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America by any other authority than that of the board of health, and that upon the basis of conserving public health. Without such supervision, however, our laws regarding the number of cubic feet required for each occupant are dead letters. It further is a question whether, except in a few large cities, the inspection of tenements might not wisely be transferred to the health department. In New York, a movement is now being initiated to combine the building department and the tenement house department.
Admittedly the enormity of the area and the population in New York makes it extremely difficult to effect such a combination of the health department and the tenement house department, but the failure to inspect carefully one and two family dwellings, which should house, in most American cities, the largest proportion of the population is disastrous in its consequences and it is imperative that the same careful supervision be exercised over all dwellings.
In conclusion boards of health have a most important duty to secure the demolition of unsanitary tenements and areas. Among the lasting disgraces of our American cities are the perpetuation of unsanitary areas and death traps which we euphemistically call "taxpayers," although they are really murder pests. The board of health should have much more extensive authorities to enforce the demolition of such areas.
It will be apparent that I would not in any way restrict, as seems to be the tendency of Dr Soper, the functions of the department of boards of health, but would greatly increase their scope of preventive effort.
CONCLUDING Remarks of DR. SOPER Several interesting matters have. been dwelt upon by the gentlemen who have contributed to this discussion and a few remarks concerning the points raised may profitably be made in conclusion.
Dr. Abbott has forcibly emphasized the desirability of covering well the essential work which boards of health must do to prevent disease and has well said that all other work must be made subsidiary to this. Such undertakings as the prevention of unnecessary noise and smoke, important though work of this kind is, should not be done by boards of health at all, or, at least, not until the safeguards raised against the commonest and most conspicuous dangers to health have been made efficient. It is unwise to require health authorities to extend their operations into fields of doubtful health significance, and they should be slow to accept such duties. Many common nuisances are as certainly preventable through the operation of other agencies, as, for example, the police department, as through a public health bureau. This view appears to the author of the paper to be eminently sane and worthy of acceptance as a principle of governing importance in public health administration.
Dr. Edwards has drawn attention to the increasingly favorable attitude of society toward public health work and has pointed out that it is
desirable to carry on the campaign against disease in a quiet as well as efficient manner. He well says that nothing of the mysterious or spectacular should attach to public health work. He rightly considers that the day for dramatic action is past, together with the foolish superstitions with which disease was once regarded.
Dr. Edwards is one of those who consider that the public should be taken into the confidence of health officers to a considerable extent. The health authority should, he thinks, be a leader of public opinion and should be capable of imparting much genuine instruction of a sanitary nature. He rightly says that much of the evils which public health authorities are created to correct are due to ignorance, not wilfulness, and that it is the duty of health officials to dispel this ignorance by teaching the public the principles and methods of preventing disease. Naturally Dr. Edwards lays considerable emphasis upon the value of unofficial agencies in assisting public health authorities in preventing the transmission of disease. No better illustration could be given of the effectiveness of such coöperation than the work which is being done in Pittsburgh to assist the efforts which Dr. Edwards is making in his official capacity as head of the health bureau.
As to the wisdom of boards of health sharing with the public the duty of investigating and eliminating the causes of disease much, doubtless, might be said on both sides, but the opinion of the author of this paper is that active work of this kind should be done by the legally constituted health authorities and not by private citizens or societies. In so far as the work is of a practical sociological nature intended to raise the standards of living for moral and religious reasons as well as for health purposes, philanthropic societies and other associations of laymen may properly employ their energies for the public welfare, but where the question at issue is only, or chiefly, one of health, the health authority should in the author's view be in supreme and undivided possession of the field. In case the health authority is not capable, through want of knowledge or equipment to do the health work of a city the health department should be reorganized. If, as Dr. Abbott says, it is the first duty of a health department to attend to those questions which most certainly and directly affect health it is no less clear, in the opinion of the author of this paper, that the health department should do all of this kind of work which may be necessary.
Mr. Baker chooses for his chief consideration two points: What is the proper field of health board work, and, How should that field be divided between town, city, state and nation? Mr. Baker agrees with Dr. Abbott that the proper work of boards of health is often not clearly understood by the public or by the boards themselves, and is apparently inclined to attribute much of the inefficiency of public health machinery to this fact and to the employment of untrained men in the technical positions. With this view the author is in full accord.
Most of Mr. Baker's discussion of the paper hinges upon the proper
division of the field of public health work between municipality, state and nation. The state boards, he considers, should be advisory, regulative and supervisory in character. They should establish standards of practice and efficiency for local boards to follow, to the end that the work of protecting the public health may be more uniformly and efficiently done throughout the commonwealth. This is an excellent point. It is highly desirable in the author's opinion that uniformity should exist, both in the methods of carrying on public health work and in reporting statistics. The measures which state boards of health are now taking to bring about greater uniformity and efficiency among the local boards are producing results, but there remains much to be done. Local boards of health in small cities and towns are often very incompetent and in need of clear and specific instruction.
An important function of state boards of health, Mr. Baker considers, is the control of the design and operation of public works such as water supplies and sewerage systems. The purity of public water supplies he says is a state problem usually beyond the jurisdiction of a single municipality and should be subject to regulation by a central authority. The author concurs in this view. In so far as questions of this kind can be regulated by the state it is obviously wise to have them so controlled. Where state boundaries make this form of management impracticable, it would seem that national supervision or a mutual agreement between the states concerned should be effected; in fact, something like an agreement between the states of New York, New Jersey and Pennsylvania is said to exist at the present moment with respect to the pollution of certain interstate waters.
Water supplies and sewerage systems, although good examples of subjects suitable for state regulation, are scarcely more important than milk supplies and other supplies of food. Quarantine does not seem to the author to be a proper subject for state control except as it relates to the quarantine of one city against another—a rare and exceptional possibility. In general, quarantine should be managed by the government.
Mr. Baker makes a plea for national regulation of certain health matters and gives reasons for his belief that such supervision is desirable. Just what form he would have the national health bureau take he does not specify, nor is it important that this should be mentioned in the discussion. The supervisory and regulative control which a national health bureau could exercise over the various state health organizations and its educative powers would undoubtedly be of much value.
Reviewing as a whole the remarks of the persons who have discussed this paper, and keeping in mind the opinions of his own which the author desires to bring out, the following matters are noted:
Greater efficiency is needed in the administration of public health work. This is required not because there exists an alarming prevalence of transmissible disease, but becaus is very bvious that better work can be done. The opportunities which exist and the promise of reward which
would follow the employment of more effective methods of doing public health work were plainly apparent in the remarks of all who have contributed to the discussion.
It is agreed that greater efficiency does not mean greater publicity for the achievements of the health bureau, nor does it mean greater hardship to individuals or the public at large. Greater efficiency means a clearer knowledge of the work to be done and better ability to do it.
It is as important to know what to avoid as what to undertake. The more simple and direct work of preventing disease is the first duty and this should be done well before anything else is attempted. The board of health should, as far as practicable, do all the public health work of the city. Well trained men are indispensable for there is much technical work which cannot properly be carried on without them.
The city, state and nation each has separate functions and duties to perform in protecting the public from necessary sickness and premature death. These several fields of work are definite and are becoming better understood.
The public, by gaining a more enlightened knowledge of the principles and laws affecting the protection of health, is capable of materially lightening the work of health officials. Charitable and philanthropic societies and associations of business and professional people can help health authorities in various ways. But they should never do essentially public health work. The constituted health authorities should be capable of fully occupying this territory.
In the past years many important sanitary reforms have been initiated by philanthropic agencies and it is common at the present time for associations of business men to take the initiative in bringing about sanitary improvements. Theoretically it should not be necessary, with efficient public health work, for outside agencies to act, but practically, as boards of health now exist often with inferior equipment and inadequate public support, it is frequently necessary that public opinion should be roused by other forces than the health authorities.
It cannot be too strongly stated that the work of boards of health is to protect the public health. No health organization should be used to further a campaign against smoke or noise or billboards or other common nuisance. Recourse for relief from these discomforts should be sought elsewhere. Health officials will find their time fully occupied if they keep up with the growing demands which are made upon them in the direct and narrow line of their duty and employ the latest scientific methods for the prosecution of their work.
THE CHAIRMAN: there is no other discussion upon this subject as at present given we will adjourn until eight o'clock this evening to meet at the Second Presbyterian Church.
The joint meeting then adjourned.
Monday Evening, November 16, 1908, 8 p.m.
The second session of the League was held in conjunction with the American Civic Association in the Second Presbyterian Church of Pittsburgh on Monday evening.
The meeting was called to order by Robert W. DeForest, Esq., of New York City, former tenement house commissioner of New York and vice president of the New Jersey Central Railroad.
MONDAY EVENING SESSION.
THE CHAIRMAN: It becomes my pleasant duty to open this meeting very briefly.
What is the
MR. DEFOREST: When I was a boy there was a game of questions, called "How do you like it? where do you like it? and when do you like it?" I do not propose to put any of these questions now with regard to the Pittsburgh Survey, because none of you as yet are in position to answer them. I do propose, however, with myself to play a somewhat similar game which may be entitled What is the Pittsburgh Survey? Why is the Pittsburgh Survey? and, How has the Pittsburgh Survey been brought about?
What is the Pittsburgh Survey? It is a close range investigation of conditions of life and labor in Pittsburgh as a typical American industrial city, and it is a study made by many of the best equipped and most experienced social workers in the United States. Its results will be summarized in several numbers of Charities and The Commons to be issued during the winter, and will be later published in book form by the Russell Sage Foundation as one of its series of educational publications. The book will be somewhat analogous to that of Mr. Booth on London.
Why such a survey? Because to improve the social and living conditions of the working classes in our industrial cities we must first know accurately what and why they are, as we find them.
Why Pittsburgh? Pittsburgh was selected for this industrial survey not because Pittsburgh needed any special treatment, surgical or medical— certainly not because Pittsburgh needed any absent treatment, but because Pittsburgh was the typical industrial American city, and because in Pittsburgh has been found a degree of local sympathy and cooperation without which such a study, no matter how satisfying to the curiosity, could have no practical results. As to practical results, I find myself quite in sympathy with the old woman who had a smoky chimney of long standing. "John," said she to her husband, "that chimney is smoking again." "Yes," said he, "that chimney should be investigated."! "John," said she, "what that chimney needs, is not investigating-it needs