~NOTE:~ WARDS 42, 43 & 44 WERE NOT INCORPORATED AT TIME OF STUDY.]
[Illustration]
Ward 21, the other section selected, is in area one of the largest in
the city, lying to the east in what is known as the Homewood District.
The population of this ward is about 26,000, living mostly in good
homes, with occasional poorer dwellings along the railroad and in
some of the "runs." In the main, they represent a high wage or small
salaried class. From this section, the other half of the cases studied,
about forty-eight per cent was taken.
The period covered by the investigation was one year, beginning July 1,
1906, and ending June 30, 1907. The field work was done by Miss Anna
B. Heldman, visiting nurse of the Columbian School Settlement, whose
personal acquaintance with many of the families of the Hill District,
and whose six or eight years' experience in caring for typhoid patients
in this same neighborhood, enabled her to secure in detail many facts
that might have escaped a person less familiar with the district or the
families concerned.
An analysis of the cases thus studied, shows that there were either
reported to the Pittsburgh Bureau of Health, or known to the
investigator, but not reported, 433 cases of typhoid fever in wards
8 and 11, 94 in wards 25, 26, and 27, and 502 in ward 21--a total of
1,029 in these six wards within the one year studied. These cases
occurred in 844 families. Miss Heldman, five months after the close of
this year period, was able to locate but 338 of these families, the
remainder having either moved out of the state, or been lost track of
by people living in the neighborhood.
There were 2,045 individuals in these 338 families, or an average of
6.4 persons per family. Of this number, 448 individuals, or 22 per cent
had typhoid fever within the year. Out of these 448 cases, there were
26 deaths and 422 recoveries, an exceptionally low percentage of deaths
to cases.
[Illustration: Line representing 8,149 people who have died from
typhoid fever in Pittsburgh since report of Filtration Commission in
1899 advising necessity of pure water. Standing in marching order,
single file, four feet apart, they would make a procession six miles
long.]
Of the 448 patients, 187 were wage earners, contributing all or part
of their earnings to the family income. As a result of their illness,
these 187 wage earners lost 1,901 weeks' work, or 36.6 years. This
averaged over ten weeks per patient, and represented an actual loss in
wages of $23,573.15. In addition, other wage earners lost 322 weeks'
work while caring for patients, thereby losing $3,326.50 in wages, and
bringing the total of wages lost to $26,899.65.
[Illustration]
The other large item of cost is that of expense for care and treatment
of patients. Ninety cases were treated in hospitals for all or part
of the time, as pay patients, half-charity, or full-charity cases.
To meet these hospital expenses, $2,332.00 was paid to hospitals by
full-pay patients themselves, and $1,834.50 was paid the hospitals
by either individuals or charitable organizations for the care of
half-pay patients, making the total cost of caring for 90 hospital
patients $4,166.50. This is an understatement, because it omits the
contribution of the hospitals themselves to the care of half-charity
and full-charity patients. If figures were available, there should
be added the amount represented by the difference in the money paid
to hospitals and the actual cost of maintenance, presumably another
$1,800.[11]
[11] Out of the 448 cases studied, twenty-four of the ninety cases
treated in hospitals were as full charity patients and sixteen were
taken as half charity cases; of the 358 cases treated at home, fifty
received outside aid and ninety-six were compelled to incur a debt
for all of their expenses, with no immediate prospects of being able
to repay it. Moreover, many received sick benefits and others were a
direct drain on the business interests of the city from the fact that
their employers kept them on their pay-rolls during sickness, at half
pay.
The expenses of the remaining 358 patients cared for in their homes
amounted to $12,889.90 for doctors' bills, $1,965.50 for nurses,
$2,640.60 for medicines and drugs; $1,810.10 for milk, $629.20 for ice,
$861.50 for servants made necessary by the illness of those naturally
caring for the home, and $1,204.45 for other expenses, of which the
largest single item was the cost of a trip to Colorado and return at
the doctor's orders, for a patient threatened with tuberculosis. The
total of these expenses was $22,000.35.
[Illustration]
The funeral expenses of the 26 patients who died, amounted to
$3,186.00. It may be argued that sooner or later funeral expenses
must inevitably be met, and that they should not, therefore, be
charged against this account. Under the circumstances, however, these
expenses were premature, and were directly chargeable to typhoid fever.
Consequently, it has seemed fair from the point of view of this study,
to include them. The grand total loss in wages and in expenses thus
outlined was $56,252.50.
Further analysis shows that the average loss in wages per patient among
the 187 wage earners was $126; that the average cost per patient in
loss of wages and expenses for the 446 patients was $128; and that the
average cost in loss of wages and expenses for each typhoid death among
the 448 cases was $2,164.
Consider the losses in these wards in their bearing upon the city as a
whole.
There were 5,421 cases of typhoid fever in Greater Pittsburgh in 1907.
If the cost to each patient was $128, typhoid fever cost the city that
year $693,888 in expenses and loss of wages alone. There were 622
deaths from typhoid fever in Greater Pittsburgh during the same period.
If we put the value of these lives lost at so low a figure as $4,000,
an additional loss of $2,448,000 was sustained. Or in round numbers
$3,142,000 was the minimum economic loss to the community of Greater
Pittsburgh, due to typhoid fever alone in the year 1907. This is a
conservative estimate, in view of recent values placed on deaths from
tuberculosis.[12] The two and a half million dollar death item might be
doubled without overstating the case.
[12] Prof. Irving Fisher, of Yale, in a paper read at the International
Congress on Tuberculosis in Washington last October, held that "the
money cost of tuberculosis, including capitalized earning power lost
by death, exceeds $8,000 per death." The average "expectation of life"
lost through death from typhoid fever is not greatly different from
that of tuberculosis.
[Illustration]
When it is considered that typhoid fever has been almost constantly
prevalent within the city limits, with practically no abatement,
for the past thirty-five years, it requires only a little applied
mathematics to calculate the probable enormity of the money loss to
the community, through the ravages of this disease alone, year after
year. Was it not time for it to stop? In the face of over a $3,000,000
loss last year, $5,450,000 was not more than the city could afford to
pay for the filtration plant that is purifying the drinking water.
Nor was it extravagance for the mayor and city councils to grant
the superintendent of the Bureau of Health an increased staff of
tenement house and milk inspectors, to make it possible to clean up
other sources of infection, and hasten the time when typhoid fever
in Pittsburgh shall constitute a no greater menace than in any other
well-kept American city.
* * * * *
I have used the term "economic cost" of typhoid fever with reference
to Pittsburgh families. The mere phrase carries with it no knowledge
of all those family readjustments and inconveniences, the distress
of mind and unalloyed misery that must be considered before we can
form any adequate idea of what such sickness holds for a wage earning
population. Were it necessary to measure the result of typhoid fever
only in cold cash, it would be a relatively easy task. In the first
place there are the thousand and one makeshifts and re-establishments
that must be reckoned with in order to get a clear idea of what
typhoid means to those poorer families, where, without the invasion of
sickness, the business of getting bread is a constant struggle. In a
family consisting of a man, wife and three children, the sixteen year
old daughter, who had not been very strong, contracted typhoid. At the
end of sixteen weeks in bed and thirty-two weeks out of work, she had
developed a marked case of tuberculosis. Not being strong enough to go
back to her former employment, she secured work in a bakery where she
was subsequently seen coughing as she wrapped up bread for customers.
The father of this girl, during her sickness, was keeping six cows on
the premises and selling milk to customers living in the neighborhood.
[Illustration]
The twenty-year-old wife of a Hungarian laborer had a six weeks' old
baby when she came down with a slow case of the fever. She remained at
home for a week with no one but herself to do the work and care for
the baby. The husband, who did not realize the cause of her weakness,
gave her a beating each day when he came home, because he thought her
lazy. He made her carry up coal for the fires until she became so
delirious that he could not keep her in the house. She was then sent to
a hospital and the baby given to friends. The woman died in a week and
the baby two weeks later.
A family of five, consisting of father, mother and three little
children, cooked, ate and slept in one uncurtained room. The mother and
four year old girl were taken sick at the same time. The girl occupied
an Arbuckle coffee box, with a pillow and pillow-case for a mattress,
and the man's overcoat was her only covering. The mother slept in the
only bed, furnished with a mattress and one small comforter, and shared
it at night with the father, the baby and their six year old girl, who
lay across the foot of the bed. The girl was in danger of contracting
pneumonia from exposure. A family of seven occupied a store and kitchen
on the first floor and two rooms upstairs. A small bedroom was the
only one which had a fireplace; and the entire family slept there; the
mother (who had typhoid), in the only bed, and the father and five
children in a row on the floor.
In another family, the six year old boy had the fever, and was found
lying on an improvised bed, his little dog tied beside him. The mother
had rested the ends of two boards in a china closet at one end of the
kitchen, and on a chair at the other, so that she might care for the
patient, do the cooking and attend to the baby at the same time. By
this make-shift, the father was able to keep at his work.
[Illustration]
One family, consisting of father, mother and five children, managed
ordinarily with a bed for the parents, a child's bed for the eight
year old girl, a two-third size bed for the eighteen and sixteen year
old daughters, and a cot for the fourteen year and ten year old sons,
one sleeping at each end. First the mother and one of the boys were
taken sick, and during the early part of their illness, no one was
disturbed. But within a month, and before the first two patients got
well, the four other children came down with typhoid, making six in
the family sick together. Then the father slept on the floor and the
sick mother got out of her bed to give place to two of the children,
she, herself, sleeping at the foot of the bed until one of the children
became delirious. After that she moved to the foot of the two-thirds
bed. In the day time she had no place to lie down, and sat all day in a
chair until she became so weak that she could hardly walk. Occasionally
she helped her husband who did the cooking and cared for the patients,
by paring potatoes and doing other small work about the kitchen. No
one had time to keep the kitchen sink clean, and the accumulation of
vegetable matter became so filthy that it had to be reported to the
Bureau of Health. With family income cut off, and with nothing saved,
the family would have been penniless had it not been that the doctor
made his bill moderate; the family was trusted for groceries, milk
and ice; friends gave about twenty dollars in cash, and Columbian
Settlement furnished bedding and the services of a visiting nurse. The
mother did not fully recover for about six months. The father, who
suffered a good deal from loss of sleep and exposure while caring for
the patients, contracted a cold. This developed into a serious case of
asthma from which he died.
[Illustration]
To these and many similar families there were more serious results
than the debts incurred. A school girl's unrecovered health, a stogie
roller's reduced speed, a blacksmith's and a tailor's loss of strength,
a case of tuberculosis developed, a boy become a truant, a family
broken up and deserted, a baby's death,--all are of tremendous concern
as items in the annual wear and tear of the city's potential resources.
They are items of "economic cost" that cannot be handled by the
statistical method. They are, after all, the real human finger marks
that typhoid leaves when its clutches are loosened.
* * * * *
Such a showing, then, of actual economic and personal loss as this
study of six Pittsburgh wards brought out, is offered as a final
leverage to those who in other American cities may be endeavoring to
dislodge inertia and clear their water supplies. This investigation
of typhoid fever, however, as it was found in the households of the
wage earners of Pittsburgh, had its immediate practical bearings. The
sanitary facts it brought out showed unequivocally the necessity for
ridding the city of other sources of infection at the same time that
the water supply was cleared.
There was evidence that many of the after cases in the families
studied, were due to conditions existing entirely apart from the water.
Reports on housing conditions in Pittsburgh show that a favorable
laboratory for the growth and dispersal of germs exists in the city's
unsanitary dwellings. Insufficient water supply renders cleanliness
almost impossible. Overcrowding means increased possibilities of
infection through contact with food and drink in the combined family
kitchen, pantry, dining-room, and bedroom. Pittsburgh's thousands of
open privy vaults afford ideal conditions for the spread of disease by
flies and other insects, and by personal contact. Such plague spots as
Saw Mill Run, with its string of double-and triple-decker rear privy
vaults discharging on the banks of a stream which are flushed off only
when the water rises after a rain, afford further examples, deplorable
and disgusting.
[Illustration]
How much of the Pittsburgh typhoid has been due to direct contagion
from such conditions as these, can only be inferred at the present
writing. In line with the general question of contagion, and secondary
cause, however, our data afford some clews. They show that in forty of
the families studied, the first case was followed in from ten days to
one or two months by other cases, seventy-six cases in all, in addition
to the original forty. It shows further that in at least eighteen of
these families, one or more of the following conditions existed: Family
crowded into one or two rooms; home dirty and poorly kept; the person
who cared for the patient also doing the family cooking; well and sick
members of the family sleeping in the same room and often in the same
bed; privy vaults in exceedingly bad condition, and often stopped up
and overflowing with filth. In one family, consisting of man, wife,
four children and three lodgers, crowded into two dirty rooms, a three
year old boy was taken sick in October. The mother did the family
cooking and cared for the patient. The cesspool in the yard which was
in bad condition was used by two families. Another member of the family
became ill November 3, and the mother came down on December 19. There
were seven cases in this one courtyard within the year.
In another instance a man, wife, and nine children were living in three
rooms. The sixteen year old son was taken sick on June 20 and was sent
to the hospital. Then in July came the thirteen year old daughter for
whom her mother cared at home. The mother also did the family cooking.
The father, mother and eleven year old son all slept in the same room
with the patient. All three of them followed within a month, and
another son twelve years old, was taken sick in August.
[Illustration]
In another family of eight, the sink in the kitchen and the toilet
in the yard were in a very filthy condition. The mother and one son
were taken sick in August. The sick and the well slept together in the
crowded bedrooms. In November four more members of the family came
down with the disease, on the sixth, ninth, eleventh and fifteenth,
respectively.
Let the reader judge for himself whether or not, in the face of these
facts, it can be expected that filtered water alone will solve the
problem.
The Pittsburgh Typhoid Fever Commission is a recognition of these
facts, and a recognition also from a national and scientific point
of view, that probably never again in the history of any large
American city will there be such a favorable laboratory in which to
study the epidemiological facts of typhoid fever both before and
after filtration. The commission was appointed in April, 1908, by
Mayor Guthrie; is made possible by a grant from the Russell Sage
Foundation, and by the co-operation of the bureaus of health and water,
which offered the free use of their laboratories for analytical and
administrative purposes. Dr. James F. Edwards is chairman, and the
membership includes Dr. Dixon of the State Board of Health, Prof. Wm.
T. Sedgwick of the Massachusetts Institute of Technology, and Dr. E. S.
Rosenau, of the Public Health and Marine Hospital Service, who has been
directing the elaborate governmental investigations into typhoid in the
District of Columbia. The following report is made (January 1) by Dr.
E. G. Matson, of the Pittsburgh Bureau of Health, executive officer of
the committee.
[Illustration]
The work of the commission to date has consisted of a minute
investigation of all cases of typhoid which have appeared
since May 1, 1908, including the sanitary condition of their
living and working places. Investigations have also been made
into neighborhoods where there appeared to be fewer cases
than the average of the city, the milk supply, and the water
supply, both public and private. It is remarkable that not even
the smallest outbreak has been traced to milk. A particular
feature of the study of water supply is that in connection
with the acidity of the Monongahela and the eastern affluents
of the Allegheny and its effect upon the sewage discharged
by an enormous town population into them. So far typhoid has
declined greatly in Pittsburgh since January, 1908, as compared
with the average or even the minimum of previous years. This
decline has naturally been a subject of great interest though
it is too soon to give the results of investigations. We have
ascertained that this decline has been shared by the towns on
the lower Allegheny, which have hitherto been supposed to be
the most important source of our epidemics. During November
and December, which would represent the first months of the
filtered water period, typhoid has been reported from the
filtered water area at the rate of the most favorable American
cities, and in Allegheny, which receives nearly the same water
unfiltered, at about twice this rate.