Public health methods of today are in great contrast with those of the past. Formerly practically nothing was done in dealing with a preventable disease until it became epidemic, and then an effort was made to suppress it. It is much easier to prevent than to suppress, and modern methods are directed to the former rather than to the latter. Undoubtedly the most important public health problem is that of preventing disease. There should not be epidemics.

Disease is easily controlled if found early. This has been thoroughly demonstrated in connection with various epidemics throughout this state during the past few years. To find early we must look for

(a) The healthy, immune carrier,

(b) The convalescent carrier,

(c) The mild, unrecognized case,

(d) The mild, concealed case,

(e) The sick person.

We try to control preventable diseases by quarantine and with our ordinary methods we reach those belonging to the last group: namely, the sick people. These are really the least dangerous of the five groups, for they are home during at least part of their infectious period, while the others are at large mingling freely with the people and exposing them to infection. The people generally object to quarantine unless the disease is severe in type. It is no uncommon thing at present, under the use of antitoxin as a therapeutic agent, to have the parties under quarantine objecting strenu ously to quarantine and severely criticise the physician who has made a diagnosis of diphtheria, even though he is supported by the laboratory findings, the argument being that individual was not sick enough to have diphtheria. Diphtheria will not be brought under control until the people as well as the physicians recognize the fact that the danger of infection does not rest with the severe cases alone. It is not uncommon when a small group of diphtheria cases appear in the school and cause general alarm, to find that there are a number of carriers of the disease in the school.

The old ideas of contagion must also be changed. The modern sanitarian knows that diseases are not air-borne to any great extent, and that disease is not spread from house to house, but from person to person. Further, the contact must be quite close indeed, as a rule, to spread infection from the individual. Individuals suffering from different types of infectious diseases may be cared for in the same room without cross infection, if the nurse is careful. This illustrates very forcibly the fact that disease is spread by the discharges or excretions from infectious patients to others, either directly or indirectly, rather than through any air transmission.

In dealing with infectious diseases, we have two groups to consider: (a) The primary cases (accidental).

(b) The secondary cases (inexcusable).

So long as infectious diseases are so general, primary cases are bound to crop out here and there, and we ask, "Where did they get their infection?" often without being able to give an answer. But we should always be able to answer the question as to where the secondary cases received their infection, for we should always be able to trace it back to the primary case. Some will say there should be no primary cases. That is true and there will be none when these infectious diseases are handled properly, but there certainly should be no secondary cases now.

The primary cases, if handled properly, should not spread infection to others. This, of course, means proper isolation of the infectious individual, and this means great expense in the home, or the establishment of proper hospitals for the isolation of the infectious. This latter need applies not only to cities but to the country and smaller municipalities. There is not a city in Minnesota that is properly equipped for the handling of infectious diseases. The idea of permitting a child to go to a hospital for treatment is often repugnant to the parents, and still it should not be so if it was properly presented. Our knowledge of the infection of wounds revolutionized hospitals so far as related to the practice of surgery. It is a well recognized fact at the present time that one who is to be operated upon can be much better operated upon at the hospital than in the home. The point is of preventing infection, in this instance, of a single individual: namely, the person to be operated upon. In the case of infectious disease, we should send the patient to the hospital, not to prevent his or her infection but to prevent the infection of many.

This is well illustrated in the case of one family, where a girl returned to her home ill with typhoid fever, and where the infection spread from her to others until finally there has been in all seven cases of typhoid fever in the family, extending over a period of five months. Had the first case been properly cared for, there would have been only one case instead of seven

cases.

Not only does illness from the infectious diseases cause trouble through its extending to others, but it is an important economic proposition, for we have to consider not only the actual cost of the illness but the economic loss, especially in the farming districts, from the prevented sale of dairy products and from the loss of labor, as well as the economic loss due to death or to reduced efficiency among those who have the disease because of a somewhat prolonged or even permanent impairment of health.

This is well illustrated by the case to which I have already referred, where there were so many typhoid fever patients in one family. The actual money loss in this instance was $1,485; but this was not all, for in this case there was one death; the mother was temporarily insane because of worry; and the health of the father, a young farmer, was permanently impaired, as he did not make a good recovery from the disease.

Another very good illustration of the cost to the individual is shown by a letter recently received in the office of the State Board of Health, which reads as follows:

"We have been sick with diphtheria this summer and were quarantined in the busiest time of the year. We were quarantined July 9th. My wife and oldest daughter had the disease, the girl being only eight years old. I have four younger children. I was left alone to take care of them all. I did not have any nurse or hired girl or even a hired man. I was obliged to take care of the sick and the children and the house and the chores and stay around the house and see my hay spoil and my grain ripen and shell out. It is a big loss and I cannot afford it.

"When the doctor quarantines anyone for contagious disease like that to protect others from getting the disease, doesn't the state help the man in such a case?"

And I had to reply, "No, the state is not interested in the man who has to go through a period such as that which you describe for the protection of other people."

Advance over the old methods in the control of diseases was made when medical supervision in schools was taken up. There are certain people who object strenuously to medical supervision in schools, yet it is one of the most important procedures not only in preventing disease but in placing the child under proper conditions in order to give it the best opportunities as relating to health and future efficiency. It is difficult to understand why people are willing to educate their children and at the same time neglect their health. It would seem apparent to anyone that an educated, unhealthy child was at a great disadvantage, and, even further, that it was useless to attempt to educate a child that was going to die as a result of neglect before it had reached the wage-earning period in life, and yet this is not an un

common occurrence.

A still further advance was made in the control of disease when the question of infant welfare was taken up. The number of deaths among children from preventable diseases is simply enormous. It has not been possible as yet to make a thorough study of this condition in Minnesota, but we do know that probably a tenth of the deaths annually in Minnesota are among children and due to preventable causes. This is a heavy economic loss, as well as a financial burden upon the parents.

Wherever medical supervision in schools has been taken up, it has been found that a large percentage of the children were defective in some way or other. Public health should have supervision of the child from its birth. The child should not be permitted to grow up to school age without someone's knowing of physical defects, if such are present. In other words, there should not be such a large number of individuals defective at the age for entering school.

It should be the duty of health authorities watching the child from birth to school age to point out these defects, if present, to the parents so that they may have them corrected, if possible; or, if the parents are not able or willing to have them corrected, in order that they may be corrected by the state, for the state has a responsibility in connection with the life of each child. The health authorities should be able, when a child enters school, to turn a complete record of the child's health up to that date over to the school authorities, and to say to the school authorities, “We are will

ing to continue the supervision of the health of this child through its school life, if you wish us to, but if, on the other hand, you wish to assume this responsibility, we will hold you strictly accountable for the condition of this Ichild when it leaves school."

Volunteer infant welfare organizations have sprung up through the country, but these are not doing work uniform in character or of such a nature as to be comparable. A few municipalities and states have already recognized the legal responsibility for the handling of this work. Probably no city in the country has given more attention to infant welfare than has New York, and, as a result, at present the mortality of the child in New York City is lower than in the state of New York at large. This is rather a remarkable condition, for we would naturally expect infant mortality in New York City to be much higher than in the state at large. We would expect infant mortality in any city to be greater than in the country districts. What it is in Minnesota we do not know, for it has not been possible to make any study of these conditions up to the present.

In 1912 the State Board of Health secured Dr. Ernest Bryant Hoag for one year to act as special director of school hygiene, with the intent of pointing out to the people the need of knowing the physical condition of the school child. Letters were sent to superintendents of schools in various parts of the state, asking if they cared to have Dr. Hoag visit them, and wherever the answer was in the affirmative an attempt was made to send the doctor. His duties consisted in pointing out to teachers the need of watching for defects among school children, and, further, of impressing upon the people the importance of medical supervision in schools carried on under the supervision of physicians and nurses trained especially for this work, as well as teachers. Dr. Hoag's work was sufficiently important to be made a bulletin of the United States Bureau of Education, No. 44, 1913. This important work had to be dropped at the end of one year because of lack of funds.

Organized health work in schools at the present time is confined chiefly to the larger cities. It is quite as important that this work should be carried on in the country districts as in the city. There is a general impression that the child in the country has an advantage over the child in the city, yet when we come to deal with preventable diseases and physical defects we find, as a matter of fact, that the city child has many advantages over the country child.

The total deaths in Minnesota for the year 1913 were 22,793, and of this group 10,890 (nearly one-half) were due to preventable causes. One of the chief of these preventable causes is tuberculosis which, in 1913, killed 2,357 people. In the past this disease has been looked upon as inherited from parents, but we now know that it is an infectious disease and should be cared for as other infectious diseases are. The only excuse for not doing so in the past has been because of the magnitude of the problem, for, with the number of deaths, it is evident that there must be at least 10,000 cases of tuberculosis annually in this state.

A large percentage of these cannot be properly taken care of at home for the proper care of these cases in the home means an amount of atten

tion that is almost impossible. The last legislature made it possible to provide county sanatoria for the care and treatment of these unfortunate people. The tuberculous should go to these institutions not only in order that they may receive the best treatment and be given the greatest possible opportunity for recovery, but also to prevent the infection of others.

The laws of the state make thorough provision for the proper care of those ill with communicable diseases, placing the responsibility upon the local sanitary authorities in the first instance, and providing that these sanitary authorities must see that necessary measures are taken for the suppression of such diseases. The expense in handling these diseases rests primarily upon those cared for, if they are able to pay, but the question of payment is of secondary consideration, for if the individuals are not able to pay (and one does not have to be a pauper to come under this group) the local sanitary district is responsible primarily for the expense incurred in this work, but it can recover half of the amount from the county in such

cases.

This is as true in the handling of tuberculosis as it is in the handling of scarlet fever, diphtheria, or typhoid fever. The control of tuberculosis is better in every way and at the same time less expensive, in the sanatorium than in the home. The law providing for the county sanatorium has made it possible for the county commissioners to take this burden of expense away from the country districts, the villages and the cities, and place it upon the state. The county is responsible for its share of the expense whether this disease is controlled under the law relating to all commun. icable diseases or under the law relating to county sanatoria. It is only a question of whether one county is willing to leave half of the burden upon the locality or relieve the locality by transferring this burden from it to the state.

With these facts before us, it would seem as though Minnesota should be giving attention to the question of reorganization of its health work, thus falling in line with New York, Maryland and Massachusetts.

During the past summer Dr. Carroll Fox, surgeon in the U. S. Public Health Service, made a survey of "Public Health Administration in Minnesota." A full report of this survey is published in "Public Health Reports," October 2, 1914.

In conclusion Dr. Fox makes the following recommendations:

"1. That the designation of the State Board of Health and its status in the state government be changed to that of a state department of health. "2. That all of the different subdivisions of the state department of health be located in the same building.

"3. That an assistant director and two additional bacteriologists be appointed in the division of preventable diseases.

"4. That the state be divided into not less than 20 health districts, each district to be composed of one or more counties, at the discretion of the state department of health.

"5. That a physician trained in sanitary science be placed in each district, and that he be given an office and an adequate number of assistants, including inspectors, nurses and a clerk.