Among the specific recommendations made by the commission and approved by the governor in his message to the legislature are:

Each city, county, village, and town should be given specific authority to employ one or more trained nurses to act as infant-welfare nurses, school nurses, tuberculosis nurses, and generally at the request of physicians or health officers, to visit the sick who are unable otherwise to secure adequate care and to instruct other members of the households in the care of the sick. The State Public Health Council should establish qualifications of eligibility and conditions of appointment for such public-health nurses. In larger communities, when several nurses are employed, some would doubtless be assigned to one or the other of these duties, but in smaller localities all of them may be performed by one trained nurse. The advent of trained nursing marks not only a new era in the treatment of the sick, but a new era in public-health administration. In the city of New York there are in the service of the department of health over 300 trained nurses in addition to those employed in hospitals for contagious diseases. Trained nurses are also employed by health authorities in some of the other cities of the State. Three counties and a considerable number of cities, villages, and voluntary committees employ tuberculosis nurses. An exceptionally interesting account was given to this commission of the work of district visiting nurses in the rural communities and villages of northern Westchester County. These nurses are in the employ of a benevolent corporation and are supported by private contributions, but in our judgment such nurses might equally well be employed elsewhere by local authorities. We strongly urge, therefore, that specific authority be given to each city, county, village, and town to employ one or more trained nurses for all the publichealth purposes for which trained nursing has now been found to be practicable.

LACK OF ADEQUATE FUNDS FOR CARRYING ON WORK.

The principal impediment to efficient work in the health department of most cities is the lack of adequate funds either to pay a suitable salary to the health officer or to provide means for carrying on preventive measures intelligently. The New York commission recommended minimum salaries to health officers of towns and villages, equivalent to at least 15 cents per inhabitant of the village or town. This in addition to expense of carrying on the work.

As a general rule the most effective health service is not accomplished when the annual resources of the department, including salary of health officer, falls much below $1 per capita of population. In cities of over 100,000, or when a great deal of work is done and the expense met by benevolent societies working in cooperation with the health department, this per capita is sometimes reduced without crippling the efficiency of the office.

That it is worth while to make some effort to arouse such an interest in saving infant lives as shall force appropriations in some degree commensurate with the work to be done is made evident by the following illustrations of the situation in two States, New York and Illinois States in which certainly the poverty of the taxing bodies can not be pleaded in excuse for parsimony.

Dr. George Thomas Palmer, of Springfield, Ill., has collected reports from Illinois cities which show that in 44 cities and towns in Illinois having a population of 3,000 or over, and averaging about 16,500 for all, the average salary paid to health officers is $300. Twelve cities, including one with a population of 30,000, another of 22,000, and one of 21,500, pay nothing. Twenty-one of the 44 cities and towns make no appropriation for expense beyond that covering the nominal salary of the health officer, if any.

His report is contained in a paper written by him, entitled "The Shortcomings of Municipal Public Health Administration," published in the American City for August, 1911. Some of the strongest paragraphs of the report are as follows:

or over.

I have ascertained the facts in 44 Illinois cities of 3,000 population * Of the 44 Illinois cities, we find that 6 have medical commissioners personally responsible for the work of their departments, and 15 have boards of health with medical officers. That is, 21 of the 44 cities have forms of health organization which may reasonably be presumed to afford efficient service. Of the others, 4 have headless boards of physicians in which no one is especially responsible; 1 has a board of physicians with layman health officer; 7 have boards of physicians and laymen with no health officer; 1 has a mixed board with layman health officer; 6 have boards of laymen with no medical guidance; and 3 intrust their health affairs to lay health officers without boards of any kind. One city of 26,000 employs merely a layman health officer, while a city of 22,000 has a board of laymen, the police matron acting as health officer when she is not otherwise engaged. While 15 of these cities cxceed 20,000 in population and 3 are over 50,000, not one pays sufficient salary to warrant a competent man in devoting all of his time to the health department. One city of 59,000 pays $1,500 per year, the highest salary paid to any municipal health officer in Illinois outside Chicago; a city of 70,000 pays $1,200, and one of 51,000 pays $1,000. Three of the 44 cities pay $900 per annum, 1 pays $800 per annum, 5 pay $600, 2 pay $400, 2 pay $300, 7 pay $200, 1 pays $150, 1 pays $100, 1 pays $75, 4 pay $50, 2 pay $25, and 12 pay nothing at all for publichealth supervision. The average population of the 44 cities is about 16,500; the average salary paid to health officers is $300. The 12 cities paying nothing, including one of 30,000, one of 22,000, and one of 21,500, should expect nothing in the way of protection of the lives and health of their people. A city of 30,000 which pays $400 per year for its health officer could not expect to receive the services of a competent man for more than one-sixth of his time, while a city of 25,000 paying $200 per year could not ask a well-qualified officer to devote a full hour a day to its public-health affairs. I make this estimate on the assumption that a competent health officer could be secured to devote all his time to the office for $2,400 per year, and it was this assumption I had in mind when I stated that, in my opinion, every growing city of 20,000 or over should employ a competent man constantly in its protective and constructive publichealth work.

* It may be noted that 36 of the 44 Illinois cities pay less than unskilled workman's wages to their health officers. Applying our third standard of preparedness and efficiency-specific appropriation for public-health purposes-we find that 21 of the 44 Illinois cities have no appropriation, or only that for the payment of the nominal salaries of board members and health

officer. In some of the appropriations given the cost of garbage disposal is included, making the showing, so far as public-health purposes are concerned, far too high. We note, however, that two cities of over 20,000 propose to give adequate public-health protection at a cost of $300 per year, while one city has no appropriation.

* Of the 44 cities, 29 employ no inspectors; among these one of over 20,000 pays nothing for its health officer, and another of 10,000 pays its health officer $25 per annum.

The New York situation is described by the Special Health Commission thus:1

There is the widest diversity as to the compensation of town and village health officers, except that in nearly every case it is inadequate and in many cases ridiculous. In some cases there is a salary, in other cases fees, in some cases both, and in a few cases no compensation at all. The average annual compensation including fees and salaries of health officers of the 771 towns and villages represented by the 652 health officers replying to our letter of inquiry (652 of a total of 1,032) was $60.84. The amounts received range from $3 to $1,400. Their average annual compensation (some serving more than one town or village) is $71.96.

There is no reason to believe that New York and Illinois are different from other States in this regard. A letter from the clerk of the board of health in a city of 687,029 population to this Bureau, dated February 20, 1913, says: "I have to advise that the health department has no funds available for organizing a division for the care of infants." Another health officer of a city of over 168,000, replying to the Bureau's letter asking what plans were being considered for a summer campaign against infant mortality, said: "We have been unable to get an appropriation from the city council for carrying on a campaign of this kind."

When the truth of the motto of the New York City Health Department—“ Public health is purchasable; within natural limitations a community can determine its own death rate "-is generally recognized, it is certain that civic appropriations will become adequate. COOPERATION OF HEALTH BOARDS WITH PRIVATE BENEVOLENT AGENCIES.

In view of this wide-spread, if not general, lack of appropriation to enable health boards to deal with the situation, direct cooperation with private benevolent societies has suggested itself and has been acted upon with excellent results in many places. Dr. Selskar M. Gunn, when health officer of Orange, N. J., said:

The campaigns against infant mortality in the past have been conducted for the most part in large cities, and this is quite natural, as in the large city the necessity for work in this direction is more evident than in the smaller community, but I venture to state that in some of our smaller cities the condi

1 Gov. Sulzer's Message on Public Health, with Report of Special Public Health Com. mission, transmitted to the legislature Feb. 19, 1913.

tions are almost as serious as in the larger places. The methods of approaching and attacking these problems are varied and many. One of the first things to be done is for the board of health to establish, if it has neglected to do so, good relationships with the various civic organizations that are present in the community. I refer particularly to the bureau of associated charities, day nurseries, diet kitchens, visiting nursing settlements, and organizations of similar character that are working for the good of the community. This is very essential in small cities where the board of health does not receive adequate financial support from the city fathers, a condition usually to be met. These societies can be of very material help in supplying the necessary weapons for the attack. Such cooperation will be found particularly useful in all branches of public-health work. * Many of these organizations are not doing the effective work they are capable of because they are not in a position to discover the cases which they really should be assisting. They have oftentimes to take the cases as they come, irrespective of the real need, and so many who most need help are never reached. All of this emphasizes the important fact that in small cities the health department should cooperate in every way possible with all the private social agencies that are at work in the city. These agencies are not infrequently doing work which probably should be done by the health department, but which, through the parsimony or false economy of the city fathers, can not be undertaken at the present time. * Milk depots are examples of this.'

When, as is sometimes the case, no private agencies exist with which to cooperate, the health officer often resorts to agitation to bring them into existence. This is done by using the local press to call attention to the infant mortality of the place, emphasizing the number of preventable deaths each week from causes so largely social in their nature that the individual parents can not be considered wholly to blame. In thus showing the need of private philanthropies, directed toward the causes of preventable infant mortality, the health officer has recourse to his wall charts. In Utica, N. Y., a fusillade of newspaper paragraphs calling attention to the fact that the infant death rate of that city exceeded that of any other city of its size in the State except two, one of which was exceptional because of its hospital population, finally brought into existence the Utica Babies' Pure Milk and Health Station Association, which most effectively entered the campaign against preventable infant mortality in 1912.

The health officer can, more effectively than anyone else, call public attention to the fact that: "The reduction of infant mortality is a public-health problem. The basis of responsibility lies with the public which must voice its decision through its mouthpiece, the government." In the event of local government neglecting or refusing, private philanthropies must step in.

2

When cooperation is offered with a view to directing and thus minimizing wasted effort, it is usually accepted in good spirit. The

1 Dr. Selskar M. Gunn, Modern Methods of Health Boards in Small Cities, Journal of American Public Health Association, May, 1911.

2 "The Principles of the Reduction of Infant Mortality," by Josephine Bakei, M. D., New York Medical Journal of Nov. 25, 1911.

excellent work being done in Atlanta, Ga., with the exception of milk inspection, is private work with municipal cooperation; this is also true in Baltimore, Md.; Columbus, Ohio; Erie, Pa.; Indianapolis, Ind.; Jacksonville, Fla.; Newark, N. J.; Washington, D. C.; and many other cities. Probably the most conspicuous examples of successful cooperation are those of the New York City Health Department with the New York Milk Committee and Cleveland, Ohio, with the Babies' Dispensary and Hospital. In the report of the latter institution for the year ending September 13, 1912, Dr. H. J. Gerstenberger writes:

The success in the reduction of infant mortality in any community depends principally upon the following factors: First, the full recognition of the various causes of infant mortality and their relative importance; second, the knowledge of the means to remedy these causes and, better still, to prevent them, and the application of these means; third, the education of the future parents, physicians, and nurses; and fourth, the degree of unity in plans for action existing among the various private philanthropies and departments of the municipality and State that are more or less directly interested in this subject.

The outcome of successful private work through the cooperation of city health officers is usually to cause the city councils to appropriate sufficient funds to allow the municipality to take over this work, gradually sometimes, but eventually completely. This has been the experience, for instance, in Bridgeport, Conn., where a private visiting nurses' association established a milk station, demonstrating its value to the city, which established two in 1912, providing a nurse in connection with them. The Milwaukee division of child welfare in the Municipal Health Department is an outgrowth of a child-welfare campaign conducted by a commission. This extension of municipal control of preventive work through cooperation with private associations is being experienced in Reading, Pa; Holyoke, Mass.; Indianapolis, Ind.; Philadelphia, Pa.; Boston, Mass.; Richmond, Va.; Jacksonville, Fla.; and many other places. The health officer of Jacksonville, Fla., writes:

We have organized an Infant Welfare Association and are at the present time preparing to employ a nurse who shall devote her whole time to that work. She will be under the direction of the welfare association and in constant touch with this department, from which she will probably receive the largest portion of her calls.

COMPLETE AND PROMPT BIRTH REGISTRATION AS A BASIS FOR EFFECTIVE WORK.

The plan adopted in some cities toward a summer campaign is to arrange for a complete and quick registration of births; to get the baby under observation as quickly as possible.1 Even where State