[Illustration: GUARDIANS OF THE PUBLIC HEALTH BY SAMUEL HOPKINS ADAMS]
John Chinaman is the logician of hygiene. To his family doctor he says:
"I pay you to keep me well. Earn your money." Let him or his fall sick,
and the physician's recompense stops until health returns to that
household. Being fair-minded as well as logical, the Oriental obeys his
physical guardian's directions. Now, it may be possible to criticize
certain Chinese medical methods, such as burning parallel holes in a
man's back to cure him of appendicitis, or banging for six hours a day
on a brass tom-tom to eliminate the devil of headache; but the
underlying principle of "No health, no pay" is worthy of consideration.
This principle it is which, theoretically, we have adopted in the matter
of the public health. To our city, State, or national doctors we pay a
certain stipend (when we pay them at all) on the tacit understanding
that they are to keep us free from illness. With the cure of disease
they have no concern. The minute you fall ill, Mr. Taxpayer, you pass
into the hands of your private physician. No longer are you an item of
interest to your health officer, except as you may communicate your
disease to your fellow citizens. If he looks after you at all, it is not
that you may become well, but that others may not become ill through
you. Being less logical in our conduct than the Chinese, we, as a
people, pay little or no heed to the instructions of the public doctors
whom we employ. We grind down their appropriations; we flout the wise
and by no means over-rigorous regulations which they succeed in getting
established, usually against the stupid opposition of unprogressive
legislatures; we permit--nay, we influence our private physicians to
disobey the laws in our interest, preferring to imperil our neighbors
rather than submit to the inconvenience necessary to prevent the spread
of disease; and we doggedly, despite counsel and warning, continue to
poison ourselves perseveringly with bad air, bad water, and bad food,
the three B's that account for 90 per cent. of our unnecessary deaths.
Then, if we are beset by some well-deserved epidemic, we resentfully
demand to know why such things are allowed to occur. For it usually
happens that the virtuous public which fell asleep with a germ in its
mouth, wakes up with a stone in its hand to throw at the health
officer. Considering what we, as a people, do and fail to do, we get, on
the whole, better public health service than we deserve, and worse than
we can afford.
_Our Health Boards and Their Powers_
As a nation, we have no comprehensive health organization. The crying
need for one I shall point out in a future article. Our only Federal
guardianship is vested in the United States Public Health and Marine
Hospital Service, which, by some mystery of governmental construction,
got itself placed in the Treasury Department, where it certainly does
not belong. It is, with the exception of a few ancient political
appointees now relegated to unimportant posts, a highly trained and
efficient body of hygienists and medical men, the best of whom have also
qualified as diplomats in trying crises. Any germ-beleaguered city may
call upon this Service for aid. It is a sort of flying squadron of
sanitative defence. When yellow fever broke out in New Orleans, it was
the M. H. S. men who, working quietly and inconspicuously with the local
volunteers, mapped out the campaign which rid the city of the scourge.
In the San Francisco panic eight years ago, when bubonic plague beset
the city, it was the Marine Hospital Service which restored confidence:
and a Service man has been there ever since as the city's chief adviser.
The Federal "surgeons," as they are called, may be in St. Louis helping
to check smallpox, or in Seattle, blocking the spread of a plague
epidemic, or in Mobile, Alabama, fighting to prevent the establishment
of an unnecessary and injurious quarantine against the city by
outsiders, because of a few cases of yellow jack; and all the while the
Service is studying and planning a mighty "Kriegspiel" against the
endemic diseases in their respective strongholds--malaria, typhoid,
tuberculosis, and the other needless destroyers of life which we have
always with us. In the Marine Hospital Service is the germ of a mighty
force for national betterment.
[Illustration: DR. CHARLES HARRINGTON
SECRETARY OF THE MASSACHUSETTS STATE BOARD OF HEALTH, WHICH, BY THE
DISTRIBUTION OF VACCINE AND ANTITOXIN ALONE, HAS SAVED THE STATE
$210,000]
Of the State boards, perhaps a fourth may be regarded as actively
efficient. The rest are honorary and ornamental. Undoubtedly a majority
would be ready and willing to perform the services for which they are
not (as a rule) paid anything; but they lack any appropriation upon
which to work. South Carolina, for example, has an excellent State
board. Its president, Dr. Robert Wilson, is an able and public-spirited
physician of the highest standing; an earnest student of conditions, and
eager for the sanitary betterment of his State. But when he and his
board undertook to get one thousand dollars from the legislature to
demonstrate the feasibility of enforcing the pure food law and of
turning away the decayed meat for which the State is a dumping-ground,
they were blandly informed that there was no money available for that
purpose. It was in South Carolina, by the way, that a medical
politician who served on the public health committee of the legislature
addressed this question to a body of physicians who had come there to
appeal for certain sanitary reforms: "What do you want of laws to
prevent folks being sick? Ain't that the way you make your livin'?"
Which is, I fear, typical of the kind of physicians that go into
politics and get into our legislatures, where, unhappily, they are
usually assigned to the public health committees.
Under the State boards, in the well-organized States, are the county
boards and officers, who report to the State boards and may call upon
the latter for advice or help in time of epidemic or danger.
In certain circumstances the State officials may arbitrarily take
charge. This is done in Indiana, in Maryland, in Pennsylvania, and in
Massachusetts. The last State not only grants extraordinary powers to
its health executive, Dr. Charles Harrington, but it appropriated last
year for the work the considerable sum of $136,000. By the issuance
alone of vaccine and antitoxin, the Board saved to the citizens of the
State $210,000, or $74,000 more than the total appropriation for all the
varied work of the institution. Some vague idea of the economy in lives
which it achieves may be gained from the established fact that death
results in only sixteen out of every thousand cases of diphtheria, when
the antitoxin is given on or before the second day of the illness; 110,
when given on the third day; and 210 when the inoculation is performed
later. The old death rate from diphtheria, before antitoxin was
discovered, ranged from 35 to 50 per cent. of those stricken.
[Illustration: DR. THOMAS DARLINGTON
COMMISSIONER OF HEALTH FOR NEW YORK CITY, WHICH HAS THE MOST THOROUGHLY
ORGANIZED CITY HEALTH DEPARTMENT IN THE UNITED STATES]
Finally, there are the city bureaus, with powers vested, as a
rule, in a medical man designated as "health officer," "agent," or
"superintendent." What Massachusetts is to the State boards, New York
City is to the local boards, but with even greater powers. Under the
charter it has full power to make a sanitary code. Matters ranging from
flat wheels on the Metropolitan Street Railway Company's antiquated
cars, to soft coal smoke belched forth from factory chimneys, are
subject to control by the New York City Department of Health. The Essex
Street resident who keeps a pig in the cellar, and the Riverside Drive
house-holder who pounds his piano at 1 A.M. to the detriment of his
neighbor's slumber, are alike amenable to the metropolis' hired doctors.
[Illustration: DR. CHARLES V. CHAPIN
SUPERINTENDENT OF HEALTH IN PROVIDENCE, RHODE ISLAND, ONE OF THE CITIES
WHICH HAS BEEN FOREMOST IN PROSECUTING PHYSICIANS FOR FAILURE TO GIVE
NOTICE OF INFECTIOUS DISEASE]
The province of the city, State, and Federal health organization is
broad. "Control over all matters affecting the public health" is a
comprehensive term. "All the powers not already given to the school
committees," observed a Massachusetts judge, "are now ceded to the
Boards of Health." In theory, then, almost unlimited powers are vested
in the authorities. But how carefully they must be exercised in order
not to excite public jealousy and suspicion, every city health official
well knows. More serious than interference and opposition, however, is
the lack of any general equipment. At the very outset the loosely allied
army of the public health finds itself lacking in the primal weapon of
the campaign; comprehensive vital statistics.
[Illustration: DR. JOHN N. HURTY
SECRETARY OF THE BOARD OF HEALTH IN INDIANA, WHICH HAS RECENTLY PASSED A
LAW FORBIDDING THE MARRIAGE OF IMBECILES, EPILEPTICS, AND PERSONS
SUFFERING FROM CONTAGIOUS DISEASE]
_Our Absurd Vital Statistics_
Vital statistics in this country are an infant science. Yet they are the
very basis and fundament of any attempt to better the general health.
Knowledge of what is killing us before our time is the first step toward
saving our lives. The Census Bureau does its best to acquire this
essential information. For years Director North has been persistently
hammering away at this point. But progress is slow. Only fifteen States,
representing 48 per cent. of our population, are comprised in the
"registration area"; that is, record all deaths, and forbid burial
without a legal permit giving the cause of death and other details.
Outside of this little group of States, the decedent may be tucked away
informally underground and no one be the wiser for it. This is
convenient for the enterprising murderers, and saves trouble for the
undertakers. Indeed, so interested are the latter class, that in Iowa
they secured the practical repeal of a law which would have brought that
State within the area; and in Virginia this year they snowed under a
similar bill in the legislature, by a flood of telegrams. Ohio, the
third largest State in the Union, keeps no accurate count of the ravages
of disease. Probably not more than 60 per cent. of its deaths are
reported. Why? Inertia, apparently, on the part of the officials who
should take the matter in charge. Governor Harris in his January message
made a strong plea for registration, but without result. As for births,
there is no such thing as general registration of them. So this matter
is neglected, upon which depend such vital factors as school attendance,
factory employment, marriage, military duty, and the very franchise
which is the basis of citizenship. It is curious to note that Uruguay,
in its official tables of comparative statistics, regrets its inability
to draw satisfactory conclusions regarding the United States of America,
because that nation has not yet attained to any scientific method of
treating the subject. Patriotism may wince; but let us not haughtily
demand any explanation from our sneering little neighbor. Explanations
might be embarrassing. For the taunt is well founded.
[Illustration: DR. GEORGE W. GOLER
HEALTH OFFICER OF ROCHESTER, NEW YORK, WHO REFUSES CHILDREN CERTIFICATES
TO WORK IN FACTORIES, UNLESS THE APPLICANTS ARE IN SOUND PHYSICAL
CONDITION]
Is it strange that, having no basis in national statistics, our local
health figures "speak a varied language"? We have no standards even of
death on which to base comparisons. But a dead man is a dead man, isn't
he, whether in Maine or California? Not necessarily and unqualifiedly.
In some Southern cities he may be a "dead colored man," hence thrown out
of the figures on the "white death rate" which we are asked to regard as
the true indication of health conditions. In New Orleans, until
recently, he might be a "death in county hospital," and as such not
counted--this to help produce a low death rate. In Salt Lake City he's a
"dead stranger," and unpopular on account of raising the total figures
for the city. They reckon their total rate there as 16.38, but their
home rate or "real" rate as 10.88. That is to say, less than 11 out of
every 1,000 _residents_ die in a year. If this be true, the Salt Lake
citizens must send their moribund into hasty exile, or give them rough
on rats, so that they may not "die in the house." As for the "strangers
within our gates" who raise the rate over 50 per cent. by their
pernicious activity in perishing, the implication is clear: either Salt
Lake City is one of the deadliest places in the world to a stranger, or
else the newcomers simply commit suicide in large batches out of a
malevolent desire to vitiate the mortality figures. The whole thing is
an absurdity; as absurd as the illiterate and fallacious three-page
leaflet which constitutes this community's total attempt at an annual
health report.
[Illustration: DR. J. MERCIER GREEN
HEALTH OFFICER OF CHARLESTON, SOUTH CAROLINA, WHO STAMPED OUT A SMALLPOX
EPIDEMIC AND REFORMED THE CITY'S WATER SUPPLY]
St. Joseph, Missouri, claimed, one year, a rate of 6.5 deaths out of
every 1,000 inhabitants. Were this figure authentic, the thriving
Missouri city, by the law of probability, should be full of
centenarians. It isn't. I essayed to study the local reports, hoping to
discover some explanation of the phenomenon, but was politely and
regretfully informed that St. Joseph's health authorities issued no
annual reports. The natural explanation of the impossibly low rate is
that the city is juggling its returns. In the first place, that favorite
method of securing a low per capita death rate--estimating a population
greatly in advance of its actual numbers--is indicated; since the
community has fewer lines of sewers and a smaller area of parks than
other cities of the size it claims--two elements which, by the way,
would in themselves tend to militate against a low mortality. Perhaps,
too, the city has that ingenious way of eliminating one disturbing
feature, the deaths under one week or ten days, by regarding them as
"still-births." Chicago used to have this habit; also the trick of
counting out non-residents, who were so thoughtless as to die in the
city. At present, it is counting honestly, I believe. Buffalo used to
pad for publication purposes. One year it vaunted itself as the
healthiest large city in the country. The boast was made on the original
assumption of a population nearly 25,000 in excess of the United States
Census figures, to which 20,000 more was added arbitrarily, the given
reason being a "general belief" that the city had grown to that extent.
Perhaps as complete returns as any are obtained in Maryland, where the
health official, Dr. Price, culls the death notices from 60 papers,
checks up the returns from the official registrars, and if any are
missing, demands an explanation by mail. It behooves the registrar to
present a good excuse. Otherwise he is haled to court and fined. The
Board has thus far never failed to secure a conviction.
Now, if the most concrete and easily ascertainable fact in public health
statistics, the total of deaths, is often qualified or perverted, it
follows that dependent data, such as the assigned causes of death, as
required by law, are still more unreliable; so I shall keep as far away
from statistics as possible except where some specific condition can be
shown by approved figures or by figures so inherently self-disproved
that they carry their own refutation.
_The Criminal Negligence of Physicians_
This unreliability may be set down to the account of the medical
profession. Realizing though they do the danger of concealment from the
proper authorities, and in the face of the law which, as it gives them
special privileges, requires of them a certain return, a considerable
percentage of physicians falsify the returns to protect the
sensibilities of their patrons. That they owe protection rather to the
lives of the public, they never stop to think. Tuberculosis is the
disease most misreported. In many communities it is regarded as a
disgrace to die of consumption. So it is. But the stigma rests upon the
community which permits the ravage of this preventable disease; not upon
the victims of it, except as they contribute to the general lethargy. In
order to save the feelings of the family, a death from consumption is
reported as bronchitis or pneumonia. The man is buried quietly. The
premises are not disinfected, as they should be, and perhaps some
unknowing victim moves into that germ-reeking atmosphere, as into a
pitfall. Let me give an instance. A clergyman in a New York city told me
of a death from consumption in his parish. The family had moved away,
and the following week a young married couple with a six-months-old baby
moved in.
"What can I do about it?" asked the clergyman. "Mr. Blank's death was
said to be from pneumonia; but that was only the final cause. He had
been consumptive for a year."
"Warn the new tenants," I suggested, "and have them ask the Health Board
to disinfect."
More than a year later I met the clergyman on a train and recalled the
case to him. "Yes," he said, "those people thought it was too much
trouble to disinfect, particularly since the reports did not give
tuberculosis as the cause of death. Now their child is dying of
tuberculosis of the intestines."
In this case, had the death been properly reported by the dead man's
physician, as the law required, the City Board would have compelled
disinfection of the house before the new tenants were allowed to move
in. The physician who obligingly falsified that report is morally guilty
of homicide through criminal negligence.
In Salt Lake City, in 1907, 43 deaths were ascribed to
tuberculosis--undoubtedly a broad understatement. And in the face of the
ordinance requiring registration of all cases of consumption, only five
persons were reported as ill of the disease. By all the recognized rules
of proportion, 43 deaths in a year meant at least 500 cases, which,
unreported, and hence in many instances unattended by any measures for
prevention of the spread of infection, constituted so many separate
radiating centers of peril to the whole community.
Why is such negligence on the part of physicians not punished? Because
health officials dread to offend the medical profession. In this
respect, however, a vast improvement is coming about. Pennsylvania,
Maryland, Indiana, Massachusetts, Minnesota, Wisconsin, and other States
are not afraid to prosecute and fine delinquents; nor are a growing
number of cities, among them Boston, New York, Rochester, Providence,
and New Orleans. The great majority of such prosecutions, however, are
for failure to notify the authorities of actively contagious diseases,
such as scarlet fever, diphtheria, and smallpox.
_"Business Interests" and Yellow Fever_
Epidemics are, nevertheless, in the early stages, often misreported. If
they were not--if early knowledge of threatening conditions were made
public--the epidemics would seldom reach formidable proportions.
But--and here is the national hygienic failing--the first instinct is to
conceal smallpox, typhoid, or any other disease that assumes epidemic
form. Repeated observations of this tendency have deprived me of that
knock-kneed reverence for Business Interests which is the glorious
heritage of every true American. As a matter of fact, Business Interests
when involved with hygienic affairs are always a malign influence, and
usually an incredibly stupid one. It was so in New Orleans, where the
leading commercial forces of the city, in secret meeting, called the
health officer before them and brow-beat him into concealing the
presence of yellow fever, lest other cities quarantine against their
commerce. And "concealed" it was, until it had secured so firm a
foothold that suppression was no longer practicable, and the city only
averted a tremendously disastrous epidemic by the best-fought and most
narrowly won battle ever waged in this country against an invading
disease.
[Illustration: THE SCAVENGERS OF CHARLESTON, SOUTH CAROLINA]
It is interesting to note, by the way, that this epidemic, with its
millions of dollars of loss to the city of New Orleans, might have been
averted at a comparatively small cost, had the city fathers possessed
the intelligence and foresight to adopt a plan devised by Dr. Quitman
Kohnke, the city health officer. New Orleans gets its drinking water
from private cisterns. Each of these is a breeding place for the
yellow-fever-bearing mosquito. Dr. Kohnke introduced a bill a year
before the epidemic, providing for the screening of all the cisterns, so
that the mosquitos might not spread abroad; and also for the destruction
by oil of the insects in the open pools. The total cost would hardly
have exceeded $200,000. But there was no yellow fever in the city then;
the public had recovered from its latest scare; and the bill was voted
down with derision. I suppose the saving of that $200,000 cost New
Orleans some forty or fifty million dollars in all.
Seldom does a Southern State discover yellow fever within its own
borders. It is always Mississippi that finds the infection in New
Orleans, and Louisiana that finds it in Galveston. This apparently
curious condition of affairs is explicable readily enough, on the ground
that no State wishes to discover the germ in its own veins, but is quite
willing, for commercial reasons, to point out the bacillus in the
system of its neighbor. In 1897 Texas was infected pretty widely with
yellow fever; but pressure on the boards of health kept them from
reporting it for what it was. In light cases they called it dengue or
breakbone fever. Now, dengue has this short-coming: that people do not
die of it. Disobliging sufferers from the alleged "dengue" began to fill
up the cemeteries, thereby embarrassing the local authorities, until one
of the health officers had a brilliant idea. "When they die," he said,
"we'll call it malarial fever." And as such it went upon the records.
Two recalcitrant members of the Galveston Health Board reported certain
extremely definite cases as yellow fever. They were forced to resign,
and the remainder of the Board passed resolutions declaring that there
was no yellow fever, there never had been any yellow fever, and there
never would be any yellow fever as long as they held their jobs--or
words to that effect. San Antonio also had the epidemic; so much of it
that the mail service was suspended; but nothing worse than dengue was
permitted to go on the records. Later a Marine Hospital Service surgeon
was sent by the government to investigate and report on the Texas
situation. He told the truth as he found it and became exceedingly
unpopular. Lynching was one of the mildest things they were going to do
to him in Texas. And all this time, while Texas was strenuously claiming
freedom from the yellow plague, her emissaries were discovering cases in
New Orleans that the local authorities there had somehow carelessly
overlooked. The game of quarantine, as played by the health authorities
of the far Southern States, and played for money stakes, if you please,
is not an edifying spectacle in twentieth century civilization.
_Newspapers, Politicians, and the Bubonic Plague_
But if it is bad in the South, it is worse in the West. To-day
California is paying for her sins of eight years ago in suppressing
honest reports of bubonic plague, when she should have been suppressing
the plague itself. That the dreaded Asiatic pest maintains its foothold
there is due to the cowardice and dishonesty of the clique then in
power, which constituted a scandal unparalleled in our history, a
scandal that, with the present growing enlightenment, can never be
repeated.
Early in 1900 the first case of the present bubonic plague onset
appeared in San Francisco's Chinatown. I say "present" because I believe
it has never wholly died out in the last eight years. A conference of
the managing editors of the newspapers, known as the "midnight
meeting," was held, at which it was decided that no news should be
printed admitting the plague. The _Chronicle_ started by announcing
under big headlines: "Plague Fake Part of Plot to Plunder." "There Is No
Bubonic Plague in San Francisco." This was "in the interest of
business." Meantime the Chinese, aided by local politicians, were hiding
their sick. Out of the first 100 cases, I believe only three were
discovered otherwise than by the finding of the dead bodies. Sick
Chinamen were shipped away; venal doctors diagnosed the pest as "chicken
cholera," "septemia hemorrhagica," "diphtheria" and other known and
unknown ailments.
In May, 1900, came the blow that all San Francisco had dreaded: Texas
and New Orleans quarantined against the city, and business languished.
At this time two men were in control of the plague situation: Dr.
Williamson of the City Board of Health and Dr. J. J. Kinyoun of the
Marine Hospital Service. Dr. Williamson and Dr. Kinyoun both declared
plague to be present in the city. The business interests represented in
the Merchants' Association appealed to Kinyoun to suppress his reports
to Washington. In return he invited them to read the law which compelled
him to make reports. They then tackled Dr. Williamson, who replied that
he'd tell the truth as he found it, and if it was distasteful to them,
they needn't listen. They went to Mayor Phelan demanding Williamson's
head on a salver. Mayor Phelan stuck by his man. Governor Gage they
found more amenable. He issued a proclamation declaring that there was
no plague. Governor Gage is not a physician or a man of scientific
attainment. There is nothing in his record or career to show that he
could distinguish between a plague bacillus and a potato-bug.
Nevertheless he spent considerable of the State's money wiring positive
and unauthorized statements to Washington. His State Board of Health
refused to stand by him and he cut off their appropriation; whereupon
they resigned, and he secured another and more servile board, remolded
nearer to the heart's desire. Meantime the newspapers were strenuously
denying all the real facts of the epidemic, their policy culminating in
the complete suppression of plague news. Before this, however, they so
inflamed public opinion against Dr. Kinyoun and Dr. Williamson that
these two gentlemen became pariahs. Here are a few of the amenities of
journalism in the golden West, culled from the display heads of the
papers:
"Kinyoun, Enemy of the City."
"Has Kinyoun Gone Mad?"
"Desperate, Kinyoun Commits Another Outrage on San Francisco."
"Board of Health for Graft and Plunder."
"Our Bubonic Board."
One gentle patriot in the State Senate suggested in a thoughtful and
logical speech that Dr. Kinyoun should be hanged. This practical spirit
so appealed to the Chinese organizations (it was Chinatown that suffered
chiefly from the quarantine rigors) that those bodies put a price of
$10,000 on Kinyoun's head--not his political head, understand, but the
head which was very firmly set on a pair of broad shoulders. Some of the
officer's friends went to the Chinese Consul-General and explained
unofficially that they would hold him responsible for any accident to
Dr. Kinyoun. That personage, supposing that they were suggesting the
slow accounting of diplomacy, smiled blandly and said:
"Gentlemen, I sympathize with you; but what can I do?" "Do?" said the
spokesman, "Why, you can climb a lamp-post at the end of a rope within
one hour of the time that Kinyoun is killed. That's what you can and
will do."
The bland smile disappeared from the Oriental's face. He summoned a
conference of the secret societies, and the reward for Kinyoun's death
was abrogated. Next, the white politicians of Chinatown tried their hand
and organized a lynching bee, but the intrepid doctor fortified his
quarters, armed his men, and was so obviously prepared for trouble that
the mob did nothing more than gather. Arrested twice on trumped-up
charges, threatened for contempt of court, he continued to fulfill his
duties. Governor Gage and the Republican State Committee now inaugurated
a campaign of influence upon President McKinley, which resulted in a
Federal Commission, consisting of Drs. Flexner, Barker, and Novy, all
eminent scientists, being sent to the troubled city; where, instead of
being received with honors, they were abused by the newspapers; insulted
by the Governor; and had the humiliation of seeing the doors of the
University of California slammed in their faces after they had been
invited there. Of course, the Commission found bubonic plague, because
it was there for any one to find.
Thus far the United States Marine Hospital authorities had stood back of
their men. Now they began to weaken. The findings of the Federal
Commission were kept out of the weekly service reports, and data of the
epidemic were edited out of the public health bulletins, in disregard of
the law. Even this subserviency did not satisfy the California
delegation; they wanted Kinyoun out.
And, on April 6, 1901, after a year's brave fight in the face of public
contumely and constant physical danger, Dr. Kinyoun was kicked up-stairs
into a soft berth at Detroit. He resigned. So the M. H. S. lost a brave,
faithful, and able public servant and for once blackened its own fine
record.
There isn't space to give the rest of the plague history; how it cropped
out in other parts of California; how it was shipped to Matanza, Mexico,
and all but ruined that town; how the hated local Health Board, in the
face of the Governor of the State, and the Federal authorities, stuck to
their guns and won the fight, for San Francisco finally admitted the
presence of the plague, and asked for governmental aid. Rupert Blue, one
of the best surgeons in the Marine Hospital Service, was assigned to the
terrified city, and though he has not been able to wipe out the
pestilence, the fact that the smoldering danger has not broken into
devastating flame is due largely to his unremitting watchfulness and his
unhampered authority. "Business Interests" have had their trial in San
Francisco. And San Francisco has had enough of "suppression." To-day the
truth is being told about bubonic plague in the public health reports,
and, I believe, in the newspapers.
Rochester, New York, one of the most progressive cities in the country
in hygienic matters, has established an excellent system of school
inspection and free treatment. But the children who most need attention
lack it through the carelessness or negligence of their parents. Now, it
is this very "submerged tenth" who are set to work early in life. Under
the law, the health officer cannot say, "Unless you are sound, you shall
not attend school." But there is an ordinance providing that, without a
certificate of good physical condition, no child shall be permitted to
work in a store or factory. So Dr. Goler refuses these certificates, not
only in cases of low vitality and under-nutrition, but for any defect in
the applicant's teeth, sense-apparatus, or tonsils, a fertile source of
future debility. What is the result? There is a rush of these neglected
youngsters to the clinics, and the Rochester schools graduate every year
into the world of labor a class of young citizens in splendid physical
condition, unhandicapped by the taints which make, not for death alone,
but for vice and crime. For the great moral lesson of modern hygiene is
that debility and immorality run in a vicious parallel.
As I have said, the most thoroughly organized city department is that of
New York City, and this is so because public opinion in New York, taught
by long experience that its trust will not be betrayed, is, in so far as
it turns upon sanitary matters at all, solidly behind its health
department. Hence its guardians work with a free hand.
_Fighting Prejudice and the Death Rate in Charleston_
But what is the guardian to do when the guarded refuse to bear their
share of the burden; refuse, indeed, to manifest any calculable
interest, except in the way of occasional opposition? Such is the case
in Charleston, South Carolina, where every man aspires to do just as his
remotest recognizable ancestor did, and the best citizens would all live
in trees and eat nuts if they were fully convinced of the truth of the
Darwinian theory. Charleston, lovely, romantic, peaceful Charleston,
swept by ocean breezes and the highest death rate of any considerable
American city; breathing serenely the perfume of its flowers and the
bacilli of its in-bred tuberculosis; Charleston, so delightful to the
eye, so surprising to the nose!
By accident Charleston got an efficient health officer not long ago. A
deserved epidemic of smallpox had descended upon the unvaccinated
negroes and scared the tranquil city. Dr. J. Mercier Green was called
from private practice to tackle the situation. For weeks he waded in the
gore of lacerated arms, and his path through darkest Charleston could be
followed by rising and falling waves of Afro-American ululations; but he
checked the epidemic, and when three months later the city physician
died, he got the place. Now, had Dr. Green been wise in his generation,
he would have been content to keep his municipal patient reasonably free
from smallpox and live a quiet life. But he straightway manifested an
exasperating interest in other ailments. He stirred up the matter of the
water supply, regardless of the fact that all Charleston's
great-great-grandfather had drunk water from polluted cisterns and died
of typhoid as a gentleman should. He pitched into doctors nearly old
enough to be his own great-great-grandfather because they failed to
report diseases properly. He answered back, in the public prints, the
unanswerable Good-Old-Way argument. He opined, quite openly, that there
was too much tuberculosis, too high an infant mortality, too prevalent a
habit of contagious disease, and he more than hinted that the city
itself was at fault.
In the matter of the cisterns, for instance. Charleston now has a good
city water supply, fairly free from contamination where it starts, and
safely filtered before it reaches the city. But a great many of "our
best citizens" prefer their own cisterns, on the grandfather principle.
These are underground, for the most part, and are regularly supplied
from the roof-drainage. Also, they are intermittently supplied by
leakage from adjacent privy-vaults, Charleston having a very rudimentary
and fractional sewerage-system. Therefore typhoid is not only logical
but inevitable. I have no such revolutionary contempt for private rights
as to deny the privilege of any gentleman to drink such form of sewage
as best pleases him; but when it comes to supplying the public schools
with this poison, the affair is somewhat different. Yet, as far as the
Charleston Board of School Commissioners has felt constrained to go, up
to date, is this: they have written to the City Physician asking that
"occasional inspection" of the cisterns be made, and decorating their
absurd request with ornamental platitudes.
With sewage it is the same situation. There is, indeed, a primitive
sewer system in part of the city. But any attempt to extend it meets
with a determined and time-rooted opposition. The Charlestonians are
afraid of sewer-gas, but apparently have no fear of the filth which
generates sewer-gas; said filth accumulating in Charleston's streets,
subject only to the attention of the dissipated-looking buzzards, which
are one of the conservative and local features of the place. I have seen
these winged scavengers at work. It is not an appetizing sight. But with
one exception they afford the only example of unofficial effort toward
the betterment of sanitary conditions, that I witnessed in Charleston.
The other came from a policeman, patiently poking with his club at the
vent of one of the antediluvian sewers, which had--as usual--become
blocked. Yet, despite public indifference and opposition, Dr. Green,
without any special training or brilliant ability as a sanitarian, is,
by dogged, fighting persistency lowering the death-rate of his city.
There is also a non-medical legislator to whom Charleston owes a debt of
unacknowledged gratitude. Mr. James Cosgrove succeeded in getting the
Charleston Neck marshes, wherein breeds the malaria-mosquito, drained.
Since then the death rate from malaria, which was nothing less than
scandalous, has dwindled to proportions that are almost respectable--if,
indeed, it were respectable to permit any deaths from an easily
destructible nuisance like the mosquito. Nearly all our cities, by the
way, are curiously indifferent to the depredations of this man-eater.
Suppose, for an example, that Trenton, New Jersey, were suddenly beset
by a brood of copperhead snakes, which killed, let us say, two or three
people a week and dangerously poisoned ten times that number. What an
anti-snake campaign there would be in that aroused and terrified
community! Well, that much more dangerous wild creature, the Anopheles
mosquito, in a recent year slew more than 100 people in Savannah,
Georgia, without arousing any public resentment. And Jacksonville's home
brood in 1901 slaughtered 90 of its 30,000 citizens and dangerously
poisoned probably 1000 more. New Orleans, by the way, having executed a
triumphant massacre of the yellow fever mosquito (stegomyia) is now
undertaking to rid itself of all the other varieties. And Baltimore's
health bureau has succeeded in obtaining a grant of $10,000 for the
purpose of demonstrating the feasibility of mosquito-extermination.
_Killing Off the City Negro_
Throughout the South, figures and conditions alike are complicated by
the negro problem. Southern cities keep a separate roster of
mortalities; one for the whites, one for the blacks. In so far as they
expect to be judged by the white rate alone, this is a manifestly unfair
procedure, since, allowing for a certain racial excess of liability to
disease, the negro in the South corresponds, in vital statistics, to the
tenement-dweller in the great cities. If New Orleans is to set aside its
negro mortality, that is; the death rate among those living in the least
favorable environment, New York should set apart the deaths in the
teeming rookeries east of the Bowery, the most crowded district in the
world, and ask to be judged on the basis of what remains after that
exclusion. New York, however, would be glad to diminish the mortality in
its tenements. New Orleans, Atlanta, Charleston, or Savannah would be
loath to diminish their negro mortality. That is the frank statement of
what may seem a brutal fact. The negro is extremely fertile. He breeds
rapidly. In those cities where he gathers, unless he also died rapidly,
he would soon overwhelm the whites by sheer force of numbers. But, as it
is, he dies about as rapidly as he breeds. Recent statistics in
Savannah, for instance, showed this curious situation:
Excess of births over deaths among the whites, 245.
Excess of births over deaths among the blacks, 10.
Health Officer Brunner has stated the case, in a manner which, I fancy,
required no little courage in an official of a Southern community:
We face the following issues: First: one set of people, the
Caucasian, with a normal death-rate of less than 16 per thousand
per annum, and right alongside of them is the Negro race with a
death-rate of 25 to 30 per thousand. Second: the first named
race furnishing a normal amount of criminals and paupers and the
second race of people furnishing an abnormal percentage of
lawbreakers and paupers.
Is the Negro receiving a square deal? Let this commission
investigate the houses he lives in; why, in his race,
tuberculosis is increasing; why he furnishes his enormous quota
to the chain-gang and the penitentiary. Observe the house he
must live in, the food that he must eat, and learn of all his
environments. The negro is with you for all time. He is what you
will make him and it is "up" to the white people to prevent him
from becoming a criminal and to guard him against tuberculosis,
syphilis, etc. _If he is tainted with disease you will suffer;
if he develops criminal tendencies you will be affected._
Will not the white South, eventually, in order to save itself from
disease, be forced to save its negroes from disease? It would seem an
inevitable conclusion.
_Private Interests in Public Murder_
Always and everywhere present are the private influences which work
against the public health. Individuals and corporations owning foul
tenements or lodging-houses resent, by all the evasions inherent in our
legal system, every endeavor to eliminate the perilous conditions from
which they take their profit. For the precious right to dump refuse into
streams and lakes, sundry factories, foundries, slaughter-houses, glue
works, and other necessary but unsavory industries send delegations to
the legislature and oppose the creation of any body having authority to
abate the nuisances.
Purveyors of bad milk decline to clean up their dairies until the
outbreak of some disease which they have been distributing by the can
brings down the authorities upon them. Could the general public but know
how often minor accesses of scarlet fever, diphtheria, and typhoid
follow the lines of a specific milk route, there would be a tremendous
and universal impetus to the needed work of milk inspection. In this
respect the country is the enemy of the city: the country, which, with
its own overwhelming natural advantages, distributes and radiates what
disease it does foster among its urban neighbors, by sheer ignorance or
sheer obstinate resistance to the "new-fangled notions of science." Such
men as the late Colonel Waring of New York, Dr. Fulton of Baltimore, and
Dr. Wende of Buffalo have repeatedly pointed out the debt of death and
suffering which the city, often well organized against infections, owes
to the unorganized and uncaring rural districts. Reciprocity in health
matters can be represented, numerically, by the figure zero. It
occasionally happens that the conflict between private and public
interests assumes an obviously amusing phase. The present admirable Food
and Drug Department of the Indiana board was not established without
considerable opposition. One of the chief objectors was a member of the
legislature, who made loud lamentation regarding the expense. Up rose
another legislator, all primed for the fight, and asked if the objector
would answer a few questions. The objector consented.
"Do you know the W---- baking-powder?"
"Yes."
"Do you know that it would naturally come to the food laboratory for
analysis, were such a laboratory established?"
"I suppose it might."
"Do you know that the W---- baking-powder is 20 per cent. clay?"
"No."
"Would it surprise you to learn that it contained a high percentage of
clay?"
No answer.
"Are you counsel for the W---- Baking Powder Co.?"
"Yes."
"That's all."
It was enough. The bill passed.
Everybody's health is nobody's business. There, as I see it, is the bane
of the whole situation at present. To be sure, epidemics occasionally
wake us up. And, really, an epidemic is a fine thing for a city to have.
It is the only scourge that drives us busy Americans to progress. It
took an epidemic of typhoid, a shameful and dreadful one, to teach
Ithaca that it must not drink filth. Only after Scranton faced a
thousand cases of the fever did it assert itself and demand protection
for its water supply. New Orleans would probably be having (and
concealing) yellow fever yet, but for the paralysis of fright which the
onset of three years ago caused. Boston's fine system of medical
inspection in the schools is the outcome of a diphtheria scare. Smallpox
is a splendid stimulator of vaccination; so much so that some of the
country's leading sanitarians now advocate the abolition of pest-houses
for this avoidable ailment, and dependence upon the vaccine virus alone.
But epidemics are only the guerrilla attacks of the general enemy. It is
in the diseases always with us that the peril lies. Tuberculosis,
carrying off ten per cent. of the entire nation, and making its worst
ravages upon those in the prime of life, is a more terrible foe than was
ever smallpox, or cholera, or yellow fever, or any of the grisly
sounding bugaboos. Why, not so long ago, three highly civilized States
went into quite a little frenzy over a poor dying wretch of a leper who
had got loose; whereas every man that spits on the floor of a building
wherein people live or work is more of an actual peril, in that one foul
act, than the leper in his whole stricken life. The twin shames of
venereal disease, blinked by every health board in the country (Detroit
possibly deserves a partial exception) are, in their effect upon the
race, in blindness, deafness, idiocy, and death so dreadful a menace
to-day, that consumption alone can march beside them in the leadership
of the destroyers. Typhoid, so easily conquerable, claims its annual
thousands of sacrificed victims. And the slaughter of the innocents goes
endlessly on, recorded only in the dire figures of infant mortality.
To-day, as I write, the whole nation is thrilled with horror at the
tragedy of 150 young lives snuffed out in a needless school panic in
Cleveland. Had my pen the power, perhaps I could thrill the nation with
horror over the more dreadful fact that some 1100 children under five
years of age die yearly in Fall River, the vast majority of them
sacrificed to bad food and living conditions that might better be called
dying conditions. One half of the total mortality of that busy,
profit-yielding city is among children under five years of age,
two-fifths among children under one year. Does no baneful light shine
from those figures?
Yet, over and above the minor discouragements, failures, and set-backs,
looms the tremendous fact of a universal and gathering movement. It is
still, in any general sense, inchoate, and, except in certain specific
relations, invertebrate. But one cannot follow the work of the public
health guardians without feeling the cumulative force of progress. As I
have said, the newspapers have been a vital element in awaking the
public. Associations are being formed the country over for the
prevention of disease. There is a steady increase in the power and
authority of those officially charged with hygienic control. Makers of
deleterious or poisonous foods, and the vultures who prey on the sick
through fraudulent patent medicines are being curbed by pure food and
drug laws. Milk inspection is saving the lives of more children every
year, as meat inspection is prolonging the lives of the poor. Definite
instances of progress are almost startling: the fact that Massachusetts
has so purified its public waters that for a year there has been no
typhoid epidemic ascribable to any public supply; the passage of a
radical law in Indiana which forbids the marriage of imbeciles,
epileptics, and persons suffering from a contagious or venereal disease;
the saving of babies' lives at $10 a life in Rochester by pure milk
protected and guaranteed by the municipality; the halving of the
diphtheria death rate by the free distribution of antitoxin; the slow
but sure and universal yearly decrease in the Great White Plague--all
these and more are the first, slow, powerful evidences of national
progress.