If the new water works bonds had been voted by the people the installation of the plant would long ago have been started and the national expert's survey of the city would have been unnecessary and the city would have been spared the exceedingly disagreeable reflection cast upon our community by publicity that has reached the eyes of thousands of people throughout the country.

Only misfortune has been caused by the delay and additional cost, for there has been a great increase in the price of every piece of material that will enter into the construction of the new plant. It means that more money must be spent to achieve the same result or that every element that was first proposed for the new system can not be utilized as originally planned.

It has been a costly delay and must be cause for the leaders of the opposition to the bond issue to feel that they not only achieved nothing by their opposition but actually brought a misfortune upon the city. Their intentions were no doubt good, in many instances, but rather than pursue individual ideas it would have been better to have accepted the recommendation of the councilmen who had made an investigation and consulted the experts.

There are rumors, that even since the state has ordered a new water supply, that some opponents will seek to interfere with legal proceedings and thus further delay the needed improvement. But it seems inconceivable that any good citizen would take a part in any plan intended to increase the predicament the city is now in.-Piqua Leader Dispatch.

A PROGRAM OF PUBLIC HEALTH FOR CITIES.*
W. C. RUCKER

Assistant Surgeon General, United States Public Health Service.

Considered in its broadest sense, the ultimate reason for cities is public health. Every other reason for which mankind collects itself into more or less permanent aggregations is subsidiary to the basic idea of community protection and betterment of every sort. This protection is external, against the outside world, and internal, each individual against the entire collection of individuals. Since every action which produces a betterment of the conditions under which the community lives and works gives a definite reaction in increased. health, it is at once seen that a public health program for cities is in reality nothing more nor less than a complete plan for communal existence.

The collection of individuals into communities without the direct interposition of health protective measures is possible up to the biological limit of individuals per acre. The moment that concentration is increased beyond this point there is increased opportunity for promiscuity with a coincident intercommunication of disease and reduction of the acreage ratio below the biological limit. Therefore.

* Published in Public Health Reports, April 6, 1917.

in order that man may dwell in a concentration greater than the biological limit, it is necessary that artificial safeguards be thrown. about him.

These safeguards take the form of those general community measures which must be exercised by the entire machinery of city government and those special measures which are exercised by health departments. Of the two, those exercised by the community machinery as a whole are of far greater importance. Health departments, for the most part, operate in end results. Under the present system, disease must appear before it can be attacked, the municipal policy being one of eradication rather than prevention. This is to be expected in cities which maintain fire departments for the purpose of extinguishing fires rather than to prevent them, and under this system. it would be more logical to call the health department the disease department. Until there is a basic change, health departments can do little more than scratch the surface of disease prevention because their authority deals with the actualities rather than with the potentialities of disease.

The entire community machinery by cooperation, on the other hand, possesses power to strike health hazards at their very root, to throttle at their inception those elements of municipal life which are the great producers of sickness, misery, inefficiency, and premature death. Furthermore, it is possible in this way to create and follow out a definite community policy of which health shall be a basic part. Heretofore the protection of health has been considered a function residing wholly in the health department as though health did not as vitally concern the other departments of the city government. The public health program of the future embraces the coordination of the entire municipal machinery and the cooperation of the whole community.

Unfortunately health has been considered in the past solely as a medical problem and the pendulum has been enthusiastically swung so far that health is almost regarded as an artificial state to be achieved and maintained solely through the interposition of medical safeguards. With entire consistence the health wardenship of cities has been committed solely to physicians, those who by training have been taught to consider the pathological in human life, the symptomatology and evidences of disease rather than the great basic, underlying, essential factors which enter into and are the vital part in the creation, spread and perpetuation of sickness. Expert knowledge of disease is absolutely necessary for the work of health departments but can not be the foundation of a broad municipal health policy. Public health is something more that a mere absence of disease. It is the physiological functionation of the community.

From the foregoing it may be deduced that the first and most important thing in a public health program for cities is a definite municipal public health policy which shall embrace every department of the city government. In order that such plan may be put into operation it is necessary that there be a central focus which shall receive impulses from all of the departments and radiate them to the

points where they will react with the greatest benefit to the public health. This is in effect the creation of a public-health center in the city's brain. If we are to expect active interdepartmental cooperation it is necessary that all of the departments shall be in close touch and that there shall be a medium whereby they can communicate. More than this, if we are to expect the mass of the citizenship to join in this cooperation, there must be some means whereby this shall be achieved.

The keyword in this public-health policy is cooperation, cooperation having as its basis the full recognition of the fact that in its last analysis the health problem is an economic problem and as such can not be solved without careful consideration of the economics of the community. There has been a great deal said about the purchasability of health. This pleasing catchword has generally been interpreted as meaning that if the general public would give sufficient funds to the health department it would receive health in exchange. Used in this way the phrase is incorrect because physical health can no more be purchased than spiritual health, and in both cooperation is a prerequisite to salvation. If we consider that health is purchasable by the full-pay envelope whose contents are outlaid for proper food, clothing, housing, and all that goes with them, then indeed is public health purchasable, but this requires the cooperation of the city and its citizens, the aim of this cooperation being the prevention of the shrinkage in the purchasing power of the contents of the pay envelope.

The heart of the program lies in the central cooperating focus. The details of the program will adjust themselves without friction if this point be well determined. This comprehends both the office and the man. The office must be removed from politics; its compensation should be sufficient to render its holder above influence; its tenure should be indefinite; it should have both executive and advisory functions, its advisory functions touching every part of the judicial, legislative and executive functions of the city government. In this way the courts in making decisions and fixing precedents having a bearing on health, can and should receive expert advice. No legislation should be enacted by the city council without the advice of its health-coordinating focus. To it the executive branches of the city government should refer all matters and plans of policy in order that all may be integrated for health. The direct and indirect authority vested in this office is great and far-reaching.

The man to fill this office must be many sided and he must be able to view health with a broad-angle vision, realizing that his duties. are not only to keep an entire municipality from being sick, but, what is of infinitely greater importance, to keep the body politic in such a condition that its functionation is at the highest degree of physiological efficiency. He must be able to visualize the fact that the least common denominator of health is the purchasing power of a day's labor. His type of mind should be that which characterizes the presidents of the great universities, a combination of catholicity of mental development with creative imagination.

This officer should be the health commissioner; the central cooperating focus should be the health department. Not the health commissioner as we know him now; not the health department as it exists today, but a health department enlarged and expanded in power to such an extent that it can and should be able to reach out and touch the every activity of the city government and harmonize the whole for the increase of health. Health departments nowadays err in one of two directions: Either they undertake to absorb and control executive functions which are not properly theirs for example, plumbing inspection, garbage destruction, and the like-or they try to limit their activities to such a narrow field that they confine their radius of action to the actualities of disease. The president of a great university does not and should not undertake the teaching of the technicalities of Greek, but he should be able to mold it into the curriculum so as to create healthy-minded education. In the same way, the health commissioner need not and should not be responsible for the operation of water-filtration plants, but he should be able to assemble them into the city's health machinery.

Since concentration is inversely as the transportation facilities, the health department should be the first to be consulted in any plans for the increase of rapid transit. All the problems connected with streets, with housing, industrial conditions, playgrounds, parks, schools, all of these bear an intimate relation to health and as such should come within the purview of the health commissioner. police, now almost solely occupied in the prevention of crime and the maintenance of peace, should be a powerful agency for health. In fact, there is no branch of the city government which can not and should not be coordinated into the health program.

The

In a 15-minute paper it is impossible even to mention the multiplicity of details which must enter into the carrying out of a publichealth program for cities. More than this, it is not desirable, even if time sufficed. The extent to which the influence of a given agency shall reach is directly dependent upon the mental caliber of its direcing head, in other words, upon the fundamental idea from which springs the entire train of thought and all the ramifications thereof. The essential element in a public-health program for cities is a definite public-health policy which shall bring the health agency into close touch with every activity of communal existence; not a policy which endeavors alone to prevent those diseases which are caused by vegetable and animal parasites, but one which aims at the control of that greater body of destructive agencies, human parasites. Not a policy which tries to control the insanitary tenement yet leaves out of consideration the cupidity which fixes its rent, but a public-health policy which shall embrace the entire political economy of disease, a policy which shall be as broad and far-reaching as human nature, since, after all, human nature is the groundwork from which arises the fabric of the public health.

DEPARTMENTAL REPORTS BY DIVISIONS

DIVISION OF COMMUNICABLE DISEASES, OCTOBER, 1917 Notifiable Diseases

Prevalence. For the month of October, 4,802 cases of notifiable diseases were recorded to date of November 12th, 800 less than were reported for October, 1916 and 1915, in which years the totals differed by only 4 cases, 5,628 in 1916, 5,632 in 1915. For October of this year. the cities of the state had reported by November 12th, 3,210 cases, 70 per cent. of all cases, leaving a remainder of 1,592 cases recorded for villages and townships. In order of greatest reported prevalence for the month, the diseases list as follows: (1) diphtheria, 1,020 cases; (2) chickenpox, 678; (3) scarlet fever, 645; (4) tuberculosis, 472; (5) smallpox, 416; (6) whooping-cough, 391; (7) typhoid fever, 344; (8) measles, 194; (9) pneumonia, 170; (10) ophthalmia neonatorum, 135; and (11) mumps, 117 cases. For no other one notifiable disease was a total of 100 or more cases recorded for October. Reports for October had been submitted promptly by 90 per cent. of health officers, 26 per cent. of whom recorded the presence of one or more cases of notifiable disease during the month, compared with 22 per cent. recording disease in September, and 18 per cent. in August.

Diphtheria. For September as well as for October, diphtheria headed the list of notifiable diseases with the largest number of reported cases. Health officers were warned last month to expect increased prevalence of diphtheria not only for October but also for November. Three times as many cases were reported from cities as from the rest of the state. Cleveland recorded 221 cases, and Cincinnati 104, the case rates 32 and 25 per 1,000 inhabitants, respectively. Lima reported 32 cases for the month, a case rate of .90 per 1,000 inhabitants, almost three times Cleveland's and four times Cincinnati's rates. Findlay reporting 17 cases showed an even higher case incidence, 1.1 per 1,000.

Smallpox. The October total for smallpox greatly exceeded the totals for this disease for October of previous years, as shown in Table I below. For the past five years of record in Ohio, smallpox has steadily increased during the winter months, reaching higher monthly totals in November, December and January than in October. From the following 20 health districts 337, or 81 per cent., of the 416 cases of smallpox were reported, case rates being shown: