2,500,000 children who, it is estimated, are born in this country yearly, and to take note of the varying social and economic conditions under which some 300,000 of them die and the others survive. As this is manifestly impossible, the nearest approach is to consider certain communities typical of the whole, and it is believed that in the course of a few years' study such data can be presented as will give the United States a fairly adequate measure of the conditions under which American-born infants survive or perish, and of the possibilities of modifying those conditions by local action.

Brilliant work for infant welfare has been done in many localities, notably by the public-health authorities and volunteer organizations of the larger cities, and incidental thereto much information regarding infant mortality has been gathered; but in the greater part of the country, especially in the smaller cities and rural communities, it is as yet hardly recognized that the problems which confront the crowded quarters of the great cities may also exist in less congested

areas.

In accordance with the plans for a general inquiry into infant mortality, Mr. Ethelbert Stewart, the first statistical expert of the Children's Bureau, directed the preparation of the schedule and the field work at Johnstown.

This study considers all the babies born in Johnstown within a single calendar year. Since the work was begun in January, 1913, it was necessary to select the year 1911 as the latest in which all babies born could have attained a full year of life.

Mr. Stewart preceded the agents by a visit to Johnstown in which he explained the purposes of the inquiry, and the courtesy with which the agents were received by the general public-the press, the clergy, civic and volunteer organizations, and especially by the mothers themselves-was a valuable factor in making the inquiry successful.

Above all, the bureau wishes to express its obligation to the mothers of Johnstown, without whose generous understanding and help the inquiry could not have been conducted. Their good will is evidenced by the fact that, out of 1,553 mothers visited, only two refused information. The readiness with which the information was given undoubtedly depended upon the appeal to the mothers to cooperate with the Government in the effort to learn how to save babies' lives and to the fact that the agents could show that the information given was not to be used in any personal way.

The schedules were taken by Miss Emma Duke, Miss Sophia Vogt, and Miss Emily Miladofsky, special agents of the bureau, while the preliminary work of transferring to the schedules the information contained on the State records of birth was done by Mr. A. V. Par

sons, special agent of the bureau, who also took the photographs reproduced.

Just as the work of filling out the schedules was being completed in Johnstown, Mr. Stewart was transferred to the Bureau of Labor Statistics, and his loss, together with other bureau exigencies, delayed the completion of the report. Miss Emma Duke has written the text and she has had the assistance of Miss Sophia Vogt and Miss Ella A. Merritt in making the tabulations. Mr. Lewis Meriam, Assistant Chief of the Children's Bureau, was interested in the inquiry from the start, and on Mr. Stewart's transfer was placed in charge of the statistics. The bureau wishes to acknowledge its indebtedness to all those who have aided in the preparation of this study by preliminary advice and by criticism of the schedule or manuscript.

The method of the inquiry is in one respect unique, so far as we are aware. Instead of taking as its point of departure the death records of children who have not survived their first year, the birth records are first secured for all children born within a certain calendar year, and each child is then traced through the first 12 months of life, or as much of that period as he survives, in order to obtain information as to the conditions which surround all the children of the town born during the given year. It is evident that this inquiry can be carried on effectively only in communities which have birth registration, and its extension to include typical units throughout the country must depend largely upon the further extension of birth registration. The law creating the bureau provided for no medical officer upon the staff, and the inquiry was necessarily restricted to a consideration of family, social, industrial, and civic factors. The original material of the schedule was secured through personal interviews between individual mothers and the women agents. As the text shows, certain facts regarding the civic surroundings of the families were secured in addition to the interviews, but the chief value of the inquiry lies in the information afforded by the mothers. It is plain, however, that a study thus limited must omit certain important considerations. It is not fair nor practicable to enter a home and ask questions regarding conditions which, if they exist, are considered personally humiliating. Hence it was necessary to omit questions bearing on matters of personal character or behavior, and therefore to omit all consideration of two recognized factors in infant mortality-alcoholism and venereal disease. It is anticipated that the bureau will be in a position later to consider these and other factors, notably those connected with the employment of mothers and with industrial diseases, by methods independent of family inquiry.

The emphasis of the inquiry, as shown throughout the text, was upon certain of the more obvious economic, social, and civic factors which have surrounded the lives of the children of Johnstown born

within the given year. Civic action can remedy defective sewerage and scavenger systems and dirty unpaved streets which are instrumental in creating conditions that endanger the lives of infants. The extension of city water to all houses; improved methods for sewage disposal, garbage collections, and general scavenging; the paving of streets and inhabited alleys; the widening of alleys; the improved grading of streets and alleys; the relief of house and lot congestion; the abolition of wells and yard privies; sewer connection for all houses; the abatement of the smoke nuisance-all of these are needed improvements for the infant health and the general health of Johnstown.

But the public's responsibility does not end merely in remedying such conditions as those just noted. There is a growing tendency on the part of municipalities to accept responsibility for furnishing information and instruction to its citizens. Some cities have reduced their infant mortality rate by having expectant mothers instructed in prenatal care; others by sending instructive visiting nurses, immediately after the birth of a child, into homes that need them. Other means which have been found effective in reducing excessive infant mortality rates are baby welfare stations, consultation stations for expectant and nursing mothers, and the distribution of sound literature on prenatal care, the care and feeding of infants, the care of milk, and other hygienic matters.

The importance of a pure milk supply in reducing infant mortality has been repeatedly demonstrated. The direct effects of impure milk on the health of Johnstown babies could not be ascertained in this investigation, but the careless handling of milk was obvious, and at the request of the Johnstown Board of Health and the local health officer the Children's Bureau secured the cooperation of the Bureau of Animal Industry of the Department of Agriculture in making a comprehensive investigation of the milk supply in Johnstown. The findings of the experts, L. B. Cook, C. E. Clement, and B. J. Davis, printed in full on pages 89 to 93 of this report (Appendix III), justify the citizens' campaign for clean milk now under way in Johnstown.

In many directions public spirit is active in Johnstown. The city is awakening to its needs and to its responsibilities as well. It supports a strong civic club and other associations which are studying ways and means to proceed. Its newspapers are virile and progressive and plans are being made to remedy insanitary conditions. Through private effort a visiting nurse has been secured to instruct mothers in the care of their homes and their children.

The Johnstown report shows a coincidence of underpaid fathers, overworked and ignorant mothers, and those hazards to the life of the offspring which individual parents can not avoid or control

because they must be remedied by community action. All this points toward the imperative need of ascertaining a standard of life for the American family, a standard which must rest upon such betterment of conditions of work and pay as will permit parents to safeguard infants within the household. Toward the slow working out of the essentials of such a standard it is hoped that the bureau's continued studies into infant mortality may contribute.

While the bureau has not yet determined upon all the units of the inquiry, it is the purpose at present to study localities outside those great urban areas whose spectacular needs have secured costly and effective work by municipal and volunteer organizations. Such work should be equally valuable and, on the whole, equally applicable in smaller towns and even in rural communities. That similar problems and needs exist also in our less congested areas is proved by the 1913 report of the New York State Health Commission, which has made plain the unfavorable health showing of the State as a whole as compared with that of the city of New York. This report and the studies upon which it is based have furnished the impetus for new legislation which extends throughout the State certain measures for improving the health of children which have already proved effective in the largest city of the State. In various parts of the world the history of intelligent efforts to surround babies with healthful conditions shows a progressively lessening infant mortality rate and leads to the belief that the problems of infant mortality can be solved.

Sir Arthur Newsholme, who has already been quoted above, says in the Forty-Second Annual Report of the Local Government Board (1912-13), "It is obvious that the complex problems involved (excessive infant and child mortality) can not be effectively stated in a single report, and that investigation is called for in nearly every center of excessive mortality."

It is therefore desired to pursue this inquiry in various typical communities throughout the country so that the facts may secure. popular attention. Clearly the law creating the Children's Bureau, framed by experts in child welfare, embodies the conviction that if the Government can "investigate and report" upon infant mortality, the conscience and power of local communities can be depended upon for necessary action.

Respectfully submitted.

Hon. WILLIAM B. WILSON,

JULIA C. LATHROP, Chief.

Secretary of Labor.