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The Cape Cod Project.

The cooperative rural health work begun in May, 1921, under the direction of a whole-time district health officer, in 10 of the 14 towns (townships) in Cape Cod, Mass.,5 has been continued satisfactorily. The funds provided from the 11 towns participating in the project and expended for the support of the work in the fiscal year 1923 aggregated 8(5,705.76 as against $5,100 provided from town sources in the first year of the activity. This project has furnished probably the severest test of the cooperative rural health work system. Cape Cod is one of our oldest and most conservative communities. The town is a distinct and zealously guarded political unit. Under the town system of government an appropriation, such as that for the health work, can be made only under a practically unanimous consent agreement of the citizens. For 10 or more of these towns to remain in partnership, pooling their appropriations for the support of a unified district health service for a period of as much as three years, is indicative of the sftundness of the plan of the cooperative rural health work and the popular approval which may be secured by a proper execution of the details.

Special Demonstration Work in Virginia Counties.

The plan of special demonstration work in rural sanitation which was carried out in Virginia in 11 counties in the fiscal year 1920, in 10 counties in the fiscal year 1921, and in 14 counties in the fiscal year 1922, was carried out in 12 counties" in that State in the fiscal year 1923. This plan, which has been described in previous reports,7 continues to prove highly successful. After four years' trial it appeal's to meet better than could any other plan yet proposed the situations in rural counties in which effective health work, if begun at all, must be started on a low-cost basis, and in which outdoor sanitary measures, such as control of soil pollution, protection of domestic water supplies, and control of mosquito breeding, are especially indicated in the beginning of the local program of rural health work. In the average of the 12 county projects in the fiscal year 1923 the total cost of the services of the county sanitary officer was about $2,740. Based on very conservative estimates the saving to the county in dollars and cents as a result of the services of the sanitary officer amounts as a rule to more than ten times the cost of the services.

»Reprint No. 699, from Public Health Reports of Oct. 7, 1921, pp. 11, 12, and Reprint No. 788, from Public Health Reports of Sept. 29, 1922, p. 14.

•Carroll, Charlotte, Chesterfield, Grayson, Greensville, Henry, Mathews, Prince Edward, Pulaski, Roanoke, Smyth, and Wythe.

'Reprint No. 615, from Public Health Reports of Oct. 1, 1920, pp. 10, 12: Reprint No. 699, from Public Health Reports of Oct. 7, 1921, pp. 12, 14; and Reprint No. 788, from Public Health Reports of Sept. 29, 191% pp. 14-17.

The sanitary progress made in the average county in which a whole-time sanitary officer has been engaged for a year or more is remarkable. By the end of the fiscal year 1923 sanitary toilets had been installed at all of the public schools in 3 of the counties, and at over 75 per cent of the public schools in 4 other of the 12 counties in which cooperative projects with the county sanitary officer were conducted during that year. Practically all of those public schools were either without toilets of any kind or were provided with grossly insanitary privies before the advent of the county sanitary officer. In each of 8 of the 12 counties more than 1,000 sanitary privies or septic tanks have been installed at private homes as a result of the strictly educational, persuasive, and practically helpful activities of the sanitary officer. In some of the counties in which typhoid fever and dysentery were veritable scourges every your before the establishment of the sanitary service the prevalence of these diseases has been so reduced that the occurrence of one case in a neighborhood now causes an acute and widespread interest in the possible source of the infection, quick action to secure needed sanitary improvements at the afflicted and near-by homes, and hurry calls for antityphoid inoculation of persons in the vicinity. In one of the larger counties (Chesterfield) in which a sanitary officer has been engaged since 1919, not a case of typhoid fever was reported in the calendar year 1922. In another county (Greensville.) a sanitary officer has been engaged since July, 1919, and good sanitary progress has been made. A hookworm survey made in that county in the summer of 1910 showed an infection of 65 per cent of the persons examined. A similar survey made in the summer of 1923 showed an infection of only 8.5 per cent. In four of the counties (Carroll, Greensville, Henry, and Pulaski) the deatli rate in 1922 from diarrhea and dysentery in children under 2 years of age was less than one-half of the rate for the State as a whole.

Since the inauguration of the plan of sanitary officer demonstration work in rural sanitation in Virginia (February, 1919) there has been no difficulty in finding in that State counties whose authorities are willing to make appropriations of county money to secure the cooperation of the State board of health and the United States Public Health Service in carrying out the demonstration projects. The boards of supervisors in a number of the counties, though compelled by economic conditions during the last two years to reduce or eliminate other expenditures, have voted unhesitatingly to continue the appropriations for the county sanitary officer service. Whenever the work has been discontinued in one county, one or more counties have been ready with county appropriations to take the place of that county on the cooperative list. Tims the funds available to the State board of health and the United States Public Health Service for the cooperative demonstration projects in rural sanitation in Virginia are always spread as far as they will go. If the combined funds of the State and Federal cooperating agencies were adequate to meet as much as two-fifths of the total cost, it is probable that whole-time county health service could be developed within a short time in a large majority of the counties in the State which are not now provided with such service. An offer from the central health agencies to supervise and financially assist in the supfwrt of the work is a potent factor in the persuasion of the average county board of supervisors to make an appropriation for whole-time county health service. Without such cooperation from the State and Federal health agencies satisfactory progress in county health work is not to be expected in Virginia or in any of the other States.

GENERAL PROGRESS IN RURAL HEALTH WORK.

Substantial progress was made in the development of whole-time rural (county) health service in the United States during the fiscal year. According to data 8 collected by the Rural Sanitation Office from the State health departments, the number of counties, or equivalent divisions, provided with local health service reaching all rural sections thereof, under the direction of whole-time county or district health officers, was 231 at the beginning of the calendar year 1923, as against 203 at the beginning of the calendar 3rear 1922, 161 at the beginning of the calendar year 1921, and 109 at the beginning of the calendar year 1920. The gain of 122 within this three-year period signifies that the cooperative demonstrations in rural health work, though as yet lamentably small in number, are making some impression upon the general situation.

Among the States in which whole-time county health service has been inaugurated within the last few years and in which good progress has been made are West Virginia and Missouri. In each of these States an officer of the Public Health Service is detailed to cooperate with the State board of health in the development, study, and supervision of whole-time county health service.

In West Virginia, during the fiscal year 1923, whole-time county health service was established in four additional counties, Hancock, Marion, Preston, and Taylor; and appropriations were made for such service by the county authorities in two others, Gilmer and Harrison, in which the work is to be started as soon as suitable personnel can be found for the positions.

The following statement prepared by Passed Asst. Surg. Thomas Parran, jr., who has been detailed since November, 1919, to cooperate with the State board of health in the development and supervision

■ Rcpriut No. S33, from Public Health Reports of Apr. 27, 1923.

of cooperative county health projects in Missouri, presents an account of progress in that State and some details illustrative of frequent occurrences in the course of rural health work generally.

STATEMENT OF RURAL SANITATION ACTIVITIES, STATE OF MISSOURI, FISCAL YEAR ENDING JUNE 30, 1923.

HISTORICAL.

The United States Public Health Service undertook cooperative rural sanitation work in Jasper and Greene Counties in 1920. Prior to that time there was no wholetime health service in any county of the State.

In April, 1921, the State legislature made an appropriation to the State board of health for rural sanitation service of $20,000. In June of that year a rural sanitation division was created, an officer of the Public Health Service was appointed director, funds were allotted from the Public Health Servico and the International Health Board, and the organization of additional county health departments was begun. During the fiscal year 1922 health departments were organized in six additional counties (Nodaway, Pettis, Polk, (ape Girardeau, Monroe, and New Madrid). These were supported to the extent of at least one-half of their budgets by the county, the remainder being contributed by the State, the Public Health Servico, and the International Health Board.

ACTIVITIES DURING FISCAL YEAR 1923.

During the fiscal year just ended additional health departments were organized in four counties (St. Francois, Dunklin. Gentry, and St. Louis), and operations were terminated in three because of unsatisfactory local conditions. The reasons for termination of the work in these counties may be given. In one county the health officer, who previously was the part-time county physician, proved to be incompetent, and the county authorities refused to allow the State to select a trained man from outside the county.

In another county the opposition of influential members of the local medical profession led to a refusal of the county authorities to renew appropriations, in spite of very efficient work on the part of the health department. This opposition was based upon fear that this work was "an entering wedge for Stato medicine,'' and ''usurpation of authority" by the health officer in enforcing State regulations for the control of communicable diseases—a function previously performed largely by individual practitioners to suit their own or their patient's whims.

In the third county work had been carried on with a director having, because of local political conditions, an unsatisfactory status for nearly three years, and in January, 1923, the county authorities refused to renew appropriations. This refusal was due primarily, it is believed, to the fact that the director of the unit was not the county health officer, and as a result the work could not be made as effective as has been possible in other counties.

In the remainder of the counties reaporopriations were secured and budgets equal to, or greater than, those previously available were provided. In several of them the county authorities have stated that they would, if necessary, try to appropriate enough money to bear the entire expense of the work.

The general conclusions drawn by this office, both from the successful and the unsuccessful demonstrations, is that a county health unit should not be started unless the director of the unit is appointed as the county health officer, and unless the county itself makes an appropriation for the work. If for any reason active cooperation of the county authorities and the public is not continued, operations should cease and a more favorable county should be selected for demonstration. 71227°—23 2

The activities conducted in the several health departments have been in accordance with the general plan in effect in other States, varied to suit local circumstances in the particular county. In some antimalaria work has been featured; in others, tuberculosis control; and in all a fairly comprehensive program for the control of contagion and in several the phases of child hygiene has been conducted.

Striking instances of accomplishment are too numerous to be fully reported. A few, however, may be of interest.

Greene County.—A reduction in the infant mortality rate in Springfield from 103 in 1918 to 61 in 1922 was recorded. Among other causes contributing to this were 1,146 examinations of infanta and 1,038 home visits of the nurses to promote infant hygiene. Four thousand seven hundred and forty-one treatments were given for venereal disease. One hundred and twenty-three tuberculosis cases were discovered and supervised and 37 placed in sanitariums.

Pcltis County.—One thousand two hundred and thirty-four treatments were given for venereal disease; regular baby clinics were held throughout the year, at which 771 infant examinations were made; defects of 625 school children were corrected.

Nodaway County.—A regular course in public health was given by the health officer to the students at the State teachers' college, with particular reference to the teacher's part in protecting and promoting the health of the school child. Marked reduction in prevalence of scarlet fever, a disease which had been highly prevalent in the county for a number of years.

New Madrid County.—Corrective clinics were held, at which 125 children were operated upon for tonsil?, adenoids, and other defects, and a total of 762 defects were corrected. This is especially remarkable in a county where there is not a hospital or a specialist to perform a tonsillectomy or examine for glasses. Sanitary privies were installed at 90 per cent of all rural schools.

St. Francois County.—Discovery was made of seven diphtheria carriers and several actual or incipient epidemics of diphtheria were terminated. Four hundred and forty-nine persons received antityphoid inoculations; 1,806 persons were vaccinated against smallpox, as a result of which, plus efficient quarantine, not a single secondary focus of smallpox occurred, whereas outbreaks of the disease occurred during every previous year for which records are available. Forty-three cases of tuberculosis were discovered and supervised.

Folk County.—This county offers a striking example of cooperation from the general public. It has been districted with local health committees, fostering the health movement in their respective communities. The child-hygiene program is complete and balanced. Every school child has been examined, and 806 children of infant and preschool age have come under the care of the health department. Immunization clinics were started during the summer and up to date 295 have received typhoid immunization. Fifty-one smallpox vaccinations were made and 86 diphtheria toxinantitoxin doses administered. All towns have recently passed a sanitary code, and, with the existing health machinery functions, a complete program of sanitation should be put in effect before the end of the coming year.

Dunklin County.—This county presented an unusual problem—malaria control. The county had for the past several years been carrying on a drainage project for agricultural purposes, so little further along this line could be urged. The solution of (he problem seemed one primarily of education; secondly, of better protection from Anophelfs: and lastly, adequate fumigation. A plan of education was instituted in all the schools, using the Carter Primer as a textbook and having the health officer or nurse supplement this instruction by actual field or classroom demonstration regarding the life habila of mosquitoes. Many of the educators have said that the children could pass a better examination on the mosquito and malaria than on most ol the subjects in the ordinary school curriculum.

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