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California's Record in It would be difficult to find better statistical Lowering Typhoid Rate proof of the proposition that typhoid fever

is preventable than that which is provided by a comparison of typhoid death rates for the past decade in Ohio and California. Starting from approximately the same level, both these states have decreased their typhoid mortality. California's decrease has been so much more rapid than Ohio's, however, that the Pacific Coast commonwealth's rate is now only half that of this state.

This notable record is the result of a determined anti-typhoid campaign inaugurated by the California health authorities in 1915. Prior to 1915 about the same degree of typhoid reduction had been accomplished in California as has been achieved in Ohio. The rate had been brought from 32.2 per 100,000 population in 1906 to 13.6 in 1914.

In October, 1915, the California state board of health, deciding that this reduction was insufficient, declared its intention to bring the typhoid death rate down to 9.6 in 1918. As a matter of fact, when the 1915 statistics were compiled, it was found that that year's rate had dropped to 9.7 --- almost the desired record for 1918 — and the 1916 figure proved to be 7.1.

Encouraged by this achievement, the board early in 1917 expressed the hope that the 1918 rate would be as low as 5.0 per 100,000. Statistics for 1917 showed no improvement for that year, but the preventive campaign is continuing vigorously.

And what has Ohio been doing during this period ? Here are the figures, by years, with those for California given for the sake of comparison (state vital statistics reports are the source of both sets of figures ) :

1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 Ohio ...... (Not available) 26.5 27.9 22.4 18.4 24.0 18.1 14.1 15.0 13.1 California 32.2 26.3 24.4 20.0 19.9 17.8 17.6 16.3 13.6 9.7 7.1 7.4

In other words, Ohio has been making improvements which are by no means negligible, but that she can easily accomplish still more is shown by California's record. California, with a rate two years ago approximately the same as our present rate, has in that brief two-year period achieved nearly a fifty-percent reduction.

Why should not Ohio have a typhoid death rate of 7.0 per 100,000 by 1920?

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What a State Must Do How did California do it? This is the to Prevent Typhoid Fever question which logically follows such a

discussion of the Golden State's work in typhoid prevention as appears elsewhere in these columns. We let the California state board of health answer this inquiry. Here are the means by which it says a typhoid fever death rate can be reduced :

(1) Prevention of sewage pollution of public and private water supplies;

(2) Insurance of safe milk supplies through the pasteurization and inspection provisions of the state milk law;

(3) Investigation of outbreaks of typhoid fever, determining and removing their sources;

(4) Manufacture and free distribution to physicians of typhoid vaccine;

(5) Inspection of hotels, eating places, summer resorts and surroundings, correcting insanitary conditions that may be present;

(6) Enforcement of laws and of the board's regulations for the
prevention of typhoid fever ;

(7) Education in the prevention of typhoid fever.
One other important point is referred to in these words:

In order to secure these results, it is necessary that the California
state board of health shall have the active support of health officers,
physicians and citizens. All of the common rules of sanitation, par-
ticularly as related to sewage disposal and water and milk supplies,
must be rigidly observed. The regulations of the board for the pre-
vention of typhoid fever should be carefully followed by physicians and
health officers.

In other words, everybody must work together. The local health official is just as important in his field as is the State Department of Health in its field, and much of the success of the campaign, especially in rural districts, depends ultimately upon the willingness of the individual citizen to follow authoritative advice.

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Carrier Danger Is Best The carrier as a source of typhoid infecAvoided by Vaccination tion must not be overlooked in a campaign

to reduce the typhoid rate. He is the most insidiously dangerous of all means of transmitting the disease, and is probably the most difficult to regulate.

It is said that about four percent of the persons who have typhoid remain carriers after apparent recovery. If this ratio prevailed in Ohio last year, the twelve months produced some thirty or forty carriers who may now be scattering the germs of their disease among unsuspecting residents of the state.

The usual methods of typhoid prevention can reach the carrier only indirectly. As we reduce our typhoid rate by purifying water, killing flies and extending our sewer systems, we will, if the law of averages is working properly, automatically reduce the number of carriers. Even one carrier, however, as bitter experience has demonstrated many times, can do a geat deal of damage if left undisturbed for a short period.

Strict regulations for the physical examination of all persons whose occupations necessitate their handling food products will lessen the danger from carriers. Pasteurization of milk will have a similar tendency. With the complexities of modern business organization, however, food may be infected at a distance from the point of consumption, and the health officials of a given community may therefore not be in a position to ward off the danger to their constituents.

Inasmuch as this is the case, vaccination against typhoid fever becomes of increased importance when one considers the carrier's part in transmitting the disease. It is the most dependable method of protection against this lurking danger.

Vaccination is especially important to those who travel or who are in the habit of eating food prepared by unknown persons who may or may not be typhoid carriers. Anybody is likely to profit by anti-typhoid vaccination, but these two classes are constantly exposed to the carrier danger and are "taking a chance" as long as they are without this protection.

Figures Show That Typhoid Typhoid fever is not being thoroughly Is Not Properly Reported reported in Ohio, despite the legal re

quirement that a notification of every case shall be sent to the State Department of Health. That fact is apparent when one compares the case reports with the death totals for corresponding years.

Students of the typhoid problem estimate that the proportion of deaths to all cases is from one in fifteen to one in ten. In other words, Ohio in 1917, with 682 typhoid deaths, must have had a case total of from seven thousand to ten thousand. Investigation of the case records, however, shows only 3,127 reported.

A great duty rests with the physicians of the state in a campaign for the prevention of typhoid. They must report cases promptly and completely. Unless the health authorities know where cases are occurring they are handicapped in their task of preventing the disease.

With one-half to two-thirds of the existing cases unreported, preventive work must be more or less of a hit-or-miss affair. It cannot be so organized that the greatest effort is expended where the greatest need exists.

The physician who fails to report typhoid cases is guilty of neglect which may result in the infection of persons who might otherwise have been protected.

Protect Vacationists Vacation trips are a fruitful source of sumfor Sake of Community mer typhoid. Persons going to summer

resorts are often exposed to typhoid infection from impure water or other imperfections in sanitary safeguards.

The vacationist rarely knows of the danger to which he exposes himself in going to a given resort. He has selected the place because the fishing and bathing were good or because the climate was pleasant, rather than because he found it to be a place where sanitary regulations were effectively administered and his health thereby protected.

This being the case, the vacationist should receive some attention from his health officer at home before he leaves on his trip to lakes, mountains or shore. Effort should by all means be devoted to guarding him against typhoid fever, since it is the greatest of the disease dangers he will face and the one most easily to be warded off.

Anti-typhoid vaccination is the surest means of protection for the vacationist. He is going into unfamiliar surroundings, where he must accept conditions which exist and are beyond his control. If the water is contaminated, he may not be so situated that he can boil all he uses. He will probably not know from where his milk supply comes. He will be unable to solve the fly problem if he finds it to exist.

If he is vaccinated before leaving, however, he need worry but little about these matters. He can brave any dangers and be reasonably sure of coming home free from typhoid infection.

Urging anti-typhoid vaccination, however, is not the whole of the health officer's duty toward vacationists. Many persons will fail to heed this advice, however strongly it be put. For their benefit, educational measures must also be emphasized. They must be taught wherein lies the danger of the summer resort, and should be urged to inquire in advance into the sanitary aspects of the place they intend to visit. The need for knowing the facts about sewage disposal, water supply and milk supply and for avoiding places where any of these appears to be dangerous must be made apparent to them.

Protect the vacationist, not for his own sake alone, but also to prevent him from bringing typhoid back to his home community and endangering his neighbors.

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“Community Health Is Does it pay to have a full-time health a Purchasable Commodity" officer? This is the question asked by

the Monthly Bulletin of the California state board of health, and answered with the following array of facts:

“Palo Alto, California, with a population of 6,000, has a full-time health officer. The Palo Alto death rate is about one-half that for the state. Since 1911, in this city, there have been no deaths of infants under two years of age from diarrhea and enteritis. During the same period the deaths of no less than 5,528 infants under two years of age, in California, were due to this cause. The health department of Palo Alto cost $3,310 last year — 56 cents per capita. At the beginning of 1918 there were three known cases of tuberculosis in Palo Alto, There was not a single case of diphtheria there during 1917."

Would it be worth 56 cents per inhabitant to your community to have such a record to present to the world?

Baby Needs Protection Public health workers who are interested Against Summer Diarrhea in the campaign to lower infant mortality

must busy themselves this summer in efforts to lower the appalling yearly total of deaths from diarrhea,

the greatest scourge of babyhood.

More babies healthy at birth die of diarrhea than from any other single cause. This situation can readily be improved, largely through educating mothers in proper care of their babies.

The baby should be breast-fed and must be protected from the heat, if it is to be kept out of grave danger during the summer months. These two facts must be constantly and emphatically kept before the notice of mothers.

The chances the breast-fed baby has of escaping summer diarrhea are infinitely better than those of the bottle-fed infant. For the protection, so far as possible, however, of the many infants who will be bottlefed, for one reason or another, despite this warning, rules for bottlefeeding must be expounded. Proper modification of milk under the physician's direction, use of milk of known purity and thorough sterilization of bottles and nipples are the principal considerations under this head. The ice supply must also be watched.

Protection from the heat is largely a matter of clothing. Most mothers put too much clothing on their babies. They must be educated up to a recognition of the fact that light clothing is perfectly safe and desirable. Frequent bathing, avoidance of the direct sun and provision of a plentiful supply of fresh air must also be urged.

Finally, mothers must be taught that if the baby develops diarrhea despite these warnings, immediate consultation with a physician is essential. “Proper treatment at the beginning of a diarrheal attack,” a recent discussion of the subject has said, “is worth more than many days' treatment later. Competent physicians, not gossiping neighbors, know what is best for the baby”

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