Reports & Studies

The Committee on Economic Security (CES)

"Social Security In America"

Part V

THE EXTENSION OF PUBLIC-HEALTH SERVICES

The basic data for part V have been abstracted from (1) Staff reports on "Risks to Economic Security Arising out of Ill Health" (the sections on public-health services derived from this source were prepared by W. F. Walker and Ira Y. Hiscock under the direction of Edgar Sydenstricker) ; (2) A statement of Josephine Roche, Assistant Secretary of the Treasury, made on February 4, 1935, at the public hearing held by the Committee on Finance of the United States Senate; and (3) Regulations Governing Allotments and Payments to States From Fund Appropriated Under the Provisions of Section 601, Social Security Act, for the Fiscal Year 1936, Issued by the Surgeon General

Chapter XVIII

THE EXTENSION OF PUBLIC-HEALTH SERVICES

NO NATIONAL PROGRAM of economic security can be regarded in any sense as complete or effective without adequate provision for meeting the risks to security which arise out of ill health. Fear of sickness with its attendant loss of earnings when the wage earner is disabled and dread of the costs of medical care are specters which haunt the great majority of the American people. Economic insecurity from illness is not the consequence of a depression; it threatens people of small means even in good times. The problem is not created in a depression period; it is only exaggerated and made more severe.

Every careful study of the economic experience of wage-earning families has revealed the inadequacy of individual savings to afford full protection against the costs of ill health. Tens of millions of families live in dread of sickness. Millions of families that are independent and self-sustaining in respect to the ordinary, routine needs of life sacrifice other essentials of decent living in order to pay for medical service. Three possibilities are open to low-income families which suffer extensive illnesses: (1) they may go without needed medical care; (2) they may carry the burden of medical debts; or (3) they may rely upon the charity of doctors and hospitals, or receive their services from tax-supported and philanthropic agencies.

The annual money loss caused by sickness in families with incomes of less than $2,500 a year in the United States in 1929 was estimated as nearly $2,500,000,000. Of this huge sum about $1,500,000,000 represents the expenses of these families for medical care and about $900,000,000 constitutes their loss in wages resulting from sickness. The cost of care in sickness thus exceeds wage loss due to temporary disability. These figures are direct costs. They ignore the much larger costs of sickness represented by the losses in capital values of human life and the losses to commerce and industry.

These enormous losses are not distributed equally among the people. Some individuals have much more sickness than others in any given year. Actuarial experience shows that among an average million persons there will occur annually between 800,000 and 900,000

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cases of illness. This might seem to mean nearly one case of sickness to each person. Actually, however, the economic burden will fall more heavily on some than on others. For although 470,000 among an average million persons will not be sick during a normal year, 460,000 will be sick once or twice, and 70,000 will suffer three or more illnesses. Of those who become ill, about one-fourth will be disabled for periods varying from 1 week to the entire year. The situation may be visualized from the actual experience in normal times of 1,000 typical families in large cities, with annual incomes ranging from $1,200 to $2,000, as follows: 218 had medical bills in a single year in excess of $100, and 80 in excess of $200; of these 80 families 16 had medical costs ranging from $400 to $700, or about one-third of the year's income, and 4 families had sickness bills amounting to more than one-half of their incomes. All these costs were additional to wage losses. The situation in families with less than $1,200 annual income is far worse, even in normal times.

The fact must be faced that, even if a minimum annual income of $2,000 could be maintained through various ways for American families, this amount would still be insufficient to enable them individually to budget against the costs of sickness. A substantial proportion of families in cities, towns, and rural areas actually obtain no medical care, or receive insufficient care during sickness. It has been shown by surveys that the proportion of families receiving inadequate care is largest among those with small incomes and that, step by step, as family income increases the proportion of families with inadequate care diminishes. In normal times, about one-third to one-half of all the families who have to seek public or private charity are compelled to do so because of the economic effects of accident and illness.

Thus, the risks to economic security arising out of ill health are of three kinds, namely:

(1) Loss of efficiency and health itself, and thereby loss of the capacity to be employed;

(2) Loss of earnings caused by disabling illness among gainfully employed persons;

(3) Costs of medical care to gainfully employed persons and their families.

PREVENTION OF ILLNESS

As stated by the medical advisory board of the Committee on Economic Security: A logical step in dealing with the risks and losses of sickness is to begin in preventing sickness so far as is possible.

Much progress has been made in this respect, yet the fact remains that despite great advances in medicine and public-health protection,

millions of our people are suffering from diseases and thousands die annually from causes that are preventable. The mortality of adults of middle and older ages has not been appreciably diminished. With the changing age composition of our population the task of health conservation must be broadened to include adults as well as children.

Evidence is accumulating that the health of a large proportion of the population is being affected unfavorably by the depression. The rate of disabling sickness was found to be 48 percent higher among families having no employed wage earners in 1932 than in families having full-time workers. The group of workers that had dropped from fairly comfortable circumstances to relief rolls during the depression showed a rate of disabling illness 73 percent higher than that of their more fortunate neighbors who had remained in the comfortable class.{1} For the first time in many decades the annual death rate in our large cities has increased, the rate for 1934 being higher than for 1933 despite the absence of any serious epidemics.{2} Concurrently with these evidences of increased need, local appropriations for public health have been decreased on the average 20 percent since 1930. The per-capita expenditure from tax funds for public health in 53 cities in 1934 was 77.5 cents as contrasted with 93.8 cents in 1931.{3}

It has long been recognized that the Federal, State, and local governments all have responsibilities for the protection of all the population against disease. The Federal Government has recognized its responsibility in this respect in the public-health activities of several of its departments. There also are well-established precedents for Federal aid for State and local health administration and for the loan of technical personnel to States and localities.

A comprehensive, Nation-wide program of lessening the risks to economic security must include adequate provision of effective measures for the prevention of ill health through organized public-health work. The soundness of the principle of prevention is obvious. Its application here, however, should be viewed in the light of four other broad considerations, as follows:

(1) Although one-third of the burden of preventable illness and premature death has been lifted in progressive communities since modern public-health procedures were introduced, there is recognized opportunity for continued progress in this field. Only a fraction of the population has benefited to the fullest extent from the application of existing knowledge of disease prevention through public-health procedures.

{1} Perrott, G. St. J., and Collins, Selwyn D., "Relation of Sickness to Income and Income Change in 10 Surveyed Communities", Public Health Reports, vol. 50, no. 18 (May 3, 1935), p. 622.

{2} "Provisional Summary of Mortality Statistics for the United States, 1932, 1933, and 1934", Public Health Reports, vol. 50, no. 42 (Oct. 18, 1935), p. 1442.

{3} Walker, W. F., "Analysis of Public Health Expenditures by Geographic Subdivisions", American Journal of Public Health, vol. 25, no. 7, July 1935, pp. 851-856.

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(2) The policy of leaving to localities and States the entire responsibility for providing even minimal public-health facilities and services has failed in large measure. Only 21 percent (75{4} counties and 102 cities{5}) of the counties and cities of the United States have thus far developed a personnel and service which can be rated as even a satisfactory minimum for the populations and the existing problems. The Federal Government has a definite responsibility for the protection of all the Nation's population against disease.

(3) The responsibility of the Federal Government for national health is well established in the United States Public Health Service and in several other Federal agencies, such as the Children's Bureau, the Bureau of the Census, the Office of Education, the Food and Drug Administration, and the Bureau of Animal Industry. The precedent of Federal aid to States for State health administration and local public-health facilities also has been established in various laws for grants-in-aid and in loans of technical personnel to States and localities.

(4) Public health has been demonstrated as a sound economic investment. Public-health authorities estimate that our annual national economic loss in wage earnings and in other items incident to preventable sickness directly attributable to lack of reasonably efficient rural health service is over $1,000,000,000. On the other hand, where reasonably effective health programs have been developed, it has been demonstrated that expenditures for carefully planned health programs executed by trained workers yield large dividends. To fail to include the fullest possible use of this powerful preventive weapon in a program of economic security would be short-sighted-even stupid.

Little need be said with respect to the need for outside assistance to certain counties too poor to meet the entire cost of public-health service. In many of our States there are counties in which the taxable wealth or other source of revenue is so small that adequate local appropriations cannot be made for a health department without making the allotment for health out of all reasonable proportion to expenditures for other necessary functions of government. State health departments must give assistance to the counties in this group if the people in these communities are to enjoy the benefits of health protection to which they are--certainly from a humane standpoint--entitled as citizens of this country.

With regard to the need for outside aid for demonstration purposes, it is well known to all national and State agencies which have endeavored to promote the expansion of full-time health service in the past that it is almost impossible to induce local boards of county commissioners to make the initial appropriation for the establishment of a new full-time county health unit unless financial aid can be offered from an outside source. The reason is not hard to under-

{4} Freeman, A. W., M. -D., A Study of Rural Public Health, Service (The Commonwealth Fund, New York, 1933), and unpublished material.

{5} Public Health Reports, vol. 49, no. 5, Feb. 2, 1934 ; Committee on Administrative Practice of the American Public Health Service in cooperation with United States Public Health Service, "Municipal Health Department Practice for the Year 1923, Based Upon Surveys of the 100 Largest Cities in the United States", Public Health Bulletin. No. 164; Research Division of the American Child Health Association, A Health Survey of 86 Cities (American Child Health Association, New York, 1925).

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stand; health work, to a large extent, does not deal with material things. It has for its objective the prevention of catastrophe which may occur in the future. The wisdom of expending public funds for school buildings and roads and for maintenance of our schools is apparent to anyone, because, we see and use the buildings and roads and know that our children use the schools. Except to statisticians, who are trained to use death rates and other "measuring rods" for demonstrating the effectiveness of health work, the anticipated results of such work are often not tangible. It is difficult, therefore, to persuade local appropriating bodies to provide funds to support an activity the result of which cannot be readily demonstrated in advance of the expenditure.

The situation in many of our smaller cities, and in some of the larger ones, is almost as bad as that existing in a large part of our rural area. There are numerous urban communities throughout the country in which such health activities as are being carried on today are under the direction of part-time physicians engaged in private practice or lay health officers untrained in modern public-health administrative practice. In some of these communities such health protection as has been afforded has been largely incidental to improvements instituted for economic and esthetic reasons or to ready access of the population to good medical care rather than a credit to activity of the health department. In many of our cities the chief health department activity still consists largely in the inspection of private premises for nuisances having little bearing on public health and an attempt to control communicable diseases through quarantine procedure--admitted by leading health workers, in this day of scientific control methods, to be of little avail in reducing the incidence of such diseases. More specifically it may be pointed out that many of the milk supplies for urban communities are still far from satisfactory, and that the unsightly, open-back, unsanitary privy still exists in the outlying sections of most of our small cities, with the result that typhoid fever is rapidly becoming more prevalent in towns and small cities than in the rural areas.

Nor is the need for extension of public-health service confined to rural and urban health organizations. Not more than half of the State health departments are adequately staffed or satisfactorily equipped to render the service which they alone can give regardless of the extent to which local facilities may be developed. Specific reference is made to divisions of vital statistics, laboratories, and sanitary engineering service for the supervision of local water supplies, sewage disposal, and other environmental sanitation activities. At least a third of the States are not now able to promote the establishment of full-time local health departments or to give proper super-

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vision to local health work because of the lack of properly trained scientific personnel, capable of performing such duty, on the State health department staff.

Before any real progress can be made in the extension of full-time local health service, there must be created in each State a reserve of trained health officers, public-health nurses, sanitary engineers, and inspectors to fill the positions which will be established in the new units, for in spite of the curtailment of appropriations for health work in recent years there is a shortage of individuals trained for health work. Until the public-health service throughout the country can offer careers which will attract qualified workers and warrant specialized training in colleges, medical schools, and universities, it will be necessary to raise personnel standards gradually. Opportunities for graduate study, extension courses, and demonstrations under experienced officials offered to or required of personnel in office may serve to bring personnel standards to a level of good public-health practice.

PREVENTABLE DISEASES AND MORTALITY

While it is true that the general death rate and the rates for tuberculosis and infant mortality for the country as a whole declined to the lowest figures on record in 1933, we should not be misled by this fact into the belief that further safeguards of the Nation's health are unnecessary. These death rates do not tell the whole truth, Edgar Sydenstricker recently said: "The plain fact must be faced that notwithstanding great advances in medicine and public-health protection, the American people are not so healthy as they have a right to be. Millions of them are suffering from diseases and thousands annually die from causes that are preventable through the use of existing scientific knowledge and the application of common social sense." {7}

Ample evidence exists to support this sweeping statement. Approximately 120,000 infants under 1 year of age died in 1933. Although our infant death rate has been reduced by half during the past 25 years, many of the leading sanitarians in this country believe that mortality in the infant age group can again be reduced by 50 percent. It is also confidently believed by some of the leading authorities on tuberculosis that the 74,000 deaths which occurred from this disease in 1933 could again be cut in half; and there is good reason to assume that, with proper health protection for pros-

{6} Much of the factual data used in this chapter has appeared already in the statement submitted by Assistant Secretary of the Treasury Josephine Roche, to the Senate Committee on Finance, on Feb. 4, 1935. Economic Security Act: Hearings before the Committee on Finance, United States Senate, 74th Cong., 1st sess., on S. 1130 (U. S. Government Printing Office, Washington, D. C., 1935), pp. 374-407.

{7} Sydenetricker, Edgar, "Health in the New Deal," Annals of the American Academy of Political anal Social Science, vol. 176, November 1934, p. 131.

pective mothers, at least two-thirds of the 13,000 mothers who die each year in childbirth could be saved.

Examination of the following table, compiled by the United States Public Health Service from mortality figures of the United States Bureau of the Census, shows that, in spite of the low general death rate, a total of 246,272 deaths occurred in the United States from causes that may be classed as preventable.

Number of deaths in the United States from preventable diseases, 1933

Typhoid fever__________________________________________ 4,389
Paratyphoid fever______________________________________ 84
Typhus fever__________________________________________ 81
Undulant fever________________________________________ 72
Smallpox ______________________________________________ 39
Measles______________________________________________ 2,813
Scarlet fever___________________________________________ 2,546
Whooping cough_______________________________________ 4,463
Diphtheria_____________________________________________ 4,936
Influenza ______________________________________________ 33,193
Dysentery _____________________________________________ 2,814
Erysipelas _____________________________________________ 2,017
Acute poliomyelitis, acute polioencephalitis ________________________ 797
Epidemic encephalitis __________________________________ 1,357
Epidemic cerebrospinal meningitis ________________________ 1, 482
Anthrax _______________________________________________ 11
Rabies_________________________________________________ 65
Tetanus _______________________________________________ 1,253
Tuberculosis of the respiratory system ________________________ 67,417
Other forms of tuberculosis ________________________ 7,419
Leprosy ______________________________________________ 27
Syphilis _______________________________________________ 11,039
Gonococcus infection and other venereal diseases ________________________ 998
Purulent infection, septicemia (nonpuerperal) ________________________ 931
Malaria________________________________________________ 4,678
Other diseases due to protozoal parasites ________________________ 61
Ancylostomiasis ________________________ 20
Scurvy ________________________________________________ 28
Beriberi_______________________________________________ 1
Pellagra _______________________________________________ 3,955
Rickets ________________________ 339
Pneumonia, all forms___________________________________ 86, 947

Total____________________________________________ 246,272

Typhoid fever and diphtheria, both now regarded as diseases easily prevented when known control measures can be applied, each took toll of more than 4,000 lives. Measles and whooping cough, often regarded by the uninformed as simple and relatively harmless diseases of childhood, killed respectively 2,800 and 4,400 in 1933.

So far as the public was concerned, these appalling, unnecessary losses of life went unnoticed, because of the lack of spectacular cir-

cumstances attending their occurrence; yet, had similar losses occurred in a series of single disasters, such as an earthquake or the sinking of an ocean liner, the Nation would have been shocked and our newspapers would have carried front-page headlines for days.

Nor do deaths alone tell the whole story. It is estimated that for each death from typhoid fever there are 10 cases; for each death from diphtheria, 12 cases. Although accurate figures are not available with respect to cases of preventable diseases for the country as a whole (for the reason that reporting of cases is not complete where satisfactory health organizations do not exist), it is believed that a conservative estimate will place the number of cases of typhoid fever at 43,000, and of diphtheria at 58,800, in the United States in 1933.

A recent survey by the Public Health Service showed by actual blood test of only 200,000 people in 11 southern States a total of 14,000 known cases of malaria. This survey was made during the winter, when malaria is least active, and included only school children. It is estimated that in the whole population in the malarious section of the South there are, every year, at the height of the malaria season, probably 6,750,000 cases of malaria. Malaria is still one of the most serious problems of our southern States and further knowledge of control methods is imperative. Here again, the disease is not only of public-health importance but also of economic importance, for each year malaria puts the wage earner out of the position as the supporter of his family and makes both him and his family dependent upon charity for their maintenance.

Three-quarters of a million patients with syphilis seek treatment annually in the United States. Unfortunately, however, largely because they are ignorant of the nature of the disease, because the cost of treatment is high, or because facilities are lacking for the treatment at a cost that can be borne by the patient, more than half of these cases do not obtain treatment during. the first 2 years of their infection. This 2-year period is the interval of greatest communicability and is of vast importance in the control of syphilis. Adequate treatment during this time will not only prevent the spread of this disease but will also make possible the cure of the individual. For this reason it is of the utmost importance that adequate treatment facilities for syphilis be made available for all indigent and borderline economic cases in both rural and urban districts of the United States.

The same factors exist in connection with the control of gonorrhea as with syphilis. About 679,000 new cases of gonorrhea annually seek treatment in this country. This number does not give a true picture of the actual number of gonorrheal infections annually because many more patients with gonorrhea than with syphilis

fail to seek treatment. While the late and crippling manifestations of the gonorrheal process are not as marked as in the case of syphilis, the vast prevalence of gonorrhea makes the disease one of primary importance.

PAST AND PRESENT DEVELOPMENTS OF THE FEDERAL PUBLIC HEALTH SERVICE

The activities of the Public Health Service were established by successive laws enacted by Congress during the period 1799 to 1879. At the beginning of the year 1880 the Service was concerned with the conduct of maritime quarantine, control measures in the case of epidemics, establishment of quarantine regulations for the prevention of the introduction of cholera, collection of sanitary data and publication of the Public Health Reports, and cooperation with State and local authorities in the prevention of the introduction of infectious and contagious diseases.

Because independent studies of yellow fever and other diseases were made necessary on account of their occurrence in epidemic form and because it became apparent that provision should be made for conducting studies relating to public health, the Hygienic Laboratory was established in 1887 for investigations of contagious and infectious diseases and matters pertaining to public health. With the establishment of this laboratory the work of the Service in the field of scientific research had its definite origin. Scientific studies and investigations of yellow fever, cholera, malaria, tuberculosis, pneumonia, and the potency of various gaseous disinfectants were immediately undertaken. In 1901 a Hygienic Laboratory building was provided by act of Congress, and the main work was divided into the four large divisions: (1) Chemical, (2) biological, (3) pharmaceutical, and (4) pathological.

In 1901 the organization of a Bureau division of scientific research was effected. In 1902 another act of Congress required that establishments manufacturing biologic products be inspected by a medical officer of the Service and upon his report, when acted upon by the sanitary board of the Service, is based the decision whether establishments shall be granted licenses for the manufacture of these products.

The Scientific Research Division activities resulted in a gradual but steady increase in work. Among the projects undertaken up to 1912 were investigations into Rocky Mountain spotted fever, special studies of milk in relation to public health, studies of Mexican typhus fever, and sanitary surveys of pollution of navigable waters.

Long-time recognition of the need of additional authority to undertake systematic field investigations of scientific and practical public-

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health problems resulted in the act of Congress approved August 14, 1912, when the name Public Health Service was given to the existing services and the powers were broadened as follows:

The Public Health Service may study and investigate the diseases of man and conditions influencing the propagation and spread thereof, including sanitation and sewage and the pollution either directly or indirectly of the navigable streams and lakes of the United States, and it may from time to time issue information in the form of publications for the use of the public.

The enactment of this law marked the beginning of a new epoch in the development of public-health work by the Federal Government. For convenience the organization of the Division of Scientific Research may be divided into two general fields, laboratory stations and field offices, although the activities of the two are so interrelated that no arbitrary boundary can be set.

The laboratory stations carry on research into such problems as stream pollution, Rocky Mountain spotted fever, cancer, public-health relations, coordination of research by public-health officials and other scientists, demonstrations of sanitary methods and appliances, breeding and rearing of pure strains of animals in connection with the control of biologics.

Field investigation offices of the Service are developed and maintained in accordance with the necessity arising in their particular fields of work. These offices are not permanent, but their work may be enlarged or terminated or additional offices established as the demand of research work of the Public Health Service indicates. At present some of the activities are investigations of heart disease, leprosy, malaria, nutritional diseases, plague, child hygiene, milk, public-health methods, industrial hygiene and sanitation, amebic dysentery, encephalitis, and poliomyelitis (infantile paralysis).

There can be no doubt that the knowledge of scientific preventive methods in our possession today, if universally applied, would enable us to go far toward eliminating much of the unnecessary economic loss now chargeable to preventable diseases in this country. That intensive application of known scientific measures for communicable disease control can completely eradicate certain diseases has been demonstrated repeatedly. The complete banishment of yellow fever from the United States, Cuba, and Panama affords an excellent example. Bubonic plague was completely stamped out in San Francisco some years ago through the intensive application of rat control. Many other examples could be cited.

Even in the face of the lack of adequate health service in much of our rural area and in many of our cities, remarkable progress has been made in the reduction of deaths from communicable diseases in the United States during the past half century. Fifty years ago

infectious diseases prevailed to such an extent and were accompanied by such a high case-fatality rate that fifteen-sixteenths of all deaths were chargeable to this group. Today, as a result of only a partial application of known scientific methods, deaths from communicable diseases have dropped to less than 50 percent of the total.

Numerous instances could be cited where intensive health work carried on by county health organizations has reduced sickness and mortality rates. In one county the health department conclusively demonstrated between 1927 and 1932 that maternal deaths could be greatly reduced in number when prenatal cases came under supervision of the department. With only 10.8 percent of mothers under supervision in 1927, the maternal mortality rate (deaths per 1,000 births) was 7.4, whereas in 1932, with 74.1 percent of the mothers under supervision, the rate was 2.2 per 1,000 births.

In another county, in 1911, where typhoid was prevalent, as cooperation of the local, State, and Federal Governments in sanitary improvements proceeded, the incidence of typhoid fever markedly diminished instead of rapidly increasing as usual in early summer. The county health department began full-time operation in 1911 and the average of 3-year annual death rates from all causes during 1912-14 was over 100 deaths less than the number in 1910.

In addition to specific instances of help in localized areas, the Public Health Service has worked on research investigations, either international or interstate in character, or problems of long-time and higher-cost study than States or communities can afford. For instance, the Public Health Service has been engaged in the study of stream pollution and sewage disposal for the past 20 years. The increasing pollution and dumping of industrial wastes into these streams have made it imperative for the Service to investigate the biological facts in connection with stream purification and necessary control of the situation through adequate sewage and waste disposal.

Another problem of importance and one which demands immediate attention is that of mottled enamel, a disfiguring condition of the teeth caused probably by excessive amounts of fluorine in the water supply. The problem is not only one of public-health importance, but also of economic importance, since it may prevent further settlement of rich land areas where the condition is prevalent. A study of the permissible amounts of fluorine in the drinking water and of a method to remove excessive amounts is most urgently needed.

There is probably no field of investigation where there is need for greater development than in industrial hygiene. Not only is every State affected but the great majority of the 48,000,000 persons in this country engaged in gainful occupations are directly or indirectly affected, as are their families. The health hazards of industries are

almost as diversified as are the number of different industries. Here again, the cost of investigations leading to the prevention of incapacitating industrial disease is extremely small compared to the economic values accruing to both industry and the industrial worker. With its limited funds the Public Health Service has contributed considerable aid in this special field. Acting as an impartial fact-finding body its investigations are accepted by the general public and by both labor and industry. Its studies of the health hazards of dusty trades, so far as time and funds have permitted, especially in the field of silicosis, a disease which affects workers in many industries wherever silica is quarried or used, serve as one of the principal guides for the control of the disease in this country.

So far as it has been possible, the Public Health Service has attempted to meet the demands of State health authorities in the investigation of diseases which are interstate in character or which have appeared in epidemic form. The ultimate control of all epidemic diseases, even the more common ones such as measles, diphtheria, and scarlet fever, can come only from continued epidemiological investigations of such diseases and by laboratory studies of the nature of the causative agent and the development of vaccines or serums for their prevention and cure. In 1933 the epidemic of encephalitis at St. Louis resulted in an excellent cooperative investigation under the general direction of the Service with the State, city, and the universities of the city of St. Louis. Besides the pertinent facts gained in the epidemiological survey--of benefit to the entire world--the virus of this disease was for the first time successfully transferred to animals, offering thereby an opportunity for the continued study of the disease in nonepidemic times. Epidemics of infantile paralysis which occur in some State or city almost annually have required Federal cooperation since the preliminary investigation of 1910. From field and laboratory studies in regard to this disease has come a substantial knowledge upon which hope of control and prevention can be based.

Venereal diseases form one of our major social problems in causing disability during the most active years of life as well as contributing substantially to the death rate in the older age periods. The Public Health Service has attacked these problems--first, in aiding States in the development of venereal-disease clinics for the treatment of those already infected, a measure which has been extensively tried out in England with an actual reduction in infected cases in the last few years; second, in cooperative studies on treatment in the cure of syphilis; third, the study of methods of making recently infected cases noninfectious in order to prevent the spread of the disease.

The few brief examples of the type of public-health investigations which are carried on by the Public Health Service do not in any way cover the whole field of public health, nor do they give any evidence of the number of similar problems of equal importance which are now before the Service. They do serve, however, to explain the interstate and national aspects of the investigational work of the Service.

RESPONSIBILITY FOR PUBLIC HEALTH

The protection and promotion of the public health has long been recognized as a responsibility of governments--national, State, or local. In the United States, however, this responsibility has not generally been discharged in so systematic or adequate a manner as such other functions of government as the protection of property, the provision of means of communication (highways, postal, and similar services), the administration of justice, and education. There is, in fact, marked inequality of health service now being rendered in different communities, resulting in unequal opportunities for citizens to acquire and maintain health. These differences derive from:

(1) Lack of local services for organized health protection; (2) lack of appreciation and understanding on the part of citizens of the measures necessary to preserve and promote individual health; and (3) lack of ability of citizens and communities unaided to obtain needed preventive services. The improvement of economic security in this country requires a comprehensive, Nation-wide program of public health, supported and administered by local communities and by States, financially and technically aided by the Federal Government.

Aside from certain services such as the improvement of a water supply or the provision of safe means of sewage disposal, the improvement of public health depends upon the summation of the improvement of protection of individual health. Health services, therefore, are best rendered on a community basis, localized or individualized to the greatest degree commensurate with economy of administration. The responsibility of government is twofold:

(1) It should supply those facilities which can best be maintained on a community basis and which the individual cannot be expected to provide for himself; (2) it should, through mass education, acquaint the citizens with the health problems, the local facilities available, and the advantage to himself and to the community of making early and full use thereof.

BASIC REQUIREMENTS OF LOCAL PUBLIC-HEALTH SERVICES

What, in the opinion of public-health experts, are the basic requirements of public-health services in a community? In the following brief outline and discussion, the standards established by the American Public Health Association have been kept closely in mind.

Nature of Local Organization.-The basis of a satisfactory health service in a community is a well-organized health department, adequately financed, with trained personnel, supported by suitable laws and ordinances, by favorable public opinion, and by all professional groups. Recognition of the need of a large population unit, and the importance of a full-time, trained, administrative head has led away from the establishment of services on the town or village basis to the county or district (city or groups of cities, part of county, or combination of counties) of 50,000 population or more, in a reasonable compass, as the unit of organization.

The basic principles of organization of such service in a community are:

(1) That the health administrative agency be a recognized part of the government of the area and be correlated with the government of the State;

(2) That in view of the responsibilities which must be placed upon the health officer or administrative head of such services, a board of health or advisory council be established as an essential factor in the administrative plan to advise the health officer regarding policies and otherwise to bring a broader community viewpoint to the administration of the service; and that such a board or council include physicians, members of other public-health professions, and representatives of the general public;

(3) That the health officer be (a) selected and appointed on the basis of professional qualifications and protected against political interference, ( b ) adequately compensated commensurate with the public responsibilities placed upon him, (c) required to devote his full time to the duties of his office, and (d) directly responsible either to the board which may have the appointing power or to the chief government executive of the area;

(4) That the major divisions of the department likewise be directed by full-time trained persons responsible to the health officer.

Local Health Services.-The physicians in a community, whether in private offices, clinics, hospitals, or homes, perform a service in the treatment of disease either as individuals or as members of organized groups. This is the usual form of medical care in this country for those able to pay for such services. Because of their training, numbers, and relationships to their clientele, physicians in private practice constitute the group which is potentially most capable of applying the lessons of preventive medicine to the habits and circumstances of the individual. The public generally, however, is not yet accustomed to demand or privately pay for such guidance in the application of preventive medicine to its own or its com-

munity's health problems. The program of local health work must, therefore, provide for activities which will:

(1) Carry out the legal responsibilities in disease control imposed, by law;

(2) Provide those facilities for institutional care (acute communicable disease, including tuberculosis), laboratory service, and diagnostic aid-services which the individual patient cannot provide for himself alone;

(3) Stimulate a public demand for services in the prevention of illness;

(4) Supplement the services of the private physician in the community;

(5) Aid in developing the interest and ability of physicians to render preventive services in their private practice.

A comprehensive local health program will include services aimed at the control of preventable diseases (the acute communicable diseases, syphilis and gonorrhea, tuberculosis), heart disease, cancer, industrial disease, and mental diseases; care of crippled children; improvement of nutrition; the promotion of maternal, infant, ,and other child-health services; the supervision of general sanitary conditions of the community; services for diagnostic aid (laboratory services and expert consultants) ; and service for the collection, tabulation, and analysis of vital statistics. Health conferences or health-center preventive and medical services conducted by the health department or other agencies in cooperation with medical groups, especially for mothers and children, are justified and desirable as a means of creating a demand for such services, as a practice ground for physicians in the art of preventive medicine, as an agency for inaugurating proper standards for such services, and as a supplement to the preventive services of private practitioners.

Cost of Local Service.-Experience with well-organized and well-administered health services in many county and city departments indicates that an expenditure of $1 per capita from official funds is required to provide these essential services for community health protection in the minimum effective degree. This minimum cost is based an the assumption that the preventive services by private physicians rendered in their own practice, as above outlined, will be improved and maintained. Many cities and some rural areas have found it desirable and profitable, in terms of increased protection, to develop services in excess of these minimums.

Since, as has been pointed out, the responsibility for the provision and administration of the public-health program rests primarily with the government, it follows that the major support of this service must be met through local taxation. Studies of the ability of counties to meet the cost of health administration from local resources show a wide variation and suggest the need that State governments be prepared where necessary to assist local communities in providing the minimum health program compatible with protection for the State.

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Such assistance is already being given to some degree in certain States and takes the form either of supplying service which can be satisfactorily rendered from the State department of health or of direct grants of money (through the State health department) to aid the local program, or both. In addition to the advantage of building up a sound local program, appropriations for State aid exercise a beneficial influence upon the standardization and improvement of the character of local work throughout the State. The need of trained personnel for effective local health work makes it imperative that the State be prepared to assist local communities by furnishing especially qualified persons and by providing special training services as already done in a number of States.

Studies of local health services, both in urban and rural communities, indicate that the minimum essentials of service, as outlined here, will require more than $1 per capita; {8} that a comprehensive program will require in addition facilities for the hospitalization of certain acute and chronic diseases. Unusually acute health problems, regional or special problems, or great community interest and demand for service may require additional services not provided in this program and budget. Some cities and rural areas have demonstrated that as much as $2.50 per capita {9} can be wisely and profitably expended. In such forward-looking programs, voluntary agencies usually participate to a substantial degree in money support. If we consider, however, $1 per capita for the field program, aside from institutional facilities and hospital care, the total allotment for public health in the local tax budgets would be' $126,000,000 a year, representing less than a mill on the gross assessed property valuation of $163,000,000,000 in 1931.{10} It is evident that a reasonable levy over the entire country would yield sufficient funds to carry this minimum program. It is recognized that assessed valuations vary from one period to another in their relation to the true value in different areas, and that the proposal of a specific tax rate to be generally applied has limitations. Considering the problem broadly, the total assessed valuation with specific millage for health purposes is used as a practical and convenient basis of discussion. The problem, however, is one of distribution, since not all corriniunities have sufficient resources to support such a program with a reasonable tax rate. The solution of this problem necessarily rests with the State and the Federal Government.

{8}American Public Health Association, An Official Declaration of Attitude on Desirable Standard Minimum Functions and Suitable Organization of Health Activities, approved on Tuesday, Oct. 10, 1933, Indianapolis, Ind. (American Public Health Association, New York City, 1933).

{9} Hiscock, Ira V., editor, Community Health Organization (American Public Health Association, New York City, 1927).

{10} Bureau of the Census, Financial Statistics of States (U..S. Government Printing Office, Washington. D. C., 1931).

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The following tabulation indicates for the counties of a southern State the money needed for a minimum health program and the amount which a reasonable tax of 1 mill would yield:

Obviously not every community and not every political subdivision is large enough or wealthy enough to equip itself with facilities and personnel to meet satisfactorily its health needs. Many communities, on the other hand, ire amply able to provide financial support for their own health programs and to lend assistance to other less able communities. With present. methods of travel, there is no isolated part of the country. Communicable diseases may readily and rapidly spread beyond political boundaries. The flow of travel is to the more urban areas which are also more able to provide for an adequate health program. To meet this condition health services are organized on a city, county, or district basis in order to provide a sufficiently large aggregate of population and wealth to support efficient organization. Yet, there are services which the local community cannot and should not provide for itself alone. These needs should be met through assistance from the resources of official State or Federal health agencies or from local voluntarily supplied resources for health service, or both.

Voluntary and nonofficial agencies at present provide approximately one-fourth of the support of all public-health work in the country.{11} Such agencies, assisting in the local health program, have grown up more extensively in cities than in rural areas because these areas contain a larger proportion of individuals who are conscious of the acute public-health problems and who also have available funds to support such work. The services which these voluntary agencies render include public-health nursing, promoting health education, maintaining clinics of a public-health nature, initiating

{11}White House Conference on Child Health and Protection, Public Health Organization (Century Co., New York. 1933).

studies of local problems, and encouraging the maintenance of sound standards. It is believed that the continued participation of voluntary groups in the community health program should be encouraged in order to provide services supplemental to the official activities which the local official agency may not be equipped or ready to render. Usually through their extensive roots in the community the voluntary groups are able to affect public opinion favorably and thus bring support for a well-rounded public-health program which the health officer finds exceedingly helpful. They have further responsibility in aiding the development of new fields of activity beyond the minimum essentials of health service here discussed.

THE FUNCTIONS OF STATE HEALTH DEPARTMENTS

With health services organized and administered locally as discussed above, the function of the State health department becomes that of (1) stimulating local areas to recognize their health problems and (2) organizing the necessary facilities to handle them adequately. The State should assist in providing those services which it is uneconomical for the, local community to provide for the sole use of a small population unit. This may include laboratory facilities and special technical services in handling problems of sanitation, water supply and sewage disposal, occupational diseases, facilities for the institutional care of tuberculosis, etc. The State should also provide advisory and supervisory service to the local administrator and through standards of performance of professional service assist the local health officer in keeping local work at an effective level. The training of public-health personnel for work in the local area should be as much a State responsibility as is the training of teachers in education. Only in limited fields and under unusual circumstances should the State department become an agency functioning directly in the local community dealing personally with the public.

Organization of State Health Departments.-The form or organization of State departments of health is similar in character to the local organization already discussed. There should be a well-trained and especially qualified commissioner or State health officer supported by a board of health or advisory council, the members of which should be appointed without political regard and solely far the knowledge which they can bring to bear upon the health problems of the State and their contribution to the solution of these problems. Such a body should assist the State health administration in the formulation of policies and in the preparation of the sanitary code. The bureaus of the State health department should be headed by especially trained and qualified individuals devoting full time to the

service. A plan of organization which has been found effective in practice, and which conforms to the plan of local organization just discussed, would provide for a commissioner of health with a supporting advisory body appointed by the Governor and a department comprising a major division of central administration having to do with the stimulation, guidance, and supervision of county and other local health work. Auxiliary divisions would provide services for the control of preventable diseases including epidemiology, maternal and child health, laboratory service, and sanitary engineering. A division concerned with the collection, tabulation, and analysis of vital statistics completes the organization of the department. As the function of the department is largely advisory and supervisory, the number of subordinate persons needed is relatively small.

Aid to Local Health Services. Since at the present time less than one-fourth of the counties of the country have organized full-time health departments and nearly 50 percent of the population is without full-time health supervision, State departments have a major responsibility in acquainting local government officials and the public at large with the importance and advantages of effective local health service. It is conservatively estimated that not more than 25 percent {12} of the counties having organized full-time health departments and not more than 50 percent {13} of the cities have as yet developed their departments to include efficient service in the minimum essentials of health protection and promotion here outlined. The State's responsibility for effective health service extends to such areas as well as to the areas which at present have no organized health departments. In fact, it must assume a continuing responsibility for the stimulation of the local departments to avail themselves of new knowledge of public-health protection.

An equally important function of the State department is that of aiding poorer counties and local areas through direct subsidy to obtain a satisfactory health program. Not all counties within the State will be in position to raise the necessary, funds for a satisfactory program from local taxes. It frequently happens that the magnitude of local health problems is overwhelming, and the responsibility for the solution of these problems does not rest entirely upon the local community. The State, then, through its general taxing power, must act as an equalizer and, through services rendered or direct monetary contributions to such areas, or both, insure the conduct of a satisfactory program and the protection of the citizenry as a whole. The precedent for participation of the State

{12}Freeman, A. W., M.D., op. cit.

{13} Public Health Reports, vol. 49, no. 39 Sept. 28, 1934, United States Public Health Service.

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in the financing of local government is found in the administration of schools and highways.

The guiding and supervisory functions which have already been discussed as responsibilities of the State are much easier and more effectively administered if the State assists the local area financially in carrying its health service. However, not all States are able, within their local resources, to meet the demand of health work, and there is a national problem of adjustment which must be met through Federal aid to States in the organization of State administrative services and in assisting the States to carry the burden of the poorer counties. An analysis of the assessed valuation and the cost of minimum effective health programs of local services by counties shows a tag deficiency in available resources on the basis of a 1-mill, tax levy of $13,409,000 for the country as a whole. States must look to the Federal Government for same assistance in meeting this problem.

Cost of State Health Work.-To carry out the normal functions of a State health department, including the stimulation and guidance of local health work, the State health department will need a staff, in addition to the health officer, of approximately 6 people per 100,000 population. The size of personnel will vary with the area and population density of the State. For example, groups of people in sparsely settled areas will require more personnel per 100,000 population. Such services as are usually provided, excluding institutional care, now require an expenditure of not less than 20 cents per capita. In addition, the State will need funds for aid to local health work on a county basis averaging about $5,000 per county to cover the cost, in part at least, of those services which are rendered locally but have a definite State implication and provide protection to citizens outside the county. On such a basis of organization, the total cost of State administration throughout the United States is $40,000,000 ($25,000,000 for State-administered service plus $15,000,000 for subsidies to counties) apart from additional subsidies to counties whose residents are too poor to carry the tax burden of the health program. This is an increase of $26,000,000 over the present expenditure. The need of this increase is better understood when it is realized that only 20 percent {14} of the States at the present time have a program of administration which comprehends the responsibilities of the State department just discussed; and, moreover, several of these programs are at present not adequately financed to permit effective operation. This total cost of State health service, aside from the funds needed to level the inequalities of county re-

{14}Health Departments of States and Provinces of the United States and Canada, United States Public Health Service, Public Health Bulletin No. 184; (U. S. Government Printing Office, Washington, D. C., 1929).

sources, would amount to 32.5 cents per capita for the country as a whole. The average expenditure in 1934 was 10 cents per capita. The range of expenditures is from 1 cent to 43 cents per capita, with only four States appropriating 20 cents or more per capita.

FEDERAL RESPONSIBILITIES FOR THE PUBLIC HEALTH

The policy of leaving to localities and States the entire responsibility for providing even nominal public-health facilities and services has failed in large measure. The uneven development of health service in the United States has resulted largely from expecting local governments to take the initiative in the organization of health activities. An adequate program with the necessary local and State support for public-health services calls for broader planning and more uniform and intensive stimulation of communities and governmental officials to recognize and meet their responsibilities for public health. The Federal Government has a definite responsibility for the protection of all the Nation's population against disease.

The responsibility of the Federal Government for national health is already accepted by the conduct of health activities through several Federal agencies. Furthermore, it is well recognized that the constructive development of public-health work cannot proceed in an effective manner throughout the entire country without assistance from the Federal Government. As has been shown, local and State governments have a great responsibility for the provision of more adequate health service. Public health, a primary government function, has for years received a relatively small share of local, State, and Federal appropriations. Recently, even these modest appropriations and this limited service have been reduced in drastic proportions in many localities. The experience of cities in 1934 shows that health budgets have been reduced on the average about 20 percent from the experience of 1931, reductions varying from 1 or 2 percent to as high as 50 percent. Where this reduction has amounted to 30 percent or more, practically complete breakdown of the public-health protective facilities has resulted. National support of local health activities is indicated as a necessary development to insure that public-health measures may go forward hand in hand with constructive economic measures in meeting the present critical national situation. Though public health, unlike certain of the social problems under consideration at the moment, is not solely an emergency demand but a continuing responsibility, the early development of a reasonably adequate public-health program reaching both the centers of population and the far corners of rural areas is urgently

needed if the people of the Nation are to receive the care which they deserve and which scientific health service will give them.

Such a program of national health service would provide for the coordination of Federal, State, and local funds and activities, the training of necessary administrative and scientific personnel, the setting up of adequate standards of efficient administration, the evaluation of results, the efficient use of Federal, State, and local funds, and the resources of voluntary agencies according to the needs as determined by health and not by political conditions.

The public-health responsibilities of the Federal Government already recognized and to a degree provided for are:

(1) The study of international health conditions and the protection of the country from international hazards to health;

(2) The study of national health conditions and control of interstate transmission of disease by regulation of the movement of persons and goods;

(3) The use of all educational means to promote public interest in disease prevention and control, in safeguarding the lives and health of mothers and children, and in the health of the worker, and in the attainment of more complete physical and mental health;

(4) The promotion of the study of hygiene and public health as a recognized part of education;

(5) The stimulation of States and local governments to organize health activities as discussed to insure more effective service to all people;

(6) The provision of personnel to State and local departments for consultation, education, demonstration, and other technical services (the training of workers for all aspects of public-health service is necessarily a part of this responsibility);

(7) The development and promotion of standards of performance of technical services in the several fields, including general administration;

(8) The conduct and coordination of research in any or all aspects of public health, particularly those problems beyond the capacity of local and State organizations relating to disease prevention, control of the incidence of morbidity and mortality at all ages, the influences-physical, social, economic, and mental--affecting or contributing to a more healthy people;

(9) The provision of direct grants to States to encourage the organization of State and local health services for all people in accordance with current knowledge and to equalize the tax burden of the public-health program.

These responsibilities are now met through the services of a number of different bureaus in several Federal departments. The Federal agencies which have to do, for the most part, with the problems of State and local health work are:

United States Public Health Service,
Children's Bureau,
Bureau of the Census,
The Office of Education,
Food and Drug Administration,
Bureau of Animal Industry.

Other divisions having certain public-health aspects and responsibilities, yet not directly nor uniformly concerned with the promotion

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and administration of local health work, are: Bureau of Labor Statistics, Women's Bureau, Employees' Compensation Commission, Consular Service, Office of Indian Affairs, National Park Service, Bureau of Mines, Bureau of Dairying, and the Bureau of Home Economics. These Federal services have grown up in response to the recognized public need and each, within its field, contributes markedly to public understanding and appreciation of health and to the improvement of the national health. With all the public interest over a long period which the present organization of services in the various departments indicates, the Federal responsibility in the specific fields just mentioned is still far from adequately met, owing primarily to lack of resources specifically directed toward the promulgation of a national plan of health services.

It is obvious from the wide responsibilities and their dispersion among many departments that the efficient administration of a national health program under the Federal Government demands the close coordination of these health services. Such coordination can be assured in part through the detail of qualified personnel from the United States Public Health Service and through its study and solution of special health problems which may arise within local departments where the health aspects of the program are subordinate to other considerations. This procedure has already developed with the Bureau of Indian Affairs, Bureau of Immigration, Bureau of Mines, Employees' Compensation, Coast Guard Service, Bureau of Standards, Federal Emergency Relief Administration, and the National Park Service. Many bureaus are deeply interested in various aspects of public-health promotion and protection and are carrying on effective educational and regulatory activities. The precedent of Federal aid to States for State health administration and local public-health facilities has been established in various laws for granting aid and in loans of technical personnel to States and localities.

The Cost of a National Program.-Federal agencies previously mentioned are now spending a total of slightly more than $5,000,000 in the discharge of their responsibilities directly related to public health. The Federal agencies primarily concerned with public health need far more funds than heretofore provided for trained personnel to be made available to States or local areas for the purposes of demonstration and initiation of work to inaugurate the enlarged State program discussed. The appropriations for further research activities by the United States Public Health Service and the United States Children's Bureau have been grossly inadequate. The more important of these problems arise

(1) As requests for aid from State health officers, for problems usually interstate in character, such as malaria, typhus fever, Rocky Mountain spotted

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fever, industrial hygiene, stream pollution, milk sanitation, public-health methods, statistical, dental, and nutrition studies.

(2) As a result of the requirements placed upon the Public Health Service by law, such as the control of biological products, development of standards and of new biological products.

(3) Within the Public Health Service to meet a national emergency of the future or other changing conditions, such as sewage disposal, water purification, cancer investigation, and public-health education.

(4) In the fields of maternal and child hygiene, including studies of mortality, growth, development, and diseases of children, mental health, and the relation of economic and industrial conditions to the health and welfare of children and mothers.

This research work is an integral part of the national plan of public-health services since the investigations undertaken are essentially concerned with problems of a regional or interstate character. The solution of these problems is not only of national significance but of vital importance to the State health officers in allowing them to utilize fully the State and Federal funds available to them in the prevention and control of disease, the improvement of the environment, and the promotion of health. The majority of such research problems come to the Public Health Service from the health authorities of the several States.

PUBLIC-HEALTH PROVISIONS OF THE SOCIAL SECURITY ACT

Recognizing the role of sickness as a cause of insecurity, the prevention of disease as the most humane and the least expensive method of dealing with this cause of insecurity, and the need for extension of Federal, State, and local public-health service, Congress authorized an appropriation for public-health purposes in the Social Security Act. For the fiscal year ending June 30, 1936, and annually thereafter the sum of $8,000,000 {15} was authorized for allotment to assist States, counties, health districts, and other political subdivisions of the States in establishing and maintaining adequate public-health services, including the training of personnel for State and local health work.

The Surgeon General of the Public Health Service, with the approval of the Secretary of the Treasury, is made responsible for the administration of these grants to States. After consultation with a conference of the State and Territorial health authorities, he will determine the rules and regulations for the allotment of the State grants. The amounts allotted will be based upon the popula-

{15} The Social Security Act was not approved until Aug. 14, 1935, and the supplemental appropriation bill, fiscal year 1936 [H. R. 9215], failed of passage in the first session of the Seventy-fourth Congress. The Supplemental Appropriation Act, fiscal year 1936, Public, No. 440, 74th Cong., 2d sess. [H. R. 10464], approved Feb. 11, 1936, included an appropriation of $3,333,000 for the remainder of the fiscal year ending June 30, 1936.

tion, the special health problems, and the financial needs of the respective States.

Prior to the beginning of each quarter of the fiscal year the Surgeon General will determine the amount to be paid the State for the quarter and will certify this amount to the Secretary of the Treasury. The grants after certification will be paid through the Division of Disbursement of the Treasury Department, prior to audit or settlement by the General Accounting Office. If any part of the grant to any State remains unpaid at the end of a fiscal year, the unexpended balance due a State will be held available for disbursement to the States in the next fiscal year in addition to the amount appropriated for the new period.

The Federal funds granted to States under the provisions of title VI are to be expended solely for establishing and maintaining adequate public-health services and for the training of personnel for State and local health work.

The Surgeon General proposes to use the funds for Federal grants to the States for the following purposes:

(1) To strengthen service divisions of State health departments;

(2) To assist in providing adequate facilities in State health departments especially for the promotion and supervision of full-time city, county, and district health organizations;

(3) To give, through the State health departments, direct aid toward the development and maintenance of adequate city, county, and district health organizations;

(4) To assist in developing trained personnel for positions to be established in the extension of city, county, and district health organizations;

(5) To provide, through the State health departments, aid in the purchase of biological products and other drugs needed for individual immunization and other preventive activities among the poor.

While it is considered unlikely that all of that part of the $8,000,000 allocated to aid of State and local health organizations which would be used for the development and maintenance of full-time county or district health units could be utilized satisfactorily in the organization of such units during the first year, it is proposed that the funds available for this purpose could be used to great advantage temporarily to aid the most needy of the 2,000 counties now without any health service whatever in providing at least a public-health nursing service until adequate full-time health service under fulltime specially trained medical health officers can be established.

It is further proposed that funds will be allotted to the States on the basis of budgets showing contributions from State and local sources for each project for each year, and that the maintenance of certain generally accepted standards of personnel qualifications and service will be required.

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Under the Surgeon General's regulations for the fiscal year 1936 {16} for the allotment of State grants on the basis of (1) population, (2) special health problems, and (3) financial needs, the following apportionment has been made: 57.5 percent of the total sum available for the year 1936 will be allotted on a per-capita basis; 22.5 percent of the total sum will be allotted to the several States on a basis of special health problems; and 20 percent of the total sum for 1936 will be allotted to the States on a basis of financial need.

Payments to aid existing State or local projects will not replace State or local appropriations already made for such projects but will supplement such appropriations.

Payments to States from the fund to be allotted on the basis of population (1930 census) fall under two classifications: (1) One-half of the amount thus apportioned will be used to match (dollar for dollar) existing appropriations of public funds within the State for public-health work. (2) One-half of the apportioned sum will be used to match (dollar for dollar) new appropriations or appropriations made for the specific purpose of matching funds to become available under the Social Security Act, subject to modification by the Surgeon General where States already have made substantial appropriations.

Payments to States from the fund to be allotted on the basis of special health problems fall under two classifications: (1) For special health needs, to include unusual exposure throughout the State to public-health hazards as in the case of certain types of epidemics or special industrial hazards, 10 percent of the entire appropriation for payments to the States will be allotted to be matched (dollar for dollar) by the States. (2) The remaining apportionment to be used for payments to the States on the basis of special health problems will be allotted, in accordance with the needs of the several States, for the training of personnel, establishment of suitable training centers, and payment of living stipends, tuition, and traveling expenses of trainees. The States will not be required to match these payments.

Payments to the States from the sum apportioned to be allotted on the basis of financial need fall under two classifications: (1) One-fourth of the amount will be used for payments to the 51 State and Territorial health jurisdictions to which the act applies to assist in providing leadership and administrative guidance in the effective use of Federal aid. The States will not be required to match these payments. (2) Three-fourths of the allotment will constitute an equalization fund to be used in assisting States most in need of

{16} "Regulations Governing Allotments and Payments to States from Funds Appropriated Under the Provisions of Section 601, Social Security Act, for the Fiscal Year 1936", American Journal of Public Health, vol. 26, no.1, January 1936, pp. 59-62.

financial aid. These funds are to be used for local health services exclusively. State financial participation is not required.

In addition to the amount authorized for aid to the States, the Social Security Act authorizes an appropriation for the extension of public-health investigations by the Public Health Service. An annual appropriation of $2,000,000{17} was established for each fiscal year beginning with 1935-36, to be expended by the Public Health Service for investigation of disease and problems of sanitation and for the pay, allowances, and traveling expenses of commissioned officers and personnel of the Public Health Service engaged in such investigations or detailed to cooperate with the health authorities of any State. Other personnel of the Service may also be detailed to assist in this investigation or cooperation with the States, and the account from which they are paid may be reimbursed from the $2,000,000. The act provides, however, that a request for Federal cooperation with a State must come from the proper State authorities before personnel may be detailed from the Federal Service to assist a State in the extension of its public-health work.

The Surgeon General of the Public Health Service proposes to use this annual appropriation of $2,000,000 for the following purposes:

(1) The employment of personnel necessary to maintain supervision and guidance over the expenditure of funds annually allotted to the States, and in such manner to render assistance to them in the continuous and steady development of State and local health services;

(2) The employment of professional, technical, and other personnel necessary to conduct the investigational work of the Public Health Service;

(3) The extension and broadening of the investigative work of the Service in relation to investigations of diseases, sanitation, and matters related thereto.

The major portion of the investigative work arises from three general sources:

(1) From problems which are interstate in character and which are brought to the Service by State health officials, through the cooperative work of the Service with the States.

(2) From problems which arise within the Service as a result of the responsibilities placed upon it by law, as, for example, the development of biologic standards in connection with the control of biologics.

(3) From problems which the trends of public health indicate will be of national or international importance in both the fields of environmental sanitation and the control of disease.

{17} The Social Security Act was not approved until Aug. 14, 1935, and the supplemental appropriation bill, fiscal year 1936 [H. R. 9215], failed of passage in the first session of the Seventy-fourth Congress. The Supplemental Appropriation Act, fiscal year 1936, Public, No. 440, 74th Cong., 2d sess. [H. R. 10464], approved Feb. 11, 1936, included an appropriation of $375,000 for the remainder of the fiscal year ending June 30, 1936, for the purposes of section 603 of the Social Security Act, section 1 of the act of Aug. 14, 1912, and section 6 of the act of Aug. 23, 1912 (31 U.S.C., Sec. 669).

It is evident, therefore, that to a large extent this investigative work of the Public Health Service is noncompetitive with the research work of universities or States.

It should be clearly understood that the additional funds which are appropriated do not mean so much the development of new fields of investigational work in the Public Health Service as (1) the opportunity for a more immediate and broader study in the fields of work which the Service is at present carrying on, and (2) undertaking problems of the greatest national importance which hitherto have been refused or delayed because of the lack of necessary funds.

It would seem a corollary that the full benefits of the funds allotted to the several States for the promotion of public health cannot be achieved if the public-health problems with which these States and their local subdivisions have to deal are not studied coincidentally and the information given to the health authorities of the States.{18}

In connection with the administration of the funds authorized by the Social Security Act for aid to States and the extensive research activities to be carried on by the Public Health Service, it will be necessary to have additional medical, sanitary engineering, and other officers. The number of officers already in the Public Health Service who have the required training in public-health work and research methods will be entirely inadequate to meet the immediate demand for personnel of this type. The Public Health Service, therefore, must plan to obtain from outside sources the highly specialized, thoroughly trained, medical, engineering, and other officers of ability that will be needed. It will be impossible to attract personnel of this type to the Service unless they can be offered either larger salaries than they are now receiving or other inducements. The advantages of a career in the Public Health Service in a commissioned status will, it is believed, attract, at much lower entrance salaries, many individuals who otherwise would not be interested. This will enable the Public Health Service to obtain at once the desired personnel at much lower cost to the Federal Government, probably as much as one-third less. Officers commissioned in the Service now would not for several years receive salaries equaling those being paid to individuals of comparable ability in many State and local health departments. The technical and clerical personnel added to the Service under the authority of the Social Security Act will be drawn from the civil-service eligible lists.

{18} Statement of Josephine Roche, Hearings Be/ore the Committee on Finance, United States Senate, 74th Cong., 1st sess., on S. 1130 (U. S. Government Printing Office, Washington, D. C., 1935), pp. 386-387.