Starting at the lowest level, let us formulate our initial axiom
in terms of dollars. A sound man can do more work than a sick man.
Therefore he can make more money. A sound city can do more work than
a sick city. Therefore, in the long run, it can accumulate more
wealth. Public health is a public asset. This is a truth which, in
her single-minded purpose of commercial and industrial expansion,
Pittsburgh long ago forgot, if, indeed, she ever stopped to realize it.
Consequently, at a time when all the other great American cities have
organized their forces thoroughly and are waging battle, with greater
or less scientific skill, against that most potent of all destroyers,
the germ, this mighty aggregation of half a million human beings has
only just declared war, and has barely established its outposts. After
two years of preparation to meet conditions which have been half a
century in forming and solidifying, Pittsburgh's little regular army of
defence now faces the most complicated problem of municipal betterment
to be found in American hygiene.
A health bureau performs a defensive and protective function. Its
intelligence department must keep it apprised of every manifestation
on the part of the enemy; and it must rally to the threatened point
to check the advance before it be too late, whether the emergency be
a school epidemic of diphtheria, or a localized onset of typhoid. It
must maintain a jealous watchfulness over the food and water supplies
that are brought into the city, lest with them shall come the invading
diseases. And its statistics of death and disability must point out for
repair, the breaches made in its walls by the never-ceasing onslaught.
Such a sanitary garrison has little rest, and no respites, for the
besieging germ never sleeps.
The date of Pittsburgh's last annual health report is 1899. That fact
is crammed with meaning. Strategically it means that for nearly a
decade the sentries have all been asleep at their posts. Politically
it has meant that those responsible for the administration of the city
were too lethargic, too ignorant, or too indifferent to disturb that
profound Rip Van Winkleism. Civically it means "Who cares!", and that
companion gem, "What's the use?". Between public indifference, private
selfishness, and political inertia, the germ has pretty well had its
own sweet way with Pittsburgh, and the city's annual waste of life
from absolutely preventable disease has been a thing to make humanity
shudder, had it been expressed in the lurid terms of battle, holocaust,
or flood, instead of the dumbly accepted figures of tuberculosis,
typhoid, and infant mortality.
Presumably, before this article gets into print, the Pittsburgh
health report for the year 1907 will have been issued. What laborious
exhumation of dilapidated statistical skeletons that report represents,
I have not space to explain here. The important and significant point
is that the authorities are at last at work, and energetically,
under the leadership of a skilled sanitarian, Dr. James F. Edwards,
superintendent of the Bureau of Health. It would be pleasant to add
that Dr. Edwards goes into action with his hands free; pleasant, but
quite untrue. On the contrary, he is bound and hampered to an extent
that would devitalize the efforts of any but the most patient of
enthusiasts. His forces are not under his own control, since under
the Pennsylvania system he is at the head, not of a department, but
of a bureau of the Department of Public Safety, administered by a
layman. The law gives him no power to choose or discharge his own
subordinates within the limits of the civil service; all that he can
do is to train and educate such of them as most need it, when they
come to him. He has no specific supervision or control over public or
charitable institutions, those prolific culture-beds of contagion. Even
the Municipal Hospital for Contagious Diseases has been taken out of
his hands and put under other management. He cannot condemn a building
inimical to the public safety, nor can he revoke a milk license. He
cannot abate a nuisance without going to court for it. And, lest the
powers of his bureau should wax too great and impinge upon individual
privilege, old laws have been raked up and carefully interpreted to
restrict the scope of its work. Yet in spite of all this, wonderful to
say, the efforts of the bureau seem to have made an initial impress
already on the death rate, and, even more important, to have gathered
to its support some tangible force of public opinion.
"Seem to have made," I say, because figures in this connection are
largely a matter of conjecture. Basis for any detailed comparison
between present and past, is lacking. What is certain, however, is
that the sanitary forces are doing work which must inevitably have
its effect in life-saving in the future; and the efficacy, if not the
qualitative result, of that work is hopefully apparent. The first
attack was made on a condition of affairs which would have disgraced
a country village, the prevalence of unprotected outhouses, scattered
over the length and breadth of the landscape; not only lurking in the
slums, but peering from the proud eminence of hilltops down upon the
homes of wealth and elegance below.
Through the agency of flies in summer and of wind or heavy rains in
winter, these relics of communal barbarity spread filth and contagion
through the city. How many of them existed at their maximum will never
be known. There are still six thousand survivors, but the number is
being reduced daily. Proceeding under an ordinance which declares
them illegal, Dr. Edwards began his campaign modestly. Opposition he
foresaw, but he waited to keep it, as far as might be, sporadic, and
to prevent it from concentrating. In the year 1905 only forty-six
of these nuisances had been abolished. In 1906, six hundred of them
fell. Thereupon the sensitive nerve of property rights thrilled the
alarm throughout the commercial body. Reform was threatening rental
profits; was becoming "radical," and "destructive." People with pulls,
real or imagined, rushed to councils with demands for the repeal of
the ordinance. But here an unexpected ally appeared. Destruction of
the old meant construction of the new and modern, with much accruing
increment to the plumbing trade. Therefore these shrewd business
sanitarians hastened before the committee with lawyers and arguments,
and so effectually backed up the case of the Health Bureau, that
the repeal project was killed then and there. In the enthusiasm of
well-won victory plumbers' supplies soared heavenward, with the result
of bringing the unfortunate property owners down upon the Bureau of
Health in agonized droves, begging for protection from the masters of
the situation. Thereupon the bureau quietly allowed an extension of
time, until the enthusiastic plumbers, somewhat chastened, saw the
point and came nearer to earth in their prices; after which the process
continued, and has been continuing, with accelerated progress. For
the issue had now been decided. The proprietors of noisome property
had lost the first skirmish. In 1907, 7,755 notices were served on
recalcitrants, and 3,590 privies were abolished. By the end of 1910,
Dr. Edwards hopes to have relegated these nuisances to a purely
historical status.
Encouraged, the Bureau of Health sought from the Legislature the power
to condemn unsanitary dwellings. At present, in order to destroy
property prejudicial to the public health, the bureau must go to
court and prove the conditions unsanitary,--a cumbrous, expensive,
and uncertain process. It is not long since a presumably upright and
intelligent occupant of the bench held that a house which leaked so
badly that the floors were rotted and the plaster peeled from the
walls could not, on that account, be adjudged unsanitary. The bill
passed the Legislature, prescribing condemnatory powers, with a proviso
for court review and damages to the owner if the condemnation should be
found unjustified. Governor Stuart vetoed the bill on the ground that
it was too sweeping. If the local undertakers haven't passed a vote of
thanks to the governor, they have missed a gracious opportunity. What
would have been the one most effectual check upon the city's mortality,
the wiping out of those death-in-life conditions of housing which make
for tuberculosis, the active contagions, and above all the undermined
vitality represented in Pittsburgh statistics under every division
from general debility to suicide,--that the gubernatorial veto has
effectually blocked. So certain large and small owners of slum property
have an extension of immunity for their rentals drawn, at the worst,
from premises where they wouldn't house their pigs,--particularly if
they designed to eat the pigs afterward.
Evil housing conditions are almost invariably reflected in the
mortality figures of tuberculosis. Yet Pittsburgh's given death rate
from tuberculosis is low; hardly half the normal rate for American
cities, in general: so low, indeed, that I doubt whether any sanitarian
would give implicit credence to it. Similarly, the death rate from
pneumonia and bronchitis is suspiciously high. For example, in 1907
there were a quarter as many deaths attributed to bronchitis, as to
consumption, an incredible assumption. Dr. Matson, who is in charge of
the bureau's statistics, has decided, with a wisdom born of experience,
to regard _fatal_ cases of bronchitis as belonging, statistically, in
the pneumonia column; so I shall lump the two diseases. In the first
eight months of last year (which is as far as the monthly figures have
been supplied to me) there were but 565 deaths set down to tuberculosis
in all forms, whereas the pneumonia and bronchitis totals aggregated
upwards of 1,100. This is a condition which, so far as I know, has
never been paralleled in any American city. The inference is inevitable
that deaths, which should properly be ascribed to the great white
plague, are reported by physicians under other heads. This is due,
usually, to the influence of the decedent's family, who fear to lose
their places if it be known that there is "consumption in the house,"
or who will perhaps, forfeit the insurance money if the true cause of
death appear on the records. Very wisely Dr. Edwards is proceeding, not
upon local certificates, which may lie, but upon universally recognized
facts, which cannot; and is planning an exhaustive tuberculosis
campaign. In this campaign will be concentrated the local official
health force, the Pittsburgh Tuberculosis League, and the local
dispensary of the State Board of Health, all working in conjunction
with a special Tuberculosis Commission now in process of organization
by the city government.
At present the consumptive poor of Pittsburgh have a small, practically
a negligible chance of life. The great, rich, busy city that slowly
kills them, has no means to care for them while they are dying. There
is no municipal tuberculosis hospital. To be sure, Marshalsea, outside
the city, can care for some thirty victims; but they are taken there,
usually, only when they are too weak to resist effectually. For
Marshalsea is the Poor House. And there is inbred in the American an
indestructible, illogical, pathetically self-respecting something which
makes the term "Poor House" a poison to his soul. Live he might, within
those walls. He prefers to stay outside and die. The late Dr. Charles
Harrington of the Massachusetts department, wisest and most human of
health officials, said to me once in one of his characteristic bursts
of impatience with the stupidity of Things as they Are:
"If I had the choice to make between naming a refuge for the helpless
sick 'Poor-house' or 'Sure-Death,' I'd choose 'Sure-Death' every time.
You could get more people to go to it."
Marshalsea doesn't save many of the consumptives who come to its gates.
Non-consumptives it does save, indirectly, since it removes from a
susceptible environment, a certain number of spreaders of infection.
Private effort does its altruistic but minute best in Pittsburgh;
the Tuberculosis League has a hospital in which it can take care of
fifty to sixty patients. And the State Board of Health relieves the
situation a little by maintaining one of its admirable tuberculosis
dispensaries in the city, with a staff of visiting nurses; and sends a
few hopeful cases to its sanatoriums. Perhaps 100 victims of the plague
can be cared for in proper institutions. There are to-day in the city
probably 3,000 sufferers in a sufficiently advanced stage to be a peril
to all with whom they come into contact. At a very moderate estimate
three-fifths of this number are unable to afford proper home care, and
of this three-fifths (all of whom will die, barring the few that can be
accommodated in the hospitals) probably one-third,--again my estimate
is conservative,--could be saved under proper conditions. That is,
Pittsburgh of the mighty mills, Pittsburgh of the heaped-up millions,
Pittsburgh of the rampant industrialism which has spread its influence
to the far corners of the world, stands by helpless while six hundred
lives are going out needlessly, not because they might not be saved,
but because there is no place in which to save them. Nor is this the
worst; since, in the slow process of dying, these victims will radiate
the poison to hundreds, directly; indirectly to thousands, who are now
well, strong, and unsuspecting the inevitable doom. What can the Health
Bureau, the officially constituted army of defence, do to remedy this
condition? Nothing. That is the answer which goes over the telephone
wires, once, twice, half a dozen times a day, to people who ask for
advice for helpless cases of consumption. I suppose that the sorriest
duty of a health official, is to deny the application of some man upon
whose life depends the support of other lives, for a fighting chance to
get well and do his work in the world. Ask Dr. Edwards, oh comfortable
resident Pittsburgher, how often he has had to do the very thing in the
last year. It may give you new light on your civic responsibilities.
Not so often will that hopeless response be made in the future. The
united forces, drawn together by the forming Tuberculosis Commission,
will make it their first business to provide some refuge of increasing
adequacy, for those who are now distributing the infection. Meantime,
though there is little to be done for those already stricken, the
city is being covered, district by district, by the visiting nurses
of the league, of the State Dispensary and of the Health Bureau, soon
to be re-enforced by five special nurses from the commission, and
all training and instructing the consumptive in those measures of
prevention which safeguard the people about him from contracting the
disease.
One-third of all who die in Pittsburgh, die without having anything to
say about it. That is, they die under five years of age. One-fourth
of all who die, die without having anything to say about anything.
That is, they die under one year of age. Most of these deaths are
preventable, being the outcome of conditions which, humanly speaking,
have no right to exist. Chief among the causes is bad milk. Pittsburgh
uses 40,000 gallons of milk per day, coming from a wide radius in
both Pennsylvania and Ohio. Before the present administration, this
vitally important merchandise received rather less attention than the
corner-stand vending of collar buttons. At the beginning of 1906 the
Bureau of Health had one lone milk inspector. He collected samples,
and, if one may judge by the brief records of analyses, he didn't
imperil his own health by over-assiduity in the job. Dairy inspection
was an unthought-of phase of activity. In August, 1906, two more
inspectors were acquired and began, by prosecutions, to do some work
in the matter of discouraging the use of formaldehyde. There was even
some inspection of stores and adjacent dairies. Now the bureau has six
men in the milk division, two of whom are dairy inspectors and one a
veterinarian, and all of whom do conscientiously the work the city
pays them to do. Two more have been arranged for, with which addition
Dr. Edwards believes he will have a sufficient force to inaugurate
a higher standard of supply. Unfortunately there is no official
standard, though an ordinance is being prepared establishing bacterial
and temperature requirements. Unfortunately, too, the law has been
interpreted to mean that the Bureau of Health must issue licenses on
demand; and that it cannot revoke these licenses. What has been done
thus far is chiefly in the line of educating the dairymen and dealers.
Dr. Edwards admits frankly that, while he regards pasteurization as a
make-shift only, he believes that it will be necessary for a time to
accept the deteriorated quality of milk consequent upon pasteurization,
for the sake of destroying the pathogenic bacteria with which the
supply swarms. Analyses made last summer showed an average of a million
bacteria per cubic centimetre. The limit of reasonable safety is
usually set at half that number.
As for conditions as they existed at that time in certain local
dairies, I can do no better than quote from the report of Dr. Goler,
the health officer of Rochester and an international authority on milk
supply:
Go out to one of those dairies near the country club which
supplies milk to some of the families living in the best
localities and see the conditions under which milk is produced
for the future citizens of the state and the nation. A dirty
one-room house that once did duty as an out-house, supplied
with water by a hose, a few old tubs in which cans, bottles
and utensils are washed in cold water, and where all the waste
flows into a vault beneath the foundation of the house. A damp,
dark, old stable festooned with cobwebs, without drainage,
where all the liquid refuse finds its way through cracks in the
floor to the space beneath the structure, and where, on filthy
floors, in some cases raised but one poor plank above the
common floor of the stable, the swill-fed cows stand and give
milk for some of the babies of Pittsburgh aristocracy, whose
parents are willing to pay the munificent sum of eight cents a
quart for the product.
Visit cow stable after cow stable within easy motor ride from
Pittsburgh, and the conditions of filthiness prevailing in the
stables are only exceeded by the depth of manure and mud in the
barnyards.
The conditions of the cows, cans, utensils and barnyards at the
distant points from which the city draws its milk may be judged
by the fact that they pasteurize the milk before bringing it to
the city and pasteurize it again before it is sent out from the
dairy.
Dairy inspection, it is fair to say, has recently ameliorated the worst
of these conditions. Increasingly careful supervision of the retail
milk dealers, and constant inspection of the less cleanly stores,
which has discouraged many of them out of existence, tend to minimize
the danger of contamination of milk at the other end of the line. There
is, however, an additional peril in the well-water supply often used to
wash cans and bottles.
The milk-inspection force faces a situation outlined in the latest
complete figures (not yet in print); those for 1907, which show a total
infant mortality of more than a thousand from diseases inferentially
due to bad milk. The poorer quarters of the city where prices rule at
six or seven cents a quart, exhibit the heaviest figures, and there is
the typical rising curve of the mortality line in hot weather. Last
summer that curve, while still unpleasantly in evidence, was noticeably
modified. Education of mothers of the slums was largely responsible.
The Bureau of Health put a corps of six special nurses in the field who
went about from house to house, instructing mothers in the hygienic
care of their children, and working in conjunction with the Pittsburgh
and Allegheny Milk and Ice Association, one of the most efficient
charitable enterprises in the city. Probably the infant mortality for
the whole year of 1908 would have been low but for the winter epidemic
of measles, which killed more victims than scarlet fever, diphtheria,
smallpox, chickenpox, and all the other active contagions put together.
Now the city, having learned a costly lesson in the seriousness of this
too commonly disregarded disease, quarantines for it. It is perhaps,
hardly ingenuous to include smallpox in the foregoing comparison,
as that disease is now a practically negligible quantity. Since the
epidemic of 1903 Pittsburgh has been the best vaccinated of American
cities. Wherefrom depends a corollary for the consideration of the
anti-vaccinationists, that for two years there has not been a death
from this loathsome and unnecessary infection in the city, nor has a
single original case developed.
[Illustration: DISEASE-INCUBATORS.
Some Pittsburgh cow-stables which lower the standards set by
progressive producers.]
We are prone, in this country, to study the public health too much
in terms of death rates, and too little in the character of the
survivors. Applying this latter test to the children of Pittsburgh's
slums, we shall find cause to wonder whether, in a sense, the deaths
are not too few rather than too many. Would it not be better for the
unfortunate and innocent victims themselves, and certainly for the
community at large, that this puny, helpless breed of hunger, filth,
and misery which creeps about the city's man-made jungles, should
succumb in infancy to the conditions that bred but cannot support
them? For there are certain phases of existence in which a high death
rate is less to be feared than a high birth rate. Anti-race-suicide
has a fine, rotund ring, as it issues from the presidential lips. But
President Roosevelt has never, I take it, been in Mulberry Alley, or
Our Alley, or a certain unnamed court off Washington street that wafts
its stenches into the boulevard below, or any one of a score of other
hopeless thoroughfares which might give him pause in the promulgation
of his doctrine.
Nor are conditions of life here in the city's choked up center greatly
worse than in the "runs" which diversify the landscape of the newer
parts of the city; damp, heavy-aired, steaming canyons, into which the
poorest classes have been pushed; over the rim, and "off the earth,"
as it were. There they live, pasty women and weazened children, in
the heavy air, polluted, as like as not, by the stenches from the
creeks which are little else but open sewers. One such little isolated
population I found, in a huddle of houses, under a towering steel
bridge, faithfully reproducing, in what was practically open country,
the deadliest living conditions of the crowded center of population.
To return to the central slums, there are whole districts which might
well (were it of any avail) be placarded, as are certain New York flats:
* * * * *