THE COMMUNITY'S HEALTH
In the early days in which the country was but sparsely settled,
sickness, except for epidemics of such diseases as smallpox and yellow
fever, was regarded as an individual affair. In recent years
bacteriology and medical science have revealed the causes of many
diseases and the manner in which they are spread. With a denser
population and with more frequent contacts as a result of better
transportation, the possibility of contagion has very largely increased
and we now appreciate that the health of the family--even of the rural
family--cannot be maintained without attention to the health of the
community as a whole. Good health has become a responsibility of the
community.
The rapid growth of cities in the last fifty years has forced them to
take measures for the preservation of health, and public health
administration has become a distinct branch of medical science. It is
the health problems which have arisen in the congested sections of our
large cities, and those which are due to a sedentary life or to
unhealthful conditions of certain trades and industries, which have
incited the discoveries of medical science and which have created a new
attitude toward sanitation and hygiene among city people.
There has been a distinct change with regard to the attitude of society
toward health. A generation or two ago many people--particularly elderly
females--were not ashamed of "enjoying poor health," and a delicate
physique was regarded as rather incidental to the more highly cultured.
To-day, although we sympathize with the afflicted, society places a
premium upon a sound physique. The importance of physical exercise, of
recreation and athletics for the development and maintenance of a sound
body are now much more fully appreciated than they were fifty years ago.
We are coming to understand that good health is largely due to habits of
personal hygiene which must be instilled by the home and the school, and
that without such habits the mere knowledge of sanitation and hygiene
will not be generally applied. This new emphasis upon physical fitness
has naturally received larger attention in the cities on account of the
more unfavorable conditions of city life, while the new knowledge and
appreciation of the value of health has not been so constantly forced
upon the attention of rural people.
Gradually we are coming to appreciate that we have an ethical
responsibility for good health, and it is even receiving a religious
sanction, for we have come to know that the cause of evil behavior may
be due primarily to an unsound body rather than to a perverted soul. The
church has ever ministered to the sick and has supported hospitals, but
to-day it is commencing to advocate the prevention of disease through
sanitation and hygiene, and to preach the religious duty of fostering
health and preventing sickness.
One of the principal factors in the farmer's relative indifference to
health measures is the fact that he has become accustomed to think that
an outdoor life and isolation from other people give him an ability to
withstand sickness and he has rather gloried in his ability to throw off
ordinary ailments and to withstand the physical hardship which his work
often demands. He can see how health conditions may need attention in
the city where people are crowded together, but he is not impressed that
other causes make such diseases as typhoid and malaria much more
prevalent in the open country, and that bad sanitation on a farm a mile
away may cause sickness in his own family. American farmers have been
educated on the nature and spread of disease by their experience with
animal diseases, such as bovine tuberculosis, hog cholera, and Texas
fever. If they can be interested to utilize this knowledge in the care
of the health of their own families, and if they will provide health
facilities for their own families equal to those which they feel
necessary for their livestock, health conditions on the farm will show
rapid improvement. It is not that the farmer is indifferent to the
health of his family, but he has been _forced_ to have his herd tested
for tuberculosis, and he faces the possibility of heavy losses if he
does not have his hogs vaccinated for cholera, while he has not
appreciated that by preventative agencies the better health of his wife
and children may be insured and the cost of remedial treatment be
greatly lessened.
The purely economic aspects of sickness and disease have been a potent
factor in the health movement, particularly in cities. The vast sums
invested in life insurance have led progressive insurance companies into
extensive campaigns for promoting public health so that their risks may
be reduced. Vast quantities of the best health literature have been
distributed by some of the industrial insurance companies and they have
done much to demonstrate the value of public health nursing by employing
nurses who visit their policy holders. The extension of the insurance
method to health insurance, and the adoption of insurance by large
corporations for their employees has furthered this general movement,
and has revealed the tremendous economic losses due to preventable
sickness and disease. The farmer has failed to appreciate the purely
economic handicap under which he labors as a result of sickness and the
lack of adequate medical service and efficient public health
administration such as cities enjoy, because the cost of sickness is
distributed and is borne by each family and he has no means of knowing
the aggregate cost for the whole community. Were it possible for a rural
community to secure and have brought to its attention the total economic
loss due to sickness in a given year and the proportion which might be
preventable with a reasonable expenditure for better health facilities,
its people would doubtless become as interested in better health
administration as does the employer in a large city industry, and the
true economy of better health facilities would be apparent.
Few concrete studies of the losses occasioned by sickness in rural
communities have been made, but one of Dutchess County,[54] New York, in
1915 well illustrates the conditions which would doubtless be found in
many another rural county. This survey covered five districts of the
county with an aggregate population of about 11,800--most of which was
rural territory. 1,600 cases of serious illness were found to have
occurred during the year. "Some 9,000 days were lost by men and women of
working age (15 to 54 years). Children lost 13,700 school days. On the
average this cost the community for each child at least 33 cents a day
for which it received no return. These two items safely represent a
money loss of $20,000 to $25,000." As a result of the study it was
estimated that the total money loss occasioned by sickness in a year
within the whole county would be at least $412,000. "Of the 1,600
patients whose care has been analyzed in this report, 72 percent could
have been cared for adequately in their own homes had there been
available medical and nursing service. The remaining 28 percent (442
patients) could not have been cared for adequately in their own homes
... 24 percent of the patients secured no medical care. Many startling
instances of unnecessary and indefensible suffering and misery were
found.... Of the 113 women who went through childbirth in their homes,
only one had the continuous care of a graduate nurse, and only 18 had
any service whatever from graduate visiting nurses. 35 percent of the
children born came into the world under unfit conditions and
surroundings." Largely as a result of this study, Dutchess County now
has an efficient county health association through which a number of
public health nurses are employed, who visit all districts of the
county.
One of the most serious handicaps in maintaining the health of the rural
community is its frequent lack of medical service. The number of doctors
practising in the open country was always inadequate, but in recent
years it has decreased until now many large sections are without any
resident physician. The influenza epidemic of 1918, following the
shortage of doctors during the war, revealed the plight of many a rural
community without medical service. The higher standards now required by
medical colleges and state licensing boards has resulted in a real
shortage of physicians and the young men are not going into the country
to practise. A recent study made by the New York State Department of
Health showed that in 20 rural counties 88 percent of the physicians had
been practising over 25 years and only 3 percent less than ten years.
This means that most of the rural doctors in these counties have less
than ten years more to practise and that there is no indication that
their places will be filled by younger men. In Manitoba one rural
municipality has employed a physician on full time, and a recent act of
the New York legislature makes it possible for towns to employ
physicians. It seems probable that country people will be forced to
employ physicians on a salaried basis if they are to secure adequate
medical service. This does not necessarily mean, however, that the
physician will be employed by the local government. Industrial workers
are now employing physicians on a salary and farmers' organizations are
employing salaried veterinarians. Why cannot a local health association
be formed to employ a physician, whose job it will be to keep its people
well?
Two factors prevent the larger use of physicians now available. Chief of
these is the cost. Farmers handle relatively less actual money than
townsmen, and their income is less frequent so that they have less on
hand, while the cost of medical attendance is necessarily higher in the
country. Fear of running up a bill deters many a farm woman from calling
a doctor, when one call might prevent many more later on. The farm home
tends to employ a physician only for serious sickness, rather than as a
medical adviser who may forestall illness. Another difficulty is one of
the physician's own making. The experience is far too common that in
cases of immediate need when the family doctor cannot be located,
doctors will refuse to attend a case on account of so-called
"professional courtesy." It is time that public opinion be aroused so
that such cases be brought to the attention of county medical societies
with sufficient public opinion to force them to take suitable action.
The ethics of every profession must be shaped to meet the needs of those
it serves as well as the pocketbooks of its members.
Lack of medical attendance is most serious for the farm mother during
confinement, and the mortality of rural mothers during childbirth, as
shown by the investigations of the U. S. Children's Bureau, is an
indictment of our supposed civilization. When we learn that in a
homesteading county in Montana there were 12.7 deaths of mothers per
1,000 births, which is twice the rate for the United States as a whole,
which is higher than that of fifteen foreign countries for which
statistics were available in 1915, we face a condition which cannot be
neglected. When we find that in Wisconsin this rate was but 6 per 1,000,
and that 68 percent were attended by physicians, and in Kansas it was
but 2.9 per thousand and 95 percent had physicians, while in Montana
only 47 percent were attended, loss of life due to isolation and lack of
medical care is apparent. In sparsely settled regions the solution of
this problem seems to demand the provision of local maternity hospitals,
for the difficulty is primarily one of isolation.
Since medical science has shown that sparkling spring water may carry
the deadly typhoid germ as a result of distant contamination, that wells
are frequently contaminated by nearby privies or barn yards, that
malaria is carried by mosquitoes, and that the house fly may carry
typhoid fever and intestinal diseases of infants, we have come to
appreciate that isolation and pure country air do not insure freedom
from infection, and that sanitation is as important on the farm as in
the city. Indeed the transmission of disease by flies is much easier on
the farm, for too often the manure pile where they multiply is not far
from the house, while in many a city the smaller number of horses and
the cleaning of manure from the streets prevents their increase. The
sanitation of the farm home thus becomes a very large factor in the
health of the rural community. Surveys made by health officers in recent
years have shown the general need of better sanitary provisions and also
the possibility of the direct benefits secured from their improvement.
In Indiana the State Board of Health surveyed nine typical rural
counties taking only the homes on farms and in unincorporated villages.
The average score of 6,124 rural homes in these nine counties was but
56.2 percent, the average for individual counties varying from 43 to 61
percent. In 1914, 1915, and 1916, the U. S. Public Health Service made
sanitary surveys of 51,544 farm homes in 15 rural counties scattered
throughout the United States, but mostly in the South. Its report[55]
states that only 1.22 percent of these farm homes were equipped for a
really sanitary disposal of human excreta, while in one county in
Alabama less than 20 percent of the farm homes had toilets of any kind.
"Sixty-eight percent of the water supply used for drinking or culinary
purposes was obviously exposed to dangerous contamination from privy
contents"; and only 32.88 percent of the houses were effectively
screened against flies. A very considerable improvement in farm
sanitation has resulted from the educational campaigns conducted during
the past decade, but effective rural sanitation awaits the employment of
public health officials who will convince the people of each local
community of their individual responsibility for the health conditions
on their own farms and of their common liability for the health of each
other.
With the above conditions in mind, let us now consider the agencies for
health conservation in rural communities. We have already seen that the
old-fashioned country doctor is rapidly disappearing. With better
transportation now available it seems probable that physicians will live
in the larger village centers, but with telephone communication and the
automobile it should be possible to secure as prompt medical attendance.
We may as well recognize that many a rural community is too small a unit
to support a resident physician and that if satisfactory medical
treatment is to be secured we shall have to have better hospital and
clinical facilities so that the time of the physician can be economized
and frequent attention can be given.
Most rural townships have a local board of health and health officer,
who is charged with reporting births and deaths and with the enforcement
of quarantines against contagious diseases, but it is notorious that
these local health officials are rarely efficient or take any leadership
in the betterment of public health. Ordinarily the health officer
receives little if any pay, and is a resident physician who is not
inclined to antagonize his own clients when the enforcement of health
regulations would meet their opposition. Students of rural health
problems are now fairly agreed that the only means of securing efficient
administration of public health regulations in rural communities is by
the employment of a full time county health officer, working under a
county board of health, who will have the same general duties as the
health officers in our cities. Local health officers would be retained,
but their work would be under the supervision of the county health
officer and would have the benefit not only of his support and
encouragement, but also of his superior technical training. If a county
superintendent is necessary for our schools, a county health officer is
equally necessary for the supervision of public health, and several
states have enacted legislation requiring or permitting the employment
of county health officers. The county is usually the best unit for rural
health administration.[56] The county health officer would have
laboratory facilities for the examination of drinking water, and samples
of blood, urine, or sputum for the detection of disease, and would give
direction for the taking of samples which might be sent to the
laboratories of the state department of health for the examination of
those specimens for which his laboratory was not equipped. He would
have general supervision of the medical examination of school children.
In numerous ways he would promote better means for health conservation,
as can be done by one who has had special training for such work and who
is giving his whole time and thought to its problems.
Although the county health officer is necessary for the administration
of the technical aspects of public health administration, the most
important gains in the health of the rural community will come through
the personal education of its people on matters of hygiene and
sanitation. This is the field of public health nurses, and I believe
that the records of their work in rural communities will show that they
have done more for health education than any other one agency. A decade
ago trained visiting nurses were practically unknown in rural
communities. In 1914 the American Red Cross first organized its Town and
Country Nursing Service and cooperated with a few rural communities in
supervising the work of trained public health nurses, but relatively few
places employed rural nurses prior to the war. The county tuberculosis
societies also employed visiting nurses who worked throughout a whole
county and whose work inevitably created a demand for visiting nurses
for a more general service. The shortage of physicians during the war
and the influenza epidemic of 1918 revealed the need for rural nurses
and since the war the local chapters of the American Red Cross, which is
devoting much of its attention to public health work, have employed
hundreds of rural public health nurses.
The success of school nurses in the cities has led to their employment
in the smaller towns, and now county school nurses are being employed in
individual counties in several states, and in other states school
nurses are employed by townships or jointly by several rural school
districts. Wisconsin and Ohio have recently enacted laws compelling
every county to employ at least one public health nurse, and a dozen or
more states have passed legislation making the employment of county or
local nurses optional. Under whatever auspices they are employed, rural
public health nurses have found that their most effective work may be
done at first in connection with the schools. Medical examination of
school children is now required in many states, but unless it is
followed up by some one who will see the parents and encourage them to
secure the necessary medical or dental treatment, the results of these
examinations are often disappointing.
A most interesting and instructive account of the work done by a county
school nurse during the first year of her work in typical Minnesota
county has been given by Miss Amalia M. Bengtson, superintendent of
schools of Renville County:
"Renville County is prosperous; there are few poor people,
no child is underfed and no one wilfully neglected, yet our
tabulated report shows an appalling amount of physical
defectiveness. Out of our school population of six thousand
we examined five thousand children, and found four thousand
and ninety-five defective, testifying that 81 percent of the
children were defective. This seems almost unbelievable, and
yet it does not tell the whole story, for I could take you
to school after school where there was 100 percent
defectiveness, where we sent a notice to every parent in
that school. Yet, as I said before, Renville County is a
prosperous county, and we have every reason to believe that
conditions in Renville County to-day are the same as in
other counties where a health survey has been taken. The
percentages of the defectiveness found were: teeth, 55
percent; nose, 40 percent; throat, 66 percent; eyes, 22
percent; ears, 17 percent; malnutrition, 16 percent;
nervous disorder, 16 percent; neck glands, 14 percent; skin,
13 percent; and general appearance, 12 per cent."[57]
In reply to the question, "What of it? What good came of the
health survey?" Miss Bengtson says: "Our records show that
about one thousand of the children examined were taken to
see either a doctor or a dentist, or both, the first year.
Parents who at first opposed the work are fully convinced
that a county nurse should be a permanent worker among us
when they see how much their children have been benefited by
a little medical help.
"Besides examining the children, the nurse has been a great
factor in bringing about a general education for better
health. In our county to-day you are behind the times if you
do not know what adenoids are and the havoc bad tonsils can
bring; why eye strain is so prevalent and how to prevent it;
why teeth should be taken care of; why we should drink
plenty of water and eat the proper kind of food; what kind
of clothing is best to wear, and why we should not wear too
heavy and too much clothing while indoors (we have induced
some little boys to remove one coat and three sweaters while
in school); why we need to be clean, etc.
"Another great service the nurse rendered us was to bring
about a veritable epidemic of school-house improvement. She
proved that the physical condition of the school-house was
reflected in the physical condition of the children. For
example, a poorly lighted and badly ventilated school-house
always housed children with eye strain and nervous disorder,
and in a school-house having ill-fitting desks were children
of poor posture.
"During the summer of that first year the nurse was with us,
we conducted so-called 'baby clinics' in the county, one in
every township and one in each village. We urged the mothers
to bring their children below school age to the clinics, and
much the same kind of examination was given them as was
given the children of school age. We found that 60 percent
of the children of pre-school age were defective."
This is but a sample of the work and experience of hundreds of rural
nurses and shows how the nurse is a health teacher in the most effective
manner, for she gets into the homes and gives personal help in bringing
about better health. She uses the demonstration method in health work
just as the home demonstration agent does with food, clothing, and home
management. Furthermore, when the nurse is devoted to her work--and most
nurses are or they would not stick to so hard a job--she becomes
endeared to the people just as does the family doctor, for the help she
gives in cases of sickness, accident, and childbirth, when she is of
invaluable service to isolated homes who can secure no other help. A
slip of a girl--though a well-trained nurse--who commenced work in a
nearby community was introduced to her new work with two confinement
cases and an accident case the first day, for none of which was a
physician obtainable. The Red Cross Nurse in my own county has spent
many a night in a farm home in order to get sufficiently acquainted with
parents to induce them to allow her to have needed treatment given to
their children, and when the parents come to realize the benefit which
their children have received from operations on tonsils or adenoids, the
fitting of glasses, and similar services, and appreciate the handicap
which such defects would have been to them through life, the nurse has a
warm place in their hearts and they eagerly support her work.
One of the difficulties of the average country doctor is his lack of
facilities for the expert diagnosis of disease and for the care of
patients who need to be kept under observation and given supervised
care. Medical science has become highly specialized. The human body is
so complicated and wonderful a mechanism that we no longer can expect
any one man to be expert on all its ailments. If one desires to secure
the best medical service, he goes to a large city hospital or a
sanitarium, where various specialists can be consulted and where
laboratory facilities are available for their aid. In the average
village or country town both specialists and laboratories are lacking
and the physician is dependent on his own knowledge and resources. The
well-trained physician who appreciates his own limitations and that he
cannot give many of his more difficult cases the care they ought to
have, sends those who can afford it to the nearest hospital, and does
the best he can for the others, but he is keenly aware that he cannot
always give them the treatment they should have and he envies his city
colleague who can take his patients to specialists for examination.
It is a fear of this professional isolation which causes the average
young doctor to start his practice in the city where he has better
facilities, and which is largely responsible for the small number of
young doctors in rural counties. It is, of course, impossible to have a
hospital in every hamlet, but it is possible to have a good hospital and
laboratories at every county seat or small city center, so that there
will be at least one such medical center in a county. Legislation has
now been enacted in several states making it possible for counties to
support a public hospital just as the larger cities have done for many
years. Here clinics may be held from time to time, to which eminent
specialists may be brought for the diagnosis of different cases, to the
advantage of both patient and physician. It is quite impossible for a
busy country doctor to maintain a private laboratory and to provide
himself with all the expensive equipment for making examination and
tests of blood, sputum, urine, for X-ray examinations, etc., but the
hospital may have all this equipment at his service.
One of the most important features of the domestic program of the
American Red Cross is the promotion of so-called "Health Centers," a
movement which is also sponsored by the American Medical Association and
other national health organizations. Such a health center may include a
hospital with well equipped laboratories and clinical facilities, or it
may be nothing more than a room in a small village, equipped with scales
for weighing children, with first aid kits for accident cases, and used
for occasional clinics for the examination of babies and children of
pre-school age and for classes in home nursing or first aid; but every
community of any size should have some place which will be a
headquarters for its local health Service, equipped as may be most
practicable to meet its needs, according to the size of the community.
Curiously enough the local physicians, who would be most helped by such
improved health facilities and whose practice would be benefited by
them, are often their chief opponents. The leaders in the medical world,
who are keen for all practicable means of improving the public health,
heartily support the "health center" movement.
We are coming to the time when the maintenance of health will be
regarded as a public function just as education is now provided for all
the people and supported by them. That country people are alive to the
need of better health facilities is shown by a resolution of the recent
(February, 1922) Agricultural Conference called by President Harding at
Washington. Its committee on farm population reported:
"The safeguarding of the health of the people in the open
country is a first consideration. Any program that looks
toward the proper safeguarding of health must include
adequate available facilities for the people in the open
country in the way of hospitals, clinics, laboratories,
dispensaries, nurses, physicians, and health officers. This
committee endorses the growing tendency through public
agencies to maintain the health of the people by means of
these facilities and agencies."
The life of rural people in America is no longer threatened by the
invasion of human foes, but it is constantly threatened by disease. It
would seem that the first public concern would be for the maintenance of
the health--the very life--of its people, but as yet we have given much
less thought to health than to education. The New York State Department
of Health has as its slogan: "Public health is purchasable. Within
natural limitations any community can determine its own death rate."
This is no longer theory, but can be demonstrated by official mortality
statistics. The death rate has declined more rapidly in cities than in
rural communities because the cities have given more adequate support to
public health organization. The rural community has all the natural
advantages in its favor and will ever have the most healthful
environment, but it must recognize that if preventable disease--with all
its attendant evils to the family and to the individual--is to be
reduced, this can be accomplished only through education and public
health agencies. Better health is a matter of the hygiene of the home
and the individual, but it has also become a concern of the common
life--a community problem.
FOOTNOTES:
[54] "A Study of Sickness in Dutchess County, New York." State Charities
Aid Association, New York City.
[55] L. L. Lumsden, "Rural Sanitation," U. S. Public Health Service.
Public Health Bulletin No. 94, Oct., 1918.
[56] See Dr. W. S. Rankin, "Report of Committee on Rural Health,"
Proceedings Second National Country Life Conference, p. 93.
[57] "An Adventure in Rural Health Service." Proceedings Second National
Country Life Conference, p. 47.