be made. Here the state can render valuable assistance and maintain laboratories for the benefit of municipalities which can not have them.
In addition to the measures of prevention and suppression which have been mentioned reference should be made to the preparation and distribution of antitoxin by boards of health. Here we have an application of the laboratory principle applied to the production of a remedy rather than to the discovery of the cause of disease. Antitoxin is a curative measure which may be and is applied more often than not to isolated cases of diphtheria. The beneficent results which have followed the use of this agent in combating one of the most common and fatal of household diseases are unquestioned, but it must not be forgotten that in supplying antitoxin without charge, boards of health lay themselves open to the charge of competing with private manufactories which prepare the same product and are presumably in a legitimate business to make money.
Results seem to show that it is desirable for boards of health to supply antitoxin, but the principle involved is an interesting one. If antitoxin is to be supplied gratis by boards of health, should not those boards also supply disinfectants, concerning which there are no greater frauds in the American markets to-day? And if antitoxin and disinfectants, why not other things such as indispensable articles of clothing?
To enumerate all the functions of boards of health, local and state, would far surpass the necessary limits of this paper, but enough has been said to show warrant for endorsing most of the work being done to approve the extension of some and the limitation of others of the ever-growing activities of health bureaus. A long paper could be written on any of a dozen phases of this subject.
Taking a rapid review of the subjects covered here, we may remark first that boards of health have ample power. The standards of public health and municipal hygiene are continually growing higher.
The dangers from disease in gross epidemic form are becoming less and less, and in their place a new set of hygienic standards is being erected. Some of these new standards verge upon the realm of esthetics. To what extent boards of health are right in extending their efforts to improve municipal conditions which bear remotely, if at all, on disease and death, but undoubtedly affect public comfort, is a question for debate.
To be effective health work must be cooperative. Statistics must be promptly and accurately collected by the ultimate units of sanitary authority, municipal health boards, and transmitted to boards having jurisdiction over larger territory. Whether or not the largest unit of health control should be the state or the nation is a question which this paper need not discuss. It is to be remembered in this connection, however, that state boundaries are only imaginary lines and that some kind of understanding is indispensable between neighboring states for some forms of sanitary control, such, for example, as the purity of water supplies, the management of epidemics and the regulation of milk and other food products. Likewise the management of quarantine, a subject of importance to large portions of the population of the nation, should not be left to the regulation of any particular locality, but should be managed in accordance with laws which are general for the common welfare.
First and foremost among the defects and needs of public health administration must be placed the want of adequate knowledge of the principles and practises of public health work on the part of officials having jurisdiction. It is a deplorable fact that special professional qualifications are not as a rule required of health officers in the United States,
If there is any department of municipal government which should be taken out of politics and put upon a high plane of professional efficiency, it is public health work. Generally, in the United States, appointment upon a health board means a thankless and gratuitous service performed for the sake of the small honor which is supposed to go with it. Where a salary is connected with the position the office is too often a reward of political rather than professional merit.
Until the need of high-class health work is demanded, appreciated and properly rewarded by compensation in money and honor, men will not be prepared by the schools for a life-work in the public health service, and the most needed improvement in the work of boards of health will not be made.
- Paper read before a joint meeting of the National Municipal League and the American Civic Association at Pittsburg, Pa., November 16, 1908.