Another nurse writes: "We shall soon be sending the 'Little Mothers' League' certificates for Dr. Freeman to sign. Some of my girls have written splendid essays on 'Baby Care or How to Keep the Baby Well.' We have helped to organize three parent-teacher associations this winter and while they are yet in infancy we hope that they will live and grow rapidly." Little Mothers' Leagues In many places where there are public health nursing centers, "Little Mothers' Leagues" are being established and the children are being taught how to care for a baby. The children are delighted to join these classes; and their new found knowledge is not limited to the children themselves, for it is taken back to the home and the parents. No one could estimate the value of teaching eighth grade and high school girls, who so often care for little brothers and sisters, the proper feeding of infants and simple rules of hygiene and health. Later when these children are real mothers they will not altogether forget the instructions received, and can take up their responsibilities with more intelligence than that which their parents possessed. A successful public health nurse reaches so many different groups of people in her work that her opportunities for helpfulness are very great. She comes in touch with women's clubs and other private organizations, with boards of health and boards of education, with life. insurance companies and social agencies, with city and county officials and chambers of commerce, with ministers, physicians and teachers. But best and most useful of all the nurse's opportunities is her welcome in the homes of the people. She gains this welcome through her services in time of sickness, through her interest in and care of the children of the family. Work in the Home Counts "A pure milk supply alone is ineffective; the milk station (in itself little more than a bait to attract the mothers) and its conferences and clinics are insufficient. It is the home modification of milk, according to an individual formula, that counts. It is the home visit that gives the nurse an opportunity to teach the mother practically and thoroughly the entire infant regimen and care and, at the same time, the hygiene of home and family and particularly the hygiene of pregnancy." Ohio's law in regard to the prevention of blindness caused by inflammation of the eyes of the newborn is closely patterned after the model law drafted by the American Medical Association and is said to be "one of the most advanced measures ever enacted in the United States for the prevention of blindness." According to this act, every case of inflammation of the eyes of the newborn must be reported immediately to the local health officer. If the case should come under the observation of a nurse, she too is responsible by law. for the reporting of the condition. If the afflicted baby should be in a family where a private nurse cannot be employed, the health officer is instructed to call upon the public health nurse if he needs help for the treatment of the baby's eyes. If the little patient should be in a locality where there is no nursing service, by telephoning or telegraphing to the State Department of Health, a nurse can be obtained to care for the baby's eyes and to teach the family the danger of the inflammation. Community's Responsibility If each community is to save its own babies and this seems a reasonable program, then the responsibility of providing the means of child welfare work goes back to each local community. A state or national department can arrange the program and stand ready to give advice to those who want it, but it cannot take the responsibility which belongs elsewhere. One important part of a program of child saving is supplying and employing public health nurses, for in the last analysis they are the workers who most easily and naturally reach the parents and the children. The Organization of a Municipal Bureau of Child Hygiene By Richard A. Bolt, M. D., Gr. P. H., Chief of the Bureau of Child Hygiene, Cleveland the factors entering into the infant welfare problem are not so simple as at first conceived. Organization implies a dynamic etc. We have come to realize that relationship of parts. In a biological sense it means a co-ordination of organs to perform a distinct service for the good of the whole. The environment in which the organization is to perform its functions will naturally determine its. structure. A very simple organization for child welfare may well meet the needs in a small homogeneous community. In a large city the hostile factors in the environment become more and more complex and call for other organs to cope with the situation. If space permitted it would be interesting and profitable to trace the various steps in the development of modern infant welfare work in our great cities. With our present organization the campaign against infant mortality has settled down to a steady push along the whole line. rather than in brilliant raids against "impure milk", poor housing, flies, Dr. Newman was perfectly correct when he said that the infant mortality in a community was the most sensitive index we possess of the social and economic conditions of that community. While milk stations and consultations for mothers rendered distinct service in educating the community to higher standards of milk for babies, it was early seen that without intelligent feeding directions of a competent physician and follow-up by nurses in the homes, much of the force in our infant work would have been lost. It was perfectly natural that the simplest factors in the infant mortality problem should first be met and largely solved. We are now face to face with complex social and economic factors which, under our present social organization, are extremely difficult to meet. The first thing for any community contemplating the organization of child. welfare work to do is to line up its local problems and face them squarely with well tested methods. The experience of other communities should be carefully studied. The infant welfare problems of small communities, or rural districts, must largely be solved by a co-operation on the part of interested individuals and existing private philanthropies. The public officials, too often apathetic, may be awakened slowly if they are "shown". In a large city like Cleveland the organization of a Bureau of Child Hygiene must be planned upon broad lines. Such an organization will not be an overnight growth. Many of the parts which are now so well integrated were adjusted only after much experiment and painstaking endeavor on the part of philanthropic individuals or societies. It is often the history of infant welfare work that three or four organizations carrying on cognate lines of work for children gradually converge until their functions blend and a new organization becomes inevitable. This has been the case in Cleveland, where the pioneer efforts of the Milk Fund Association, the Visiting Nurse Association and the Infants' Clinic resulted in the organization of the Babies' Dispensary and Hospital. A decade of education along child welfare lines in Cleveland has convinced the community that the municipality is largely responsible for the welfare of its children, and that the city should carry on definite work along preventive lines for its babies and older children. To carry out the most effective work in large centers it is essential that the work be centralized in a Bureau or Division of Child Hygiene under the Division or Board of Health. The administrative head should be a chief on full time who is directly responsible to the commissioner of health. It is desirable that the chief of the bureau be in close touch with the health educational work of the community, and active in the instruction of physicians and nurses along child welfare lines. The further a Bureau of Child Hygiene can be removed from any political influences the better for the community. It would be ideal to have every member of the bureau working under efficient civil service. In order to keep in touch with the daily work in the infant welfare centers throughout the city it is advisable to have an assistant chief who could devote a large share of his time to visiting the centers. The backbone of any infant welfare organization will be well trained physicians and nurses with a "vision" as well as a "feeling" for social service. The importance of training physicians in modern methods of infant feeding and child hygiene cannot be over-estimated. The public health nurses should be on full time and, whether doing "generalized" or "specialized" nursing in the the districts, should be kept in touch with advances in the work by courses of lectures. With a good corps of nurses and physicians, and an adequate office force to keep up the records, the following organization of departments under the Bureau of Child Hygiene should meet the needs of a modern city: 1. Infant Welfare Centers as integral parts of the health centers. in each health district, to be equipped as prophylactic babies' dispensaries for weighing babies, keeping careful records, examination by physicians, directions as to feeding and general hygiene of infancy. Public health nurses in attendance who follow the babies in their homes. Milk prescribed from the centers. These centers could also be used as diagnostic clinics. All ill babies to be referred to private physicians or suitable hospitals and dispensaries for treatment. 2. A Department for the Inspection and Supervision of Midwives. One nurse should be placed in charge of this important work. All problems coming up in regard to illegal practice should be taken up with the chief of the bureau or commissioner of health. 3. Department for the Prevention of Infant Blindness. Special nurses should be delegated to this work. The number of nurses will depend upon the size of the community and the character of the physicians and midwives in it. 4. Department of Boarding Homes for Babies. At the present time this department is a necessity in every large cosmopolitan city. One or more nurses should be assigned to make investigations of boarding homes and keep in very close touch with them. Co-operation with the Humane Society, or other agencies receiving young children, is essential. It may be wise, as we have thought in Cleveland, to combine. the work of (2), (3) and (4) into one Department of Eye, Midwifery and Boarding Homes for Babies. 5. Some department or individual who can check up on the Milk Supply going to the babies in the infant welfare centers. Medical Inspection and examination of all school children. In Cleveland the medical inspection in the public schools is carried out through the board of education. The public health nurses under the Division of Health, however, inspect the children in seventeen parochial schools. 7. Sanitary and hygienic supervision of institutions taking dependent or delinquent children, or of day nurseries. While this is not carried out in Cleveland to any great extent at present, it is felt that this phase of the work should be developed. 8. A Department of Maternity Welfare or Prenatal Care for the examination and instruction of mothers, or expectant mothers, is absolutely necessary if we are going to make any impression upon the appalling number of deaths during the first days of life. Cleveland is just beginning this important piece of work. In all of our organization it should never be lost sight of that the Bureau of Child Hygiene is simply one of a number of bureaus operating under the Division of Health for the welfare of the community. The Bureau of Child Hygiene must constantly co-operate with all the other bureaus. Its aims and problems should frequently be discussed with the other bureau heads. It is furthermore necessary never to get out of touch with private philanthropies and other organizations doing similar work for children of the community. The closest possible co-operation should be cultivated with babies' dispensaries, mothers' clubs, Federation of Women's Clubs, the public schools, etc., etc. After all it is the community which needs and demands the sort of work the bureau is attempting to do, and the community should accordingly be educated to back up this work. Child Hygiene Activities of Municipal Health Departments of Ohio What is being accomplished by Ohio cities which have organized work in child hygiene under bureaus within their municipal health departments is outlined in the series of accounts for separate cities presented herewith. The information contained in these sketches was furnished by health officials of the cities in question in response to requests from the State Department of Health. Dr. Richard A. Bolt's article on "The Organization of a Municipal Bureau of Child Hygiene," contained in this issue, while it deals with such organization in general, yet touches in some detail upon Cleveland's activities. For other cities the accounts follow: A REVIEW OF CHILD HYGIENE DURING THE PAST Abstract of a Report by W. H. Peters, M. D., Chief Medical Inspector, |