Institute a program for the education of physicians, nurses, and the public in the early recognition of pneumonia, its diagnosis, and prompt treatment. Place laboratory diagnostic service on 24-hour basis. Provide nursing care for pneumonia patients. Enlarge the advisory committee on pneumonia control. Sanitation (sanitary inspection): Provide additional office space. Arrange for more supervision of field activities. Provide eight additional inspectors, four with sanitary engineering training. Require education, training, and experience of personnel prior to employment. Hold classes continually for education of personnel. Employ experienced sanitary engineer as director of bureau. Look for and eliminate cross connections. Place all inspectors in distinctive uniform. Clarify jurisdictional problems arising between Federal and local officials. School medical inspection: Provide more adequate office space for this activity. Establish a closer working relationship between the health department and the board of education. Make more frequent and detailed inspections of field activities. Replace "complete physical examinations" by examinations based on needs. Establish standards of physical defects requiring remedial efforts. Arrange schedule for regular visits to schools. Have sanitary inspections of school buildings made by bureau of sanitary inspection under direction of sanitary engineer. Arrange for supervision of school cafeterias by nutritionist. Tuberculosis control: Augment and improve clinic facilities by additions to medical, nursing, and clerical personnel. Provide 500 additional beds for persons suffering from tuberculosis, as follows: 200 at reopened Upshur Street Hospital; 150 at Freedmen's Hospital; 150 at Gallinger Hospital. Employ a physician skilled in chest surgery. Inaugurate and intensify the educational program against tuberculosis. Provide full-time physicians for supervision of the tuberculosis clinic and Glenn Dale Hospital. Utilize the beds in the children's building for children only, filling any vacant beds with patients discovered through more intensive case finding. Provide means for continuing hot lunches for school children and for improving the nutrition of families in which tuberculosis is now or has been present. Foster better cooperative relationship between public and voluntary agencies engaged in tuberculosis-control work. Venereal disease control: Establish a separate venereal disease-control section in the department. Augment venereal disease clinic service. Establish a clearing house of records relating to venereal disease patients. Provide for free distribution of antisyphilitic drugs. Place greater emphasis on early detection and adequate treatment of syphilis in pregnant women. Improve the epidemiologic work in connection with early infectious cases. Continue check on efficiency of serological laboratory. Determine extent of venereal disease problem by study of all medical sources of treatment. Vital statistics: Provide additional office and storage space. Enact a new vital statistics law. Employ a trained statistician. Expand the personnel to permit analyses and study of statistics, with application of findings. Establish a central statistical agency for use of all divisions of the department. Provide funds for printing the data gathered. COMMENT It will not be practicable immediately to acquire all of the recommended personnel and facilities. Therefore, it is suggested that the needs be budgeted over a period of approximately 6 years, remembering that, in the meanwhile, the population of the city will probably have increased steadily, making the 1938 estimate of needs only approximately applicable. In this connection, it may be pointed out that the population of Washington will undoubtedly continue to increase steadily, even without the stimulus of such extraordinary happenings as have, on several occasions in the past, caused sudden and large additions to the citizenry. Because Washington is a growing medical center, persons in need of instruction and others searching for medical aid will come in increasing numbers. Adequately to care for a growing population will require facilities of a high order. The increase in the life span has brought and will continue to raise new and perplexing problems in connection with the ageing population, many of whom are harassed by chronic ailments which are more difficult to relieve than are acute conditions. It would appear desirable, then, to plan for adequate public health, clinical and hospital facilities, particularly in institutions which, for obvious reasons, have been unable or unwilling to assume the financial obligations required for expansion. From a public-health viewpoint Washington is a good place in which to live. The community has, to mention a few advantages, an ample supply of safe drinking water, an excellent milk supply, highgrade medical service, and a health department that is vigilant, diligent, and increasingly successful in safeguarding the public health. While the climate of Washington may not be considered ideal for health purposes, there are periods during which highly favorable conditions prevail. It is easy to criticize the procedures of any governmental agency. A health department, because of its numerous and varied activities, makes an especially inviting target. However, it may be said that, despite certain shortcomings, of which the department itself is well aware, the District Health Department is performing a creditable and increasingly effective piece of public health work, and has so performed this work especially during the past few years. In this connection a tribute should be paid to the personnel of the department, which has labored faithfully, intelligently, and usually efficiently in performing alloted tasks, often under conditions that would have been discouraging to less courageous individuals. The suggestions made in the present report for improving the efficiency of the health department are presented in a friendly and helpful rather than a critical manner. Especially is it realized that many of the recommendations depend upon the acquisition of funds and in some instances may not be susceptible of early fulfillment. However, the hope may be expressed that as funds and trained personnel become available, the recommendations of this report will be adopted and utilized. The frequently quoted and now famous slogan, "Public health is purchasable; within natural limitations a community can determine its own death rate," is particularly apropos in the District of Columbia. Manifestly, the principles involved in this statement are applicable only so far as the citizens of the community are able to comprehend the needs and are willing to submit to the increased taxation necessary for meeting the proposals. It is quite possible that considerable educational effort may be required properly to present the situation to the people and to members of the Congress directly concerned with shaping the affairs of the District. Therefore, it will be necessary to decide between the status quo, which is not creditable, and the obvious advantages offered by the application of advances in the field of public health and medicine. The likelihood that expenditures for the construction of expensive hospitals and asylums for the terminal care of victims of preventable diseases undoubtedly can be reduced by early preventive measures is a potent argument for the changes that are recommended in the present report. REPORTS BY SPECIFIC ACTIVITIES INTRODUCTION Even before the transfer, on July 1, 1937, of the municipal hospitals from the Board of Public Welfare to the health department, there had been criticism of the administration of these institutions. Continued criticism culminated in a decision by the Board of Commissioners of the District of Columbia to ask the Public Health Service for a survey of the entire department. In accordance with this request, a study, having for its purpose the determination of the character and efficiency of the various branches of this department, was begun early in December 1937 and continued for a period of approximately 2 months. In making this survey it was especially necessary to keep in mind the peculiarities of the local form of government, the racial composition of the population, and the natural limitations of funds. It is too often true that the people who cry most loudly for better health protection are often least willing to bear the increased taxation required to promote an acceptable program. As may be expected, there is much to commend in the operation of the District health department, many things being well done. Therefore, an attempt has been made to indicate the strong as well as the weak points of the health-department activities and to suggest practical ways of increasing the effectiveness of the efforts put forth. Washington is a national show place and the object of pilgrimage of patriotic Americans. Many visitors from home and abroad come to the city with the expectation of seeing the best in all forms of governmental activity, including public-health administration. However, if these expectations are to be realized, the best possible methods must be sought and made to work. In organization, methods, and results the health department of the District of Columbia should be a model that can be observed and emulated. In making the survey of the health department the persons engaged in the work made use of the valuable outline contained in the appraisal form for cities, prepared by the committee on administrative practice of the American Public Health Association. While the conclusions upon which the recommendations have been made are not based upon the score attained in this appraisal form, advantage has been taken of the opportunity to see how the local health department appears in the light of present day knowledge and practice. In 7 addition to the guide provided by the appraisal form, numerous special reports were consulted and outlines were prepared for the acquisition of knowledge believed to be helpful in formulating an opinion as to the efficiency and needs of the organization. While the consideration of a few points has been omitted because of lack of time, it is believed that the essentials have been included and that the final report represents a reasonably accurate picture of the department as it exists and what will be required for better results. Collaborators.-As the Public Health Service maintains its headquarters in Washington, it was a comparatively simple matter, when the Service was requested to undertake the survey of the health department, to call upon many of its ablest officers to assist in the work. In most instances the persons who participated were specialists and thus applied their skill and knowledge in fields with which they were already fully acquainted. The Public Health Service desires to make special acknowledgment to the Chief of the Children's Bureau and the Director of the Bureau of the Census for permitting members of their staffs to participate in studies in which their officers are especially skilled. Therefore, far from being a survey by the Public Health Service, the study may be considered a cooperative Federal undertaking in which several departments of the Government lent freely of their best talent. Order of consideration.-There first will be considered some of the general matters relating to the health department, and thereafter the principal activities and problems of the department will be discussed. In this introduction a brief summary is presented under the following headings: General considerations. Changes in the make-up of the department. Organization of the health department. Quarters, present and proposed. Public health advisory council. GENERAL CONSIDERATIONS The Bureau of the Census estimated that the population of the District of Columbia on July 1, 1937, was 627,000. This places Washington among the large cities of the country, the fourteenth in point of size. According to the census of 1930, colored people comprised 27.1 percent of the total population. There were comparatively few foreign-born residents. The city of Washington, usually described as coextensive with the District of Columbia, is chiefly a residential community, the citizens being largely employed in the various departments and enterprises |