TABLE I. SMALLPOX. REPORTED CASES AND DEATHS, OHIO BY YEARS, 1912-1917, AND BY MONTHS OCTOBER, 1917–MAY, 1918. the disease, but only a normal monthly figure for Ohio, making allowance for the state's toleration. For October, however, 510 cases were recorded, more than doubling our tolerated normal. Monthly totals continued to increase until in January 2,009 cases were reported. The decline since January has been gradual as shown in Table I, giving the number of reported cases and deaths by months during the present epidemic, epidemic, 10,103 cases and fourteen deaths, together with reported cases and deaths by years 1912-1917, a grand total of 29,008 cases and sixty-two deaths for Ohio in six years and five months. Assuming twenty-one days as a minimum for illness and quarantine in each reported case, 609,168 days or 1,669 years of normal activity were squandered by residents of Ohio during the period because they preferred smallpox to vaccination, preventable illness to health. Such a state record cannot be proclaimed today as patriotic. The accompanying diagram indicates quickly the unusual prevalence of smallpox within the past nine months. June's record is already high above the tolerated normal. Before the epidemic ends. over 12,000 persons will have suffered from smallpox since October 1, 1917. From the date of our entrance into the war to June 15. 1918, 10,903 persons in Ohio are known to have had smallpox, entailing a loss of 20,000 days or 630 years of work at low estimate. To bring home with greater reality Ohio's investment in smallpox, an attempt was made to procure statements of actual expenditures of local communities. Α questionnaire was sent to health officers in epidemic centers in twenty counties and to health officers of our five largest cities. Looking at Table II, listing the results of inquiries in the five cities, our failure to secure complete information is quite evident. Columbus and Toledo did not supply any information as to public ex * Less complete than records for succeeding years. penditures. Cleveland gave only an estimate with this explanation: "The reason I am unable to give you this accurately is because some of the cases have been taken care of at the city hospital, some at the pest house at Warrensville; here we furnish an attendant at seventy dollars a month and a cook at sixty-five dollars a month, and the food is furnished through the workhouse." The per capita expenditure for Cincinnati and Dayton differs by $6.45. Since hospitalization of cases is the practice in Cleveland as in Cincinnati and Dayton, the estimate cited for Cleveland is probably far from the actual cost and places the average of $14.81 much too low for the 1,162 cases in the three cities. Using the per capita cost of cases in Cincinnati and Dayton, $34.99, the probable public expenditures in the five cities for the 1,573 cases would total $55,039.27. If our larger and better organized health departments are not yet keeping books on a business basis, it is to be expected that the bookkeeping of health officers in the smaller districts could not supply the information required in the questionnaire. A bill of $38,780.68, however, charged to the account of 3,151 cases of smallpox is shown in Table III, summarizing the incomplete statements of public expenditures in the twenty counties. In the same table, the distribution of this expense is given by counties with the cost per county showing a variation from $36.75 in Stark County, reporting $4,961.72 spent on 135 cases, to $2.15 in Allen County, which reported expenditures of $349.78 for 162 cases. The average expenditure reported for the 3,151 cases in the twenty counties figures $12.31 per case. These cases were for the greater part handled without hospitalization, being located outside of cities with hospital facilities, Akron's six months' total of 571 cases not being included, for instance, in figures for Summit County. How the thirty-nine thousand dollars (round figures) was invested in the twenty counties is shown in Table IV. The sum reported spent for TABLE II. SMALLPOX. REPORTED CASES AND CASE RATES, WITH REPORTED PUBLIC EXPENDITURES, OCTOBER, 1917-APRIL, 1918, IN FIVE LARGEST CITIES OF OHIO. * Cleveland submitted an itemized estimate and Columbus and Toledo no information as to expenditures. TABLE III. SMALLPOX. SUMMARY OF QUESTIONNAIRE FOR REPORTED PUBLIC EXPENSE IN TWENTY COUNTIES. food is more than one-third of the whole bill, while medical and nursing attendance cost a thousand dollars less than food. Health officers reported a total of 568 families provided for at public expense, which makes the bill for food per family less than $23. The average length of quarantine reported by health officers for the 3,151 cases was twenty-five days, four days longer than the minimum used in estimating financial losses. At such figures, the 568 families were provided with ninety-two ninety-two cents worth of food per day per family. How much of this bill may have been illegally paid for families able to provide for themselves during quarantine has not been determined. In answer, however, to the query in the questionnaire, "How many quarantined families were in such financial condition that they were unable to pay expenses?" health officers stated 515, or fifty-three families fewer than were reported to have been provided with food. Considering the many complaints of broken quarantine made to the State Department of Health by persons who demand the placing of guards rather than protect themselves by vaccination, eitherthe reported expenditures of only four thousand dollars for guards is too low or guarding smallpox patients is a poorly paid occupation. It is to be hoped that on the * Estimate on basis of eighteen days' work lost at two dollars per day wage for all reported cases over eighteen years of age. whole the $4,200 for fumigation was more wisely invested than the $14.40 reported spent by one health. officer for candles for fumigating in eight cases in four families. This same health officer reported. a donation of $75 towards expenses by a business concern, the amount to be subtracted, although expended, from the total of $541.01 for the eight cases, one of the highest statements of cost per case submitted, $67.63. For these eight cases, $154 was spent for guards and less than five dollars for free vaccination. The last two columns in Table III attempt to reach an estimate of loss of earnings for cases over eighteen years of age. Counting eighteen working days at the minimum of two dollars per day wages, the amount is $62,352, too large a sum for twenty counties to lose in six months from an easily preventable cause, and yet an absurd understatement considering the value of a day's work to the state and nation at this time. Adding the $38,780 reported expended and the $62,352, SQ conservatively figured for lost work, $101,132 were invested by the twenty counties in the six months for 3,151 cases of smallpox, deaths and community unrest being wholly ignored. The same counties, however, reported 4,389 cases during the six months, the difference of 1,238 cases to be accounted for by health officers failing or being unable to fill in the questionnaire. Figuring on the same basis for the 4,389 reported cases as for the 3,151 cases covered by the questionnaire, the total investment by the twenty counties increases to $144,252 for the six months, $24,042 for one month's average. $1,200 per county per month. If the twenty counties had expended $1,200 a month each for the services of well qualified health officers with nurses and other assistants, the return on the investment would not have been smallpox. If a public health bill should be presented at the next legislature to provide efficient public health administration at a cost not to exceed the investment in smallpox, how many petitions for the passage of such a bill would be forwarded from the twenty counties? With twenty counties tolerating smallpox for six months at a cost of over $140,000, conservatively figured, what was expended by Ohio's eighty-eight counties from the first of October, 1917, to June 15, 1918, eight and one-half months? The sum exceeds $360,000 on the low basis of the reported expenditures in the twenty counties and the minimum wage loss of two dollars per day for eighteen days for all cases over eighteen years of age. If the case cost in the cities prevailed in other sections of the state the total reached $620,000 for the eight and one-half months with every indication of a million-dollar investment by the end of a year. What are the returns upon this investment? At least 16,000 persons in the state have secured immunity from smallpox for the rest of their lives by enduring illness and quarantine because of a loathsome disease rather than submit to the slight discomfort of a clean vaccination. Health officers reported in the questionnaire an average of three exposed persons vaccinated for each case reported upon, 9,586 vaccinated exposures for the 3,151 cases. At such a rate, 48,000 exposures were vaccinated and have secured immunity by a much cheaper and more desirable method than the 16,000 persons who were the source of exposure. To be added to this total of 64,000 immune persons are the thousands tens of thousands, let us hopewho had the wisdom to be vaccinated or revaccinated when the disease became prevalent in their communities. This form of dividend can be over-estimated, however, since the questionnaire revealed 473 exposed persons who refused to be vaccinated, 4 percent of reported exposures, and 639 secondary cases who neglected vaccination even after exposure. S. K. Nothing new can be added to what has already been written relative to the control of smallpox; neither can anything additional be said as to why it has been and now is prevalent. To take up the transmission, diagnosis and prevention of the disease in any extended form would be repeating what has been said many times before. The value of vaccination as a preventive measure has been so long and so thoroughly established that only a very few need convincing and it would be foolish to try to convince them. The importance of isolation, quarantine and concurrent and terminal disinfection in controlling the spread, not only of smallpox but of other communicable diseases, is so universally accepted that further discussion would be useless. Some of the causes given for the prevalence of smallpox in Ohio are: first, many cases do not require a physician's aid; second, many physicians are misled by the mild character of the disease; and third, the people do not dread the present form enough to guard against it by vaccination. These different causes might be discussed in detail but most of Ohio has knowledge by actual experience that these statements are true. However, despite the many reasons which may be and have been given-carelessness in quarantine and other lax measures of control of which many inexperienced health officers have been guilty, there is only one good and sufficient reason for the prevalence of smallpox in Ohio and that is lack of vaccination. Knowing that vaccination is the method for the control of this easily prevented disease and knowing that the public in general cannot be convinced by mortality records, which are comparatively insignificant in the present mild form of smallpox, the writers have aimed to prove by the foregoing statistics that there is another important factor in considering smallpox: the economic loss to each community where the disease is prevalent. Local health officials will be able to find much that is startling in the statistics which are presented herewith. Realizing the importance of vaccination as a means of preventing smallpox and knowing that smallpox does cause suffering, that it has caused deaths and that the data given shows evidence that it is expensive, why should health officials |