it is planned to have 32 health centers, each serving approximately a quarter of a million persons. Twelve of these health centers are already operating satisfactorily in specially designed buildings. It is very much to be hoped that there will be no deviation from the plans already prepared for the health center in northwest Washington, for which the site has been selected. The attempted conversion of existing structures into health centers can result only in dissatisfaction, inadequate service, and an expense for alterations exceeding the cost of an original, specially designed building. Plans for this facility have been prepared and a tentative site selected, but the actual construction is being held in abeyance because additional sites, and buildings, apparently unsuited to the purpose, have been proposed. It is very much to be hoped, inasmuch as the physical requirements of a health center are exacting, that there will be no departure from the original plans. It has been found advantageous elsewhere to establish a close affiliation between health centers and medical schools. Not only should it be possible for medical students to observe and participate in the work of a health center, but it is helpful to have the center in relatively close proximity to the school. The unique opportunity of teaching public health methods should be taken into consideration. when selecting sites for health centers. Incidentally, it may be said that there is no better method of imparting authentic information regarding the details of public health endeavor than to have a close and well-defined affiliation of medical schools and the health centers. PER CAPITA EXPENDITURES In considering the amount that should be expended by a health department it is customary to calculate the total and specific per capita costs and to make comparisons with other cities of approximately the same size. The per capita expenditures for health conservation in 100 cities surveyed in 1923 was $0.884. Expenses charged to health departments in that year represented 1.78 percent of the total spent for purposes of municipal government. While these figures were obtained 15 years ago, they are still used to a considerable extent in justifying requests for increased funds. Other per capita estimates run as high as $2.50, but only one large city in the United States, Detroit, approximates this figure. Very interesting in this connection is the report of the Bureau of the Census, Financial Statistics for 1935 of 94 Cities Having a Population over 100,000. This report was issued in 1937. While the items making up the "conservation of health" per capita expenditures are not definitely stated in the report, the calculations undoubtedly in clude the same activities in all of the cities listed and may thus be used for comparative purposes. There is a discrepancy between the per capita figure of $1.24 given by the Bureau of the Census for health conservation in the District of Columbia and the figure $0.93 submitted by the health department itself for the same year, 1935. This is undoubtedly due to the inclusion by the Bureau of the Census of certain activities which have not been similarly included by the official health agency. In table 3 are listed three groups of cities: (1) Those with populations of 500,000 and over; (2) those with populations between 300,000 and 500,000; and (3) those with populations between 100,000 and 300,000. TABLE 3.-Per capita expenditures in large cities of the United States for conservation of health in 1935 1. Cities with populations of 500,000 and over Average per capita expenditure for health conservation, 14 cities, $1.26. Average per capita expenditure for health conservation, 12 cities, $1.36. Average per capita expenditure for health conservation, 64 cities, $0.73. Worcester, Mass----. Yonkers, N. Y___ Trenton, N. J. Syracuse, N. Y____. $2.31 | Grand Rapids, Mich. 1. 84 Bridgeport, Conn__. 1. 71 Albany, N. Y_--- 1. 66 Peoria, Ill. 1. 65 Jacksonville, Fla-. 1. 59 Paterson, N. J_--_- 1. 36 Erie, Pa___ 1.27 Knoxville, Tenn_. 1. 22 Utica, N. Y. $1.42 .79 .66 .53 .52 48 $1.13 1.04 1.04 1.04 1. 01 .94 .90 .78 .77 .74 Fort Worth, Tex. Norfolk, Va____. Miami, Fla___ 61 Scuth Bend, Ind_. . 60 Omaha, Nebr____ TABLE 3.-Per capita expenditures in large cities of the United States, for conservation of health in 1935-Continued 3. Cities with populations between 100,000 and 300,000—Continued 68 Wilmington, Del. .36 . 66 Chattanooga, Tenn. .36 . 64 Akron, Ohio--- .35 62 Long Beach, Calif .34 .33 33 .30 Duluth, Minn_. St. Paul, Minn.. Salt Lake City, Utah. Tacoma, Wash.. 42 Des Moines, Iowa--.40 Oklahoma City, Okla__ 39 Atlanta, Ga---. A study of the first group, in which the District of Columbia is included, shows an average per capita expenditure of $1.26 for health conservation in 14 cities, Detroit leading with $2.48 and Philadelphia trailing with $0.69. The District of Columbia is sixth in order of the per capita expenditures for conservation of health in this group. The second group of seven cities has an average per capita expenditures of $1.36, which is higher than the average of the cities in the first group and also higher than that for the District of Columbia. It is interesting to note, in table 4, also taken from the report of the Bureau of the Census, the average per capita expenditures for conservation of health in 94 cities having populations over 100,000, these figures including the costs of operating communicable disease hospitals. Items are also included covering the cost of sanitation and the operation of municipal hospitals in 1926, 1935, and 1936. There is included the percentage distribution of expenditures for these activities in relation to the total municipal expenditures. It will be seen that the per capita expenditures for conservation of health in 1936 have not increased over those of 1926, in sanitation they have decreased, while for hospitals they have increased materially. TABLE 4.-Per capita expenditures in 94 cities of the United States having populations over 100,000, for conservation of health, sanitation, and hospitals, with percentage of the entire municipal expenditures, for 1926, 1935, and 1936 While Washington apparently occupies a favorable position with regard to per capita expenditures for conservation of health, it should be noted that the figure is slightly lower than the average for 14 cities of its class. It is believed that the District of Columbia, with peculiarities of health administration, due to special problems, such as tuberculosis control, requires a higher per capita allowance than it is receiving at the present time. Expenditures should be based upon demonstrable needs rather than upon mere comparative data. Throughout the present report an earnest effort has been made to have both the recommendations and the proposed increases of expenditures conform to reasonable requirements. CANCER By H. R. SANDSTEAD, Assistant Surgeon, United States Public Health Service Recommendations. It is recommended that the city health department consider the advisability of establishing a cancer control section, possibly in the bureau of preventable diseases. The program should be designed to coordinate all interested agencies into a unit. Conferences with committees from the various institutions would aid in making uniform the management of cases. The department should have a program for education of the public and the medical profession in the prevention, recognition, and treatment of cancer and should work toward making cancer a notifiable disease. The medical profession and the general public consider cancer a public health problem; logically the center of public health activities is in the health department. The minimum requirement for this work is a full-time employee, preferably a physician, skilled in coordination and educational efforts. A stenographer-clerk should also be provided. A tumor clinic should be established and beds should be designated for the care of cancer patients at Gallinger Hospital. Cancer control.-The District of Columbia Health Department does not have a section devoted to cancer control. Any interest which it may have in this field is combined in the general public health program. There are, however, several other agencies in the District which are active in the control of cancer. A survey on cancer control in the District was made by the American Society for the Control of Cancer (1) in 1934, the results being published in 1936. At that time the District was given 5 points out of a total score of 20 in the appraisal form.. Many of the conditions present at that time exist today. The information contained in this report was obtained by hospital questionnaires, by interviews with men prominent in the cancer field in this area, and by the assistance of the statistical division of the United States Public Health Service. Cancer mortality in the District of Columbia as compared to the United States registration area.-An analysis of cancer mortality rates for the United States shows that the death rate from this disease is increasing annually. In 1905 the death rate per 100,000 for the United States registration area was 71.4; for the same area in 1935 the rate was 107.9, with a total of 137,649 deaths. The death rates for the District in the corresponding years were 75.6 and 132.8, respectively, as shown in table 1. This table also shows the actual number of deaths and death rates from cancer in the District of Columbia at 5-year intervals from 1905 to 1936. The general increase in cancer mortality would appear to be a wellestablished fact. There are, however, several factors which have a very important bearing on this increase. They are as follows: Improved methods of reporting deaths, better diagnostic facilities, improved diagnostic ability within the medical profession, and an increase in longevity which brings more people into the "cancer age." TABLE 1.-Annual death rates per 100,000 population from cancer in the registration area and corresponding death rates and number of deaths from cancer in the District of Columbia at 5-year intervals 1905–1935 The high death rate from cancer in the District may be explained in part by the relatively large proportion of people above 45 years of age. Table 2 shows the cancer death rate per 100,000 population for 1935, with percentages of population above 45 years in 1930, by States. |