The principal criticisms of the hospital management of cancer cases, with a few exceptions, are as follows: There are inadequate recording or filing systems for cases, the follow-up systems are not uniform, and the cancer educational programs have been neglected.

REFERENCES

(1) Herring, R. A.: Cancer in the District of Columbia. Am. Society for the Control of Cancer. 1936.

(2) Bigelow, G. H., Lombard, H. L.: Cancer and other chronic diseases in Massachusetts, 1933. Riverside Press, Cambridge.

COMMUNICABLE DISEASE CONTROL

By ROLERT OLESEN, Assistant Surgeon General, United States Public Health

Service

Recommendations.-The nature of the changes needed to place the bureau of preventable diseases on a better footing are plainly discernible in the text of the report. However, for greater clarity certain recommendations, which are believed to be reasonable, practicable, and in keeping with modern public-health practice, will be presented herewith.

1. If the entire health department were housed in a separate, suitable building, its efficiency would undoubtedly be greatly enhanced. In no less degree would the efficiency of the several bureaus, including the bureau of preventable diseases, be notably increased. Most business organizations have long since learned the beneficial effects of adequate and suitably arranged office space upon the morale of employees and the promotion of efficiency.

2. Until adequate provisions are made for the transportation of persons engaged in official business it need not be expected that communicable disease control will be accorded the prompt and efficient attention that its importance demands. In this connection it may be pointed out that the elimination of the so-called disinfection service would make available funds which could be put to better use in providing automobile transportation for officers attached to this bureau.

3. Plans should be made to supplant the part-time by full-time medical inspectors. In the event of the death, retirement, or separation of a medical inspector now receiving $3,400 per annum, consideration should be given to the amalgamation of this salary with that of another part-time position for the employment of a full-time physician. It is believed that the interests of the community will be better served by the presence of such an employee.

4. The sanitary code should be revised in its entirety. Instead of publishing all of the rules and regulations in a large single volume there should be small section booklets, each containing a lively interpretation, which will be sufficiently interesting and instructive to command and hold attention. Information relative to communicable disease control should be issued in relatively small editions and subjected to frequent revision. The mistake is now being made of issuing the same material repeatedly without revision.

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5. The procedure by which reports of communicable disease are received and handled in the office, and by the medical inspectors, should be thoroughly revised. Telephone reports of communicable-disease cases should be encouraged and authorized. The recovery card should be discarded immediately. Consideration should be given to obtaining, through the Public Health Service, report cards bearing the penalty mailing privilege.

6. A daily list, giving the names and addresses of, and schools attended by, persons reported as having communicable diseases should be issued by the health department. The list should also contain the names and addresses of, and schools attended by, recovered cases. This list should be sent to the principals of schools, school medical inspectors, and others who may have a definite interest in contro! measures. There appears to be no good reason for sending these lists to milk dealers.

7. The release from quarantine is a duty of the health department which should be met by the use of medical inspectors, school medical inspectors, and public health nurses.

8. A complete list of notifiable diseases should be printed on each report card. 9. Efforts should be made to obtain more complete case reports of typhoid fever and whooping cough.

10. The receipt, recording, and follow-up of venereal disease reports should be transferred to the bureau of venereal diseases.

11. The cards on which data relating to communicable diseases is collected should be revised in accordance with good public health practice.

12. Public health nurses should be used for visiting patients suffering from the minor communicable diseases.

13. Immunization against diphtheria should be regarded as a task that must be continued unremittingly and energetically.

14. The search for typhoid carriers should be more diligent, and the control of carriers should be regarded as an unremitting task of great importance.

15. An effort should be made to encourage vaccination and revaccination among persons beyond school age. It is quite likely that, with the large influx of persons from other parts of the Nation, there exists a considerable population that is not protected against smallpox.

16. Practicing physicians should be encouraged to seek diagnostic aid, and the health department should assert its authority in visiting private cases, especially prior to the transfer of patients to the communicable-disease hospital.

17. The bureau is in need of pamphlets dealing with each of the communicable diseases and should distribute these liberally. These pamphlets should be original in construction and appealing in their authenticity to citizens who may thus be induced to institute measures for the prevention of communicable diseases. 18. Consideration should be given to the amalgamation, under a single head, of the ambulance services in this bureau and in the permit bureau, with a view to reducing the existing facilities, yet meeting the requirements and effecting a saving of funds.

19. Disinfection following communicable diseases should be permanently discontinued. Cleaning and renovation should be done by the householder under the direction of a visiting public health nurse. There is no need for longer perpetuating a procedure which was long since shown to be useless.

From what has been stated it will be apparent that the remedies for the correction of existing inadequacies in the bureau lie largely within reach of the present personnel. It will be noted particularly that no additional personnel or considerable increase of funds has been recom

mended. Instead, by internal adjustments of procedure and closer coordination with other bureaus in the department, it should be possible in a short space of time to enhance the efficiency of control

measures.

The expenditures, positions, and salaries of the persons employed in the bureau of preventable diseases are as follows:

Particular attention is invited to the fact that each of two medical inspectors receive a salary of $3,400 per annum for part-time duty. It is felt that this work requires full-time duty, and it is suggested that in the event of a vacancy in this grade the position be combined with that of a temporary part-time medical inspector and a full-time position created. It is believed that the services of a competent and trained medical inspector could be obtained for an entrance salary of $3,600.

Considered at one time, and that not so long ago, as the most important function of a health department, the prevention of the acute communicable diseases has assumed a role of secondary importance. By this it is not meant that diphtheria, scarlet fever, whooping cough, measles, and similar diseases have been reduced to the vanishing point, or that effective immunizing agents and measures are available for the control of all these common diseases. However, vaccination and immunization have proved to be efficient weapons in some instances, and other diseases, such, for instance, as scarlet fever, have become milder in their manifestations, while still others have responded to the institution of special measures during convalescence. Then, again, there has been a pronounced shift in emphasis from the communicable diseases to the prevention and treatment of the chronic diseases, particularly among the underprivileged portion of the population which is unable individually to provide itself with needed medical care.

The terms "preventable" and "communicable."-It will be noted that the title "bureau of preventable diseases" has been retained in this department just as it has been kept in other public health organizations. As a matter of fact, the chief emphasis has been, and is

being, placed upon communicable disease control, to the almost complete exclusion of, and consideration of, such diseases as cancer, heart disease, mental disorders, and other conditions presumably susceptible to preventive measures. Without finding fault with the original conception that this bureau should devote its attention to the preventable as well as the communicable diseases, the hope may be expressed that there may develop numerous opportunities for developing new technique and approaches to the broader, yet more difficult and challenging, fields of public health.

Personnel and duties.-The personnel and duties of the bureau of preventable diseases have changed considerably since the Preble report was made in 1927. The principal changes which have occurred during the past 10 years were the creation of separate bureaus for such activities as venereal disease and tuberculosis control and the diagnostic laboratories. With the adoption of generalized nursing service the bureau no longer has nurses attached to its staff. The control of pneumonia is a new and added activity which will be made the subject of separate consideration in the present report. In the way of new personnel there has been added a full-time, trained epidemiologist, making possible the more careful, complete, and prompt investigation of typhoid fever, meningitis, poliomyelitis, and other such ailments. Special forms on which suitable data may be recorded are in process of preparation. Otherwise the bureau, as will be seen from the accompanying summary of positions, remains much the same as it was at an earlier period.

Quarters.-Like the remainder of the health department, the bureau of preventable diseases is now, and previously has been, seriously handicapped by lack of proper office space. Neither the chief nor the epidemiologist have separate offices where they may meet visitors, confer with colleagues, or concentrate upon the problems in hand. Instead, all members of the staff are located in a single room, in which the chief of the school medical inspection service and his staff are likewise compelled to work without privacy. Obviously, efficient work cannot be conducted under such circumstances, for continuous confusion and interruptions are not conducive to the orderly transaction of business.

Transportation.-At the present time no provision is made for the transportation of the chief, the epidemiologist, or the medical inspectors in the bureau of preventable diseases. This means that each of these physicians must use his private car for the transaction of public business. Obviously, the failure to make an allowance for transportation seriously interferes with investigations, as the physicians will consider the matter of personal expense as a reduction of income and will not be energetic in performing public duties under such

conditions. Unless a car can be provided for the use of the physicians in the bureau, an allowance should be made for mileage while personal cars are used, or a flat monthly allotment made.

The bureau of preventable diseases, directed by a full-time chief, discharges the following functions:

1. Control of the ordinary communicable diseases.

2. Pneumonia control.

3. Epidemiological investigations.

4. Diagnosis and transfer of communicable disease patients to the hospital.

Legal provisions for the control of communicable diseases.-These provisions were cited in considerable detail in the Preble report and need not be repeated in the present dissertation. The rules and regulations governing communicable-disease control appear in many places, as, for instance, the sanitary code, separate pamphlets, and on certain forms, but in no instance in a single place is a clear, comprehensive, and up-to-date account presented. It is quite apparent that the communicable-disease regulations, like other legal provisions in the health department, suffer greatly from antiquity and more latterly from failure to make changes in keeping with modern practice. Naturally, it is difficult for lay people to learn from the available literature what is desired in the way of conformity, and likewise difficult for members of the department to indicate where suitable information may be found.

GENERAL PROCEDURES IN COMMUNICABLE-DISEASE CONTROL

Notification. For many years the weekly Public Health Reports of the Public Health Service has sounded the keynote of effective communicable-disease control in the slogan, "No health department, State or local, can effectively prevent or control communicable disease without knowledge of when, where, and under what conditions cases are occurring."

The reporting of the following diseases is required in the District of Columbia: