Home Occupations of Consumptives—Sewing and Sweatshop Work—Food—Milk
and Cream—Lunch Rooms and Eating-Houses—Laundry Work—Boarding- and
Lodging-Houses—Miscellaneous Occupations—Summary—The Consumptive
Outside the Home—Cooks—Personal Contact in the Factory—Supervision
Outside the Home.
=Home Occupations of Consumptives.= Up to this point we have considered
the patient solely in relation to his own family, or to those with whom
he comes in immediate, constant contact. The people surrounding him are
in their turn infected, transmitting the disease to others who in like
manner are intimately exposed. Roughly speaking, all of this infection
takes place within the four walls of the home. The home, therefore, is
the centre of infection,—the focus from which tuberculosis radiates into
the community. The further one is removed from this focus, the less the
danger.
There are certain ways, however, in which danger from the home threatens
people who live outside, people in no wise connected with the patient,
and unaware of his existence. This occurs when the patient leaves his
home to seek employment in the community, or when he makes or handles
certain articles which go forth into the community as carriers of
bacilli. Infections of this sort may be termed accidental. They are
infrequent as compared to house infections, but infrequent as they are,
they should be prevented.
In Baltimore, nearly fifty per cent. of the patients under supervision
are able to work. They seek a livelihood in office, factory, shop,
hotel, and private home. We also find that nineteen per cent. of the
families under supervision carry on some sort of gainful occupation
within the confines of their own homes. As a rule, the patients who
conduct these little home industries or occupations are more advanced
cases than those able to find employment in shops and factories. In some
instances, this home industry was carried on before the patient became
ill; in others, by far the greater number, it is the direct result of an
illness which has modified his earning power and compelled him to eke
out a scanty income by this means. In many cases the actual work is not
done by the patient himself but by some other member of the household.
Sometimes these industries are not dangerous to other people, or the
risk is so slight as to be negligible. At other times, the menace is
grave. Each case must be considered upon its individual merits—one must
not generalize and condemn in wholesale fashion.
=Sewing and Sweatshop Work.= A number of our patients are dressmakers,
or do factory sewing at home. Much has been written about the danger of
clothing made under such conditions, either by the patient himself or by
other members of his family. This output is not as dangerous as many
people suppose, although such an admission would deprive the campaign of
much picturesque photography. Much of this clothing is of washable
material, such as cotton shirts, blouses, overalls, and the like,
therefore any germs they might carry would be removed in the first
washing. The danger has also been exaggerated in the case of woollen
materials, such as coats, trousers, etc. Any organisms contained in
these articles would soon die, or their virulence become so attenuated
that little harm would result. This also applies to artificial flowers.
It is not the occasional dose of bacilli, conveyed in this or any other
manner, but the large and repeated implantations which do the damage.
Infected clothing doubtless plays considerable part in the spread of the
acute contagious diseases, such as measles, diphtheria, and scarlet
fever, but in tuberculosis the risk is so slight that it may almost be
called non-existent. Under such conditions, the danger is not to the
wearers, or probable buyers, but to workers who make this clothing while
in contact with the consumptive himself.
=Food.= There are other home occupations about whose danger to the
public there can be little doubt. Many patients keep small grocery
stores, confectionery shops, and lunch rooms, and prepare and handle
foodstuffs of all kinds. Again we must discriminate. The consumptive who
sells tinned foods (which he does not handle), or meat, fish, or
vegetables which are cooked before they are eaten, is not necessarily
spreading disease among his customers. On the other hand, he who sells
and handles milk, cream, ice-cream, bread, cake, candy, and so forth, is
a decided danger to all who buy his wares. The alimentary tract is one
of the main portals of entry for the tubercle bacilli, and every
precaution must be taken to prevent the contamination of food. The
patrons of these little shops are the people of the neighbourhood, who
are regular customers, and their health is endangered not by occasional
but by repeated doses of germ-laden food.
=Milk and Cream.= There is an ordinance in Baltimore forbidding the sale
of milk and cream in a house where there is an infectious disease; this
includes tuberculosis. In order to sell milk, it is first necessary to
obtain a permit from the Health Department, but this permit may be
revoked whenever occasion demands. If the nurse finds that one of her
patients is selling milk (as is often done in connection with a small
grocery business), she reports this fact to the Health Department. It
may be that the patient himself never comes near the shop, and is out at
work or away all day. This sometimes happens, but not often. Usually he
waits upon the customers himself, selling milk in penny amounts, with a
dirty finger inside the measuring cup. Or he may be too ill to attend
the shop, but sits or lies in an adjoining room, so that his wife may
wait upon him and upon the customers alternately. Under such conditions,
the danger may be almost as great as if he himself handled the milk,
since she does not take time for proper cleanliness.
To revoke a permit usually occasions considerable hardship, and the
reduction of an already pitiful income. Yet summary measures must be
taken unless the milk is sold without risk to the purchasers. The
patient should be removed to a hospital, and the family must choose
between letting him go and giving up the permit. When there are no
hospital facilities and the permit must be withdrawn, leaving the family
under financial stress, the nurse should ask assistance of the Federated
Charities. This assistance, however, should never be offered as an
alternative to removing the patient to a hospital.
There are other foods besides milk and cream liable to contamination,
the sale of which is not controlled in any way. Thus as we have seen,
while a consumptive may be prohibited from selling milk, he may sell
ice-cream without let or hindrance. And furthermore, an ice-cream cone
or “snow-ball,” handled by dirty, germ-laden fingers, is most often sold
to the most susceptible of all customers—the child.
=Lunch Rooms and Eating-Houses.= Many patients earn their living by
keeping eating-houses, oyster-parlours, ice-cream saloons, and so forth.
There is danger to the customer whenever the cooking and serving of food
are done by a consumptive, or by those in contact with a consumptive. A
community to be well protected should enact comprehensive legislation
controlling every aspect of the food supply, and special emphasis should
be laid upon the handling of food by those with a transmissible disease.
=Laundry Work.= Another home occupation is laundry work—unskilled labour
requiring no capital and largely resorted to, especially among negroes.
This is heavy work, hence not always done by the patient, but often by
some other member of the household. Whether the patient irons the clean
clothes or sits coughing in the same room where this is done (we have
often seen newly ironed clothes spread upon the bed of a last-stage
case), the result is much the same. Under such circumstances clothes
become contaminated. Since this sort of laundry work is usually done for
regular customers, they week after week wear clothing that has come from
an infected house. It is dangerous to sleep constantly on pillow cases
that have been coughed on by a consumptive, and to use towels and
napkins that have been subjected to a like infection.
Since there are no laws to govern conditions of this sort, the question
arises, what is the nurse to do in such a case? Must she look on and say
nothing, or must she warn those for whom this laundry work is being
done? It would be futile to argue with the patient’s family—they would
refuse to recognize the danger to others, seeing instead the financial
loss from giving up the work. The nurse must first try to remove the
patient to a hospital, thus doing away entirely with the danger. Failing
in this (through lack of hospital facilities), the family may be willing
to give up the work on condition that an income be substituted by some
charitable agency. Simple as the latter course may seem, so many
obstacles to procuring this aid will arise, that it offers no practical
solution of the matter. If the home surroundings cannot be altered and
the danger reduced, then the patrons or customers should be told of the
conditions under which their laundry work is done. It is not always
possible, however, to locate these customers, since the patient is very
wary of giving information upon this subject. Whenever possible,
nevertheless, they should be told; if they prefer to continue the risk,
they are at least not in ignorance of it.
It is deeply regrettable that exposure to infection by tuberculosis is
still an optional matter, and that the necessary curtailment of
individual liberty has not yet been made in regard to all opportunities
for it. In the case of impure milk, for instance, the law at least makes
an effort to curb the preference which any individual may entertain for
it.
=Boarding and Lodging Houses.= There are other home occupations in which
the menace is of a personal nature, and does not come through
contaminated articles. Many patients take in boarders—an occupation
which frequently entails considerable overcrowding of the home. This
brings healthy individuals directly within the danger zone, and subjects
them to the same risks incurred by the family itself. Other patients
take in lodgers; here the risk is less, because meals are not included.
In either case, there is great personal exposure, with equally great
opportunities of infection.
=Summary.= To sum up: Among 3107 patients under supervision, we find
608, or 19 per cent., carrying on some sort of gainful industry within
the confines of their own homes. The resultant danger is of two kinds:
from personal contact with the patient, and the remoter possibility of
infection through articles which he makes or handles. The most serious
risk is that incurred in boarding- and lodging-houses, where the inmates
are subjected to a high degree of personal exposure. In other
occupations there may be some personal risk, but it is slight and
transitory, and therefore insignificant. In considering contaminated
articles, we find there also two classes: those dangerous to a high
degree, and those but slightly so, if indeed they may be called
dangerous at all. Among the former, the most harmful are the
contaminated foodstuffs, in which the risk is almost as great as through
personal contact. Next comes laundry work, where the risk is in the
repetition of infection, as in the use of household linen. Then comes
the output of clothing, cotton and woollen, where also the risk is
slight. In the case of other articles handled by the consumptive the
risk involved is so insignificant as not to be worth mentioning.
The following table shows the nature of these various Home Occupations,
ranged in order of their risk to the community:
Personal: Boarders 104
Lodgers 18 122
———
Food: Bakeries 4
Confectioneries 4
Cook shops 6
Groceries 73
Oyster-parlours 1
Saloons 13 101
———
Clothing: Laundry work 222
Sewing 109
Millinery 1
Tailor shop 4 114
———
Miscellaneous: Barbers 8
Basket-maker 1
Cigar store 2
Cleaning and Dyeing 1
Drygoods 10
Second-hand shop 1
Shoemaker 21
Umbrella-mender 1
Wall-paper shop 1 46
———
Total, 605
=The Consumptive Outside the Home.= We must now consider the patient who
is employed outside the home. As we have said before, nearly fifty per
cent. of our patients are able to work. The danger to the public is of
two kinds, that arising through personal contact, and through certain
articles which the consumptive may make or handle. In the latter case,
just as we find it among the home occupations, the risk to the community
depends upon the articles themselves. Whatever affects food, is far more
dangerous than the contamination of articles not taken into the
alimentary tract.
To prevent the possibility of food infection, we should enact and
enforce laws forbidding the employment of consumptives in any factory,
shop, or establishment of any kind in which food is either prepared or
sold. This would include candy factories, bakeries, cake, biscuit, and
cracker factories, canning and preserving establishments, as well as
dairies, restaurants, lunch rooms, sodawater stands, candy shops, and
the like. We must never forget that the home is the chief centre of
danger, the place responsible for the vast majority of infections, and
that every infection which occurs outside the home is accidental, so to
speak. Yet accidental infections, while relatively few in number, are
still plentiful enough to make it necessary to safeguard the community
in every way. An effective tuberculosis campaign demands the stoppage of
all leaks.
For example: on our visiting list was a girl employed in a biscuit
factory, packing cakes. She was an advanced case, and every now and then
had a hemorrhage which compelled her to stop work, though sometimes only
for a few hours. Between hemorrhages, she worked steadily. The cakes
packed under these conditions doubtless carried a full quota of germs.
We tried to induce her to go to a hospital, but she declined. The
manager was appealed to but he wanted to keep her—she was a quick
worker; besides, he did not have to eat the cakes—so he refused to add
his influence to ours to get the patient to an institution. The public
should be protected by law from the possibility of such infection.
The saving phase of the situation is this: while the patient who keeps a
bakeshop and sells his wares day after day to practically the same
customers, fulfils the condition that repeated implantations are
necessary to contract the disease; on the other hand, the cakes
distributed by a factory cover a wider range of territory—thus, while
many more people get doses of germs, the doses themselves are probably
too small to be harmful. This also may be said for other kinds of
foodstuffs, handled in factories by tuberculous persons; these articles
are distributed so widely that no individual consumer is really
endangered. In this way, the risk is minimized. But still we must
remember that every factory in the country has its tuberculous
employees, with their output of bacilli to be reckoned with. The
consumer is thus threatened on every side. No wise community should
tolerate such chances of infection.
=Cooks.= There is considerably more danger from the tuberculous cook
employed in a private family. Under such conditions the household is
steadily infected day by day, not through personal contact, but by
small, repeated doses of bacilli received into the alimentary tract.
If typhoid fever permitted a patient to work—if it were a chronic
instead of an acute disease—we should consider it a highly dangerous
expedient to permit such a patient to handle food in any way, and we
should be exceedingly wary of restaurants which employed typhoids as
cooks or waiters. This argument applies with equal force to
tuberculosis. In typhoid, there is but one portal of entry—the digestive
tract. In tuberculosis there are two—the respiratory as well as the
alimentary—and they are equally important.
=Personal Contact in the Factory.= While the patient in the factory is a
menace, he is less dangerous than the patient in his home. A man well
enough to work is seldom in the most advanced and infectious stages of
tuberculosis. Moreover, his fellow-workers, unlike the members of his
household, are not in constant but rather in casual and intermittent
contact with him. These two conditions tend to diminish the risk to his
associates; still, it always exists. The consumptive does not seek
employment from a malicious desire to spread tuberculosis—he seeks it
because of economic conditions compelling him to work until he falls in
harness. We must recognize this driving necessity, but at the same time
we must protect the workers who perforce surround him. They too are
impelled by the same need, and their rights equal his.
When a patient is visited at home, he and his family are often
stimulated to a high degree of carefulness. The patient uses a sputum
cup for his own convenience, and the family insist upon this for their
own interest and safety. The result is a lessening of danger, and an
improvement upon a neglected and uninstructed case. In the factory,
these conditions are reversed. His cup is no longer a convenience, and
he dreads being conspicuous through its use. Moreover, since his illness
is unknown to his fellow-workers, there is no one to insist upon
precautions of any kind. The result is that we maintain in the factory
conditions which we seek to abolish in the home. We give one set of
people information whereby to protect themselves, and we withhold this
information from another group of people who need it almost as much,
which is illogical and stupid and costly. Enormous sacrifices have been
made to this policy of silence, and it is time for these sacrifices to
cease.
Those in contact with a consumptive, whether this contact takes place in
the home or in the factory, are entitled to know the nature of his
disease. It is not the degree of consanguinity, but the degree of
contact which should determine this knowledge. We cannot trust the
patient to protect others—it is a trust too often violated. We must
surround him in the shop with a public opinion even more potent than
that which he finds at home. His fellow-workers will be less tolerant of
breaches of technique, will make less excuse for whims and temper, than
does the tired family. We knew of one patient who insisted on spitting
on the floor—at home; when his wife remonstrated, he knocked her down.
In the shop, such conduct would cost him his place, and rightly.
=Supervision Outside the Home.= Whenever the infectious case is at large
in the community, his whereabouts should be known to those most exposed
to the danger. This applies alike to employer and employee. The head of
the department in which the consumptive is at work should see that those
in contact with him know of his condition. The patient should be
compelled to use his sputum cup when he expectorates. Knowledge of the
patient’s condition does not necessarily mean that he should be
dismissed—it should merely mean that he will be held up to the required
standard of carefulness. For example: the Baltimore Health Department
received a letter from a certain firm in the city, stating that many
cases of tuberculosis had developed among the employees on a certain
floor in their factory—and on this one floor alone. This led them to
suspect that a consumptive might be among these workers, distributing
the disease. A list of all the employees was submitted. Investigation
promptly showed that on this particular floor was a chronic case of
tuberculosis of long standing, a man who had been under supervision at
home for several years. In his home, this patient was exceedingly clean
and punctilious in the use of the sputum cup; at his work, however, he
was absolutely the reverse. On receipt of this information, the employer
had a sound talk with this man, which resulted in the use of the sputum
cup and all other precautions. The patient did not lose his place, but
he was no longer permitted to jeopardize the health of his
fellow-workers.
Patients with chronic tuberculosis are also found in domestic service,
and go in and out of private homes, carrying infection with them. This
danger is especially great in the South, where there is a large negro
population, and we constantly find consumptives employed as cooks,
housemaids, nursemaids, and butlers, as the case may be. For the most
part, the employers are entirely ignorant as to their condition. In
these cases, just as in the factory, office, department store, and so
forth, the employer should be notified of the presence of tuberculosis.
To give this information should be the duty of the Health Department.
The municipal nurses are aware of the facts, and they also know when a
patient changes his occupation, or place of employment. But to give this
information without following it up, would not be enough. To notify an
employer of the presence of a tuberculous worker, would not necessarily
mean that any action resulted. A poor workman might be summarily
dismissed, and a good one retained, without those in his vicinity being
enlightened as to the nature of his disease. To make this information of
value, it would be necessary to supervise the patient in the factory,
just as he is supervised in the home. This double supervision would
demand a greatly increased staff of nurses, since factory visiting
should not be done through curtailment of the nurse’s other duties. We
must once more emphasize the fact that the home is the fountainhead of
tuberculosis, and that every infection which occurs outside the home
circle (or its equivalent) is practically an accidental infection. But,
as we have already said, a comprehensive plan for checking tuberculosis
must include the stoppage of all leaks, and the unknown, unsupervised
consumptive, at large in the community, is a leak which should be
recognized by common-sense.
Yet certain conditions must be complied with before we can extend this
municipal supervision. Outside-the-home supervision will create an
enormous amount of phthisiphobia. Consumptives are now tolerated because
their presence is either unknown or but dimly guessed at; when this
ignorance is dispelled—as it must be if the nurse visits them at their
places of employment, and their presence and numbers are made known, a
great wave of fear will spread over the community. Such a result is
inevitable when for the first time the public realizes, suddenly and
concretely, the extent to which it is threatened. Tuberculous workers
will be discharged by hundreds, and there will be widespread suffering
in consequence.
On the other hand, however, thousands of non-tuberculous workers will be
relieved of a great danger. Our factories already produce workers so
worn out and devitalized as to fall ready victims to any disease that
presents itself. Would not these same factories be somewhat less
dangerous if swept clear of consumptive employees?[9]
Footnote 9:
However bad certain factory conditions may be, these of themselves
cannot produce tuberculosis any more than they can produce scarlet
fever or diphtheria. The disease itself must be brought into the
factory by a carrier—someone who is himself infected.
Outside-the-home supervision is the next logical step in the
anti-tuberculosis campaign. But valuable as this would be, from the
point of view of the general health, it cannot be done until the
community is prepared to care for all who would undoubtedly suffer as a
result. Some patients, of course, would not lose their situations, but
the majority would be turned adrift without a moment’s hesitation. These
the community must take charge of. Therefore, before we can supervise
tuberculosis beyond the boundaries of the home, we must have ample
hospital facilities. Hospital accommodation must be so extensive, so
complete, and so excellent that institutional care can be given to all
who need it.
In this way, the community will be relieved automatically of a vast
amount of danger. Patients will either seek institutional care, or, if
they continue at work, will do so under conditions which do not
jeopardize other people. For the reaction from the first intense
phthisiphobia will be a demand for carefulness on the part of the
consumptive, and sane toleration of him.
The one objection to this policy of supervision and publicity is the
seeming interference with the personal liberty of the individual, but to
curtail the liberty of the patient to transmit a communicable disease,
is to increase the liberty of hundreds to escape it. There should be no
question as to which has the superior claim.