The Health bulletin [serial] - University of North Carolina at Chapel Hill

C&e itffirarpofttjeDtetsion of pzaltb affairsOniuewitp of ji3ort& Carolina

This Book Must Not Be Takenfrom the Division of HealthAffairs Buildings.This JOURNAL may be kept out TWO DAYS,and is subject to a fine of FIVE CENTS a daythereafter. It is DUE on the DAY indicatedbelow:>1HL ff _J15&JjCiJUL- !::- iy ;n ? m'i9-5IW^-lrfr-1951 1c pptt—*^

i.cMEDICAL LIBRARYU . OF N. CCHAPEL HILL, N. C©gjfc&i W>I TKis Bulletin will be sent free to ai\M citizen of tRe State upon request IPublished monthly it the office of the Secretary of the Board, Raleigh, N. C.Entered as second-class matter at Postoffice at Raleigh, N. C. nnder Act of August 24, 1912Vol. 70 JANUARY, 1955 No. 1GUILFORD COUNTY HEALTH CENTER, r.-GREENSBORO, NORTH CAROLINA-^JAN 26 1955D!.HEALTH AtTn.uoRY

MEMBERS OF THE NORTH CAROLINA STATE BOARD OF HEALTHQ. G. Dixon, M.D., President AydenHubert B. Haywood, M.D., Vice-President RaleighJohn R. Bender, M.DWinston-SalemBen J. Lawrence, MJJ RaleighA. C. Current, DJ3.S GastoniaH. C. Lutz, Ph.G HickoryGeo. Curtis Crump, M.D. AshevilleMrs. J. E. Latta Hillsboro. Rt. 1John P. Henderson, Jr., M.D. Sneads FerryEXECUTIVE STAFFJ. W. R. Norton, M.D., M.P.H., State Health OfficerJohn H. Hamilton, M.D., Assistant State Health Officer and DirectorState Laboratory of HygieneC. C. Applewhite, MJ)., Director Local Health DivisionErnest A. Branch, DD.S., Director of Oral Hygiene DivisionA. H. Elliot, M.D., Director Personal Health DivisionJ. M. Jarrett, BS., Director Sanitary Engineering DivisionFred T. Foard, M.D., Director Epidemiology DivisionFREE HEALTH LITERATUREThe State Board of Health publishes monthly The Health Bulletin, which willbe sent free to any citizen requesting it. The Board also has available fordistribution without charge special literature on the following subjects. Askfor any in which you may be interested.Diphtheria Measles Residential SewageFlies Scarlet Fever Disposal PlantsHookworm Disease Teeth Sanitary PriviesInfantile Paralysis Typhoid Fever Water SuppliesInfluenza Typhus Fever Whooping CoughMalariaVenereal DiseasesSPECIAL LITERATURE ON MATERNITY AND INFANCYThe following special literature on the subjects listed below will be sent free toany citizen of the State on request to the State Board of Health, Raleigh, N. C.Prenatal CareFive and Six MonthsPrenatal Letters (series of nine Seven and Eight Monthsmonthly letters)Nine Months to One YearThe Expectant MotherOne to Two YearsInfant CareTwo to Six YearsThe Prevention of Infantile DiarrheaInstructions for North CarolinaBreast FeedingMldwivesTable of Heights and Weights Your Child From One to SixBaby's Dally ScheduleYour Child From Six to TwelveFirst Four MonthsGuiding the AdolescentCONTENTSPagePaper Presented at North Carolina Public Health Association Meeting. __ 3Public Health Speaks 6Where Do We Go From Here in Public Health? 11Notes and Comment 15

IPUBLI5AED BYTAE N°RTA CAROLINA STATE B°ARD*AEALTAVol. 70 JANUARY, 1955 No. 1J. W. R. NORTON, M.D., M.P.H., State Health Officer JOHN H. HAMILTON, M.D., EditorPAPER PRESENTED AT NORTH CAROLINAPUBLIC HEALTH ASSOCIATION MEETINGRaleigh, North Carolina, September 23, 1954L. C. AMOSChairman of Guilford County Commissioners.Past President of N. C. County Commissioners Association,Greensboro, North CarolinaNearly everyone today accepts theIdea that organized public health serviceIs one of the fundamental responsibilitiesof government in our society.It is true that opinions differ as towhat proportions of public health responsibilityshould properly be borneby Federal, by state, by county, andby municipal government. However, thebasic theory of governmental responsibilityfor protecting the public healthhas advanced in practice to the pointthat modern American government atevery level is now engaged in some partof the work—the Federal governmentthrough the United States PublicHealth Service and related agencies,the state government through theState Board of Health, and the localunits through district, county, andsometimes municipal health departments.Development of State GovernmentalResponsibility for HealthIn North CarolinaThe first substantial piece of healthlegislation applicable to the territorywhich is North Carolina was enactedin 1712 by the "General Assembly" ofthe Province of Carolina and was entitled"An Act for the More EffectualPreventing of the Spread of ContagiousDistempers." It was of course a maritimequarantine law and appointed a"Commissioner for Enguireing into theState of Health" of persons arriving atports in the province, particularly atCharleston.In the 241 years between the GeneralAssembly of 1712 and the GeneralAssembly of 1953 hundreds of pieces ofhealth legislations, most of them aimedat "The more effectual preventing" ofone or another of a myriad of threatsto the public health, were spread uponthe statute books of North Carolinaduring its progress from crown colonyto sovereign state.The early statute in the field ofmaritime quarantine regulation wasfollowed during the next century anda half by other statutes on the samesubject, but the seed thus planted didnot quickly ripen into general recognitionof governmental responsibilityfor public health. In terms of sheervolume and number, comparatively fewof our statutes enacted prior to theCivil War had anything to do with

The Health Bulletin January, 1955health. Taken altogether, the statewidelaws for protection of the public healthin effect at the beginning of the CivilWar added up to not more than threeor four pages of printed matter andprovided for no governmental agenciesto enforce them.During the two decades followingthe Civil War state boards of health inroughly the modern pattern began tobe established throughout the country.North Carolina joined the movement in1877 by enacting a law designating theentire membership of the State MedicalSociety as a state board of health, toact through a health committee establishedby the Society—with an annualstate appropriation of $100 for its expenses.Two years later this unwieldy arrangementwas terminated by a statutecreating a nine-member Board ofHealth which was to be a regulardepartment of the state government.But it was not until 1909 that theboard acquired the services of itsfirst full-time health officer and administrator,thus beginning the developmentof a state health agency staffedby professional men and womenworking under the general directionof the Board of Health.Development of Local GovernmentalResponsibility for HealthIn North CarolinaThe pattern of statutory developmentof organized public health work at thelocal level was a similar one. It is truethat town government from earliestcolonial days had to concern itselfwith threats to community health. Butit is also true that organized publichealth work in the modern sense developedat the local level largely duringthe period since the Civil War andunder a statutory pattern parallelingthat of state health work.North Carolina's first statute providingfor a statewide system of countyboards of health was enacted in 1879,when the legislature decreed that eachcounty should have a county boardof health composed of all the practicingphysicians in the county, plus thechairman of the board of county commissioners,the mayor of the countytown and the county surveyor. Thisboard was as unwieldy for administrativepurposes as the original stateboard had been. Like the old stateboard, the 1879 county board functionedin practice as something on theorder of a medical "Vigilante committee,"organized to deal with epidemics,nuisances and similar urgent threats tothe community's health, usually afterthey had already begun—rather thanas an agency administering laws andregulations aimed at preventing suchdisasters.It was not until 1911 that the countyboard of health statute was first expressedin substantially its present form,providing for a seven-member boardcomposed of both medical and laymembers. However, for most of thestate's counties, the formal statutorychange had little immediate effect onthe type of health work being locallyadministered. The only full-time contyhealth service in the state by 1911was that of Gulford County, whichwas established in that year (first inthe state and second in the nation.)The year 1911 thus marks the beginningof organized full-time county healthwork in North Carolina. It was notuntil 1949 that the state reached the100 per cent mark with respect to fulltimelocal health service in all its counties.Incorporated cities and towns inNorth Carolina have had explicit statutoryauthority under statewide lawssince 1893, and under particular towncharter provisions since colonial days,to tax and spend, adopt regulationsand impose penalties in the interestof the public health. However, exceptin a decreasing number of the morepopulous centers, most of the state'salmost 400 incorporated municipalitieshave left organized health work to thecounties and districts.Suppose you should stop any averagecitizen on the street, or on the farm,and ask him who takes care of hisfamily's health. He would probablyanswer, "Why, my wife and physician

January, 1955The Health Bulletinand dentist." The matter-of-fact toneof his voice would tell you that he hastaken for granted the many other servicesthat your public health departmentand other health agencies makepossible in addition to those of hisprivate physician and dentist. Keepingwatch over Mr. North CarolinaCitizen and his family is the healthdepartment's responsibility.Beginning before Baby Citizen isborn, he is of interest to the HealthDepartment. The prenatal blood testrequired of every expectant motheris made in the laboratory of the healthdepartment. Should an expectant motherbe unable to afford a private physician,she may visit the prenatal clinicat the health department.The birth of Baby Citizen and everybaby in North Carolina is of concern tothe health department. All births arereported to the Vital Statistics Divisionof the Health Department.The public health nurse under thedirection of the family physician willvisit any home and instruct the motherin care of the baby.The Health Department, with the cooperationof local physicians and schoolofficials, conducts pre-school clinics inwhich the children are examined forobservable defects and determines thatthe necessary immunizations have beencompleted.Mr. and Mrs. North Carolina cansend their approximately one millionchildren off to school each day feelingconfident that school buildings andgrounds are free of insanitary healthhazards and that the food served themin school cafeterias is prepared andserved in a safe and sanitary manner.One of the major health problemsaffecting children in North Carolinais dental defects. Some of the countiesare giving special attention to thismatter by employing full-time dentiststo work in cooperation with schoolofficials and the local dental societies.Wonderful results are being attained,and without a doubt this phase ofpublic health should be expanded.One shudders at the thought ofwhat the results of venereal diseasewould have been had there been nopublic health program to deal withthis problem. Through the public healthprogram of three-fold-nature, embracingeducation, case-finding and treatment,venereal diseases are being controlledand progress is being made towardtheir elimination.Through public health programs, withthe cooperation of the medical profession,clinics are being conducted,open to all citizens for the purposeof detecting cancer and diseases of theheart before it is too late to do somethingabout them.North Carolina citizens should betold clearly and often of the fact thatpublic health touches and benefits eachand every one each day of our lives,in such ways as: meat inspection beforeand after the animal is killed; inspectionand approval of all public eatingplaces and food handling establishments;the program of rabies controlin connection with domestic animals,and the inspection and approval ofsewage disposal, septic tanks and pittoilets.What I have said about the publichealth program is not news to you,and I have not intended that it be.My purpose is to impress upon youthe importance of keeping the publicinformed as much as possible as to thevalue of the health department to eachand every citizen of North Carolina.It is my opinion that a good job ofpublic relations could be done by eachlocal health department in makinga special effort to see that its boardof county commissioners is at alltimes well informed about the healthprogram and its importance and thatthe local health organization is setup on a businesslike basis, with aminimum of lost motion. It is alsoImportant to keep in close touch anddevelop good relations with the localpress, as this is a health department'sgreatest asset in keeping the public informed.Dont use top sergeant methodsin dealing with problems that arise inconnection with minor violations, rememberingthat all the public does notknow the importance of these matters

6 The Health Bulletin January, 1955asyou do.Public health in North Carolina, youmight say, is at a cross-road. A financialproblem faces us as a resultof the loss of certain Federal funds.Which way shall we go? I am optimistic.I believe we can and will go forward.When you consider the Statebudget asking for $3,135,637.00 for 1955-57, which is $690,000 greater than thecurrent budget, largely to offset thereduction in Federal funds, and furtherconsider the fact that this askingrepresents about 78 cents per capitacost for the job being done by publichealth, you and our legislature willagree, I believe, that is a good buy.It is my considered opinion thatNorth Carolina citizens get as much,or more, benefits from their dollarspent for public health as from anyother function of local and state government.We must not stand still inthis important job, but rather we mustgo forward. Remember, to stand stillis to go backwards.I want to take this opportunity toexpress to each of you here, and toeach and everyone engaged in publichealth work in this grand old NorthCarolina, my personal thanks to youand my admiration of you for the partyou have played and are now playingin protecting my family's health andmine, and that of every citizen of thisstate. Your pay is by no means all thecompensation you receive for a jobwell done. I know you and all thoseengaged in public health that are nothere get a great deal of satisfactionfrom being engaged in this great workand thereby being a member of God'sgreat work in guarding and protectingthe health of His people.When I reflect back over the pastforty years of North Carolina's historyand think of the wonderful leadershipwe have had and the splendid progressthat has been made in publichealth and public schools, the social,industrial, and agricultural progress,I am reminded and feel somewhat likethe old Negro I once heard of, whowas somewhat over-emotional and hada habit of losing control at churchservices and going into a shoutingspree. This disturbed the minister andthe services so much that the pastorappointed a committee of two to callon the shouting brother and informhim of their problem and ask himto try to control his enthusiasm. Thecommittee called at the old man'sfarm and was told that he was plowingin a nearby field. They proceededto go to the field, but saw the old mancoming toward the barn leading hismule. As he approached they informedhim of their mission and explained thepreacher's problem. The old man listened,and, when they finished, he replied,"Brother, I understand the preacher'sproblem and I assure you that I willmake every effort to keep quiet inpreaching from now on, but when Ilooks at this old hat of mine, and Ithinks of that golden crown, andwhen I looks at these old shoes, andthinks of dem golden slippers; Here,hold this mule"!PUBLIC HEALTH SPEAKSE. H. ELLINWOOD, M.D., PresidentN. C. Public Health AssociationCounty Health OfficerGreensboro, N. C.Your North Carolina Public HealthAssociation has assumed a new role thisPresident's address at 1954 meeting ofN.C.P.H.S.year, and in keeping with the theme ofour convention — "Public Health Speaks"—I wish to review some of the highlightsof the present year. First, I wouldlike to congratulate you for selecting

January, 1955The Health Bulletinsuch an excellent Executive Committee.Its members have worked diligently inyour behalf and have made it a realpleasure for me to serve as your president.Our secretary has done an outstandingjob and we now have 1157paid members. This is the largest paidmembership we have ever had.Moreover, we have become a more effectiveAssociation because we haveunited in a common cause—cuts in Federalfunds have made it necessary forpublic health workers to join forces.There are other factors, which, if moregenerally understood, would increaseour membership and make us a morepotent force as public health continuesto speak. Many of our members are notfamiliar with the history of our Associationand have little knowledge as toits purpose. For this reason, I wouldlike to give you a brief resume of ourconstitution. In the preamble it states,"In order to carry forward and enlargethe services of the North CarolinaHealth Officers' Association organizedJune 20, 1911 and since that time incontinuous active operation protectingand promoting public health, providingfor scientific advancement of members,and extending and developing the publichealth movement, there is herebyformed this Association of PublicHealth Workers." Article I: "This organizationshall be known as the NorthCarolina Public Health Association accordingto the Amendment adoptedApril 24, 1922." Article II: "The purposeof this Association shall be to bringinto one organization the public healthworkers of the State of North Carolina,so that by regular meetings and interchangeof ideas they may secure moreefficient cooperation and uniform enforcementof sanitary laws and regulations,and for the better disseminationof such knowledge as will make moreeffective the opinions of the professionin all scientific, legislative, publichealth, material, and social affairs."My reasons for reviewing the purposeof our organization are: (1) To remindyou that there is more to our organizationthan the annual meeting, whichin reality is a yearly review of the progressof the Association, and to keep itsmembers up-to-date on the latesttrends in public health. (2) To pointout that through a special committeeto study "Merit System Salary Regulation"you have been ably represented.Many of our members would not havereceived salary increases were it not forthe study and effort of this Committee.This Committee, over the years, hashad your interests at heart and hasworked diligently to cooperate with theState Board of Health and the StateMerit System Council in an effort tokeep salary ranges in line with socialand economic changes. (3) Throughyour Legislative Committee, this Associationhas taken a forward step in informingthe people of North Carolinain a positive manner, of the importantpart our Health Department personnelis playing in meeting the health needsof our people.The primary purpose of this addressis a report to you on our EACH ONETEACH ONE movement. I would liketo make it clear—so far as the recordis concerned—that this movement isnot the "brain child" of any particularperson or group. It represents the combinedthinking of many people. It hadits origin at the American PublicHealth Association meeting in NewYork in 1953, when one of the speakersstated that Federal funds to publichealth had been cut over 50 per centwithout a protest. This idea began topenetrate the thinking of various membersand it was discussed in numeroussmall groups. Our North Carolina delegatescontinued to talk about it whenthey returned home. They were concernedover the previous reduction inFederal funds and what it did to ourprogram; more particularly were theyconcerned about the proposed cuts forthe coming fiscal year 1955. We wereinformed that we could anticipate abouta 27 per cent cut. What could be doneto prevent it? We knew that the Stateand Territorial Health Officers Associationwere organized to voice its opposition;but what could we in North Carolinado to help reverse this trend? Ireceived numerous telephone calls and

8 The Health Bulletin January, 1955from many of you whopersonal visitswanted the North Carolina PublicHealth Association to take an activepart in this movement.At the January meeting of the ExecutiveCommittee it was voted that yourAssociation should take an active part—not just the Executive Committee, butthe whole Association. How could thisbe done? Certainly, since it was a legislativeproblem, it should be referredto the Legislative Committee. Furthermore,a liaison committee was appointedto work with the Legislative Committeebecause it was felt that theState Board of Health, as well as theSchool of Public Health, should takean active part. The first step was toset up twelve regional meetings, plustwo special meetings at the State Boardof Health and the School of PublicHealth, which were designed to giveevery public health worker an opportunityto attend at least one of thesemeetings. Here you could learn howthese cuts were affecting the budget ofthe State Board of Health, and of yourown county, as well as the program atthe School of Public Health at ChapelHill.The response at these meetings wasexcellent and for the first time yourAssociation began to assume a new rolein public health affairs in North Carolina.The slogan EACH ONE TEACHONE—began to echo throughout thestate and finally reached not only yourrepresentatives in Congress but also thePresident of the United States. Thesuggestion that each Health Departmentstaff, as well as each individualmember, write to its Senator or Representative,caused the mail to be flooded.I received many carbon copies ofthese letters. Even the Executive Committeeof your Association wrote a specialletter to President Eisenhower andto every Senator and Representative ofthe Federal and State governments, aswell as to every chairman of countycommissioners in North Carolina. Thereplies to these letters were prompt andpractically every response was in favorof more support for public health needs.The most significant reply was fromMrs. Oveta Culp Hobby, Secretary ofHealth, Education and Welfare, datedMay 24, 1954. I will read you part ofher reply which indicates the Administration'schange in point of view:The President has asked me to replyto your letter of April 12 relative toFederal funds for public health services.You will be glad to know that thePresident has within the past few dayssent to the Congress a request forsufficient funds for health grants toStates so that the total Federal fundsin fiscal year 1955 for this purpose willbe — if approved by the Congressequal to the current year's appropriations. . .Thank you for writing. The opinionsof those who know the health programin the communities are extremelyhelpful to us in administering theFederal grants-in-aid.You will also be interested in a letterI received June 1 from Harold D.Congressman from the FourthCooley,District, which is as follows:I read your letter with great interest,since I was, at the time of its receipt,engaged in preparing a statement forpresentation to the House AppropriationsCommittee in behalf of an adequateappropriation for this very importantpurpose. I was very glad tohave the information supplied in yourletter and utilized the pertinent portionsin my statement, which wasmade on May twenty-seventh and copyof which I enclose herewith for yourinformation.Assuring you that it was a pleasure toattempt to be of service to the Associationin this matter, and with everygood wish, I am . . .In our State, John D. Larkins, Jr.,who is now Chairman of the StateAdvisory Budget Commission, wrote thefollowing letter:This is a very informative letter andI agree with you that all of the onehundred counties have felt the cut inappropriations to Public Health Serviceduring this year.However, I think this is only the beginningand eventually the States aregoing to have to assume more andmore of the burden of Public HealthService which will necessitate increasedtaxes.I wish to thank you for calling thismatter to my attention and I shall be

January, 1955 The Health Bulletin 9glad to do what I can in continuingthe health needs of the people of ourState.In order to complete the picturelocally, I wish to commend the variousmembers of the Health Departmentswho not only wrote letters to theserepresentatives, but encouraged manyfriends to write also. My only disappointmentin this program is thatonly a small, but effective minority,assumed this responsibility. I hope inthe future that we will have a largemajority taking an active part.You will be interested to know thatDr. Norton and I appeared before theannual convention of the County Commissionersof North Carolina atWrightsville Beach on the 17th ofAugust. This Association was told ofthe efforts that the North CarolinaPublic Health Association had madein bringing to the attention of ourFederal and State representatives theproblem that local appropriating bodiesare facing as a result of these Federalcuts.The County Commissioners Associationwas informed that the North CarolinaPublic Health Association has aright to be proud of the response itreceived, but this was by no meansthe end of its endeavor. It plans tocall to the attention of our state legislators,before the next General Assembly,the need for more state funds toreplace the Federal funds lost in 1954.We are also proud of the response manyof our county commissioners have madein appropriating additional funds tomeet local needs. Yet we realize thefull burden cannot be assumed locally.Unfortunately, these cuts came justafter the General Assembly had adjournedfor the biennium when statefunds were already set. Now is thetime for your county to re-evaluateits public health needs and for youto let your state legislators know exactlywhat you want. We want yourhelp and suggestions to enable the 1955General Assembly to understand thevarious communities' needs and to planwisely for meeting these needs throughan increase in State funds for publichealth.On behalf of the North CarolinaPublic Health Association, we appealedto the County Commissioners Associationto help each county board ofhealth to review the needs and problemsin its own county. We suggestedthat, if they were not thoroughly familiarwith the situation in their owncommunities, they visit their healthdepartments and find out what canbe done to strengthen their programs.In view of the many problems whichare arising as the result of increasingpopulation and mounting costs of service,I am sure you will agree with usthat these are mutual problems withwhich all of us are directly concerned.You will be interested to know that asa result of this meeting with the NorthCarolina County Commissioners Association,their Executive Committeeagreed to appoint a special committeeto meet with Dr. Norton and his budgetcommittee. This committee can becomea potent factor in arriving at a moreequitable distribution of funds for thesupport of local public health departments,as well as for the State Boardof Health.I would like to recommend to our Associationthat the EACH ONE TEACHONE movement be continued. In orderto do this effectively, each memberof the Association should become familiarwith the needs as well as thetotal budgetary request made to theGeneral Assembly by Dr. NortonTherefore, let me stress the four mostimportant items in his request. First,the $250,000 for each year of the nextbiennium is to be distributed in its entiretyto the local health departmentsin accordance with established policies.This amount will not fully replace theFederal funds lost during the last twoyears, but it will help the many countieswhich have about reached theirlimit in providing public health funds.Second, I strongly urge that $100,000of State funds be appropriated fortraining of public health personnel.Securing trained personnel is one ofthe major problems each local healthdepartment has to face. At the present

10 The Health Bulletin January, 1955time, there is no surplus supply oftrained public health physicians, dentists,nurses, sanitarians, nutritionists,or health educators available to ourHealth Departments for employment.For example, this means that from$1200 to $1500 has to be spent out oflocal funds to train one sanitarian.The quality of public health activitiesis directly related to the training andqualifications of public health personnel.The protection of the public'shealth today requires workers witha high level of training and competencebecause of the highly technical andspecialized nature of many publichealth activities. Thus, without adequatefunds for a state public healthtraining program, our local health departmentswill continue to suffer.Third, those of us in the local healthdepartments often have to turn to theState Board of Health for help throughits consultant staff. This service isparticularly needed in many of thecounties which do not have full-timehealth officers. It is often needed inmany of our heavily populated areaswhere new programs are inauguratedand where the problems are most acute.Unfortunately, these consultants arenot always available where the needis the greatest because of the lack offunds for state personnel. Furthermore,many of our consultants are still paidfrom Federal funds and if the presenttrend continues further cuts will bemade. Therefore, it is necessary tosee that such positions as the Chiefof our Health Education and PublicHealth Nursing Sections are paid outof State funds. Also, Dr. Norton is requestingan appropriation for an EducationalConsultant in the PublicHealth Nursing Section. There has beenjustification for this position for years,but now, with the development of fourcollegiate schools of nursing, the establishmentof this position is definitelyneeded. In the field of Maternal andChild Health, the Pediatric Consultantshould be paid from State funds. Anotherimportant position—the Chief ofthe Nutrition Section—has had moredemands for service than it is possibleto render, and our Nutrition programwould be seriously crippled, ifthrough reduction in Federal funds, theState were unable to pay the Chief ofthe Nutrition Section.There are other important consultantpositions in the State Board ofHealth which are still paid out ofFederal funds. It is our responsibiliyto take an active part in encouragingour General Assembly to provide sufficientfunds to insure the continuationof these programs. I would like to callto your attention several other keypositions which should be supported byState funds. All of us are familiar withthe efforts of the Department of Epidemiologyto develop a home accidentprogram. This program should be expanded.Yet, the chief of this serviceis paid out of Federal funds. Likewise,in the same Department, the supervisorof the Central Tabulating Unitand the chief of the Venereal DiseaseControl Section should be paid out ofState funds. Those of us in the largercities are becoming uneasy over theincrease in primary and secondarysyphilis. Surely we cannot afford tolose our venereal disease control programfor want of a competent medicalofficer and staff to head up this activity.The chief of the VeterinaryPublic Health Section is another ofour more recent consultants in theEpidemiology Division. This servicehas been most helpful to local departmentsin their rabies controlprograms, but its efforts are directedprincipally toward the control of diseasesprimarily among animals—secondarilyof man—many of which areimportant to North Carolina's livestockand milk industry. I am sure wewill agree that all of these consultantsshould be paid out of State funds.Fourth, the State Board of Healthis proposing a sound, effective approachto North Carolina's mental healthproblems. It is requesting a sum of$380,000 for the biennium to increasethe number of Mental Health Clinicsfrom 6 to 10. In so doing, it proposesto set up these additional clinics inareas where the need is greatest. At

January, 1955 The Health Bulletin 11the present time, there are no mentalhealth clinics east of Raleigh. Thesefunds will go directly to the local communitieswhere the program can bemost effectively developed.Public health should continue tospeak, and we, as members of theNorth Carolina Public Health Association,should back Dr. Norton in hisrequest to the General Assembly foradditional funds for public health.The pressing need in North Carolinais for extension, not curtailment, ofpublic health work. The maintenanceof good health is the goal for whichwe are all striving; it is our duty tobe ever vigilant and to maintain thehigh quality of public health practiceswhich are so necessary in achievingthis goal. All of us should assume ourresponsibilities by giving these problemsour best thought and effort.Above all, let us be ever mindful of thetheme of this convention "PublicHealth Speaks"—and strive to keepit ever before us, throughout this yearand the years to come.WHERE DO WE GO FROM HERE IN PUBLIC HEALTH?WILSON T.SOWDER, M.D.State Health Officer, Jacksonville, FloridaThe title of my talk is "Where DoWe Go from Here in Public Health?",but before I try to play the risky roleof a prophet, let's consider the pastand present of public health. I donot think that I would be adding toyour present knowledge or stimulatingyour thinking very much if I took thisopportunity to review for you theastounding accomplishments in thefield of public health that have beenmade in the last 25 to 50 years. Thealmost complete disappearance of malaria,typhoid fever and typhus feverand the precipitous drop in maternaland infant death rates, and deathrates from syphilis, tuberculosis andother communicable diseases is an oldstory to most of you; and, althoughit is well worth retelling, I am sureyou didn't need to have me come upfrom Florida for the purpose. However,I do want to point out the danger oftoo much emphasis on our glorious past,because it is apt to have a lullingeffect on us and interfere with ourplans for the future. I went to schoolat the University of Virginia, and IPaper delivered at 1954 Annual MeetingNorth Carolina Public Health Association,September 24, 1954, Raleigh, North Carolina.remember a professor there telling withan air of injury how some Yankeevisitor had cautioned him not to usethe great traditions of the Universityas a rocking chair. I fear the remarkwas very appropriate to some at myAlma Mater at the time in spite of thefact that feelings were hurt. However,let me hasten to add that, from allthat I have known or heard aboutyou North Carolinians, it is not customaryin this State to let traditionshamper the path of progress. I knowthat you will agree with me that it isnot enough today to tell the public andour appropriating bodies that due toour efforts many diseases are no longerso common or cause so many deaths.We know that the people and theirelected representatives are very likelyto be even more practical than the fellowfrom whom a friend wanted toborrow five dollars and who remindedhim of the many favors he had donehim in the past; and the fellow replied,as we all know, "Yeah, but whathave you done for me lately?" Thepeople are willing to applaud our pastaccomplishments but are not willingto pay us today or tomorrow for whatwas done yesterday.In fact, we have a tendency to exaggerateour past accomplishments and

12 The Health Bulletin January, 1955are shameless in taking credit for improvementsfor which we should, butfor which we were not solely responsible.Public health, meaning personsworking for official and non-officialhealth agencies, contributed to but didnot do the whole job of reducing thedeath toll from tuberculosis. Improvedeconomic conditions and better educationhave been important factors. Loweredinfant mortality rates are not entirelya product of our work. Refrigeratorsalesmen, plumbers and even thelowly iceman have helped as have manygroups and many factors. We havedone enough to be very proud aboutit, but more and better hospitals, newerand more effective drugs and bettertrained physicians and nurses haveprobably done more to lower mortalityrates.I believe that one of the greatesthandicaps that we have in public healthtoday is a certain lack of confidencein the future and a lack of plans forit. Perhaps this is because our publichealth problems seem to have becomeso numerous and complex. Many of ushave been in public health long enoughto remember when it was not so difficultto get agreement on what the majorpublic health problems were and whenit was easier to explain to the publicand to appropriating bodies why moneyfor public health was needed and howit would be spent. A few cases of typhoidfever in a community were allthat was necessary to illustrate theneed for a county health department,and this one disease could be used toexplain the work of a health officer sanitarian,sanitary engineer, public healthnurse—in other words the work of thewhole public health team. I would certainlybe the last to deplore the passingof this terrible disease, but I do wantto point out that we have not beenable, even with all the improvementsin audio visual aids, etc., to devisean exhibit that is quite as dramaticand effective as a real live, or dead,case of typhoid fever.Now before the old-timers amongyou take offense at any seeming implicationfrom what I have just said,that you had an easy time in publichealth in the old days, I hasten to saythat I didn't mean that at all. I didn'tmean that you had an easier time gettingappropriations. I know you didn't.What I mean is that by limiting yourfield of endeavor your problems weremore clear-cut, more dramatic, easierto discuss and explain; and the solutionsto them were clearer. You couldpromise much greater returns to thepublic in better health and fives savedper dollar spent than can be done now.You could show impressive graphswhose lines plummeted dramaticallyfrom high peaks to low incidence. Andpublic health, like the virgin soil inthe pioneer days of this country, wascheaper then. Now, as in the case ofland, the price of public health hasgone up. We have been compelled,both by the lessening of the communicabledisease problem and by publicdemand, to broaden the scope of ourwork and to cultivate what formerlylooked like very barren soil. We areno longer allowed to plow only thebottom land. The pioneers in publichealth, and I'm thinking mainly ofthose who worked in the period of from15 to 40 years ago, did not have aneasy time, but I think they had morefun than we do now. They had abetter idea of what they wanted todo and where they wanted to go. Theywere not assailed by doubts, nor hamperedby ideological disputes. Theyknew what the public health problemswere. Your own Dr. Applewhite is oneof those crusaders that I am talkingabout, and I am sure that each of youhas already thought of others who fitin this picture and who fought a goodfight. Public health then was more likea crusade and for reasons somewhatsimilar to those which brought aboutthe original crusades in the MiddleAges. At that time the Holy Land wasin the hands of the infidel Saracens,and the true believers of the Christianfaith had no doubt but that the propercourse was to take it away fromthem and let the purifying air ofChristianity replace the evil smell ofheresy. Our public health crusaders

January, 1955 The Health Bulletin 13encountered many unbelievers, and itwas very satisfying to tilt with them.They lost many battles, but they wonall the wars and public health becamea "knight in shining armor." Appropriationsincreased and county healthdepartments multiplied. We got morepersonnel but also more jobs to do.Our reputation for near-miracles becamealmost a handicap, and everysession of Congress and of our statelegislatures gave us new duties andresponsibilities. For some of these,funds were provided, but some we wereexpected to do "in addition to our otherduties." The State Board of Healthin Florida, established in 1889, originallyhad only one duty, to controlcommunicable diseases and among thesemainly yellow fever. By 1950 the listof duties had grown to 84, and severalnew ones have been added since.But many of us nevertheless havean uneasy feeling about the future.One of our difficulties is explaining ourneeds in public health. There are undoubtedlyin this audience plenty ofindividuals who can make a fine tenminuteor hour-long talk on any programthat you have here in NorthCarolina, be it nutrition, industrialwaste disposal, cancer control or infantcare. But I am sure that all ofyou will agree that it is quite difficultto say enough about public health'snumerous present problems in any reasonablelength of time. I know howdifficult (or impossible) it is to do thisbecause I have had the job of tellingwhat the Florida State Board ofHealth does to civic clubs, our statebudget commission, governors and legislativeappropriating bodies in timelimits ranging from ten to thirty minutes.The program chairman casuallysays, "take all the time you want,doctor (up to 30 minutes); that is,tell us everything about public health."This frustrating predicament is facedconstantly by responsible public healthofficials every day on national, stateand local levels of government. Weare favored by an interested and enlightenedpublic, and by and large ourlegislators are sympathetic and far fromparsimonious. They actually want to giveus money to improve health and sanitationand to prevent illness and needlessdeaths. I make this statement in spite ofthe trend in Congress in the past fewyears to reduce appropriations for grantsto states. These reductions were based inpart at least on the philosophy thatthe states are responsible for this importantjob; partly by a swing of interestfrom the types of work that6tate and local health departments doto vocational rehabilitation, to the constructionof hospitals and related institutions,to research, and to medicaland hospital insurance. (In parentheses,I'd like to add that if we do not agreewith these congressional actions andpolicies we should express our viewsto them in every proper manner, byletter, by telegrams and by personalconferences.) However, we should notspend too much of our time lamentingthe whims of the Federal government.Our principal sources of support, financialand otherwise, are our ownstate legislatures and city and countyofficials. I have already touched brieflyon the fact that our principal handicaplies in the difficulty of presentingbriefly and clearly the answer to thesimple question: "What are your problems?"When I was the director ofa state venereal disease control programand had over 30,000 new casesof syphilis reported in a year and over30,000 persons under treatment forthis disease, it was possible to answersuch a question concisely. Now the answeris not easy because you don'tget very far if you answer, "My problemis the need for $2,000,000 to betterhandle ten or twenty or more problems."Sometimes people seem more interestedin buildings than the peopleworking in them. I congratulate youon the new building that you havegotten for the health department herein Raleigh but I know that my oldfriend, Dr. Norton, will agree withthe old Chilean proverb "The bird ismore important than the cage." Theproblem of keeping well trained, experiencedand competent personnel by

14 The Health Bulletin January, 1955providing adequate salaries and optimumworking conditions is not onethat has wide appeal. It is intangibleand therefore difficult to sell.I believe that one of our major problemstoday and in the future in maintainingpublic interest and support isthe very multiplicity of our problems.More and more we must examine thatperplexing question: "What is a publichealth problem?" We have a multitudeof friends and supporters who will helpus get all the money we need for tuberculosiscontrol, if we choose toconcentrate on that alone. We have amultitude of friends and supporterswho will help us get all the money thatwe need for cancer control, if wechoose to concentrate on that alone.The same can be said for mentalhealth, sanitation, mosquito control,stream pollution and a host of otherdiseases and conditions. We have enthusiasticgroups in Florida who areanxious, willing and able to help usget money for inspection and laboratorywork in connection with crabmeat inspection,for research on better methodsof getting rid of waste, for more andbetter food handlers' schools, for tuberculosiscontrol, for cancer control,etc. But, when we ask for help ingetting funds to protect the people ofFlorida from all diseases and all unhealthfulconditions, and to promotehealth and longevity, the line of helpersthins out. Few seem to be enthusiasticabout coordinated public health actionin tuberculosis, cancer, venereal diseaseand maternal and child health,even though these problems occur inthe same communities, in the samehouseholds and at times even in thesame persons. There are few rooters,(except for a few sanitary engineersand sanitarians in supervisory positions,and the State Health Officer),for an overall environmental sanitationprogram, including water supplies, sewagedisposal, pure food, milk, streampollution, etc. Outside our public healthlaboratories, there are no organizedgroups and few individuals who realizethat laboratory work is basic to practicallyevery endeavor undertaken bythe health department. I never heardof any interested outsider being achampion of one health departmentactivity which is the oldest of all,namely the collection and filing ofbirth and death certificates, the furnishingof certified copies of them andtheir analysis.People know more about disease todaythan ever before. We can take some ofthe credit, but so can radio, TV, newspapersand popular magazines. Since thepublic is more knowledgeable, I hear agreat deal these days about encouragingthe ordinary citizens in communitiesand states to study their own problemsand help determine their ownneeds. I think this is an excellentthing if we, who are trained in publichealth, are not restrained from providingsome leadership in arriving atthe conclusions. A democracy such asours is based on the principle of thepeople being able to get what they want,but I believe that even in a democracypeople trained in special fields, suchas we public health workers, have aresponsibility to say what they thinkis best. Whether or not our advice istaken is up to the people when all issaid and done. I am not such anidealist as to think that an endeavorsuch as public health, which is basedon public support and financed withpublic funds, can maintain a perfectbalance between what is done andwhat ought to be done. Furthermore,I am not so conceited for our group asto think that were all our advice heededwe would necessarily have a state ofperfection. For one thing, we in publichealth do not unanimously agree onwhere we want to go. We come frommany professions and groups. We havedifferent interests and points of view,and this contributes to our strengtheven though it prevents unanimity ofopinion. True, in some ways it confusesthe public, and better public understandingis one of the goals of thefuture in our field.We cannot, however, afford to driftaimlessly with the tide of public opinion,nor succumb to easy pressure whichwould not, in our opinion, advance

January, 1955 The Health Bulletin 15the cause of health improvement. Wecan protest, and can recommend—andwe should. We should study our problemas a farmer does his land and decidewhich fields would best be plowedand which can most profitably be leftfallow. We can and should take thepublic and public officials, includinglegislators, into our confidence andask for their help in planning; but weshould be frank with them and resistthe tendency to favor always the popularand expedient course.It seems to me, though, that weshould agree on some basic action forthe future. We must recognize thefact that our job in public health haschanged and is changing and will continueto change. We should recognizethe fact that past successes do notjustify our present and future existence.We should not exaggerate ourpast contributions, but, on the otherhand, we should emphasize the possibilitiesfor effective work in the future.We must realize that the work aheadof us may not be so dramatic as thatin the past. We must reconsider ourformer major objective of reducingmortality from specific diseases andcauses, such as pellagra, diphtheriaand the like. Our present objectivesshould include holding the line againstthe return of these diseases that havebecome minor public health problemsand shift gradually to a program ofgeneral health conservation. Helpingpeople to stay out of the hospital, tolead more vigorous and longer livesand to maintain a better mental andemotional balance may not be sospectacular, but it is the job, as Isee it, that remains for public healthto do in the future. We will find ourselvesdoing more and more to makeliving conditions pleasant and enjoyable.For example, we are alreadyspending sums of money in Florida tocombat pest mosquitoes, as distinguishedfrom disease-bearing mosquitoes. Weare paying more attention to publicwater supplies which have had tastesand odors or which discolor laundryor clog pipes. Industrial plants whichgive off unpleasant odors or dust areinvestigated. We are beginning to learnthat to be healthy physically, mentallyand emotionally, we must be happy andcontented where we live.Our criteria for selecting programsof the future should be based notonly on preventing illness and savinglives but also on the newer theorythat they promote health andphysical and mental well-being. Suchprograms as those concerned withchronic diseases (cancer, heart diseaseand diabetes) and mental and emotionaldisturbances, including alcoholism,will be promoted in the yearsto come. In the field of environmentalsanitation, pest mosquito control, atmosphericpollution, stream pollutionand control of allergy-producing substances,I feel will be important. Manyother problems, now unthought of, willcome to the fore and occupy our mindsin the next few years. But I haveenumerated enough to keep all of usbusy for quite a while.NOTES AND COMMENTBY THE EDITORTHE GENERAL PRACTITIONER'SAWARD*At the annual Clinical Meeting ofthe American Medical Association inMiami, Fla., Nov. 29, 1954, the annualEditorial. Vol. 156,Dec. 11. 1954.No. 15. J.A.M.A.General Practitioner's Award, consistingof a gold medal and a citation wasgiven to Dr. Karl B. Pace, who haspracticed medicine in Greenville, N. C.for nearly 40 years except for his militaryservice in World War I. Theselection of Dr. Pace as the typicalfamily doctor of 1954 was announcedat the opening session of the House

16 The Health Bulletin January, 1955of Delegates by Dr. Dwight D. Murrayof Napa, Calif., chairman of the Boardof Trustees. Dr. Pace completed thefirst two years of his medical trainingat the University of North Carolinaand then went to Philadelphia, wherehe received the degree of doctor ofmedicine from Jefferson Medical Collegein 1914. After an internship atGouverneur Hospital in New York Cityand at Nassau Hospital in Mineola,N. Y., he returned to North Carolinain 1916 and began a career that hasbeen devoted to helping his fellow menand to the betterment of his profession.Dr. Pace was a leader in the reorganizationof the Pitt County Medical Society,a president of the Tri-StateMedical Society, and for six years amember of the North Carolina Boardof Medical Examiners and is a memberof the Seaboard Medical Society,the American Academy of GeneralPractice, the Medical Society of theState of North Carolina, and theAmerican Medical Association and headof the Atlantic Coast Line SurgeonsAssociation. He was a member also ofthe original committee to reorganizethe medical college of the Universityof North Carolina, which led to theestablishment of a four year medicalschool in his state. He, with threeother physicians, led a movement manyyears ago to build the first hospital inPitt County, for which all four physiciansmortaged their homes and borrowedmoney on their insurances andother valuables. In 1920 Dr. Pace startedthe first venereal disease clinic in NorthCarolina. His civic activities includedirectorship with the Boy Scouts, theRed Cross, the chamber of commerce,and a bank. He was chairman of theGreenville Utilities Commission foryears, president of the Greenville RotaryClub, and an organizer of theGreenville American Legion Post andof the Pitt County Executives Club.He has been chairman of the financecommittee of the Jar vis MemorialMethodist Church for 25 years andactive in the work of the CommunityChest and the March of Dimes campaignof the National Foundation forInfantile Paralysis. Dr. Pace has threesons, two of whom are physicians,while the third recently completed thesenior year at the University of NorthCarolina. When earlier this year, hewas selected by the Medical Society ofthe State of North Carolina as thegeneral practitioner of the year, themayor of Greenville said, "He is lovedand respected by the rich and pooralike as he has unstintingly given ofhimself to all who have called uponhim not only for medical treatmentbut for business and spiritual assistancein times of need. Although busy dayand night with the practice of his medicalprofession he has somehow beenable to find the time to be outstandingin almost every important civic endeavorof this city." His type of serviceis described also by a colleaguewho said, "In spite of the enormousdemands made upon his time andstrength by virtue of his professional,religious, and civic activities, Dr. Pacehas never become too busy to stopand listen to people's troubles and totry to help in solving their problemsthrough sympathetic counsel, encouragementand financial aid."The Annual General Practitioner'sAward of the American Medical Associationhas been awarded to sevenother physicians since it was first givenin 1948. They are Archer ChesterSudan, Kremmling, Colo.; the lateWilliam L. Pressly, Due West, S. C;Andy Hall, Mount Vernon, 111.; thelate Dean Sherwood Luce, Canton,Mass.; Albert C. Yoder, Goshen, Ind.;John M. Travis, Jacksonville, Texas;and Joseph I. Greenwell, New Haven,Ky.

MEDICAL LIBRARYU . OF N. C .CHAPEL HILL,NinPuTMeJby Tffi/rafflCAKIMft SEfflElfflKD^flEALTflI This Bulletin will be seht free to dtMj citizen of tne State upon request tPublished monthly at the office of the Secretary of the Board, Raleigh, N. C.Entered as second-class matter at Postoffice at Raleigh, N. C. under Act of August 24, 1912Vol. 70 FEBRUARY, 1955 No. 2

MEMBERS OF THE NORTH CAROLINA STATE BOARD OF HEALTHG. G. Dixon, M.D., President AydenHubert B. Haywood, M.D., Vice-PresidentRaleighJohn R. Bender, M.DWinston-SalemBen J. Lawrence, M.D RaleighA. C. Current, D.D.S GastoniaH. C. Lutz, Ph.G HickoryGeo. Curtis Crump, M.DAshevilleMrs. J. E. Latta Hillsboro, Rt. 1John P. Henderson, Jr., M.D Sneads FerryEXECUTIVE STAFFJ. W. R. Norton, M.D., M.P.H., State Health OfficerJohn H. Hamilton, M.D., Assistant State Health Officer and DirectorState Laboratory of HygieneC. C. Applewhite, M.D., Director Local Health DivisionErnest A. Branch, D.D.S. , Director of Oral Hygiene DivisionA. H. Elliot, M.D., Director Personal Health DivisionJ. M. Jarrett, B.S., Director Sanitary Engineering DivisionFred T. Foard, M.D., Director Epidemiology DivisionFREE HEALTH LITERATUREThe State Board of Health publishes monthly The Health Bulletin, which willbe sent free to any citizen requesting it. The Board also has available fordistribution without charge special literature on the following subjects. Askfor any in which you may be interested.DiphtheriaFliesHookworm DiseaseInfantile ParalysisInfluenzaMalariaMeaslesScarlet FeverTeethTyphoid FeverTyphus FeverVenereal DiseasesResidential SewageDisposal PlantsSanitary PriviesWater SuppliesWhooping CoughSPECIAL LITERATURE ON MATERNITY AND INFANCYThe following special literature on the subjects listed below will be sent free toany citizen of the State on request to the State Board of Health, Raleigh, N. C.Prenatal CarePrenatal Letters (series of nine)monthly letters)The Expectant MotherInfant CareThe Prevention of Infantile DiarrheaBreast FeedingTable of Heights and WeightsBaby's Daily ScheduleFirst Four MonthsInstructions for North CarolinaFive and Six MonthsSeven and Eight MonthsNine Months to One YearOne to Two YearsTwo to Six YearsMidwivesYour Child From One to SixYour Child From Six to TwelveGuiding the AdolescentCONTENTSPageDeaths From Poisonings—North Carolina's MostPreventable Accidents 3Have Shall They Survive? 9Discussion Of Dr. Mezera's Paper 14

T?T«£IPUBLI5MED BYTAE N°RTA CAROLINA STATE B°ARD^AEALTAlVol. 70 FEBRUARY, 1955 No. 2J. W. R. NORTON, M.D., M.P.H., State Health Officer JOHN H. HAMILTON, M.D., EditorDEATHS FROM POISONINGS—NORTH CAROLINA'SMOST PREVENTABLE ACCIDENTSBy CHARLES M. CAMERON, JR., M.D., M.P.H.Chief, Accident Prevention SectionandEDGAR F. SEAGLE, B.A., M.S.P.H.Sanitation Consultant, Accident Prevention SectionN. C. State Board of HealthThe wider recognition of the importanceof home and farm accidentsas a health problem has focused particularattention on those deaths in thehome resulting from poisonous solids,liquids and gases. Since the incidenceof such accidental deaths is five timeshigher in children under five years ofage than in other age groups, deathsfrom poisons are of paramount interestto pediatricians, general practitionersand public health workers. Of furtherimportance is the fact that studiesshow five out of six poison deaths occurin the home, still considered by manyas the safest place on earth.Bain, in a recent review, has pointedout that the death rate from this causein the United States is four times thatof the British rate and that twelvesouthern states have a death rate fromaccidental ingestion of poisoning twicethat of the United States.*In children under five years of agein the entire United States, the deathrate from poison accidents is 2.6 per100,000 based on a two-year sample,1949 and 1950. During a correspondingperiod, the North Carolina death ratein the same age group was 4.2 per100,000. Figures just released for theyear 1953 indicate that in North Carolinatwenty-one deaths occurred amongchildren under five years of age frompoison accidents. The 1953 rate alsois 4.2 per 100,000 in this age group.Accidental deaths from poisons accountedfor about five and one-halfper cent of the 1,034 non-motor vehicleaccident deaths in North Carolina in1953, with this cause having been listedas the cause of death on fifty-ninecertificates. Forty-nine of these deathsoccurred either in a home or on afarm.A review has been made of thepoison deaths to delineate possibleepidemiological factors concerned intheir causation and to discover possibleavenues along which one may approachthe control of such deaths.Of the 59, a total of 16 deaths werelisted as resulting from drinking beveragealcohol or an alcohol containingproducts such as a paint diluent, solventor commercial preparation em-

The Health Bulletin February, 1955bodying methyl alcohol. In fifteen ofthese instances the death seemed tofollow the deliberate ingestion by anadult of these products in an effort toobtain some degree of intoxication,and these fifteen cases have been excludedfrom further study. In one instancea four-year-old Negro male diedafter drinking a quantity of illicitwhiskey in his home. This case hasbeen classed as a true accidental poisondeath since it is highly unlikely thatthe child's primary intent was to becomeintoxicated.Of the remaining 44 deaths classedas resulting from poison, an additionalfive case were excluded from the study.In four of these, the information onthe death certificates indicated thatthe poisonous agent only secondarilycontributed to the death. Typical ofthese cases was that of a twenty-yearoldwhite male working in a well wherehe became overcome by gas, fell unconsciousand drowned prior to beingpulled from the well. The final caseexcluded from the study was that ofa four-year-old Negro male who waslisted as having succumbed "due toacute intoxication resulting from theingestion of an unknown toxic substance."The absence of more specificdata makes classification of this casedifficult.Of the 39 cases studied, 34 occurredin the home, four occurred in someother specific location and the placeof occurrence of the final one is unknown.A total of 19 of the accidentsinvolved white persons and 20 involvedNegroes.Twenty-one of the 39 accidents claimedtheir victims among children underfive years of age, with deaths amongNegro children outnumbering thoseof white children three to one. As inother accident studies, males were involvedfour times more frequently thanfemales. Children under five years ofage experienced about five times greaterincidence of poison deaths thanother age groups. (See Graph I.)The race specific death rate is 0.6per 100,000 white residents, comparedto 1.8 per 100,000 non-white residents.The sex specific death rate for bothraces among males is 1.6 per 100,000and among females is 0.3 per 100,000.The sex specific rate among nonwhitesis 3.4 per 100,000 males and .3per 100,000 females. Among whites, thesex specific rate is .9 per 100,000 malesand .3 per 100,000 females. (See TableI.)The 39 deaths occurred in twentythreeNorth Carolina counties. Cabarrus,Cumberland, Durham, Forsyth,Gaston, Guilford, Lenoir, Mecklenburg,New Hanover, Richmond and WakeCounties recorded more than one deathfrom poisonous solids, liquids and gases.The largest number reported fromany single county were in Wake County,where five accidental poisoningsoccurred in 1953. Durham and LenoirCounties each recorded three poisondeaths.These 39 deaths were analyzed asto poisonous agent, and the agents wereclassified. (See Table II.) Drugs andother medicinals caused 18 of the 39deaths to account for almost one-halfof the total. Carbon monoxide gas wasencountered the next most frequently,leading to seven deaths. Pesticides werelisted as the injurious agents in six ofthe poisonings. Petroleum productscaused three children's deaths, lye andother caustics two, and alcohol andfurniture polish one each; while onedeath from an unclassified toxic agentwas recorded.Of the medicinal agents leading toaccidental death, aspirin was the mostfrequent offender, causing the deathsof five children under five years ofage. Investigation revealed in mostinstances a male toddler discoveringa bottle or package of aspirin tabletsand, emulating the adults whom hedoubtless had observed, eating thecontents. The role of the candy flavoredaspirin is highly suspected in thesecases, although in many instancespalatability is not a factor insofar asa child's eating or drinking toxic substancesis concerned.Analgesics, such as dolophine andmethadone and barbiturates, were encounteredthe next most frequently.

February, 1955The Health BulletinLaxatives, anti-hypertensives and avariety of other therapeutic agents accountedfor the remaining deaths inthe drug group.Insect and rodent poisons accountedfor the majority of the deaths classedas pesticide accidents. The syntheticorganic pesticides were not encountered,the majority being of the heavy metalgroup.Since information available to theinvestigators was limited to that containedon death certificates, no accurateinformation is available on the totalnumber of non-fatal accidents resultingfrom toxic materials. One study completedby the Insect and Rodent ControlSection of the North CarolinaState Board of Health indicated a possiblehigh incidence of eye injuriesresulting from the use of organic insecticidesin agriculture in easternNorth Carolina.The National Safety Council, on thebasis of large-scale surveys among policyholders of several insurance companies,has estimated that, for eachaccidental death, there will occur from100 to 200 non-fatal accidents.2 Applyingthese estimates to the 1953 experiencein North Carolina and utilizingas a base only the 39 cases studied,one may estimate from 3,900 to 7,800non-fatal poisoning accidents each year.Admittedly, poisoning accidents mayhave a higher fatality rate than othertypes of accidents, but all would acknowledgethat the loss of life, disabilityand economic loss from this singletype of accident are tragic. Arena,Dietrich, and others frequently havecited the physically and mentally traumaticcrippling resulting from non-fatalaccidents with lye and other caustics.3-4All safety authorities agree that,except in the most unusual circumstances,an accident experienced bya child under five years of age representsa failure on the part of the parentsin exercising the necessary protectionand education to equip it tomeet the hazards of day-to-day livingwithin the home.Since the protection of children fromdeath by the accidental ingestion orinhalation of a toxic material can beachieved by the total and completeseparation of the child from the toxicagent, one is tempted to observe thatwith these accidents the etiological relationshipsare not as complex as inthe case of falls, fires and other typesof home accidents. While the preventionof these accidents hinges on the relativelysimple principle of separation ofthe child and the poison, stimulatingthe parent to institute such controlof toxic materials in the home is exceedinglycomplex.Doubtless some of the poison deathsand injuries each year can be attributedto apathy, carelessness and a genuinelack of concern on the part of the parentfor the safety of the child. Somepossibly can be attributed to the greatnumber of highly toxic agents whichare marketed, purchased and broughtinto the home without the labels notingthe toxicity of the contents. This istrue of furniture polish, paint solvents,cosmetics, floor wax, bleaches,soaps and many of the householdcleaning aids now on the market. Astudy recently completed by the Departmentof Pharmacology of a largeEastern university pointed out theextreme reluctance on the part ofseveral of the leading manufacturersof waxes, polishes, cosmetics and otherproducts to divulge even the barest detailsas to the constituents used in themanufacturing process.Pharmacists and physicians fromtime to time have been exhorted tocaution patients receiving prescriptionsas to the toxicity of the medicine. Themanufacturers of "baby aspirin" havebeen petitioned to reduce the amountof aspirin per tablet, reduce the numberof tablets in each package and removethe candy flavoring and coloringfrom the tablets. Some degree of cooperationis being obtained from all ofthese sources.While an attack on all these frontscan contribute to the protection of thechild from the toxic agent, none cancreate a complete barrier, since the finalact of this modern tragedy is writtenwithin the home, where the child is

6 The Health Bulletin February, 1955the total responsibility of the parents.Parents must be impressed with theimportance of investigating all solidsand liquids—medicine, cosmetics, cleaningagents, paints, solvents, preservatives—whichare within the reach ofthe child, keeping in mind at all timesthe toddler's remarkable climbing abilityand removing all the known orquestionable toxic materials. Old prescriptionsand highly toxic materialsshould be discarded from the home ina safe manner, such as by burning orburying. Certain non-toxic cleaningagents may be substituted for the highlytoxic caustics and alkalis. Thosemedicines and other chemicals, absolutelyessential to home operation, maythen be stored in a special lockedcabinet completely inaccessible to thechild.The education of the parent as tothe importance of this two-step procedure—removalfrom the home ofthe useless and most toxic, and totallyand completely locking up that whichremains—must fall to all those individualsand agencies which influenceparents and family living today. Almostdaily the impracticability and lackof success of safety campaigns, specialdays, weeks and months and widespreaduse of mass media for safety educationis more clearly demonstrated to safetyleaders. Learning is most efficient whenbased on firm footings of intra-personalrelationships and it will be the "faceto-face"teaching of safety by physicians,public health personnel and professionaland lay adult educators thatholds the most promise for controllingAmerica's growing accident problem.Until such time as this method ofsafety education may gain momentumin North Carolina, the reductionof poison deaths may rest heavily onthe ready availability of competentmedical aid to counteract the effectsof the poison. To meet this need, withinrecent months the Duke UniversitySchool of Medicine has established aPoison Control Center, patterned tosome degree after the initial endeavorof this type in the Chicago area.» TheDurham institution offers not onlytwenty-four-hour treatment facilitiesfor poison victims brought tothe hospitalbut also ready information forphysicians as to the constituents ofmost toxic agents, the antidotes andmethods of treatment. This informationcan be obtained by anyone in thetristate area day or night by callingDuke Hospital.The control of accidental deaths frompoisons may be looked to as anotherexample of the necessity for the skillfulblending of preventive and curativemeasures which holds promise ofsavingthe lives of scores of North Carolinianseach year.BIBLIOGRAPHY1. Bain, Katherine, M. D., "DEATH DUE TO ACCIDENTAL POISONING INYOUNG CHILDREN," Reprint from The Journal of Pediatrics, Vol. 44, No.6, 616-623, (June 1954).2. Proceedings of the first conference on "HOME ACCIDENT PREVENTION,"Sec. I, p. 20, University of Michigan Press, Ann Arbor, Michigan, (Jan. 20, 21,and 22, 1953).3. Dietrich, Harry F., M. D., "ACCIDENTS, CHILDHOOD'S GREATEST PHYSI-CAL THREAT, ARE PREVENTABLE," Reprint from Journal of The AmericanMedical Association, Vol. 144, 1175 - 1179, (Dec. 2, 1950).4. Arena, Jay M., M.D., "POISONING IN CHILDREN—RECENT TRENDS,"N. C. Medical Journal, Vol. 15, No. 11, 555, (Nov. 1954).5. Press, Edward, M. D., and Mellins, Robert B., M. D., "A POISONING CON-TROL PROGRAM," American Journal of Public Health, Vol. 44, No. 12, 1515,(Dec. 1954).

February, 1955The Health BulletinGRAPH IAccidental Poisoning DeathsNorth Carolina— 19532$20NO. *£DEATHS100-5 5-lij. 0S-22l 25-Mi- ^4-64 65 & overAGE

8 The Health Bulletin February, 1955TABLE IAccidental Poison Deaths By Age, Sex, and ColorNorth Carolina—1953Age

February, 1955 The Health Bulletin 9HOW SHALL THEY SURVIVE?L. R. MEZERA, M.D., DirectorMaternal and Child Health, Kentucky State Board of HealthMay I ask your indulgence to moreor less introduce the theme of this:"How Shall They Survive?" AlthoughI shall specifically limit myself to survivalin the area of maternal and childhealth, we as public health workersmust consider the total environmentbecause mankind in its search for survivaland longer life has banded togetherin community life as one meansfor reaching the objective of its search.As a natural result of a communitybanding together some organization orgoverning body had to come into thepicture. With this type of setup thenext step was logical—the people beganlooking to their government in a furthersearch for survival. This search,as you all know, was fruitful. Publichealth came into being and a salientresponsibility was accepted, namely, theresponsibility of safeguarding thehealth of all people. Specifically, thisresponsibility became a mandate—lifemust be saved, health must be preserved.With this mandate before us weprivileged public servants are meetingat this time to also search for meansand methods of performance to complywith the mandate and to renderthe duty and service inherent in ourjobs as public health workers.We must recognize the demand forgood health and longer life, and wemust come up with the answers toquestions such as "What shall bedone?" "Who shall do it?" "How shallit be done?" We cannot sit idly bycontent merely to gather informativestatistics relative to human morbidityand mortality. We must provide foran adequacy of follow-up. A constructiveprogram must be the result of acareful and scrutinizing survey of localactivities. This survey, when care-Paper delivered at 1954 Annual MeetingXorth Carolina Public Health AssociationSeptember 23, 1954, Raleigh, N. C.fully obtained, should, when evaluatedin proper scope, then point out pertinentproblems as to their existenceand their reality. Then, and only then,can we come up with a program ofsurvival, a program of preventing unnecessaryillness, a program of salvage,a program of prevention of needlessdeaths. Progress requires continuingchange and improvement, and we stillhave a long, hard road ahead of us.Our currently accepted philosophythat a community is bounden to do forits people that which they cannot dofor themselves is what motivates us.We have accepted this philosophy aspart of the mandate from the people.A condition which increases the burdenof the community is demanding of ourattention, and preventive efforts mustbe expended to lower the burden anddecrease the load. Economic productivity,standards of living, ways of life,all are in jeopardy if we fail to acceptthe concept that our people have aright and a duty to demand and takemeasures for the prevention of illnessand the preservation of life. The goaltoward which to strive is the creationof an environment in which there willbe no human suffering or prematuredeaths.This brief introduction leads me intothe specific field of maternal and childhealth. "How Shall They Survive?"I approach this subject with timidity.The expanse of maternal and childhealth is infinite. There is no segmentof life that can be divorced from thearea encompassing the mother andchild. Here again we find a circle withoutend.Despite tremendous strides in recentyears, many mothers continue todie, and many deaths still occur ininfancy and childhood, deaths thatneed never occur if we would but explorethe reasons for their occurring.As an approach to a program of salvage,I must refer you to certain sec-

10 The Health Bulletin February, 1955tions of the "Children's Charter" promulgatedat President Hoover's WhiteHouse Conference on Child Health andProtection. Section IV of this Charterreads as follows: "For every child fullpreparation for his birth, his motherreceiving prenatal, natal, and postnatalcare; and the establishment of suchprotective measures as will make childbearingsafer."Section V — "For every child healthprotection from birth through adolescenceincluding: periodic health examinations,—protectiveand preventivemeasures against communicable diseases,the ensuring of pure food, puremilk, and pure water."Thus we see a further strengtheningof the mandate—life must be saved,and health must be preserved.Maternal health and child health areinseparable and when we speak ofthe mother we must include the child.The road the mother travels duringher pregnancy and at the time of deliveryis directly reflected in thehealth of the child. Therefore, whenasking "How Shall They Survive?"maternal health services cannot beremoved from a child health program.Recognizing this concept, we must gofarther and state that a program ofsurvival and salvage must be community-wide.It must have the interestof all the mothers and all the childrenof that community. By a method ofhealth education, the mother must havethat guidance and educational serviceavailable which will lead her to seekmedical supervision as early in pregnancyas possible and guide her inmaintaining the good health of herchild at all times, during sickness andin health. In some instances, servicesmust go beyond the educational phase.They cannot be restrictive, since, asmentioned above, it is bounden uponany community to do for its peoplethat which they cannot do for themselves.This calls for a complete communitysupport of an organized publichealth program, a program that inno way will remove the family doctorfrom the key relationship role of patientand physician but will recognizehim and his colleagues as the hub ofa total community program."How Shall They Survive?" Thebaseline of any program whatsoevermust be sound, must be feasible. Certainquestions immediately face us.1. Is there a problem? Does it exist?Is it real?2. What is the extent and range ofthis problem?3. Why does this problem exist? Areavailable services adequate? How canwe expand? What are the needs?4. Are finances and financial supportadequate to expand services?5. Are facilities available?In short, we must first make a carefulsurvey of the situation, carefullyevaluate all segments of thissurvey and then, and only then, formulatea program.The health officer is the one authorityto whom every community shouldlook for wise guidance in the totalhealth program of any community. Hehas the real responsibility for the goingon record against any wasteful anduseless programs. If he is sponsoringsuch programs (otherwise than by legalcompulsion) he should abandon themwithout delay. If he is required bylaw to provide such programs, he shouldmake vigorous efforts to have the lawchanged.Surveys in the field of maternalmortality point out that much progresshas been made in the last twenty years.In 1934 in this country sixty mothersdied for every 10,000 live births. Todayless than eight die—in other words,chances of death's not occurring arebetter than 999 out of 1,000. Yet tenyears ago 12 deaths for each 10,000live births were considered the irreducibleminimum. Today such states asMinnesota, with a rate of 3 per 10,000live births, and Oregon and Connecticut,with rates of 1 per 10,000 livebirths, clearly and with emphasis, indicatethat there is still room for improvementand there is no irreducibleminimum. Intensive studies in thesestates also brought out that, despite theprogress in reducing deaths, many ofthose mothers who did die should not

February, 1955 The Health Bulletin 11have died."How Shall They Survive?" Our mandateis clear. The importance of earlyand adequate prenatal, natal and postpartalcare emphasized through publichealth services such as education of thecommunity, and through evaluated surveysfor the education of physiciansand hospitals, demands a high priority.Where the need exists, direct servicesmust be provided.We take for granted that pregnancyis a normal physiological process; yetthe need for continuity and adequacyof care throughout the gestational cycleis frequently overlooked. We fail to recognizethat a healthy birth is predicatedon being born of a healthy normalmother and that poor health of themother may precipitate a serious, if notfatal, outcome to mother and/or child.It is imperative that preparation formotherhood begin long before theculmination of the miracle itself. Premaritalguidance and guidance in maritalproblems must be incorporated ina program of salvage which shouldalso include measures encompassingthe physical and mental condition ofthe mother.Priority should be given to a programof educating the mother toseek medical care, observation and directionas early in pregnancy as possiblein order to harvest the full benefitof adequate prenatal care. We mustemphasize this point in all our healtheducational activities, and particularlyin those areas where medical facilitiesare lacking must some provision bemade to make such a program andfacilities available.Adequate prenatal care is essentialand must include a complete historyand physical examination with provisionfor periodic examinations atstated intervals. The examination isnot complete unless it includes serologicaltesting for syphilis and determinationof the Rh status. An X-rayof the chest should be mandatory, certainlyhighly desirable. Educationalefforts to stimulate the mother to reportany irregularities or symptomatologymust be expended, and any untowardsigns or symptoms should beexplored immediately.Recent research projects in the fieldof nutrition during pregnancy point upthe fact that nutrition today is morethan a counting of calories. Maternalnutrition must meet the demands ofboth mother and child. We have reasonto believe that where nutrition is goodand deficiencies corrected by supplements,the incidence of toxemia islower than where nutrition is inadequateor deficiencies occur. Also, fetaland neonatal mortality rates showed adecrease where diet was adequate, andthe incidence of premature birth wasdecreased. The studies further pointout that toxemias of pregnancy aremore apt to occur in the overweightmother and that prematurity and toxemiaare more prevalent in the underweightthan in the mother whoseweight remains within average limits."How Shall They Survive?" To preservethe health of mothers and infants asound nutritional program must be promoted.The prospective mother must be protectedagainst syphilis and tuberculosis.A diagnosis of existing syphilis by prenatalserology calls for all-out effortsto cure or arrest the disease in themother, which efforts, in turn, willin almost all instances protect thefetus. A diagnosis of tuberculosis callsfor close medical observation, supervisionand education throughout pregnancy,and the removal of the infantfrom the maternal environment immediatelyafter birth.Control measures for the preventionof German measles must be institutedin view of what is known of the roleof this disease early in pregnancyand its effect on the child.Basically then "How Shall They Survive?"In maternal hygiene the primeobjective is the conservation of lifeand health of the expectant motherand her developing infant. The objectiveleads us to promote a programwherein medical care is made availableto every pregnant mother and themother is persuaded to obtain itthroughout the maternal cycle. It is

12 The Health Bulletin February, 1955most desirable that this service berendered by a single physician of thepatient's choosing in order to maintaincontinuity and adequacy, but, whenunavailable from this source, this serviceshould be obtained through communityfacilities sponsored by the localhealth department.To aid the mother in preparing forconfinement and acceptance of thepregnancy, periodic nursing visits shouldbe made. The total environment is thusexplored and when conditions existwhich would make delivery at homehazardous, arrangements for a clean,decent place are in order.Continued and wise health educationof all prospective mothers in all phasesof maternal health should be pushed,and, when necessary, through the useof such media as pamphlets, news articles,speeches, etc., measures createdto stimulate community understandingof the need for proper ethical instructionand care of expectant mothersshould be promulgated.The seriousness of activating a programof maternal survival is accentuatedby acquainting ourselves withthe fact that in any one year ofrecent date mothers' deaths as a resultof complications and sequlae ofpregnancy exceed the total death occurringfrom such communicable diseasesas diphtheria, scarlet fever, poliomyelitis,meningitis and typhoid. Whenone further realizes that these maternaldeaths occur in only one period of life,the child-bearing period, and in onlyone sex, the gravity of the situation isreadily apparent.Any success in improving healthservices to mothers requires developmentand maintenance of standardsthat must be universal, standards thatmust be carefully thought out, promotedethically and kept current withnewer thinking and a changing world.These standards should be developedas desirable goals; but, if necessary andconditions warrant, they should beset up as minimal rules or regulationsand become mandatory. They shouldbe so created as to serve as the yardstickfor measuring adequacy of healthservicesand facilities.The salvage of lives of infants andchildren in the last 25 years has beenthe factor in assessing life expectancytoday. Tremendous progress has beenmade in reducing mortality not onlyin the infant age group (0-1 year) butalso the later periods of childhood.This progress is emphasized by statingthat, had mortality rates of a half -centuryago prevailed last year, approximately1,000,000 children 15 years andunder would not be with us today, yet800,000 or more are with us who wouldotherwise be dead and, everything beingequal, they should attain the proverbialfour-score and ten. That is progress,but, notwithstanding this tremendoussalvage, a dark cloud blots out thesun. Little, if any, progress has occurredin salvaging the life of the infant duringthe newborn period, the first 28days of life, and the shorter the periodof time after birth, the less markedhas been the rate of decline.As to causes of death in the newbornperiod, they are rather poorly defined,more so than in later infancy. Prematurity,congenital malformations, birthinjuries, infection, these are the mostoften cited causes.Speaking in a broad sense, we recognizecertain hazards as contributingto infant mortality, particularly neonatalwastage. Specifically, we recognizehazards to be hazards of developmentand hazards of injury. We knowthat defects in development occur,culminating in a monstrosity or congenitalmalformation. We also knowthat toxemia in the mother or the presenceof infection in the mother, such assyphilis or influenza, may and frequentlydoes exert its effect on the fetus.We have also seen where instances ofmechanical injury to the mother; injuryto the infant incident to difficultlabor; abortion, criminal or therapeutic,all have contributed to many needlesspreventable deaths of the infant.Exhaustion of the infant in trying toovercome an impassable barrier suchas contracted pelvis, injury to thecranial vault through injudicious useof forceps, and toxemic conditions in

February, 1955 The Health Bulletin 13the mother, as in eclampsia, furtheradd to the deaths of infants, manydeaths which perhaps are needless andtragic."How Shall They Survive?" AgainI must repeat that a program of salvagemust begin as early in pregnancyas possible. Since contributing factorsto early infant death, even fetal death,have their incipient stages in prenatallife, it is demanding that early andcontinuous supervision be available tothe mother, preferably by a physicianof her own choosing but, in any instance,one available in the community.No program is worth a grain of salt ifit does not provide an adequacy ofcontinuity and follow-up. Constantsupervision and observation allow fora detection of deviations and/or complicationsearly enough to allow forremediable measures to be instituted.Supervision of the newborn must beginimmediately after birth, and, ifconditions are favorable, a completephysical examination is done to ruleout any condition of immediate dangerto the infant. This is then followedby constant medical and nursing observation,regardless of where the deliveryoccurred. Particularly in home deliveriesis it imperative that the publichealth nurse be involved to the extentof postpartal visitation. In this strategicrole the nurse may be the discovererof hazardous abnormalities which werenot evident when the infant was examinedat birth. The nurse, however,must be cautioned to refer her observationsto the family physician firstand through his follow-up efforts thehealth of the infant will be safeguarded.If prematurity, congenital malformationsor birth injury, our universaltriumvirate of killers in the newbornperiod, are not involved when the infantis born, our next compelling duty isthe prevention of infection. Infants donot seek out the lethal organisms.Somewhere a second party is involved,be it through immediate contact or respiratoryspread. It is here that thepublic health nurse plays a majorrole in a program of "How Shall TheySurvive?" Through her efforts the motheris stimulated to maintain earlycare and observation of her child byher physician or through the facilities,where available and indicated, of thelocal health department. She it is whocan ethically and soundly instruct themother in the principles of good nutritionand promote the maintenance ofa clean, safe, sanitary home environment.We must consider, if only briefly,the problem of prematurity. Although,we in public health recognize prematurityas a sign rather than a diagnosis,it is recorded as the greatest killer ofinfants.The premature infant is born saddledwith the threat of death. His immaturitydisturbs many physiological functionsas well as physical, all of whichare not conducive to survival. But wefirmly believe, in fact we know, thatmany prematures can be saved. "HowShall They Survive?" The approachto a program of salvage is a preventiveapproach. Basically, it calls for a soundmaternal health program, continuouslypromoted and maintained. This programmust particularly stress the importanceof nutrition of the pregnantwoman. It must also allow for theobservation, care and, if necessary,treatment of any complications attendantto the pregnancy. This must implythe availability of properly equippedand staffed hospitals where the propermanagement of a premature deliverywill go a long way toward insuring themaintenance of life.As in a program of maternal survival,the acceptance of hospital standardsas guides in infant care will insurea marked decrease in needlessdeaths. These standards must emphasizedesirable and recommended medicalprocedures and should serve as abaseline for hospital policy.What can we do to promote the survivalof the older infant, the preschooler,the school-age child?In a report of the Committee forthe Study of Child Health Services,American Academy of Pediatrics, 1949,we read the following:

14 The Health Bulletin February, 1955"All children are entitled to preventivehealth services irrespective of theeconomic status of their parents. Opinionmay vary about the extent whichofficial health agencies should providethese services to certain economicgroups. But there can be no differenceof opinion about the right of everychild to receive such service from eitherprivate practitioners or public healthagencies."This statement implies, and rightfullyso, that a community child health programmust be promoted either to supplementthe services of the privatepractitioner or to provide the specializedservices through the facilities ofthe local health department. Basically,health education of the community asto the value of child health care, observationand supervision are the coreof a program of salvage. This educationalprogram must permeate down tothe individual parents to alert themto their responsibilities in maintainingthe good health and preserving andprolonging the lives of their children.How does this type of program aidin survival? The public health nurse isthe instrument in the picture. She itis who supplements the services of thephysician by stimulating the parent tomaintain early and regular care of thewell child and the handicapped childby the private physician or throughthe facilities of the health department.It is she who persuades the mother tofollow her doctor's instructions. Sheis also the instructor in the generalprinciples of sound nutrition, in the desirabilityof maintaining a safe, sanitary,clean environment. She extols thevalue of early immunizing proceduresand the necessity for maintaining acertain level of immunity through recallinjections. All of us must recognize thatthe widespread use of immunizingagents and the maintenance of highstandards of community sanitation arefar more effective than placarding ahome as a quarantine measure.Thus we see that in order to answerthe question "How Shall They Survive?"a program designed to prevent oralleviate those conditions which contributeto maternal and child morbidityand mortality must be all-encompassing.Certainly it must reflect down toantenatal life with the continued careof the pregnant mother, the maintenanceof good nutrition and soundhealth and the prevention of illness.This objective, in its total nature, willgo a long way toward the prevention ofprematurity, congenital malformationsand birth injury. This is demanded ofa sound, ethical maternal program. Afurther adjunct is the promotion andestablishment of measures affectingthe child in all age groups. The teachingof good nutrition, the advantagesof immunizing procedures, the necessityof periodic physical examinations andobservation, the correction of remediabledefects and the promotion of asafe environment are all basic toolswithout which the objectives of a longerlife and good health are unattainable.We could go on endlessly exploringfurther means of salvaging lives. Ihave tried to give you a broad pictureof what can be accomplished. True, itis somewhat sketchy but if we only continueto remember that as a team ofpublic health servants our job is withand for the people and that it is ouraim to expend the health dollar in sucha way that the health dividend willbe maximum, we shall have accomplishedour objective.DISCUSSION OF DR. MEZERA # S PAPEREDWARD P. BENBOW, M.D.Greensboro,North CarolinaI congratulate you and your ProgramCommittee for bringing Dr. Mezera tous. His strength, the wisdom of hisideas and chosen words are indispensablein the planning of our expandingpublic health program in North Caro-

February, 1955 The Health Bulletin 15Una.I'd like to express some of mythoughts as Dr. Mezera's words fellupon the ears of a pediatrician vitallyinterested in the things of which hespeaks:I am immediately cognizant of hisawareness of the fact that tomorrow'scitizen is but the continued growth oftoday's child and of the importancehe attaches to every item and detailinfluencing the growth and developmentof that child from conceptionthrough birth, infancy, childhood andadolescence.I am reminded—by Dr. Mezera's quotationfrom the Children's Charter fromthe White House Conference—of aBritish naval captain who stood onthe bridge of his ship when it sailedalong the African coast in the 19thcentury. It was loaded with many ofHis Majesty's troops and their families.The ship struck an unchartedrock, and it was immediately apparentthat she would sink. It was also apparentthat there were not enough lifeboats to accommodate the number ofpersons aboard. (Hence Dr. Mezera'sthought-provoking title "How ShallThey Survive?") The captain saw hisduty and set a precedent followed sinceby practically all mankind. He calledthe ship's crew to their stations; calledthe troops in formation at attention onthe decks before him, and ordered:"You men at attention will stand fast.Ship's crew, lower the life boatswomen and children go first!" and thatwas the way it went—and has in everydisaster since then.Dr. Sture Siwe stated it in 1948:"Everything in the world revolvesaround the mother. The new generationis being formed by her, while thefather is engaged in pursuing his specialinterests. Men may create workof more or less lasting value, yet onlythe mothers of children are forminglives and shaping human beings." Itstill stands that maternal and childhealth and welfare are the sine quanon in health and social planning.I'm glad Dr. Mezera read from thereport of the committee for child healthservices of the American Academy ofPediatrics in 1949, in which it wasparticularly stated that there can beno difference of opinion about theright of every child to receive preventivehealth services from either privatepractitioners or public health agencies.I should also like to add a part ofthe report of a committee representingthe American Academy of Pediatrics,the American Pediatric Society and theMaternal and Child Health AdvisoryCommittee of the U. S. Children'sBureau, which was unanimously acceptedby the members of the Academy.It committed them to the following objective:"To make available to allmothers and children of the UnitedStates all essential preventive, diagnostic,and curative medical servicesof high quality which, used in cooperationwith other services for children,will make this country an ideal placefor children to grow into responsiblecitizens." Hence the academy undertooka nationwide study, and NorthCarolina was selected as the pilot statefor study of existing facilities and servicesfor medical and health care ofchildren.The North Carolina Pediatric Societyundertook the responsibility forthis pilot study, and the complete report—finallypublished in a supplementto the North Carolina Medical Journalin 1948—cited:1. The dire need for an AdvisoryCommittee on Child Health representingall agencies in the state with majorinterests in child health;2. The need for subsidies for physiciansin areas of need, including betterdistribution of hospital facilities;3. The need for more opportunitiesfor training in child health;4. The need for rapid expansion ofcommunity health services;5. The need for a total increase inhospital facilities;6. The need for a program for prematureand other newborn infants.But remember this is the pediatricians'viewpoint of 6 years ago. Remembertoo that in 1948 79% of theprivate physicians' care received by

16 The Health Bulletin February, 1955children in North Carolina was providedby general practitioners.We must now bring all physicians toan acute awareness of the facts andfigures as they exist in our own Stateand compare them one by one withthose related here by Dr. Mezera.He has given us the "Whys," and inso many instances the "Hows" in relationto our acknowledged responsibilitiesfor maternal and child health services.We must now supply the "When."We must realize that medical knowledgeis useless unless we are able toapply it for the common good and tomake it known and understood to societyas a whole. The difficulties attimes seem overwhelming, but courageand persistence will bring us to ourgoal:"To let all children enjoy the benefitof scientific advancements and clinicalapplications; to make available a placebewhere every American mother willable to go for advice, to present awidespread campaign to inform themabout available facilities, and to providesufficient hospitals and clinics tomeet everybody's needs." Dr. Mezerahas repeatedly emphasized the idea ofprevention first and then adequate treatment.The ramifications of both aremyriad and are paramount to thepreservation of health and to the savingof lives. Indeed, we are grateful to himfor focusing our thoughts so clearlyand for pinpointing the minute detailsof the over-all program of maternal andchild health. He has even mentionedthe necessity for control measures forthe prevention of German measlesa mere speck on the wide panoramareviewed for us here. Yet we are forcedto assume our own duties in this regard;to evaluate the problem of therisk of congenital malformation andstillbirths resulting from maternal infectionduring the first trimester; tolearn to diagnose the disease accurately;to properly evaluate the role ofGamma Globulin in preventing rubella;and finally, to make up our mindswhether or not to institute a moreeffective program for attacking therubella problem by deliberate exposureof girls to the disease before the childbearingage, with rigid control necessaryto avoid exposing gravidas.It occurs to me that there is oneconcept which might be advantageouslyincluded in the general foundation onwhich adequate maternal and childwelfare programs must be built.Why not include in our educationalcampaign the dissemination of newlygained medical information and ideason the probable desirability of familyplanning and birth control under thesepossible tragic conditions:1. In those instances where childbearingis definitely detrimental to thehealth of the mother; where there isa possibility of diminishing her activitiesat home, or of removing her fromthe family circle completely?2. The prevention of the birth ofanother child in a family where thereis hemophilia, epilepsy, familial idiocyor muscular dystrophy?Isn't it a part of our preventivemedical and health program to presentthe consequences of further familyexpansion to those non-comprehendingparents who are faced withthese tragic conditions?We can see how the ideas and wordsof our speaker serve to stimulate awhole new, broader segment of activitywhich must necessarily fit and dovetailinto the general plan for maternaland infant care. He has given us ideas,has made us want to start movingand has even provided us with mapsto follow. What we need now is to"Hitch up old Bess and get down theroad."

MgrMEDICAL LIBRARYU.\OF N. C.CHAPEL HILL, N. C.bfMlPullisKeJkv THENfflKCffiflMft SEHIEKffBD»flEAUflI TKis Bulletin will be sent free to dni| citizen of ti\e State upon request tPublished monthly it the office of the Secretary of the Board, Raleigh, N. C.Entered as second-class matter at Postoffice at Raleigh, N. C. under Act of August 24, 1912Vol. 70 MARCH, 1955m—No. 3m-MAR 28 1955HEALTH AfiDIVISIO JFHELP'; S LWRARYGIVEWALICTHE NATL. SOCIETY FOR CRIPPLEDCHILDREN AND ADULTS, INC. 11 S.LASALLE STREET, CHICAGO 3, ILL.

MEMBERS OF THE NORTH CAROLINA STATE BOARD OF HEALTHG. G. Dixon, M.D., President AydenHubert B. Haywood, M.D., Vice-PresidentRaleighJohn R. Bender, M.DWinston-SalemBen J. Lawrence, M.D RaleighA. C. Current, D.D.S GastoniaH. C. Lutz, Ph.G HickoryGeo. Curtis Crump, M.DAshevilleMrs. J. E. Latta Hillsboro, Rt. 1John P. Henderson, Jr., M.D Sneads FerryEXECUTIVE STAFFJ. W. R. Norton, M.D., M.P.H., State Health OfficerJohn H. Hamilton, M.D., Assistant State Health Officer and DirectorState Laboratory of HygieneC. C. Applewhite, M.D., Director Local Health DivisionErnest A. Branch, D.D.S., Director of Oral Hygiene DivisionA. H. Elliot, M.D., Director Personal Health DivisionJ. M. Jarrett, B.S., Director Sanitary Engineering DivisionFred T. Foard, M.D., Director Epidemiology DivisionFREE HEALTH LITERATUREThe State Board of Health publishes monthly The Health Bulletin, which willbe sent free to any citizen requesting it. The Board also has available fordistribution without charge special literature on the following subjects. Askfor any in which you may be interested.Diphtheria Measles Residential SewageFlies Scarlet Fever Disposal PlantsHookworm Disease Teeth Sanitary PriviesInfantile Paralysis Typhoid Fever Water SuppliesInfluenza Typhus Fever Whooping CoughMalariaVenereal DiseasesSPECIAL LITERATURE ON MATERNITY AND INFANCYThe following special literature on the subjects listed below will be sent free toany citizen of the State on request to the State Board of Health, Raleigh, N. C.Prenatal CareInstructions for North CarolinaPrenatal Letters (series of nine) Five and Six Monthsmonthly letters)Seven and Eight MonthsThe Expectant MotherNine Months to One YearInfant CareOne to Two YearsThe Prevention of Infantile Diarrhea Two to Six YearsBreast FeedingMidwivesTable of Heights and Weights Your Child From One to SixBaby's Daily ScheduleYour Child From Six to TwelveFirst Four MonthsGuiding the AdolescentCONTENTSPageEfficient Management In Public Health 3The Easter Seal Society 10Notes And Comment 13Mrs. Bell Served Wilkes 25 Years 16

Bl IPUBLI5AED 5YTAE N°ftTA CAROLINA STATE 5°ARD*AEALfA] BVol. 70 MARCH, 1955 No. 3J. W. R. NORTON, M.D., M.P.H., State Health Officer JOHN H. HAMILTON, M.D., EditorEFFICIENT MANAGEMENT INBy C. L. GUYTON, M.D., M.P.H.Assistant StateHealth OfficerColumbia, South CarolinaPUBLIC HEALTHEfficient means highly capable orproductive. Management means judicioususe of means to accomplish an end."Efficient Management In PublicHealth" means the judicious use of allavailable means and resources in theart and science of preventing disease,prolonging life and promoting physicaland mental efficiency through organizedcommunity effort. Since this is acontinuous process difficult of final accomplishment,the chief function orpurpose of management becomes one ofimproving and increasing the servicesrendered by wise and stimulating guidanceof the staff and coordination of allhealth activities.Efficient Management in Overall Administration.In this day when there isa tendency for governmental budgetboards, county delegations or commissionsand taxpayers to look intently atoverhead expenses of all agencies, someState Boards of Health seem inclinedto dispense with State and Districtsupervisory personnel and assign themas field workers, and some departmentsare discussing the idea of replacingregistered nurses with licensed practi-Paper Delivered at 1954 Annual MeetingNorth Carolina Public Health AssociationSeptember 23, 1954, Raleigh, North Carolina.cal nurses, replacing sanitarians with"inspectors" and replacing health officerswith lay administrators. It behoovesthose of us who have observedthese tendencies over the past severalyears to take stock and determine whythis has occurred. Is it because of a realshortage of personnel and the fact thatindividual staff members are bettertrained and, therefore, need less supervisionand management, or is it becauseour management is so indifferent andinefficient that those in control of themoney feel that it can be more effectivelyused by employing a larger staffof lesser trained and qualified personnelat lower salaries? If the healthofficer is concerned only with the medicalaspect of his job and pays littleattention to efficient management ofhis staff and program, then the questionmay well arise: Should not his fulltime be spent as a clinician and he bereplaced with a qualified lay administrator?However, I think that thisshould not apply to supervisory personneland staff workers in every unit. Inthe small and medium-sized healthunit of six to eight employees, weshould strive to have every member ofthe staff well educated and trained soas to require a minimum of supervision.Little economy can be effected by theuse of less-trained and less-qualified

The Health Bulletin March, 1955personnel in such units. In units withlarge staffs, it may be possible to savesome money by the use of less-trainedand less-qualified personnel, such aspractical nurses, nurses aides and inspectorsto carry on some of the routinefunctions in clinics, to check on nuisancecomplaints, etc. When such personnelare to be used, it becomes mandatoryto have well trained and qualifiedsupervisory staffs if efficiency isto be maintained.Continuing progress and improvementof health services are, in part, dependenton research and increasingknowledge in our health sciences, butof equal or even greater importance isthe improvement in the efficient applicationof this knowledge to meet theneeds of the public. This latter is thedirect responsibility of local health departments.Therefore, my remarks willbe confined to local health unit activities.Local health units will dischargethis responsibility most successfully ifthey have flexible programs built onthe needs and expressed desires of thepeople in the community. With thegradual shift from the control of acutecommunicable and infectious diseasesto those of a chronic nature and withthe shift in population from youth tothe old age group, we must shift ourinterests so that we include in our programnot only the prevention of theonset of illness but also the preventionof the progress of disease, of its complicationsand of the disability thatmay follow. Failing to prevent disability,we must rehabilitate the individualto his maximum physical andmental efficiency and aid him in hisemotional and social readjustment.Efficient Management of Staff. Toadminister this type of program wouldrequire a well trained and qualifiedstaff of sufficient size to meet the needsof the population involved, but, asstated in the beginning, we cannot expectto have sufficient staff and facilitiesto obtain a full and complete solutionof all problems and meet all needsat once; therefore, in discharging theseresponsibilities, our programs must bebased on community needs and resources,must be flexible so as to changeas needs are recognized and be of atype that can be adapted to the sizeand quality of the staff, rememberingalways that when we can't increase itssize we can always improve its qualitywith in-service training, wise guidanceand stimulation.andStaffs come in a variety of sizesquality and, like equipment, are purchasablewithin the limits of the budget.However, there are other factors,such as a local availability and politicalexpediency, which have a definiteinfluence so that the administrator,whether a newcomer or veteran, mayfind the size and quality of his staffpredetermined by these factors alone.This by no means justifies letting thestaff remain in status quo. (An elderlyjudge in my home town has a servantwho, through long association, haslearned several legal phrases which heuses and defines to suit his needs. Recentlyduring the judge's illness theservant met a personal friend and thisconversation ensued: "Good mornin'!How's the Jedge?" "Oh, he's just staturequo, just stature quo." "What doyou mean stature quo?" "Boy dat meanshe is a powful sick man.") So it is witha health department that remains instatus quo for a long period of time.What are some of the things the administratorcan do to insure the efficiencyof his staff, regardless of itsexisting state of training and experience?First, he can establish a smoothrunningoffice. Every employe's efficiencyis materially affected by the overallconditions under which he or she works.If one is to have a smoothly operatingunit, all policies should be clear-cutand easily interpreted and understood.If policies are to be clear-cut, then theobjectives must be accurately defined.Work hours, vacation time and leavepolicies should be established on afair and impartial basis. The work loadof employees should be equitably distributed,taking into consideration thegeographical area, population densityand health needs of the assigned territory.The fiscal affairs of the officeshould always be in good order, with

March, 1955The Health Bulletinadequate pay based on training, responsibilitiesand efficiency. Too oftenwe begin with the established salariesand then, when funds become available,every member of the staff receives apercentage increase without considerationof his qualifications or efficiencyin his assigned task. Job tenure andpromotion should be based on qualityand effectiveness of work rather thanon the personality pull of individuals.There must be a good record system.Assuming that we have a smooth-runningoffice with a good record systemand suitable arrangements for orientationand training, we are still facedwith the necessity of having the entirestaff operate as a unit. The staff shouldfunction as a unit in a democraticmanner, using group opinions on broadpolicies and individual conferenceswhen it concerns one individual's work.There should be not only frequent conferencesof supervisory personnel inlarge units but regular meetings of theentire staff. In small units withoutsupervisory personnel, the entire staffshould meet frequently. All of these arenecessary if the staff is to have a feelingof security and contentment.Efficient Management of IndividualMembers of Staff. An entire staff cansometimes be upset by the personalityof one individual. This is where an administratorfaces his most difficult andagonizing problem. In all such casesone should remember that emotionalproblems and personality defects arenot self-limiting diseases and cannot becured by treatment of symptoms andwaiting for the crisis to pass. The basiccauses must be found and treated oreliminated. Failing in this, the employemust be discharged. Even the smalleststaff is larger and more important thanthe individual member. However, emotionallystable individuals can be upsetby continued unstable working conditions.Every effort should be made toavoid them. All workers and their workneed a reasonable amount of supervisionand evaluation. This is neededto correct or improve faulty and inferiorwork and to praise good work.Every staff member's work, good orbad, justifies recognition by the manager.Too often we overlook bad workand fail to praise good work. Everyhuman, in addition to his emotionalneed for love and security, craves recognitionand the assurance that he andhis work are significant. The delegationof authority and responsibility carrieswith it the obligation of sufficientsupervision and guidance to insure efficientdischarge of duty.Every staff member's efficiency can beimproved by additional training and individualguidance. This can be done bythe administrator, the supervisor or afellow staff worker who has had thebenefit of better training and/or experience.When a new member is addedto the staff, it is necessary that hehave a reasonable period of orientation,even though he may have an adequateeducation and prior experience with anotherdepartment. This need for orientationis imperative when there hasbeen no previous experience in publichealth work. Part of it is better givenby a unit that has a large and welltrained staff and should be taken in acounty other than the one in which heis being employed, because, when astaff begins to orient its own employes,the tendency is to shift them into theirregular assignments without adequateoverall orientation in public healthpractices. Postgraduate and in-servicetraining is likewise mandatory for thosewho have not had any. Like orientation,this in-service training should be givenby those who are able to teach anddemonstrate public health activities,preferably in a well organized departmentadequately staffed for this purpose.Efficient Management by IndividualStaff Workers. Individual staff workersare managers in the same manner asadministrators and supervisors. It istrue that their responsibilities and thescope of their activities are more limited.However, they have the same responsibilityfor the efficient planningand conduct of their work. It is theirresponsibility to function as a memberof the team. They must keep adequatedaily, weekly and monthly records

6 The Health Bulletin March, 1955which are as necessary for the planningof an individual's work as they arefor planning the overall duties and theprogram of the entire staff. Modernpublic health practice requires that individualsgo beyond the routine performanceof their work. In fact, nowork should ever be treated as routine.Each home visit or environmental surveyis an individual activity differentfrom every other. Each person attendinga clinic or seeking advice is a differentindividual with individual problems.His is an individual personalitythat always reacts differently with thepersonality of the public health worker.This requires constant revising andchanging of methods of approach to agiven problem affecting different individuals.Efficient Management in ProgramPlanning. What is a program? Shouldit not be planned procedure toward achosen objective? Too long now havewe been quail hunting in public health,i.e. using shotgun programs on coveyneeds as determined by his own evaluationand appraisal.Informing and educating the communityregarding the program andbringing them in on the planning andexecution of the activities are necessaryto insure that the program will be acceptable.Finally, the program must beadapted to the capabilities of your staff.It is sometimes advisable to set yourobjective a little above staff capabilitiesas an incentive to raising its level ofefficiency, but the program must notbe so far above the staff's capabilitythat it leads to frustration of personnelor makes it impossible to render servicesexpected by the community afteryou have publicized your program.The A. P. H. A. outlines "The LocalHealth Department's Services and Responsibilities"as seven. Let's examinethese in relation to our topic.Efficient Management in Recordingand Using Health Data. One of thebasic responsibilities of a health departmentis the proper recording andanalysis of health data, i.e. births,aeaths, notifiable diseases; maintenanceof registers of individuals known tohave certain specific diseases or dis-objectives. Just blazing away, hoping tohit something. Frankly, fifteen or twentyyears ago this produced results.When typhoid, smallpox, diphtheria,V. D., hookworm, malaria, infant diarrheaand similar diseases afflicted a pretation of morbidity data from allabilities; and the collection and inter-large percentage of the population, available sources. A study and analysismost any action paid big dividends. of these records will frequently bring toToday we must literally pin-point our light unrecognized health needs.objectives and accurately aim our procedures.It is one thing to know we that not only contains health data butThere is need for a record systemhave fifty cases of active tuberculosis also records activities of the staff andon register or that we annually have contains all the data that can and willfifty cases of diphtheria or early V. D. be evaluated to the betterment of thebut, if we are to aim our procedures, service. These records should list thewe must know where they are geographicallyand in what social or ecoanceand facilities and environmentsnumber of home visits, clinic attendnomicgroups they exist. I realize that inspected or surveyed. More important,one of the difficulties of the local administratoris keeping his program ballishedas a result of these activities.they should tell what has been accompancedin the face of pressure by directorsof categorical programs originated ered denotes efficiency. If this is done,Quality, not quantity, of services rend-at the State level and pressure from it will assist staff members in planninglocal voluntary agencies, each thinking their day-to-day work, serve as a basisthat its particular program is the most for program evaluation and revisionneedful and urgent of all. The efficient and become documentary evidence ofadministrator will incorporate all these work accomplished. This last-mentionedactivities in his program but will emphasizeeach in proportion to local of funds received as categoricalcan be used to justify the expendituresgrants.

March, 1955The Health BulletinMost public health employes have acongenitally acquired and administrativelyaggravated aversion to filling outrecords and making reports. Always askyourself: Will it be useful and will itbe used? No record should ever beadopted if it serves only to collect dataand dust.The keeping of registers of individualswho are known to have certain chronicdiseases or impairments is usually referredto with a great deal of prideby the administrator; however, frequentlythey are not put to good usebecause they are not analyzed and reviewedfrom time to time. A study ofthese registers will often show thatcertain diseases tend to be more prevalentin certain geographic areas oramong certain social and economicgroups. This should lead to an evaluationof that particular program todetermine if it is meeting the needs ofthis particular area or group.Efficient Management of Health Educationand Information. Every publichealth worker is daily engaged inhealth education, teaching and givinginformation. While he may not realizeit, the truth is that every public healthactivity is, or at least should be, ofhealth education value. Otherwise theactivity has been inefficiently performed.We must educate as we serve. Inaddition to this daily educational work,we must also have a planned programof health education and information;otherwise the community soon takesour activities for granted. Like anyother program, this one must alwayshave a definite objective. The promiscuousdistribution of literature, showingof films, furnishing articles fornewspapers and using radio and televisionshould not be done simply forthe sake of being able to list theseactivities in our annual reports. If wedecide to stimulate or motivate thepublic, then it must be for a definitepurpose. If a film is to be shown, itshould be in support of an educationalprogram toward a definite objective.Organized classes should be well plannedand the teaching supported by allthe educational media available. Fortunateis the health unit that has atrained health educator on its staff, forhe is an expert in the efficient managementof all the tools of health education.Every State department nowhas one or more health education consultantswho are available and can beof great assistance, not only in healtheducation programs but in stimulatingcommunity interest in health activitiesand assisting in the overall programplanning of the local unit.Group teaching can save much timein giving basic information on diet,preparation of baby formulae, operationof food-handling equipment, etc. Thismethod is also applicable to groupshaving similar problems, such as foodhandlers' classes, classes for diabetics,the obese, etc. However, we should notforget the adage—"What I hear I forget.What I see I remember. What I doI know." This means that classes andgroup instruction will have to be supplementedwith individual counselingand teaching regarding those activitiesthat the individual must know.Efficient Management In Supervisionand Regulation. The laws of our statesgive health departments legal authorityto supervise and regulate many activitiesin the field of health. If a departmentfrequently finds it necessary toresort to legal action, then it is performingthis responsibility in an inefficientmanner. Health laws and regulationsare usually established to set astandard and serve as a starting pointfor the education of those concerned.Only as a last resort should we takelegal action to enforce them.Is it not better to keep in touch withhousing projects and contact the developmentagency early so as to inspectthe site, test the soil and agree on sizeof septic tanks, etc. instead of waitinguntil the buildings and tanks are completedand we are asked to make finalinspection? We should prevent publichealth problems as well as disease.Are we to continue our program ofinspecting dairies, foodhandling establishmentsor other institutions in aroutine manner with a check sheet andgrade card? When are we going to

8 The Health Bulletin March, 1955organize classes for operators and theirstaffs to educate them to properly operatetheir facilities and assume responsibilityfor compliance with regulationsand then, less frequently, survey theirestablishments and counsel with themregarding efficient operation that willnot only protect the public but paydividends to the owner?Efficient Management in the Provisionof Direct Environmental HealthServices. With the rapid advancementin health consciousness by the publicand the rise in our economic level andgeneral standard of living, many of thedirect environmental health services areno longer required and could be dispensedwith if we would educate thepublic regarding them sufficiently forindividuals and families to assume moreresponsibility for the control of theirenvironment. The efficient health departmentwill only engage in thoseactivities which require the use oftrained public health personnel andwhich cannot be carried out by lay individualsand groups.Now that we have practically eradicatedmalaria, are we going to keepup a spray and fogging program to keeppeople comfortable or are we to educatethe public that this activity is nolonger a health measure and shouldbe transferred to another agency, usingpersonnel not trained in public healthprocedures?Are we to keep on advocating thebuilding of pit privies in rural areaswhen we know full well that even atrained health educator could not motivateyou and me to use one in thecold gray dawn of a winter's day?Would it not be better to raise ourvision from the lowly pit and observethe new REA lines that have been extendedinto rural areas and persuadethe home owner to install an electricwater pump which eventually will leadto the installation of a plumbing systemand proper sanitation of the entirehome environment?Efficient Management In the Administrationof Personal Health Services.Improved sanitation and the use ofmodern drugs and treatment havemarkedly reduced the need for someof our immunization programs. If thisresponsibility is to be efficiently discharged,we must review our morbiditydata and adjust our immunization programto fit present day communityneeds.Are we to continue to routinely givetyphoid inoculations to large groupsof citizens now living in a sanitary environment,without a single case oftyphoid over a period of years, just becausewe have trained them to submitto the annual roundup? Would it notbe better if we analyzed the morbidityrecords and surveyed the environmentalsanitation of the various communitiesand limit such programs to thosewhere they are needed, thus saving thetime of personnel for use on more urgentproblems?When are we going to stop limitingour rabies control program to immunizinghousehold pets and subjecting childrento painful and somewhat dangerousinjections of anti-rabic vaccine andbegin to attack the problem at its mainsource by preventing stray and ownerlessdogs from running at largethroughout the community?Are we going to keep on making chestX-ray surveys in which we routinelyX-ray the same individuals year afteryear, even though we find little or notuberculosis in this group, just becausethey are readily available and we aredetermined to do a certain number ofexaminations each year? Would it notbe better to concentrate on those communitiesand social or economic groupswhich are less readily available butwould yield much higher dividends incases diagnosed?Are we going to keep inspectingschool children by the thousands justbecause we have them congregated inan easily accessible place and wish topoint with pride to a large number ofindividual services? When are we goingto concentrate our activities on thosepupils that have been screened out byteachers under the guidance of nurses,because of some obvious physical defect,because they are unable to keepup with their school work or else de-

March, 1955 The Health Bulletin 9velop into classroom problems, andthen secure adequate examinations,physical and mental, to determine thecause so we can take steps to correctthem through family and/or communitycooperation?Efficient Management In the Operationof Our Health Facilities. We goabout constantly preaching efficiencyin the operation of restaurants andschools and in the sanitation of homesand their environment, but I ask, inall sincerity, do we practice this in ourhealth centers, auxiliary centers andother places where clinics are conducted?Just because we use an auxiliarycenter a few hours once or twice aweek, that is no reason why the yardshould be knee high in weeds and thesurroundings in general like those of adeserted house. The building and surroundingsshould be neat and clean.There should be a posted schedule ofthe clinics of sufficient size and soplaced that it can readily be read bycitizens passing in their cars. The firstlaw of efficient management is to practicewhat we preach.Efficient Coordination of Activitiesand Resources. In addition to the efficientmanagement of his staff, it is theadministrator's responsibility to coordinateits work with that of all othercommunity agencies concerned withhealth. It istrue that many of the detailsof the cooperation between variousagencies can be carried out by the juniormembers of the health departmentstaff and those of the various agencies;however, the top administrators of allagencies concerned are responsible and,therefore, should initiate the overallcoordination of work by their combinedstaffs.It is true that supplying all thehealth needs of a community is not theexclusive responsibility of the healthdepartment, but is a joint responsibilityof the allied medical, nursing and dentalprofessions, voluntary health agencies,service clubs, official governmentalagencies and the citizens who are consumersof the service. Nevertheless, thehealth department staff must providethe leadership in coordinating all thesecommunity resources to the end thatthe health needs are met. Unless thisis done, then much inefficiency and unnecessaryexpenditure of both publicand private funds will result. It isamazing to see how a community'shealth resources can be brought intoplay and coordinated during an emergencyor local disaster. During suchtime every agency and organizationforgets its vested interests and agencyambitions to pitch in and do a job. Itdoes seem that we should be able todo the same on a long-range basis soas to guard and improve the healthof the people and be better preparedfor emergencies and disasters.One of the greatest helps in the coordinationof the community agenciesis for the individual members of thehealth department to really becomecitizens of the community in whichthey live and/or work. This should bedone in the capacity of lay citizens butby using the knowledge which theyhave as health workers to enable themto become leaders in all communityactivities pertaining to health. For thisreason, it is my belief that health departmentpersonnel should be assignedon a geographical basis and that theseassignments be permanent or, at least,that personnel not be rotated so frequentlythat they never get to learn theneeds of their assigned area or knowthe people intimately enough to counseland work with them as group orcommunity leaders.In conclusion, if we are to be efficientin public health practice, each of usmust believe in it, be loyal to it, studyit, work at it and actually live it.

10 The Health Bulletin March, 1955THE EASTER SEAL SOCIETYA Program and Financial Report for the Fiscal YearEnding August 31 , 1954By ALBIN PIKUTIS, Executive Director,North Carolina Society for Crippled Children and Adults, Inc.Chapel Hill, North CarolinaIt is with gratitude that we have thisprivilege of reporting to the people ofNorth Carolina on the use of fundsmade available to us through the annualEaster Seal Campaign. Much ofthe information contained in this reportis filed in detail with the StateDepartment of Public Welfare, our licensingagency, and the National Societyfor Crippled Children and Adults,our parent organization. The public isfurther informed of the Society's activities,both financial and service-wise,through its monthly publication, the"Outburst," and through the annualreport of the executive director. Wewish to thank the State Board ofHealth for this opportunity of reachingadditional thousands through theHealth Bulletin.Among the principal objectives of theNorth Carolina Society for CrippledChildren and Adults and its local affiliates,are to engage in activities to improvethe health, welfare, education,rehabilitation, employment and recreationalfacilities and opportunities forcrippled children and adults of theState, regardless of race, creed or color;to cooperate with all public and privateagencies in any and all services for thecrippled and handicapped; to expendevery effort to meet unmet needs; andto establish and operate projects renderingdirect service to the handicappedin accordance with the definition ofcrippling and the principles of programplanning of the Easter Seal societies.For the purpose of the NCSCCA, acrippled child or adult is "an individualwho by birth, illness or injury, is deprivedof normal neuromuscular functions."Under this definition are includedcrippling conditions due to infectionand to developmental defect or injurybefore, during or after birth;those dueto trauma; those due to pathologicalbone conditions or developmental diseases;and congenital orthopedic andrelated neurological anomalies.The NCSCCA receives its principalfunds from the annual Easter SealCampaign. Close to 73 per cent of allfunds received come from the mailingof seals, which is acknowledged astotally non-pressure and voluntary, andconsist of many thousand $1.00 contributors.Additional funds are obtainedfrom coin containers (3%), school sales(9%), lily parade (5%), and specialevents (8%). The Easter Seal Societyhas never encouraged direct or in-plantsolicitations.This report is based on expendituresyear endingand services for the fiscalAugust 31, 1954, for which funds wereobtained from the Easter Seal Campaignheld in the spring of 1953. The NCSCCAreceives its funds from the Easter SealCampaign directed at the county level.Of all the funds raised, 55% of netreceipts remain in the county for localservices and 45% are allocated to theState office. The State office pays theNational Society 8.3% of gross receiptsout of its 45% allocation. These fundsare used to support a national programof care, treatment and education. Lastyear, with the initial beginning of aresearch program by the National Society,the State office paid an additionalone-half of one per cent of grossreceipts. Contributions to the researchprogram will be increased to one percent this year, and two per cent eachyear thereafter. Over 90% of all fundsraised through the Easter Seal Campaignremain in North Carolina to helpour crippled children and adults.In 1953, a gross of $145,769.94 was

March, 1955 The Health Bulletin 11raised through the Easter Seal Campaign,at a cost of $17,846.03, which lefta net of $127,846.03 for local and Statepiograms. Of this amount, $68,983.21was retained by local societies, $12,-098.90 was allocated to the National Society(8.3% of gross), and $42,765.03 tothe State Society. The NCSCCA spent$30,670.59 during the 1953-54 fiscal yearand reserved $10,000 for a rehabilitationprogram or state project to be developedin the near future. The Society'sfixed assets total $26,130.20, consistingof land and building in the amount of$14,369.31, house improvements of$558.58, and furnace, furniture andoffice equipment valued at $11,202.31.The second floor of the State office isrented as apartments, for which incomeis received.Of the 100 counties in North Carolina,95 participated in the Easter SealCampaign. Most local affiliates are governedby duly elected officers, an ExecutiveCommittee, medical advisors,boards of directors and Service ProgramExpenditures committees. Thereare instances where local societies arenot fully organized and where theyoperated as small committees. However,each county society is being urged toadopt local by-law, and meet full requirementsof membership before beingchartered. Local societies work closelywith health and welfare agencies andother community organizations in determiningneeds before expendituresare approved.Expenditures during the 1953-54 fiscalyear were, for the most part, in thearea of direct services. Some local societiessupport, either wholly of partially,centers for the care and treatmentof handicapped children. These are locatedin Asheville, Fayetteville, Gastoniaand Wilmington. In addition,speech rehabilitation centers have beenheld in Newton, Tarboro, Hickory, Wilson,Sanford, Hamlet, Salisbury, Goldsboro,Wadesboro, Washington, Smithfieldand Carthage.A total of $55,899.71 was expended bylocal societies covering all phases ofservices to the handicapped. Of thisamount, $14,023.38 was spent for thepurchase of aids and appliances (wheelchairs, artificial limbs, etc.) ; a sum of$17,269.01 for physical, occupational andspeech therapy, hospitalization, surgery,medication, x-rays, etc.; $6,589.26 foreducation (homebound instruction, specialclasses, tuition, workshops for professionalpersonnel, etc.) ; $4,713.82 fortransportation to hospitals, clinics,schools, etc.; $4,241.37 for personal services,such as salaries for case workers,clinicians' travel expense, therapists'salaries, etc.; $3,444.14 for campershipsto the Easter Seal Crippled Children'sCamp and Camp Sky Ranch; and $3,-758.50 for scholarships to teachers enteringand working in the field of specialeducation and for grants to schoolsin support of special education workshops,centers and hospitals providingcare and treatment programs for crippledchildren. The sum of $1,860.13 wasspent for general expenses, such asparties and camp activities for crippledchildren, Christmas parties and specialentertainment.A total of 3,473 handicapped childrenand 801 handicapped adults receivedhelp through local and State programs.These services covered the above expendituresand included such handicapsas poliomyelitis, congenital deformities,amputations, speech defects,cerebral palsy and crippling conditionsdue to accidents. It is significant thatthe Easter Seal Society operates at thelocal level entirely without any paidstaff members. All services renderedare provided by volunteers.The State Society is governed by aBoard of Directors consisting of threemembers from each of 12 districts inNorth Carolina. Policies are determinedby the Board of Directors and ExecutiveCommittee, in cooperation with aMedical and a Program Advisory Committee.All serve on a voluntary basis,and they come from all walks of life.In the fiscal year 1953-54, the StateSociety operated with an executive director,one field representative, oneoffice supervisor, one full-time and onepart-time secretary, a part-time shippingclerk (during the campaign only)and one part-time multilith operator.

12 The Health Bulletin March, 1955The staff at headquarters devotes muchof its time to local societies, assistingwith chapter organization, programplanning, development of parent studygroups and the Easter Seal Campaign.A total of 180 field trips were made,with travel averaging approximately20,000 miles. Attendance at meetings,conferences and chapter affairs totaled230.Operating expenditures for 1953-54fiscal year amounted to $30,670.59, andwere expended in the following manner:Administrative $ 6.528.76Chapter Development andGuidance 7,272.67Education Services andGrants 9,289.89Direct Services 2,791.39Easter Seal Campaign ___ 4,787.88$30,670.59The NCSCCA provides direct servicesto those local areas where no formalchapter exists. Consequently, these expenditureshave remained low in thepast because of the small amount offunds currently made available in mostof the counties. Included among directservices is the cost of the Easter SealCamp for Crippled Children held lastsummer at Camp New Hope for 52orthopedically handicapped children.Since 1947 the N. C. Society hascontributed over $25,000 in grants toour colleges in support of special educationsummer workshops and clinics.The Society will continue to assist withthis program until such time as theneed is met through legislative andother channels. Grants totalling $2,500were provided to East Carolina College,Western Carolina College and the N. C.College at Durham. Additional grantswere made to the Duke Anti-ConvulsiveClinic and the State Parent's Associationfor Handicapped Children.The Daisy Alice Ward Fund, whilenot officially a part of the assets ofthe North Carolina Society, is in thecustody of the executive director andhence a responsibility of the Society.The fund was established by legislativeact on April 14, 1951, from unexpendedcontributions received as a result of anappeal by Mr. W. E. Debnam, wellknownradio commentator, to help defraythe expenses of hospital care forseverely burned Daisy Alice Ward ofThe purposeEdenton, North Carolina.of the fund as established by the legislativeenactment includes assistance"for the immediate needs of any child,regardless of race, who needs emergencytreatment over and beyond thatavailable by the ordinary welfare provisionsof the law and the ability ofthe parents or family of such child toprovide." Expenditures are limited tosuch care and medication as specialnursing, blood plasma, special medication,etc., and to children who havebeen burned or injured because of accident.The fund is not for the purposeof paying hospital bills or doctors' fees.A total of $2,705.75 has been expendedto date, and a balance of $9,465.37 remainsat present.The Easter Seal Research Foundationof the National Society is directing amodest research program which willdevelop measures for the prevention ofphysical and associated disabilities orimproved methods for their treatment.The program will encompass preventionof physical disabilities and the preparationof the physically handicappedfor useful work through improvedmethods of treatment. The programwill receive its entire support from specialallocations from the Easter Sealsocieties across the nation.An important phase of our service isdirected to parent education. Reprints,leaflets, pamphlets, books and otherpublications are available to parentstudy groups, as well as doctors, volunteersand other specialists workingwith the handicapped. Parent studygroups receive monthly packets at nocharge. A total of 5,000 reprints weredistributed during the past fiscal year.Other publications available from orthrough the North Carolina Society include:The Crippled Child Magazine, publishedby the National SocietyThe Crippled Children's Bulletin,also a national publication

March, 1955 The Health Bulletin 13The Outburst, a publication of theN. C. Society.The Outburst is mailed monthly atno charge to a mailing list of approximately2,500. The Society has a numberof films and special displays formeetings and other purposes. A total of32 film loans were made to groups andindividuals.It is estimated that there are approximately130,000 handicapped childrenand adults in North Carolina.Some splendid services are being providedby the State- and Federal-supportedagencies and other organizations.The Society is interested in thedevelopment of a rehabilitation programwith the possibility of developingthis service in conjunction withone of the medical centers in NorthCarolina; in the establishment of astate-wide itinerant therapy projectwhich would meet needs in the ruralareas of the State and provide thoseservices which the tax-supported agenciesneed and are ready and willing topurchase; a study and evaluation ofthe camp program to determine itsposition in a long-range plan; and emphasisto be placed upon the recruitmentand training of needed rehabilitationpersonnel in such fields as physicaltherapy, occupational therapy, andsocial service in addition to specialeducation.It is with a very deep sense of appreciationthat this report is presentedto the people of North Carolina whocontribute services and funds in makingthe Easter Seal program possible.NOTES AND COMMENTBy THE EDITORNORTH CAROLINA PUBLICHEALTH ASSOCIATION AWARDSThe North Carolina Public HealthAssociation grants three basic awardseach year:1. Reynolds Award—Is limited to anindividual for outstanding contributionsto public health in North Carolinaduring the past year, for meritoriousservice above and beyond thecall of duty;2. The Association Award—For an individualin recognition of outstandingcontribution to public health inNorth Carolina over a period of severalyears;3. The Merit Award—For outstandingcontributions or activities during thepast year for a local health departmentor group.Recipients of the Reynolds Award in1954 wereMargery J. Lord, M.D.Frederick J. Wampler, M.D., M.P.H.The Merit Award for 1954 was grantedto Pitt County Health Department,Greenville, North Carolina.Citations accompany these awardssetting forth the basis upon which theyare granted. The citations for 1954follow:CARL V.REYNOLDS AWARDofThe North Carolina Public HealthAssociation1954Margery J. Lord, M.D.A review of the many accomplishmentsduring Dr. Lord's 15 years ashealth officer of Asheville shows theoutstanding leadership which she hascontinuously exhibited. From surveys tocivil defense, Dr. Lord has fearlesslysought for new and better ways toserve her community. The motto "ItCan Be Done" prevailed under Dr.Lord's leadership. Regardless of the request,Dr. Lord has the reputation inher area for "doing something aboutit." The North Carolina Public HealthAssociation particularly cites Dr. Lordfor her efforts and selfless devotionduring the past year when she wasresponsible for maintaining public

14 The Health Bulletin March, 1955health services within her area in theface of overwhelming odds. At the sametime her leadership sparked and guidedthe transition and amalgamation of hermunicipal health department into theexisting county-wide organization. Atthe zenith of her accomplishments asa public health administrator, Dr.Lord further demonstrated the heightto which she holds the torch of publichealth as well as her depth of humanunderstanding and devotion by subordinatingher personal position in theinterest of perpetuating the publichealth services which her efforts madea reality to the people of Asheville andBuncombe County.Dr. Lord's career and accomplishmentsshould serve as an example andinspiration to all the public healthworkers of North Carolina.For outstanding contributions to thefurtherance and maintenance of publichealth and for selfless application of itshighest principles, Margery J. Lord ishereby presented the Carl V. ReynoldsAward.CARL V. REYNOLDS AWARDDr. Frederick J. WamplerHealth Officer, Granville CountyIn this age when youth is glorifiedand considered essential for success inmost fields of endeavor, it is somewhatunusual to discover an individual whohas embarked upon and achieved noteworthysuccess in a new enterpriseafter he has passed the Biblical lifespan of three score years and ten.Fourteen months ago, Dr. Frederick J.Wampler assumed the position ofHealth Officer in Granville County andinstead of pursuing the usual routineline of activities generally expected ofone of his age, he launched a ratheraggressive program for the improvementof health conditions in that county.Since his arrival, local funds for themaintenance of the health departmenthave been increased 29 per cent in acounty having low per capita income.Failing to obtain from the countycommissioners an appropriation of thecounty's share for the construction ofa health center, through his persuasiveleadership, he induced one of thelocal citizens to donate the county'sshare for such a center as a memorialto a relative. He also persuaded the cityofficials of Oxford to provide the countywith a beautiful site for the healthcenter. Through his persistent efforts,this new health center will be providedwith photofluographic X-ray equipmentpaid for largely from non-official funds.As a result of his constructive leadershipin the field of public health, GranvilleCounty was selected as one of thefield training units for supplying trainingin the clinical aspects of publichealth to the students of the NorthCarolina School of Public Health.His perseverance in the face of apparentlyinsurmountable odds, his abilityto locate hidden funds and channelthem into the realm of public health,and his intelligent and constructiveleadership in public health administrationshould be a source of inspirationand stimulation to all public healthworkers in North Carolina.On the basis of these achievements,the Carl V. Reynolds Award is herebypresented to Frederick J. Wampler.PittMERIT AWARDCounty Health DepartmentGreenville,North CarolinaDuring the past two years the PittCounty Health Department has madephenomenal progress in its contributionto the health of the people of PittCounty and eastern North Carolina.Local appreciation of this developmenthas been indicated by: a budgeted increaseof 47%; a long range plan forincreasing the number of personnel; anew branch office including an attractivebuilding in Farmville; a written,scheduled plan for salary incrementsand expense reimbursed in-service activities;and a new health center in thecounty seat.New programs have been launched inrural sanitation, milk control, accidentprevention, hearing conservation, useof mass education media and rabies

March, 1955 The Health Bulletin 15control. The latter was recognized bythe North Carolina Wild Life Magazinewhich gave a feature write-up of thisprogram.Old programs have been reorganizedand revitalized. Especially is this truein the area of venereal disease, withthis department reporting more diagnosedcases of infectious syphilis during1953 than any other unit in theState.Other counties have been assisted bythis department. During the past yearit has been the only agency in thatarea giving a 5-weeks orientation periodto the registered nurses in publichealth employed by other departments,and the staff has given this service unselfishlyand repeatedly, never refusinga request from a neighbor department.The television programs planned andpresented by the staff have broughtpublic health education via new mediato all of eastern North Carolina.For the reasons above, the MeritAward of the North Carolina PublicHealth Association for 1954 is herebyconferred upon the Pitt County HealthDepartment of Greenville, North Carolina.THREE UNUSUAL OPERATIONSNEAR HEART DESCRIBEDSurgical success with new techniquesand wider use of blood vesselgrafts for patients with serious andunusual vessel disorders was reportedtoday by physicians from New YorkCity, Chicago and Houston.Three operations were described inthe current (August. 14) Journal ofthe American Medical Association.In Chicago, three doctors successfullycut and relocated a misplacedvein which pressed against the windpipeand aorta and was threatening tosuffocate a five-months old baby. Withoutthe operation there seemed littlehope for the infant's life, they said.In Houston, in perhaps the firstoperation of its kind, a patient's circulationwas stopped for an hourwhile a new section was grafted intoa faulty main artery just above theheart. The patient suffered no apparentdamage to the spinal cord or vital organswhich usually follows stoppageof circulation for even a few minutes."Freezing" the patient by gradual coolingfor several hours before the operationprevented damage.A New York operation indicates asuccessful surgical method is now availablein the "desperate plight" of patientssuffering closure of the mainblood vessel leading into the heart.Doctors used a preserved arterial graftto start circulation again.The Chicago infant had troublebreathing just after birth, and atfive months "it had become obviousthat one of the constantly recurringattacks . . . would prove fatal," Drs.William J. Potts, Paul H. Holinger andArthur H. Rosenblum said. They saidthe child's condition was "unique.""The future of the child was hopeless"unless something could be done,while an operation was dangerousand might accomplish nothing, thephysicians said. The parents agreed tothe attempt. The child's left pulmonaryartery, which carries bloodfrom the heart to the lungs, was cut,moved to its normal position, and sewedtogether. Since then the baby has beenfree of trouble except for occasionalnoisy breathing.Drs. Michael E. DeBakey and DentonCooley, Houston, said they performedwhat appeared to be the first successfulgraft on the aorta where it archesover the heart. This is the trunk fromwhich the entire arterial system proceeds.Grafts have been used onstraight portions of vessels in similarcases of aneurysms, or balloon-likeswellings in vessel wall. Grafting ofthe aorta above the heart has beenlimited because of the increased dangerof blood-deficiency damage to vitalorgans.The physicians said their success indicatesthat "freezing" the patient isan effective way of slowing circulationfor long periods while grafts are performedabove the heart. Attempts toprovide detours for the blood whilea vessel is being cut have had limited

16 The Health Bulletin March, 1955application, they said.Relief has long been sought for patientssuffering gradual closure of ablood vessel like the New York patient.Drs. Cranston W. Holman and IsraelSteinberg said. Although they havehad only a short time to observe thepatient since the operation, they said,grafting to replace the stopped-upvessel seems to be "a satisfactory method"and is worth further trial in thesecases.MUSIC PROVED ATHERAPEUTIC AID"In acutely ill patients music oftenproduces effects of sedation and reassurance,while in chronically ill patientsmusic is able to divert the mindduring long periods of convalescenceand enforced rest," it was stated editoriallyin the Journal of the AmericanMedical Association."Patients with tuberculosis, rheumaticfever, malignant tumors, neurologicaldiseases, orthopedic disordersand many other chronic ailments frequentlydiscover that music helps whileaway tedious hours and removes nightsof the imagination to more pleasantand relaxing spheres of thought. Thiscan be accomplished with the aid ofbackground music, records, books, musicalinstruments and singing."Since almost all children enjoymusic that is tuneful, accompanied bysimple words, and that relates a story,music is especially applicable as atherapeutic modality for the juvenileaudience. It is useful as a vehicle accompanyinggames, and it also providesa pleasant distraction from the disturbingcries that invade pediatricwards of hospitals. It is of particularvalue to chronically ill children whoare required to stay in bed for longperiods of time."Music is a useful adjunct to physicaltherapy, the editorial pointed out. Mentallydefective persons are more easilyhandled when soothing rhythmic musicis performed, and it has been found indentistry that music allays anxiety,raises the pain threshold, and improvesthe doctor-patient relationship.MRS. BELL SERVED WILKES 25 YEARS(Editorial in N. Wilkesboro Journal-Patriot)On December 1 Mrs. Bertha Bellretired as public health nurse in Wilkescounty.Yesterday marked the end of 25 yearsservice by Mrs. Bell to the people ofWilkes County.Beginning her duties in 1929, Mrs.Bell served as public health nurse duringthe latter years of Dr. J. W. White'sservice as Health Officer and throughthe many years when Dr. A. J. Ellerheaded the department and when itwas without a Health Officer.Mrs. Bell, whose retirement was dueto ill health, always was genuinelyinterested in the people she served,especially the children, whom she dearlyloved.She worked faithfully in connectionwith the cripple clinic and made numeroustrips to carry crippled childrento Gastonia and Charlotte for correctivesurgery and hospital treatment.Nothing pleased her more than to observethe good results of the work,which often made an able-bodied personof a cripple.The children whose lives were affectedby the work of Mrs. Bell willnever forget her kindness, her interestand her efforts to make themwell. Her career in Wilkes was one offaithful and loyal service. All whoknow her wish that her remainingyears may be filled with happiness andthat she will realize the satisfactionof having served well and long in aposition of public trust.

fY-C-MEDICAL LIBRARYU. OF N. C.CHAPEL HILL, N. Cdfflb&l B>PuTMedby TfltMMCfflCLlNA SIMSMyflEflLTflTKis Bulletin will be sent free to anij citizen of the State upon requestPublished monthly it the office of the Secretary of the Board, Raleigh, N. CEntered as second-class matter at Postoffice at Raleigh, N. C. under Act of August 24, 1912IVol. 70 APRIL, 1955No. 4fED1955/ \&j£j%&>,.DUPLIN COUNTY HEALTH CENTERKenansville, N. C.

MEMBERS OF THE NORTH CAROLINA STATE BOARD OF HEALTHG. G. Dixon, M.D., President AydenHubert B. Haywood, M.D., Vice-PresidentRaleighJohn R. Bender, M.DWinston-SalemBen J. Lawrence, M.DRaleighA. C. Current, D.D.S GastoniaH. C. Lutz, Ph.G HickoryGeo. Curtis Crump, M.DAshevilleMrs. J. E. Latta Hillsboro, Rt. 1John P. Henderson, Jr., M.D Sneads FerryEXECUTIVE STAFFJ. W. R. Norton, M.D., M.P.H., State Health OfficerJohn H. Hamilton, M.D., Assistant State Health Officer and DirectorState Laboratory of HygieneC. C. Applewhite, M.D., Director Local Health DivisionErnest A. Branch, D.D.S., Director of Oral Hygiene DivisionA. H. Elliot, M.D., Director Personal Health DivisionJ. M. Jarrett, BJS., Director Sanitary Engineering DivisionFred T. Foard, M.D., Director Epidemiology DivisionFREE HEALTH LITERATUREThe State Board of Health publishes monthly The Health Bulletin, which willbe sent free to any citizen requesting it. The Board also has available fordistribution without charge special literature on the following subjects. Askfor any in which you may be Interested.Diphtheria Measles Residential SewageFlies Scarlet Fever Disposal PlantsHookworm Disease Teeth Sanitary PriviesInfantile Paralysis Typhoid Fever Water SuppliesInfluenza Typhus Fever Whooping CoughMalariaVenereal DiseasesSPECIAL LITERATURE ON MATERNITY AND INFANCYThe following special literature on the subjects listed below will be sent free toany citizen of the State on request to the State Board of Health, Raleigh, N. C.Prenatal CareInstructions for North CarolinaPrenatal Letters (series of nine) Five and Six Monthsmonthly letters)Seven and Eight MonthsThe Expectant MotherNine Months to One YearInfant CareOne to Two YearsThe Prevention of Infantile Diarrhea Two to Six YearsBreast FeedingMidwivesTable of Heights and Weights Your Child From One to SixBaby's Daily ScheduleYour Child From Six to TwelveFirst Four MonthsGuiding the AdolescentCONTENTSPageOverweight Clinic—Cumberland County Health Department 3Just How Healthy Can You Be? 5Life And Death In North Carolina In 1954 9Program Outline Louisiana Public Health Association Meeting 11Mental Health Week 12Notes and Comment 13

Bl lPUBLISMED 5YTAE N°RTA CAROLINA STATE B°ARD-/AEALTAl |E1Vol. 70 APRIL, 1955 No. 4J. W. R. NORTON, M.D., M.P.H., Sute Health Officer JOHN H. HAMILTON, M.D., EditorOVERWEIGHT CLINIC—CUMBERLAND COUNTYHEALTH DEPARTMENTMISS BETH DUNCAN, M.S.,M.P.H.Senior NutritionistN. C. State Board of HealthMRS. KATE W. WILLIAMSON, R.N.,B.S.Supervising NurseCumberland County Health DepartmentFayetteville, North CarolinaMuch is being said and written aboutthe problem of overweight, and it is asubject which is being approached frommany angles. In almost every magazine,newspaper and radio and televisionprogram articles and comments appearand calories are being attackedwith full force. Doctors have longwaged the "Battle of the Bulge", andinsurance companies are refusing toempty their pockets to potential short"livers". We are sure that, if doctors,insurance companies, commercial companiesand many food producers areaware of the dangers of overweight,it is time that public health put hershoulder to the wheel and not only dosomething to help others who are alreadyoverweight but assume her naturaland intended role by doing somethingto help prevent overweight.In Cumberland County we are doingsomething. The problem of overweighthas long been acknowledged byour health officer, who has continuallyadvised overweight patients he hasseen in clinics and examined andtreated as county physician to do somethingabout their overweight problem.He has urged nurses on the staff tointegrate into all their generalizedprograms some effort to induce patientswho tend to be overweight to eat less,and also to stress the dangers of overweightto the heart and blood vessels,along with the possibility of diabetesand the danger of being a poor surgicalrisk.Not until November, 1953, with thepart-time services of a nutrition consultantfrom the N. C. State Board ofHealth, was any real organized effortmade to help the overweight patient.At this time a clinic for the purposeof examining and giving continuousguidance to such persons was established.Patients who appeared to be overweightwere referred from all otherclinics, from homes which the nursesvisited, by the health officer and byprivate physicians. As the clinic hasgrown, may old patients refer theirfriends to this clinic. We started withone clinic a month in the morning, butbecause of the increase in case load and

The Health Bulletin April, 1955the demand for an afternoon clinic,the second clinic was started in October,1954.The case-load status of the clinic asof December 31, 1954, was as follows:Patients in active file 54Patients in inactive file 43Total case load 97Number of visits to clinic by cases inactive file 140Number of patients who have lostweight in active file 36.Number of patients who have notlost weight 13.Number of patients gaming weight(y2 -5 lbs.) 5.Highest weight loss, 35 lbs.Most of the patients who are in theinactive file enrolled during the firstfew months of the clinic. Some ofthese were screened and not encouragedto attend, some were not interestedand some probably became discouraged.In the beginning, in orderto build a case load, we were a bitover-anxious and not as careful inscreening patients for referral as weare at present.Average Weight Loss According toNumber of Visits Made to Clinic.No. of Visits Average Weight Loss7 246 285 244 143 132 6We realize that the above data meanvery little unless each patient is consideredindividually. The regularity andnumber of visits to the clinic is onlyone of the factors in the problems inlosing weight. However, we have foundthat patients who attend the clinicmore often and regularly tend to averagea greater weight loss.We have found that, unless a patientis sufficiently motivated and is sincerein his efforts to adhere to a reducingdiet, he will not attend the clinic.Some patients come to the clinic hopingto find an easy, short way to loseweight, and, finding that we cannot dofor them what they must do themselves,will not return. However, wetake advantage of the opportunity toeducate the patients and hope that itwill play a part in motivating themto become more interested later on.Some of the patients have many problems,which are deep seated, and habitsacquired in youth are carried overto adult life. In this clinic the familyfood pattern is usually a high-fat,high - carbohydrate and low - proteindiet. Many of our patients also eathigh-calorie foods for two reasons, becausethey have learned to like themand because those are the ones whichare available to them. Seemingly, theydevelop the habit of over-eating duringpregnancy or following an operationand fail to return to normal eatinghabits. Perhaps their activity islimited as a result of their physicalcondition, but they fail to reduce theircaloric intake, so it is these circumstanceswhich start their weight gain.Emotions play an important role inovereating, for some of the patientsfind that eating a lot of food is pleasurable.In other words, eating is a recreationalpursuit. There are some whosay that eating relieves nervous tension.There are other patients who aremore exposed to temptations thanothers. Restaurant workers, housewivesand cooks are all in frequent contactwith food and find the temptationgreater.There is danger of over- encouragingpatients as to the rate of weight lossto expect. That may vary with eachindividual; therefore, we use the approachthat weight loss, frequently likeweight gain, is a long-range process.Many patients, once they have decidedto do something about their weightproblem, want quick results; so theworkers have a continuous job of encouragingand motivating to keep patientsreturning to the clinic. There isusually a short waiting period at theclinic, and the group therapy, that is,one patient talking over his problemwith another who has the same one,seems to be helpful. The spirit of competitionas well as understanding isevident in the conversation betweenthem while they wait.

April, 1955 The Health BulletinAt the present time the clinic isstaffed by the nurse, nutritionist andhealth officer. During each clinic sessionthe patients are registered,weighed and measured. The nurse takesblood pressure, checks hemoglobin andexamines the urine for albumin andsugar. The record is filled out, includinga short medical, surgical and obstetricalhistory, and a history of thepatients' weight gain. At this time thenurse also makes an effort to determinethe attitude of the patient abouther weight, and what motivated herto come to the clinic. If the patienthas not had a recent examination(many of those who attend this clinichave been examined by their doctorsand referred), the nurse helps her planto go to her private physician or beexamined by the health officer. Thehealth officer is also consulted regardingthe recommended amount ofweight loss and when this has beenattained, she is referred to him forexamination. After the interview withthe nurse, the patient is seen by thenutritionist, who reviews the diet historyand attempts to evaluate theneeded caloric intake for each individualpatient. Patients are advised individually,and problems such as foodlikes and dislikes and the availabilityand cost of foods are taken into consideration.Frequently fad diets, andeven other diets prescribed, are expensive.Therefore, it is very important inplanning a reducing diet to make surethat it is planned to meet the needs ofthe patient and falls within the possibilityof his obtaining it. Taking thesefacts into consideration, a diet isplanned for each patient, and timeenough is spent to enable him to workit out in a satisfactory manner. Frequentlyon return visits the diet isreviewed or changed at the suggestionof the patient.Patients are encouraged to attendthe clinic every month, and, when theyfail to return, a notice of the clinic ismailed to them. In some cases thenurse makes a home visit to encouragethe patient to return.Although the clinic is still too newto make an official evaluation, it isencouraging that some results havebeen attained. We are certainly moreaware of the need to try not only tohelp those who are overweight but alsoto prevent overweight.JUST HOW HEALTHY CAN YOU BE?ROBERT F. YOUNG, M.D.County Health OfficerHalifax, N. C.The impact of research, educationand socio-economic changes on publichealth has been so great in the pastfifty years that its full measure cannotbe taken in a brief discussion. So Ishall try merely to present some ofthe present-day general concepts ofwhat we in the official public healthfamily consider to be public health atthe present time. We shall use fewstatistics to describe the remarkableprogress in our total health; first, toavoid monotony as much as possible;and, secondly, to avoid an egotisticalapproach.I think it is generally agreed thatit is well for a person to begin witha definition of his subject so that hecan firmly anchor himself and avoiddrifting to and fro with the currentsof random thoughts.In my opinion, the best definitionof health today is that which comesfrom the World Health Organization,namely, "Health is not merely the absenceof disease but is the sum totalof the physical, mental, emotional andsocial well-being of the individual."Public health, to continue with ourpresent-day concepts, is not just "theprevention of disease, but the prolongationof life and the promotion of phy-

6 The Health Bulletin April, 1955sical, mental and emotional healththrough organized community efforts."To further avoid an egotistical approach,so far as the official publichealth family is concerned, I shouldlike to explain what I shall mean by"we" when I speak of accomplishmentsin public health.Formerly, when we referred to publichealth, we generally thought onlyof the full-time personnel, namely, thehealth officer, the public health nurses,sanitarians, public health secretariesand others who were in the local officialpublic health agency. But todaywe realize that the broad objectives ofpublic health can be realized onlythrough organized community effort inaction. So the term, "we," today, includesnot only the full-time personnelfrom the local, State and Federal publichealth agencies and from the schoolsof public health, but also the physiciansin private practice, with their valuablecontribution to preventive medicine,the Lions Clubs, with their outstandingprogram in vision conservation, theother civic clubs, with their worthyhealth projects, the voluntary agencies,such as the Tuberculosis Association,the local Chapter of the NationalFoundation for Infantile Paralysis, thelocal Cancer Society and Heart Associationand many others, together withtheir state and national affiliates, thehospitals, school officials and teachers,and the individual public-spirited citizenswho so generously give of theirtime to the various phases of publichealth.The first present-day concept of publichealth which I should like to emphasizeis that today we are concernedwith total health - physical, mentaland emotional. In years gone by, therewas a tendency on the part of physiciansand public health departmentsto place emphasis on the purely physicalcondition of patients. We were interestedprimarily in whether the patienthad a stomach ulcer, heart condition,typhoid fever, tuberculosis orpneumonia.Today, we are interested in morethan just the physical condition of apatient. We are definitely concerned aswell in the emotional and mentalphases of his life and in what effectthese conditions have on his totalhealth. It has been reported that approximatelyfifty per cent of the patientswho call on our general practionersdo so primarily because of complaintshaving a mental or an emotionalbasis. Therefore it is imperative thatthe total patient be evaluated, and heis being evaluated totally, in order tolearn the cause of his illness or disabilityand thereby to be in a positionto treat him accordingly as the totalpatient.To further emphasize this conceptof the total patient, Dr. Alverez, EmeritusProfessor of Medicine, Mayo Foundation,in the preface of a recent bookof his, tells of his early practice—of thefeverishly scientific but sadly misguideddiagnoses; of the cases thatwouldn't respond to the clearly indicatedtreatment. Then, he tells of theunderstanding that came with fortyfiveyears of experience—of the carefulsearching past the laboratory findingsdown into the soul of the patient,into hopes, fears, desires, worries,mothers-in-law and errant husbands.In other words, "Many people sufferpoor health not because of what theyeat, but rather from what is eatingthem."In public health our patient is aBy thecommunity or the body politic.same token, we must carefully evaluatethe mental and emotional problemsof our areas, as well as the physical,in order to be in a position to plan andexecute a public health program thatwill meet all the needs of the entirecommunity.Our public health diagnosis, too, mustbe specific, since, just as is the casewith the individual patient, no twocommunities are exactly alike. Whatwould be a good public health programfor County A might not meet the needsof County B.When we consider that over halfthe hospital beds in America are occupiedby mental patients, that one outof every twenty citizens will eventual-

April, 1955 The Health Bulletinly require the services of a psychiatristand that the annual economic loss forindividuals housed in mental hospitalsin this country is approximately onebillion dollars — and remember, also,that we have 750,000 confirmed, chronicalcoholics, approximately 750,000 epilepticsand approximately one million patientswith various degrees of mentaldeficiency we immediately realize thatthe mental and emotional phases oftotal health are formidable phases thatmust be met with total planning.Many of the mental conditions andcertainly many of the emotional disturbancescan be corrected and thepatient restored to a normal and productivelife if only he is seen soonenough by his family physician, by apsychiatrist or by the personnel of amental hygiene clinic.Perhaps the present-day mode of livinghas a great deal to do with our attendantills. The pressures of our routineexistence are so tremendous thatthe average citizen today in meetingthe complexities of life, lives under agreater strain than did his forefathers.Someone has said that "worry is themost subtle and destructive of all humandiseases". Another has suggestedthat, in order to take proper cognizanceof our present individual status, itwould be well to: "take off half a daya week and spend it in a cemetery;wander around and look at the gravestonesof men who are there permanently;meditate on the fact that manyof them are there because they felt evenas we do now that the whole worldrested on their shoulders; meditate,also, on the solemn fact that when weget there permanently the world willgo on just the same; and, as importantas we are, others will be able to do thework we are now doing." This writersuggested farther that we might siton one of these tombstones and repeatthis statement, "A thousand years inthy sight are but as yesterday when itis past and as a watch in the night."And so we soon see that, in thinkingof health, we must consider total healthand, likewise, in planning our publichealth programs, we must meet thetotal needs of the physical, mental,emotional and social well-being of allthe people in our area.JUST HOW HEALTHY CAN YOU BE?Now I should like to mention and emphasizeanother concept of publichealth as we understand it today.As stated previously, we are not justinterested in the absence of disease,but we now have as one of our principalobjectives the promotion and attainmentof the highest level of totalhealth of which a given community iscapable and to which this area isjustly entitled. We are interested inpositive health.A few years ago we had our backs tothe wall and were struggling with all ourmight to prevent deaths from diphtheria,whooping cough, scarlet fever,typhoid fever, malaria, infectious diarrheaamong infants, tuberculosis andother communicable diseases thatranged the length and breadth of ourland. But, through the heroic effortsof the total public health team, withthe aid of improved immunizations,through increased knowledge of thesediseases, with the coming of the modernmiracle drugs, with improved socioeconomicconditions and certainly witha greater awareness of the generalpublic of these conditions, these communicablediseases that once stood as"giants in the land," one by one havebeen controlled until now we are directingour program toward their uttereradication.We have changed from defensivetactics to offensive maneuvers. We arenot satisfied with just preventingdiseases and death but are aiming towardoptimum health for our givencommunities. We are not only interestedin children's remaining free ofcommunicable diseases and other disabilitiessuch as result from accidents,but we want children who are robustlyhealthy.We are not content with adults' justbeing able to follow the routine ofearning their livelihood, but we wantadults who are at the peak of health,who can produce more goods and moreservices and who can enjoy life to the

8 The Health Bulletin April, 1955fullest. We want the cup of health forevery citizen to be full to the brimand even to run over.JUST HOW HEALTHY CAN YOU BE?For example, in years past, we conductedour food sanitation programsfor restaurants, meat markets and otherfoodhandling establishments by routinevisits to these concerns, routine inspectionsand the use of public methods,if you please. But today we plan andpromote food service schools which theemployers and employees of foodhandlingestablishments can attend andwhere they can learn the fundamentalprinciples of proper foodhandling. Theemployers and employees alike, evenunto the disnwasher and bus boys, arebeing made to feel in these foodhandlingschools that they have a responsibilityand a real challenge to promoteand maintain a foodhandling industrythat is second to none. So thatthe thousands of North Carolinians whodine out every day can do so with theassurance that the food served themis appetizing, wholesome and safe.Another example of the positive approachto our present health programsis the cancer detection and diagnosticclinics which we urge all citizens over35 to attend who are apparently well,because we want to find cancer whenwe can cure it, and not when it is toolate. A Seattle physician who is vicepresident of the American Academy ofGeneral Practice, after he was told hehad incurable cancer, stated: "Thefear of cancer is a friend of cancer —because it shuts far too many peopleoff from going to a doctor for earlydiagnosis lest they find they have cancer."We want the citizens of our respectiveareas to report to these clinicsand to their family physicians whencancer can be discovered as it firstraises its ugly head so that these peoplecan be restored to total health andreturned to society as normal and productivecitizens. The same thought appliesequally to heart disease — thenumber one killer today.JUST HOW HEALTHY CAN YOU BE?I am sure it is not necessary to pointout that, in the light of our presentday concepts of public health, healthis purchasable. Purchasable through anadequate public health program in thisor any other community. Total healthcan be bought by organized communityeffort and by everyone's putting hisshoulder to the wheel.During recent years, we have becomeaccustomed to complex and efficientmachines and gadgets. These deviceswith electric eyes, electronic controlsand other mechanisms almostthink for themselves. We have automatictransmissions on our automobilesalong with power steering and powerbrakes. We have windows that slideup and down with the push of a button.We have machines that assort andclassify data and materials. We havetelevision, 3-D and Cinemascope movies.Wonderful, ice say, and rightly so.However, in order for these machinesto function properly, there must beconstant and adequate maintenance.And let us not forget that the mostintricate and perfect of all machines isthe one made in the image of God—the human being. The average life ofthis marvelous machine has lengthenedfrom approximately forty-five years atthe turn of the century to over sixtyfiveyears at the present time. But thishuman machine during the added yearsof life is subject to new and increasedhazards which must be met with totalplanning on the part of the publichealth team. This machine, also, requiresconstant attention and propermaintenance if it is to function properlyand to survive the span of yearswhich is its rich heritage today.Heart disease, cancer, obesity, mentaldiseases, accidents and other conditionsnow loom as the "giants in ourland," ready to challenge us at everyturn. We must meet these present-dayenemies of total health as we met thecommunicable diseases and other problemsof yesterday.And: "If you have faith as a grainof mustard seed, nothing shall be impossibleunto you."JUST HOW HEALTHY CAN YOU BE?

April, 1955 The Health BulletinLIFE AND DEATH IN NORTH CAROLINA IN 1954WILLIAM H. RICHARDSONState Board of Health, Raleigh, N. C.We hear much discussion these daysabout the future of our public schools.While the problems connected withpublic education have changed, withthe complexities of our modern civilization,no one factor has contributedmore to these problems than the continuingand prospective growth in ourpopulation. It so happens that withthis increase have come new ways andmeans of preventing death among infantsand small children. This meansthat more children are reaching schoolage today than ever before. Therefore,the need for educational facilities ison the increase and will continue tobe for the duration of the foreseeablefuture.During last year, that is, 1954, therewere 115,889 live births reported to theNorth Carolina State Board of Health,as compared with 113,404 in 1953. The1953 total exceeded that for any previousyear in our history, up to thattime; but 1954 topped that, by a marginof 2,485. By 1960, surviving childrenborn last year will be ready forschool. Each year brings an avalancheof first graders. Primarily, of course,public health is not concerned with thebuilding of new school houses to meetthe need brought about by our increasingpopulation; but public health ISconcerned with the health of the people,from conception to death. Thisis a wide range, it is true, but one thatbrings with it inescapable responsibilities.Reported deaths, from all causes inNorth Carolina, in 1954, totaled 32,076,which was only twenty more than werereported the previous year. In view ofthe increase of 2,485 in the numberof births, this was a very gratifyingfigure. While the increase in the totalnumber of reported deaths was onlytwenty, as you have just been told,there were 226 fewer deaths amongbabies under a year old in 1954 thanwere reported in 1953, while the numberof maternal deaths connected with thebirth of 115,889 live babies was only82, as compared with 118 in 1953, whenlive births totaled a smaller figure,113,404.Let us pause here for a significantcomparison. In 1916, when only 76,658live births were reported in North Carolina,there were 7,112 deaths amongbabies, under a year old, the infantdeath rate being 92.8 per thousand livebirths, while, in 1952, the total numberof infant deaths had dropped to 3,929,although there were 111,000 babiesborn, and the rate was only 35.4. Thenumber of mothers dying as the resultof pregnancy and childbirth in 1916was 593, compared with 113 in 1952,while the rate dropped from 7.3 perthousand live births to 1.0. The 1952figures are used in this instance, becausethey include both totals andrates, while the 1954 rates have notdefinitely been worked out and published.Let us now turn our attention todeaths in the upper age brackets. Infantsand maternal figures reflect, ofcourse, the progress medical sciencehas made in the saving of infants duringthe first year of life and mothersas the result of pregnancy and childbirth.Preventive medicine, however, haswoven a wonderful pattern of extendedlife for those who will avail themselvesof what it offers, through public healthand the medical profession. More peopleare living to what we term a ripeold age than ever before. Time waswhen a man was considered old atforty. Now, at that age, he is in theprime of life. Formerly, hiring practicallyceased at forty; now, men andwomen remain in harness as long asthey are mentally alert and physicallyfit, if their employers are farsightedenough to avail themselves of the benefitsof accrued experience and ripenedjudgment.

10 The Health Bulletin April, 1955Let us consider a few of the diseaseswhich, through the efficacy of preventivemedicine, now have become almostextinct. In 1954, for example, therewas only one death from typhoid feverreported in North Carolina, as comparedwith four the previous year. In1916, typhoid deaths in this State totaled702. Yet, if we should revert tothe insanitary conditions which prevailedin 1916 and abandon vaccinationas a means of prevention, we coulddrop back to where we stood approximatelyforty years ago.Here is a comparison that is nothingshort of amazing: In 1954, there wereonly 329 deaths from tuberculosis, inall forms, reported to the North CarolinaState Board of Health, comparedwith 3,557 in 1916. The year 1916 ischosen as a comparative year, becauseit was then that we began keeping anaccurate record of all deaths from reportablecauses. Now, what has broughtabout this reduction in tuberculosisdeaths? In brief, more accurate anduniversal reporting of the disease andearly treatment. It is not, of course,against the law to contract tuberculosis;but it IS against the law for thosewho have the disease in the infectiousstage to refuse treatment. If they do,they can be compelled to go to a sanatoriumand remain there until theybecome non-infectious and cease to bea menace to society. They may not beable to avoid the disease; but, on theother hand, the innocent public nolonger is required to mingle with thosewho are infected. Without going intofigures, it can be stated that NorthCarolina today is in a better positionto provide accommodations and treatmentfor those with infectious tuberculosisthan at any previous time inthe history of the State.Another disease that has beenbrought under control is diphtheria,which now is practically 100 per centpreventable. Under the law, parentsare required to have all children immunizedbefore they reach their firstbirthday. An overwhelming percentageof parents do this, but last year therewere enough negligent parents to causethe death of eight children in thisState. In 1916, however there were 410deaths from diphtheria among childrenin North Carolina. There should neverbe another death from this cause.Parents who refuse to have their childrenimmunized are guilty of criminalnegligence.As previously has been stated, preventivemedicine has prolonged thelives of more children than those inany other age group. This means thatmore people are living to become victimsof what we know as the degenerativediseases, prominent amongwhich are heart disease, apoplexy andcancer, which continues to claim thelives of considerably more than halfof those who die from all causes inNorth Carolina every year.The degenerative diseases of middleand late life have come to be recognizedas public health problems, along withaccidents and other causes of deathwhich affect people of all ages.The North Carolina State Board ofHealth now is making a special studyof diseases of the heart, accidents andcancer. One of the most active sectionsin the entire State Board of Healthsetup is that which is devoted to astudy of home and farm accidents, withtheir ultimate elimination.The fight against degenerativea view to their reduction and, if possible,diseases and accidents will be a longand tedious one and must have thesupport of an enlightened and cooperativepublic. In the matter of conqueringthese causes of death, a great deallies in the field of education. Thereare no means of immunization againstsuch causes of death as heart disease,apoplexy and cancer. Therefore, theymust be dealt with primarily in therealm of research and education. Mostaccidents are preventable. Heart diseaseand cancer are not, in the commonlyaccepted use of that term. However,in the case of heart disease, those whobecome victims may greatly extendtheir lives by following the advice offeredby medical science. Formerly,physicians hesitated to tell patientsthey had heart disease. Now, the soon-

April, 1955 The Health Bulletin 11er a patient learns that he does haveany one of the diseases of the heartthe better, because he can begin atonce to adapt his way of living to hisphysical condition.During recent years there has beena sustained decline in deaths fromnephritis. From conversations withpracticing physicians, this decline seemsto be due to the use of antibiotics andother so-called wonder drugs whichcure illnesses of which nephritis formerlywas the terminal result. Suchdrugs may influence the incidence ofother diseases. However, we are notprepared to discuss this at the presenttime.According to the provisional vitalstatistics report, there were only 55deaths from syphilis reported in NorthCarolina during 1954, as compared with70 the previous year. No deaths werereported from malaria, Rocky Mountainspotted fever or typhus fever. Thepoliomyelitis death toll was only 23 forthe year, as compared with 34 in 1953.There was very little difference in thenumber of homicides and suicides reportedlast year, in comparison withsuch deaths during previous years.Dr. J. W. R. Norton, State HealthOfficer, recently stated that he wouldlike for a study of causes of suicidesto be made, with a view of determiningwhether such deaths might be prevented,if thoroughly understood. Thisstudy has not yet been made, but will,in due course.PROGRAM OUTLINELouisiana Public Health Association MeetingGeneral SessionRegistrationInvocationAddresses of WelcomeFelicitations From and Facts aboutthe Southern Branch, APHADr. J. W. R. Norton.Historical Sketches on Public Healthin Louisiana—Dr. Ben Freedman.Public Relations and Public HealthMr. E. J. Forio.Tuesday, May 10, 1955—A.M.Tuesday, May 10, 1955 — P. M.Section LuncheonsSection Business MeetingsGeneral Business SessionSOUTHERN BRANCH, APHAWednesday, May 11, 1955 — A. M.1st General SessionAddresses of WelcomeRepsonse — Dr. George A. BunchPresidential Address—Dr. J. W. R. NortonFringe—Dr. M. B. BethelPioneering in Public HealthA Heritage of the South—Dr. Ben FreedmanLuncheon—Governing CouncilLuncheon—Sanitation SectionWednesday, May 11, 1955—P. M.Section MeetingsCurbstone Planning MeetingSocial ProgramSOUTHERN BRANCH, APHAThursday, May 12, 1955—A. M.Curbstone Consultation ProgramLuncheon—Public Health NursingSectionLuncheon—Health Education SectionThursday, May 12, 1955—P. M.2nd General SessionAnnouncementsInternal & External Public Relations—Dr. Kenneth A. ChristiansenProgram Development and Evaluation— Dr. H. E. Hilleboe, President,APHA and New York Commissionerof HealthInter-American Health ProgramDr. Gustavo MolinaDr. Charles L. Williams, Jr.Dr. Jorge BoshellDr. Albert V. HardyEntertainmentFriday, May 13, 1955—A. M.3rd. General SessionWhere Do We Go From Here—Dr. Boscoe Kandle

12 The Health Bulletin April, 1955Business SessionFriday, May 13, 1955 —P.M.Section MeetingsANNOUNCEMENTSSPECIAL FIELDS, PUBLIC HEALTHNURSING, SCHOOL OF PUBLICHEALTH, DEPARTMENT PUBLICHEALTH NURSING, UNIVERSITYOF NORTH CAROLINASummer Session—July 11-August 5, 1955Chapel Hill, North CarolinaSPECIAL FIELDS IN PUBLICHEALTH NURSINGCancer Control—July 11-16 — MissNelson (Monday through Friday)Home Accident Prevention—July 18-23—Instructors to be announcedTuberculosis Control—July 25-30 —Mrs. Cady (Monday through Friday)Cardiovascular Diseases—August 1-5—Mrs. Hall (Monday through Friday)GENERAL INFORMATIONAdmission Requirements: For admissionto Special Fields in PublicHealth Nursing, a nurse must bea graduate of an approved schoolof nursing and also registered.Meeting the regular requirementsof the University will be necessaryfor non-nurse students.Tuition Rates: The fee for the entirecourse of 4 weeks is $40.00. Thecharge for one week of instructionis $10.00.Residence: Cobb Dormitory reservedfor students of special Fields.Single room—$12.00 a weekDouble room—$8.00per person perweek.Tuition and Room Rent payable atRegistrationRegistration: In Cobb Dormitory, onthe Sunday preceding the week thesubject is offered.Application must be made to: AssociateProfessor Margaret Blee, Box229, Chapel Hill, North Carolina.NORTH CAROLINA WATERWORKSOPERATORS ASSOCIATIONANNOUNCES1955 Water Works SchoolJune 6 through June 10Conducted by theInstitute of Government and theSchool of Public HealthUniversity of North Carolinawith the Cooperation and Sponsorshipof North Carolina Section,American Water Works AssociationNorth Carolina League of MunicipalitiesNorth Carolina State Board of HealthThe School is operated in conjunctionwith the voluntary certificationprogram of the North Carolina WaterworksOperator's Association, and willoffer intensive preparation for examinationsfor "A", "B", and "C" Certificatesand discussion periods for theadvanced group. Lecture and laboratoryinstruction will be presented June6 through June 9, and examinations forall grade certificates will be given onJune 10th. The School will be held inthe Department of Sanitary Engineeringof the School of Public Health. Forinformation, write to Institute of Governmentor Department of SanitaryEngineering, University of North Carolina,Chapel Hill.Mental Health Week is to be observednationally the week of May 1-7. It isdirected and coordinated by the NationalAssociation of Mental Health inco-sponsorship with the National Instituteof Mental Health of the federalgovernment. In this State the Week issponsored by the North Carolina MentalHygiene Society.MENTAL HEALTH WEEKThe purpose of the week is to makeevery citizen aware of his stake inmental health. Ways in which thecitizen can work through mental healthassociates to create better mentalconditions will be presented in programsof the various sponsoring organizations.Emphasis will be laid upon theneeded facilities to adequately deal

April, 1955 The Health Bulletin 13with the problem of mental illness inthe state.Dr. W. Carson Ryan, Chapel Hill, ispresident of the North Carolina MentalHygiene Society and Ethel Speas isExecutive Secretary. A small steeringcommittee with some fifty county leadersare cooperating in the plans forMental Health Week.Cooperating state-wide organizationsinclude: Hospitals Board of Control,Board of Public Welfare, Board ofHealth, Department of Public Instruction,Eugenics Board, Congress of Parentsand Teachers, Home DemonstrationDept., Alcoholic RehabilitationProgram, Council of Churches, LocalMental Hygiene Societies, Mental HygieneClinics, Ministerial Associations,N. C. Medical Society, Conference forSocial Service, and others.You are urged to contact your countyleader or the North Carolina MentalHygiene Society, Box 2599, Raleigh, andoffer your assistance in this worthwhilecause.Facts about the prevention of mentalillnesses and the facilities available fortreatment of the mentally ill and mentallydeficient will be presented by programs,literature and other means duringMental Health Week and in followupactivites thereafter.NOTES AND COMMENTSBY THE EDITORSAFETY RULES DURINGTHUNDERSTORMS OUTLINEDEach year several hundred personsare killed by lightning.In an effort to prevent such deaths,an editorial in the Journal of theAmerican Medical Association presentedthe following rules for personalsafety during thunderstorms:1. Do not go out of doors or remainout during thunderstorms unless it isnecessary. Stay inside of a buildingwhere it is dry, preferably away fromchimneys, fireplaces, stoves and othermetal objects.2. If there is any place of shelter,choose in the following order: largemetal or metal-frame buildings, dwellingsor other buildings which are protectedagainst lightning, and large orsmall unprotected buildings.3. If remaining out of doors is unavoidable,keep away from small shedsand shelters if in an exposed location,isolated trees, wire fences, and hilltops and wide open spaces.4. Seek shelter in a cave, a depressionin the ground, a deep valley or canyon,the foot of a steep or overhanging cliff,in a dense woods, or in a grove of trees."One of the safest places during alightning storm is in some metal enclosure,such as an automobile with ametal top, a steel railway coach or asteel building," the editorial pointedout. "A dangerous place is in the middleof a field away from all trees or ina wooden boat in a large expanse ofwater."In a residential area, if the houseis higher than the surrounding trees,the lightning may discharge throughthe building. If the trees in the samevicinity are higher, lightning may dischargethrough them instead of thehouse. Pointed lighting rods will dischargethe atmosphere and conductthe lightning to the ground. A farmerplowing the field would be safer underthe tractor than perched in its seat."It is probably unwise to lean againstan isolated tree trunk during a thunderstorm.If nothing better is available,it is probably safer to sit underthe tree, but one should stay severalfeet away from the trunk and nottouch it."FAINTING IS ITS OWN CURE;LEAVE VICTIM ALONEThe best way to "cure" a faint issimply to leave the victim lying flat,according to a New York City physician.

14 The Health Bulletin April, 1955This is because a faint actually is acure in itself, Dr. Alfred Soffer said.It's nature's way of giving the bodya short adjustment interval to recoverfrom sudden changes in blood movement."Fainting occurs when deep-lyingblood vessels throughout the body, butparticularly in the leg muscles and abdominalorgans, are temporarily widenedby paralysis or active dilation,"he said. "This dilation—the result ofcomplex nerve impulses — may bebrought on by fright, shame, drug reactions,temperature sensitivity, painand sudden blood loss."Contrary to popular belief, heartdisease is rarely responsible for fainting,"Dr. Soffer said in Today's Healthmagazine, published by the AmericanMedical Association.Changes in circulation may causeoxygen shortages in blood movingthrough the heart and brain. Thesemake the body's protective mechanismwork overtime. The body can meetthis "challenge," but an adjustmentperiod is needed. A faint and a fall tothe ground is nature's way of gettingstagnant blood moving back to theheart and brain."Forcing a fainting person to sit upwill only prolong the unconscious state,and may initiate irreversible damage,"Dr. Soffer said.He also advised loosening a victim'scollar to take pressure off sensitive neckblood vessels. Giving him a drink ofsweetened fluid after he recovers mayhelp, particularly if he is sensitive toBut aromatic stimu-hunger faintness.lants are of slight importance comparedto the value of having thepatient lie flat. This is nature's ownwise remedy, Dr. Soffer said.PSYCHOSOMATIC ILLNESSNOT "ALL IN THE MIND"Internal illnesses resulting from nervousor emotional disturbances arenot just "all in the mind," a Philadelphiaphysician said.Actually, these illnesses involve nervechannels from the brain to the internalorgans, and can possibly be treated bydrugs which slow down or stop thenerves' actions, Dr. J. Earl Thomassaid in the Journal of the AmericanMedical Association.The "dream" of treating such diseasesby medicine alone has not been realized.But it is possible to make manysymptoms disappear, in a disease suchas duodenal ulcer, to "the great reliefof the patient."Dr. Thomas said the brain is "anavenue of communication" between externalstimuli and internal reactions,and "confusion in the brain is likelyto be communicated to the internal organs."Diseases caused by such errorsof function are called "psychosomatic."However, he said any influence thebrain has on the body must comethrough material channels, the nerves.Thus, these mental-emotional disordersdo have a physical basis in the nervoussystem."The idea that the viscera (internalorgans) are in some way involved inthe major emotions is as old as recordedhistory," he said. Emotions,like other experiences, are responsesto stimuli and may react in the sameway as ordinary reflexes. Once a responseis made, the next time thesame stimulus appears the response returnsand eventually may come if thestimulus is only suggested, such as bymemory or imagination. The nervechain involved thus becomes a "path oflow resistance."If the pathways are stimulated oftenenough in the same way, the consciousemotional response and the unconsciousinternal reaction may become permanentlyassociated. They appear atthe same time. This may result evenfrom the appearance of nothing morethan the circumstances usually associatedwith the stimulus. This factmay explain the seasonal or annualrecurrence of a disease such as pepticulcer.Assuming that some diseases, notablypeptic ulcer and ulcerative colitis, arestarted or become worse because ofoveractivity of the nerves, interferencewith the paths of low resistance shouldprevent illness. Dr. Thomas said this is

April, 1955 The Health Bulletin 15possible with drugs which depress theparticular nerves involved.WEATHER IS IMPORTANTTO WELL-BEINGBlaming the weather for "blue"moods and bad colds is not at all unscientific,a Chicago physician said.The weather was blamed for thecommon cold as long as 2,000 yearsago and scientific investigation hasshown that Hippocrates was right, Dr.Noah D. Fabricant said.In fact, weather changes are reflectedin all of the body's processes,and can have an effect on emotions,colds, asthma, heart disease, and evensuicide. The weather can often be "thestraw that breaks the camel's back,"Dr. Fabricant said in Today's Healthmagazine, published by the AmericanMedical Association.There's an explanation for it, hesaid. Tests have shown that "everychange in weather involves a physiologicaladjustment in everyone." For instance,colds increase when temperaturedrops because the membranes ofthe nose and throat become alteredand fall easy victim to invading germs.In fact, scientists have said that theform of the nose depends on the climate—thecolder the climate, the narrowerthe nose. Eskimos have narrowernoses than Africans.At least somebody is trying to "dosomething about the weather," Dr.Fabricant said. Taming the weatherhas become a foremost interest ofmany engineers, architects, meteorologists,and physicians. Some plannersare convinced that buildings could beplaced to serve as windbreaks, streetslaid out to avoid wind channels, andhouses built to reject rather than absorbheat.One way to prevent the shock of goingfrom an air-conditioned room intothe heat, or from a heated room intothe cold, is to have a closer adjustmentbetween the two atmospheres."Some physicians believe that a numberof diseases will respond to controlledweather and climatic conditions,"he said. "Though more than abeginning has been made toward deflatingthe common cold nuisance, it isreasonable to expect that in the futureattention to controlled atmosphereicconditions will play a role in amelioratingcolds."ORDINARY BALDNESSCAN'T BE CUREDThe first known written medical recordcontained a remedy for baldness,including fat from the lion, hippopotamus,crocodile, goose, serpent, and ibex.It had one thing in common withmodem "cures."It also failed to cure baldness.One of the reasons baldness "cures"have continued to appear for thousandsof years is that baldness is a"mysterious condition about which peoplecan be easily fooled," according toVeronica L. Conley, assistant secretaryof the American Medical AssociationCommittee on Cosmetics.Another reason is that it is the kindof problem that breeds quackery, shesaid in Today's Health magazine, publishedby the A.M.A. The "pseudoscientificarguments supporting most baldnesscures" are frequently "so convincingthat their unsound basis can bedetected only by trained scientists."For instance, "before and after" picturesof bald men whose hair grewagain after using a "restorer" areamong "the most potent advertisingweapons."The trouble is that in many typesof baldness, hair will return regardlessof treatment or lack of it. This typeof baldness and "spontaneous regrowth"often follows infectious diseasesaccompanied by fever, includingerysipelas, pneumonia, typhoid, andinfluenza. Serious loss sometimes followschildbirth or surgery. In all theseconditions, normal hair growth returnswithout help.But for ordinary baldness, massageand hair tonics with or without vitamins,hormones, ultraviolet light, diets,sulfa drugs, and antiseptics have "nospecial place" in treatment. A completephysical examination to discovera possible cause in disease is wise. Reg-

16 The Health Bulletin April, 1955ular and gentle scalp massage, brushing,and intermittent tugging at thehair to lift the scalp are "measuresfor good scalp hygiene."However, once ordinary baldness getsunder way, "it is progressive and permanentand there is no known way ofpreventing or retarding its progress,"Mrs. Conley said. The tendency towardbaldness is hereditary but will appearonly where there is a normal amountof male hormone.Scientists are mostly optimistic aboutan eventual solution to the problem ofbaldness, except for one factor."In the course of evolution there hasbeen a marked reduction in the amountof hair covering the human body," shesaid. "The loss of scalp hair may bepart of an evolutionary trend. If thisis true, future centuries will bring nota cure but the appearance of more andmore bald men."HOME REMEDY OVERTREATMENTCAUSES SKIN DISEASEDermatitis from overtreatment withhome remedies is one of the leadingcommon skin diseases in this country.The American Medical Association'sCouncil on Pharmacy and Chemistryhas issued a report on the "appalling"incidence of the disease in the Journalof the A.M.A. The report was writtenby Dr. L. Edward Gaul, Evansville,Indiana, dermatologist."The public has virtually no knowledgeof infection or its prevention,yet persons treat their skin with antiseptics,germicides, disinfectants, andvarious home concoctions," the reportsaid. "The cause of overtreatment isevident; skin disorders are being treatedinstead of diagnosed."The report said common cases ofovertreatment skin disease result fromapplying store or home remedies tominor injuries such as cuts, chemicalirritations, infections, sunburn, andathlete's foot. Among the preparationsused which have resulted in "overtreatmentskin disease" are the organomercurials(such as Merthiolate andMercurochrome) ; the sulfonamides;local anesthetics (such as benzocaine,often found in athlete's foot and poisonivy remedies) ; antihistamines (advertisedfor relief of itching, sunburn, andpoison ivy), and the antibiotics, especiallypenicillin.One of the factors making the problemurgent is the large number ofchemicals used for skin remedies, andthe opportunities for contact withthem. They are stored in many medicinechests. Seventeen of 106 remediesfor athlete's foot, 5 out of 114 preparationsfor poison ivy, and some eye andear remedies contain mercurials. Antisepticsand local anesthetics are availableover the counter in many preparations."Persons store them indefinitely;they loan them to friends; and theyfeel they are the answer to all skintrouble," the report said. "The onlypractical way to free the human skinfrom overtreatment sensitization is bya program of public instruction."The report warned the public "tobeware of all semiprofessional adviceand ideas," and to use only skin preparationsordered by their physician,and nothing else. Remedies should bedestroyed when a cure is effected, andnot given to anyone else. Among theskin conditions which call for a doctor'sattention are:Puncture wounds from nails, glass,steel wool, thorns, light bulbs, andsimilar materials; contaminated cutsand scratches; persistent bleeding ofall injuries; oozing of bleeding any timeduring healing or the beginning of irritation;chemical burns, sunburn notrelieved by milk of magnesia or calaminelotion without phenol; tick orspider bites; all animal bites, and especiallyhuman bites; and itching,burning, redness, swelling, suspectedinfection, or fungus infections.Little cuts, scatches, and burns shouldbe bandaged with sterile gauze, withbandages changed frequently, and keptdry. Soap, household cleaning agents,wax, and cosmetics should be kept off.An ice cube or cold cloth pressed on theinjury will relieve pain.

MEDICAL LIBRARYU. OF N. C.CHAPEL HILL, N. C.n> ©I TKis Bulletin vriD be sent free to dMj citizen of tKe State upon request \Published monthly at the office of the Secretary of the Board, Raleigh, N. C.Entered as second-class matter at Postoffice at Raleigh, N. C. under Act of August 24, 1912Vol. 70 MAY, 1955 No. 5.::;:::::.:: :.;;: : ;-::; "** •:;:. RtCtlVEDIAY 25 1DMSKM OFHEALTH AfhAlKS LIBRAPCHARLES M. CAMERON, III

MEMBERS OF THE NORTH CAROLINA STATE BOARD OF HEALTHG. G. Dixon, M.D., President AydenHubert B. Haywood, M.D., Vice-PresidentRaleighJohn R. Bender, M.DWinston-SalemBen J. Lawrence, M.DRaleighA. C. Current, D.D.S GastoniaH. C. Lutz, Ph.G » HickoryGeo. Curtis Crump, M.DAshevilleMrs. J. E. Latta M. Hillsboro, Rt. 1John P. Henderson, Jr., M.D Sneads FerryEXECUTIVE STAFFJ. W. R. Norton, M.D., M.P.H., State Health OfficerJohn H. Hamilton, M.D., Assistant State Health Officer and DirectorState Laboratory of HygieneC. C. Applewhite, M.D., Director Local Health DivisionErnest A. Branch, D.D.S. , Director of Oral Hygiene DivisionA. H. Elliot, M.D., Director Personal Health DivisionJ. M. Jarrett, B.S., Director Sanitary Engineering DivisionFred T. Foard, M.D., Director Epidemiology DivisionFREE HEALTH LITERATUREThe State Board of Health publishes monthly The Health Bulletin, which willbe sent free to any citizen requesting it. The Board also has available fordistribution without charge special literature on the following subjects. Askfor any in which you may be interested.DiphtheriaFliesHookworm DiseaseInfantile ParalysisInfluenzaMalariaMeaslesScarlet FeverTeethTyphoid FeverTyphus FeverVenereal DiseasesResidential SewageDisposal PlantsSanitary PriviesWater SuppliesWhooping CoughSPECIAL LITERATURE ON MATERNITY AND INFANCYThe following special literature on the subjects listed below will be sent free toany citizen of the State on request to the State Board of Health, Raleigh, N. C.Prenatal CarePrenatal Letters (series of ninemonthly letters)The Expectant MotherInfant CareThe Prevention of Infantile DiarrheaBreast FeedingTable of Heights and WeightsBaby's Daily ScheduleFirst Four MonthsInstructions for North CarolinaFive and Six MonthsSeven and Eight MonthsNine Months to One YearOne to Two YearsTwo to Six YearsMidwivesYour Child From One to SixYour Child From Six to TwelveGuiding the AdolescentCONTENTSPageMedicine's Greatest Challenge—An Effective Safety VaccineFor Children 3Mosquitoes And Their Control 7Notes And Comments !3

«$stgIPUBLI5AED BYTAE N°RTA CAROLINA STATE B°ARD*AEALTA| BVol. 70 MAY, 1955 No. 5J. W. R. NORTON, M.D., M.P.H., State Health Officer JOHN H. HAMILTON, M.D., EditorMEDICINE'S GREATEST CHALLENGE—AN EFFECTIVE SAFETY VACCINE FOR CHILDRENCHARLES M. CAMERON JR., M.D., M.P.H.Chief, Accident Prevention and Communicable Disease SectionsDivision of EpidemiologyNorth Carolina State Board of HealthPublic interest in the positive approachto good health through theprevention of sickness prior to the onsetof the actual disease has beenheightened by the recent announcementof a partially effective methodfor the control of poliomyelitis.Imagination has been captured bythe idea of a "miracle vaccine" which,once injected, may ward off foreverthe threat to children arising frombacterial and virus diseases. Despitethe limitations of the present poliomyelitisvaccine, all are encouragedthat medical science has taken theinital steps in the development of animmunizing agent offering protectionagainst poliomyelitis.To those with perspective as to theentire gamut of childhood health problems,however, the greatest need foreffective control methods remains inthe area of childhood accidents, sinceit is these needless mishaps whichcontinue to stand unchallenged as themajor detriment to health and happinessof children in the United Statesin 1955. The hope of those concernedwith this problem is for a "wonderdrug" or "magic vaccine" which willrender impotent the ranking killerand crippler of children.Latest official statistics released bythe National Office of Vital Statisticsfor the year 1952 show that 10 percent of the 144,715 deaths in childrenunder fifteen years of age were causedby accidents and that 15.5 per centof America's 96,000 accident fatalitiesoccurred among children under fifteen.(1)In comparison with all other conditions,accidents rank as the leadingcause of death for persons from onethrough thirty-four years of age andin the age groups under ten years ofage the number of accident fatalitiesis larger than the combined total ofthe next five leading causes of death.Official records show that, in comparisonwith the total deaths occurringat each age, accidental deathsincrease in relative importance throughthe age groups of childhood and reacha peak for the age group fifteen totwenty-four years, when this causeaccounts for nearly half of all deaths.In 1952 for every child under fifteenyears of age killed by polio, ten losttheir lives in accidents; for every childkilled by whooping cough, fifty losttheir lives in accidents; for every childkilled by diptheria, 100 lost their livesin accidents; and for every child killed

The Health Bulletin May, 1955by typhoid, over 1,400 lost their livesin accidents. (2)In comparing deaths from accidentsand poliomyelitis, the argument hasbeen raised that the greatest threatof poliomyelitis lies in its cripplingeffects, which invalidates such comparativereasoning. A special reportfrom the Children's Bureau showingthe diagnoses of children served bythe Crippled Children's Program in1952 reveals that about 30,000 childrenwith a primary diagnosis of acutepoliomyelitis or with handicappingconditions resulting from the diseasereceived physician's services undercrippled children's programs. (3)During a corresponding period about13,000 children were served in thecrippled children's program because ofa primary diagnosis of injuries due toaccidents. Thus it is shown that, whilethe number of children crippled bypoliomelitis is about double the numbercrippled by accidents, the fact thataccidents in addition claim ten timesthe number of lives as does poliomelitismakes accident preventionamong children worthy of prime considerationby all those who professconcern for the welfare of the citizensof tomorrow.North Carolina's experience during1952 was similar to that observed onthe national scene. In that year poliomyelitiscost the lives of sixteen childrenunder fifteen years of age, whileaccidents claimed the lives of 518. (4)A total of 1,463 children received crippledchildren's assistance for defectsresulting from poliomyelitis and duringthe corresponding period 634 childrensought aid for the correction ofhandicaps resulting from accidents.It has been estimated that eachindividual during an average lifetimecontributes at least $50,000 to thegeneral economy of the State in termsof wages earned, productive labor andservices and goods purchased. If oneassumes that the death of a child removesfrom the general economy anamount equal to the average lifetimecontribution of one citizen, then theloss to North Carolina from childhoodaccidents amounts to over 26 milliondollars each year. Applying the sameprinciple, the loss from poliomyelitisamounts to slightly over one half million.Although the handicap resultingfrom both accidents and disease willvary with each individual, all mustagree that the earning capacity of theperson will be materially limited becauseof the condition. On the assumptionthat the lifetime contribution tothe economy of the State will be cutin half by handicaps resulting fromeither poliomelitis or accidents, onemay estimate that the loss for theState from the crippling effects ofpoliomyelitis each year amounts toabout 35 million dollars and the lossfrom accidents totals about 17 milliondollars.However, when one combines theloss due to both deaths and cripplingfrom each condition, it is apparentthat accidents each year cost the Statean estimated 43 million dollars, ascompared with an estimated loss dueto poliomyelitis of 35 million dollars.None would suggest that a monetaryvalue can be placed on the personalsuffering and family grief resultingfrom either condition; however, on thebasis of economics alone, there seemsample justification for assigning higherpriority to the development of forcefulaccident control procedures thanto the development of a control methodfor poliomyelitis. That this concept isforeign to the philosophy of many isevidenced in the pennies and dimesspent for accident control in a yearwhen expenditures for poliomyelitiswill amount to millions of dollars.The interest which official and volunteerhealth agencies have developedin accident control holds the greatestpromise for the development of meaningfulsafety activities. This is particularlytrue in those instances wherea sound community diagnosis has beenmade to determine the nature of thelocal accident problem prior to launchingprograms in suspected accidentareas or against any problem withgreat emotional appeal. Community

May, 1955The Health Bulletindiagnosis must be based on the triedand true techniques of communityexamination, embracing not only thescience of epidemiology in its broadestsense, but also an appraisal of communityresources which may be mobilizedto meet the health needs of thepopulation.There remains a great necessity,however, for a greater appreciation ofthe total accident problem of thegeographical unit, be it the nation, astate, county or community. Few indeedare the safety workers in any ofthe specialized fields of accident preventionwho can cite the relativemagnitude of the accident problem onthe highway, in the home, on thefarm, in industry and in recreationalareas or in any of the somewhatcompartmentalized approaches whichsafety activities have assumed.An example of the need for communitydiagnosis is evident in theconcentration on motor vehicle safetyactivities to the exclusion of concernregarding other types of accidentswhich has been manifest in NorthCarolina in the past two years. Thereis no diagreement that motor vehicleaccident control is important andworthy of every effort which has beenexpended to reduce street and highwayaccidents, but all should realize thatthe prevention of every motor vehicleaccident involving a child would reducethe total accident experience ofthose under fifteen years of age by lessthan one-third.Table I shows a classification offatal accidents in children by agegroup, which illustrates the number oftransportation and non-transportationaccident deaths recorded at each age.A total of 342 deaths, or about 66 percent, were caused by non-transportationaccidents in the home, on thefarm, in recreation areas and in otherpublic places. Transportation accidentsare comprised of motor vehicle, train,plane and related types of accidents,of which over 90 per cent are relatedto the motor vehicle and account foronly 34 per cent of accident deathsamong children.The total accident deaths for allpersons in North Carolina in 1952 was2,550, of which 1,173 were classed astransport accident deaths and 1,387 asnon-transport accident deaths. It issignificant to note that only 12 percent of all transport accidents involvedchildren under fifteen years of age,while over 30 per cent of the nontransportaccidents claimed childrenas their victims. The significance inthese figures is clear: (1) that motorvehicle safety activities will only partiallyreduce the accident loss amongchildren; and (2) that the greatestaccident hazards for North Carolina'schildren are in the homes, on thefarms and in parks and playgroundsand are not concentrated on the highways,as many suppose.Additional epidemiological study ofthe State's accident experience hasrevealed that consistently the highestaccident fatality rates are recordedamong the nonwhite male children,followed by white male children inthe next most frequently observedposition. Nonwhite females amass thethird highest accident rates, with thewhite females recording the lowestrates in the State. (5) From theseobservations one may conclude thataccident control activities should beconcentrated on the nonwhite elementsof the population, which are predominantlyNegro in this State. Inaddition, safety programs among allresidents must be designed to reachthe male elements of the population.This step-by-step analysis must becarried into each county and communityin the State so that health andsafety officials may plan programsaimed specifically at the major typesof accidents in each area. For example,it has been noted that the frequencyof firearm accident deaths amongchildren is highest in the rural countiesof North Carolina, while thehighest incidence of accidental poisoningshas been recorded in the morethickly populated counties. Similarly,the prevention of accidental drowningsis of more importance to certaincoastal counties than to those in the

6 The Health Bulletin May, 1955western areas of North Carolina.In addition to the need for thedrafting of community-specific safetyactivities, there continue to be largevoids in the knowledge of all concerningthe background and etiology ofaccidents. To a large measure, safetyspecialists are limited to statisticsconcerning fatal accidents, and thereverse side of the coin, non-fatalaccidents, is virtually unexplored. Pilotstudies have demonstrated that themost frequently observed fatal accidentsare not the most common accidentsresulting in injury withoutdeath, and since it is estimated thatless than one per cent of accidentsresult in death, this facet of the accidentproblem cannot be ignored.Much has been said about accidentproneness, and certain studies seemto indicate that children with certainpersonality patterns may be most frequentlyinvolved in accidents, but theexact influence of physical, mentaland emotional factors on the accidentthreshold of an individual is worthyof considerable additional emphasis.The activities and methods of inspiringparents and children to seeksafer ways of living must receive extrastudy in the same manner that scientistsare obligated to test the relativeefficiency of any disease control procedure.There seems to have been madea basic assumption that the safetycampaign is the best way of motivatingindividuals to safer living in theface of experience in other fields,which has shown that activities onsuch a superficial intellectual level maybe uneconomical and inefficient. Howindividuals can best be made awareof the implications of safe homes, safeappliances and safe habits remains aparamount question facing all safetyspecialists.It has been said that individuals livingin an era when history is beingmade either over-emphasize or underemphasizethe true significance ofevents occurring about them. This isparticularly apt in the second half ofthe twentieth century, when almostdaily new scientific frontiers are beingcrossed and the tools for public informationare developed to an extentnever before reached. There has neverbeen a greater need for the quietscientific appraisal of health problemsand approaches to these problems,completely devoid of emotionalism.With the realization of the areaswherein the major health problems arecentered will come an atmospherefavorable to the establishment of laboratory-centeredand community-centeredresearch which can give birth tothe "safety vaccine" so badly neededto halt the needless deaths, injuriesand disabilities experienced by thechildren of the nation.Table IReported Accident Deaths AmongChildren Under Fifteen Years ofAge By Major TypeNorth Carolina, 1952AgeGroupUnder 11-4 Years5-9 Years10 - 14 YearsTransport Non-TransportAccident AccidentDeaths Deaths8 164506652913156Total 176 342Data from Public Health StatisticsSectionNorth Carolina State Board of HealthReferences1.: Vital StatisticsSpecial Reports, Accident FatalitiesUnited States, 1952. Volume40, No. 11, National Office of VitalStatistics, Public Health Service,April 4, 1955.2.: Vital StatisticsSpecial Reports, Deaths andDeath Rates for 64 Selected Causes,by Age, Sex, and Race, United States,1952. Volume 40, No. 4, NationalOffice of Vital Statistics, PublicHealth Service, December 21, 1954.3.:Children'sBureau Statistical Series, No. 25,Diagnoses of Children Served in the

May, 1955The Health BulletinCrippled Children's Program, 1952.Social Security Administration, U. S.Department of Health Educationand Welfare, 1955.4. : Annual Reportof the Public Health StatisticsSection, Part 2, Live Births, Stillbirths,Deaths and Population, 1952.North Carolina State Board ofHealth, Raleigh.5. Foard, Fred T., M. D., and Cameron,Charles M., Jr., M. D.: "Accidents —Childhood's Greatest Threat." Tri-State Medical Journal, October 1954.MOSQUITOES AND THEIR CONTROLCHARLES M. WHITEChief, Insect and Rodent Control SectionSanitary Engineering DivisionN. C. State Board of Health, Raleigh, N. C.There are fifty or more species ofthese annoying, disease-bearing insectsin North Carolina. People who studymosquitoes find that when they areexamined under a magnifying glasssome species differ from others asmuch in size, shape and color as dothe many kinds of birds. Variations intheir habits are just as great. Somespecies seldom travel more than a fewhundred feet from their breedingplaces, while others fly many miles. Afew mosquitoes bite only cold-bloodedanimals, such as frogs and snakes,but most species feed on warm-bloodedanimals, including man. Their selectionsof breeding places differ just aswidely. There are species that breedonly in salt marshes; others preferlarge bodies of fresh water. Manybreed in woodland pools and seldomventure into open country. Some highlydomesticated species that live aroundhuman habitation breed in artificialcontainers, such as tin cans, discardedautomobile tires, rain barrels, flowervases and roof gutters that do notdrain properly. They all have onething in common. Mosquitoes breedonly in water, regardless of theirspecies. There is a mistaken belief thatthey breed in grass, hedges, weeds,chinaberry trees and other types ofvegetation, because they are oftenfound resting in such places duringthe daytime, because of the protectionoffered against the sun, wind andenemies.HOW MOSQUITOESAFFECT HUMANSMany authorities regard mosquitoesas one of mankind's worst scourges.They transmit organisms that causehuman diseases, are sources of irritation,annoyance and general discomfortand in many instances adverselyaffect our economic welfare.MalariaThe only means in nature wherebymalaria can be transmitted from oneperson to another is by the bite of amosquito of the Anopheles genus. Ona worldwide basis, it has been proventhat numerous species belonging tothis genus carry the disease. Whilethere are several species of Anophelesmosquitoes in North Carolina, it isbelieved that only one, the Anophelesquardrimaculatus, transmits malaria inthisState.Extensive mosquito control operationsconducted by local health departments,in co-operation with theNorth Carolina State Board of Health,during recent years have resulted inthe near-eradication of malaria in theState. As late as 1936, 150 deaths fromthe disease were reported. It is nowvery difficult to find a positive case.In spite of this gratifying reduction,it woud not be safe to discontinuemalaria control activities, as it ispossible that the disease could returnin epidemic form. In many parts of

8 The Health Bulletin May, 1955the world, malaria is still a publichealth problem of the greatest magnitude.Present-day travel facilitiescompel us to be continuously on thealert to prevent its becoming reestablishedhere.YellowFeverHistorically, this highly fatal diseaseis of primary importance in NorthCarolina, and the other Southernstates. During the last century epidemicsoccurred in which thousandsof people died. At present, yellowfever is confined to parts of SouthAmerica, Central America and Africa.Tn 1953 two Brazilian states had 92verified cases, of which 88 died.Mosquitoes of the Aedes aegyptispecies, which transmit the disease,are distributed throughout North Carolina.The re-introduction of yellowfever in certain areas where thesemosquitoes occur in abundance wouldprobably result in many human deathsbefore effective control operationscould be inaugurated. The UnitedStates Public Health Service, by disinfectingairplanes which come fromcertain tropical areas and examiningthe passengers before they are allowedto land, along with other precautions,has been very successful inkeeping yellow fever out of thiscountry.EncephalitisSeveral types of encephalitis aretransmitted by mosquitoes and are ofincreasing public health importance,due to their seriousness and the factthat they are spreading to many areasin which they have not formerly occurred.Three strains have occurred inparts of the United States, includingthe South. In 1952, during an outbreakin California, 753 cases of thedisease were reported, with 51 deaths.The Japanese B strain, an extremelyvirulent form, has recently been shownto be spreading eastward from Japan.With conditions favorable to itsspread, this type could become a publichealth problem of the highest magnitudein North Carolina. With rapidmeans of transportation and the increasinginclination of people totravel, it becomes increasingly difficultto keep exotic diseases out of theUnited States.Dengue and FilariasisThese two mosquito-borne diseasesare of considerable importance in tropicaland sub-tropical regions, buttheir transmission in North Carolinahas not been recorded.Animal Diseases Transmittedby MosquitoesEquine encephalomyelitis, a diseasehighly fatal to horses, fowl pox, adisease common to poultry, and severalother animal diseases are transmittedby mosquitoes in North Carolina. Statisticsshow that from 30 to 90 percent of the horses infected by theformer disease died. Several outbreaksof this malady have occurred in NorthCarolina.Other Ways in Which MosquitoesAffect ManAside from their role as transmittersof diseases, mosquitoes have verydecided adverse effects on the wellbeingof mankind. The presence ofthese insects in abundance renders lifemiserable and causes drastic reductionsin property values. Mosquitoes influencethe mental as well as thephysical well-being of people. Someindividuals can tolerate large numbersof mosquito bites without obvious illeffects, while others manifest reactionsbased on varying degrees of tolerance.Some suffer extreme annoyance fromonly a few bites. With many people,in addition to swelling and itching,mosquito bites result in the formationof pustules, which persist for longperiods, bringing on nervousness, irritationand loss of sleep.LIFE CYCLE AND HABITSThe EggAll mosquitoes go through a completemetamorphosis. After mating, whichsometimes takes place while flying, the

May, 1955The Health Bulletinfertilized female must have a bloodmeal before her eggs will hatch. Theeggs are laid on water or in placeslikely to hold water. If not laid directlyupon the water, they will not hatchuntil the place is flooded. Eggs ofCulex mosquitoes float in rafts, whilethose of other species occur separately.Sometimes hatching takes place in oneday, but occasionally several weeksare required, the time being dependentupon several factors, such as thespecies of mosquito, temperature andpresence of water.The LarvaeThe larvae, commonly called "wiggletails,"which are hatched from theeggs, are so small at first that theycan hardly be seen without the aidof a magnifying glass. They feed onorganic matter and organisms in thewater and grow rapidly. Before developinginto pupae they molt fourtimes.Practically all species remain justbelow the water surface and get airthrough breathing tubes which penetratethe surface. Anopheles larvae lieunder and parallel to the water surface.When disturbed, they will usuallymove rapidly and appear to be glidingon top of the water. Mosquitoes of thisgenus have rudimentary breathingtubes. Most species of mosquitoes,other than those belonging to theAnopheles genus, hang head downwardfrom the water surface at anangle and appear to be suspended bytheir breathing tubes which penetratethe water surface. When disturbed,they usually dive with a wigglingaction.Larvae of the Mansonia perturbaneremain below the water surface at alltimes and obtain oxygen from vegetationto which they attach.The duration of the larval stage isusually only a few days but it sometimeslasts several months, the periodbeing determined by the species of mosquito,temperature and other factors.The PupaeWhile in the pupal stage, mosquitoesare encased in a shell and cannot eatbut retain their motility. They appearto be almost all head with a smalltail attached. They become very activewhen disturbed, darting around ormaking fast dives, returning withequal rapidity or slowly floating to thesurface. Sometimes they bob up anddown. This stage seldom lasts over afew days; then the adult mosquitoemerges from the pupal case.The developmental cycle of themosquito from egg to adult seldomtakes less than seven days and usuallyrequires around ten days, althoughunder unfavorable conditions, resultingfrom low temperatures or shortageof food, several months may be required.The Adult MosquitoThis is the only stage in the life ofmosquitoes that is not spent in water.After emerging from the pupal case,adult mosquitoes rest for severalminutes, in order that their soft, dampbodies may become dry and firm. Themales hover around the breedingplaces and usually mate with the femalessoon after they emerge. Withsome species this takes place beforethe female takes flight. Other species,including the Anopheles quadrimaculatus,our malaria mosquito, never mateexcept when flying. One mating makesthe female fertile for life.The male mosquito does not bite. Infact it has no mouth parts capable ofpiercing the skin. Food is obtainedfrom sap of trees, nectar from flowersand fruit juices. As these necessitiescan usually be found near the breedingplaces, males seldom fly great distances.The female mosquito must have ablood meal before her eggs will hatch.For this reason the distance she fliesis to a large extent influenced by theavailability of humans or animalsupon which she can feed. Flight distancesare also determined by thespecies of mosquito, weather conditionsand other factors.There are many species of non-bitingmidges that look like adult mosquitoe?

10 The Health Bulletin May, 1955and are frequently mistaken for them.These midges, like male mosquitoes,have antennae that are heavily plumedon each side of the mouth and do nothave biting mouth parts.In nature it is estimated that adultmosquitoes seldom live over 30 days.Under favorable conditions that canbe maintained in the laboratory, theycan be kept alive several months. It isalso true that females of some specieslive through the winter in the adultstage. Other species spend the winteras eggs or larvae.When feeding or resting, mosquitoesof the Anopheles genus usually holdtheir bodies on an angle of 45 degreesor greater with the surface. Otherspecies rest in a humped-up positionalmost parallel to the surface.IMPORTANT SPECIESOF MOSQUITOESIN NORTH CAROLINAAs there are over 50 known speciesof mosquitoes in North Carolina andabout 1500 in the world, it is notpossible in a writing of this kind todiscuss each species, nor is it practicalto present detailed information regardingany of them. It is suggested thatthose who desire more complete knowledgeconsult a textbook on MedicalEntomology, or one of the bulletinsprepared by the U. S. Government."Mosquitoes of the SoutheasternStates," Miscellaneous Publication No.336, a good bulletin on the subject, canbe obtained from the Superintendentof Documents, Government PrintingOffice, Washington, D. C, for 25 cents.Condensed information regardingsome species that are important inNorth Carolina is given belcw:Anopheles quardrimaculatus, themosquito that transmits malaria inNorth Carolina, is rather dark in colorand has four spots on each wing. Itbreeds principally in permanent bodiesof fresh water that contain aquaticvegetation and floating trash. Ponds,stagnant ditches and swamps in whichthe acidity of the water it not highare ideal breeding places. It seldomlays its eggs in artificial containers.The flight range of this mosquito isusually not over one mile. As thesemosquitoes seldom fly, except at night,and spend the daytime resting inhollow trees, stables, homes, or otherprotected places, there is no dangerof becoming infected with malaria byvisiting places where they occur inlarge numbers during the daytime.More information regarding thismosquito and the diseases it carriescan be found in "Your Pond—A PublicHealth Responsibility," SpecialBulletin No. 466 of the North CarolinaState Board of Health.Aedes aegypti, the mosquito thattransmits yellow fever, is small andalmost black in color, with a lightdesign in the shape of a lyre on itsback. It breeds in small water containers,such as discarded automobiletires, tin cans, bottles, flower vases,roof gutters and flush tanks in emptyhouses. Clean water is preferred, butthey will breed in water that is highlypolluted.These mosquitoes rarely fly morethan a few hundred yards from theirbreeding places. They seldom bite,except during the daytime, and aremost active early in the morning orlate in the afternoon. These are veryannoying pest mosquitoes that usuallybite around the ankles or wrists.Mosquitoes of this species are foundin abundance in North Carolina, but,fortunately, they must bite a personwith yellow fever before they cantransmit the disease.Culex quinquefaciatus, an averagesizemosquito, is grayish brown incolor, with white bands around theabdomen. Like the Aedes aegypti, itusually breeds and remains in thevicinity of human dwellings. In mosturban areas it is one of the mostabundant night-biting mosquitoes andis extremely annoying. This speciesbreeds in rain barrels, catch basins,the effluent from sewage treatmentplants, polluted ground pools andditches, street gutters, garbage dumpsand other places.This mosquito transmits encephalitisand filariasis.

May, 1955 The Health Bulletin 11Aedes sollicitans, our most troublesomespecies of salt marsh mosquitoes,are fairly large in size and goldenbrown in color, with white rings aroundtheir legs. Because of their abundance,long flight range and fierce bitinghabits, these mosquitoes often makelife miserable for residents and summervisitors in our coastal areas. Theywill fly as much as 40 miles andoccasionally greater distances fromtheir breeding places and attack withreadiness day or night, and they areso plentiful at times that is is hardto keep them brushed off the faceand other parts of the body.These mosquitoes breed in brackishwater. The eggs are usually laid onthe mud in pot holes and other depressionsin salt marshes that are notflooded by daily tides. These eggs maydry out entirely and still retain theirviability. After rains water collects inthese places and causes the eggs tohatch. Within a short time, usuallyless than a week, the mosquitoes aregrown. By this process large numbersof eggs that have collected over longperiods of time hatch almost simultaneously,and within a few days anenormous brood of mosquitoes emerges.During the daytime mosquitoes ofthis species usually rest in the grassand low brushes. When disturbed, theyattack viciously. Just before dark theyfly off in large swarms looking forblood meals.Aedes taeniorhynchus, another annoyingsalt marsh mosquito thatoccurs on the North Carolina coast,is medium in size, nearly black, withwhite bands around its abdomen andlegs. It is less inclined to bite duringthe daylight than the Aedes sollicitans.Unlike the Aedes sollicitans, these mosquitoeswill breed in water varying insalt content from sea water to thatwhich is completely fresh. Mosquitoesof this species will fly several miles.MOSQUITO CONTROLFrom the foregoing it will be seenthat it is necessary to give considerationto the breeding, flying and feedinghabits of the mosquito species involvedbefore planning an effectiveand efficient control program. As threeof the four stages in the life of amosquito are spent entirely in water,it is in general advisable to applycontrol operations to the breedingplaces. To be completely successful, itis often necessary to employ measuresdirected at them in all stages fromegg to adult.Responsibility for the control ofmosquitoes is shared by both individualsand public officials. The propertyowner can help prevent mosquitobreeding in the immediate vicinity byapplying simple control measures, butthere is very little that he can dotoward control of many far-flying,fierce-biting mosquitoes. These areproblems for the community as awhole.What The Home Owner Can DoShown below are some of the thingsyou can do on your own premises toprevent the breeding of mosquitoesand to protect yourself against thosethat fly in from the outside:1. Drain all standing water, if it ispossible to do so.2. Fill depressions in the ground thathold water.3. Apply kerosene or No. 2 fuel oilto collections of ground waterthat cannot be eliminated bydrainage, such as stagnant ditches,clay pits, ponded areas, privy pitsand hog wallows.4. Build and maintain farm pondsin accordance with the directionsin Your Pond — A Public HealthResponsibility, Special Bulletin No.466. This bulletin can be obtainedfree of charge from your localhealth department.5. Eliminate unnecessary receptaclesthat hold rain water, such as tincans, old rubber tires, discardedwater buckets, fruit jars andbottles.6. Keep roof gutters free of trash,such as tree leaves, and maintainthem in such a manner that theydo not sag and hold water.

12 The Health Bulletin May, 19557. Drain watering troughs, bird baths,flower vases and other unprotectedwater containers once a week.Allow them to dry thoroughly beforerefilling.8. Keep 16-mesh wire screens overbarrels and other containers usedto save rain water.9. Mosquito-proof the home by puttingsnug-fitting screens of 16-mesh wire over the outer openingsof all doors, windows and exhaustfans. Sub-standard homes withholes in the floors, roofs or outsidewalls require additional mosquitoproofingby patching over suchplaces. Porches and chimneys withopen fireplaces should also bescreened in areas where mosquitoesare abundant.10. Apply residual sprays of DDT orother approved chemicals to outbuildings,porches and screens. Inhomes that are not mosquitoproofedthe interiors should alsobe treated.11. Use space sprays both inside andoutside the home where othermeasures are not effective.Material used for both residualspraying and space spraying shouldbe purchased from a reliablesource. It is important to readthe label carefully and follow thedirections exactly. Do not use thematerial for any purpose otherthan those recommended and besure to heed all safety precautionsgiven. Insecticides are poison. Keepthem stored in places where theycannot be reached by children orirresponsible persons.12. Repellants, such as commercialpreparations that contain oil ofcitronella, dimethyl phtalate, indalone,or Rutgers 612, are effectivefor several hours as protectionagainst mosquitoes and someother insects. They should beapplied according to directions onCare should be taken tothe label.avoid getting these materials inthe eyes.13. Make periodic inspections of thepremises to ascertain that thescreens are in good repair andthat no places exist that breedmosquitoes.What Communities Should DoThe control of most species of mosquitoesis a community problem, as itis not practical for individuals to providethe necessary personnel andequipment. Many species have suchlong flight ranges that it would beimpossible for a person to determinewhen to apply control in order to doaway with them, even if he had thenecessary facilities. Shown below aresome of the measures that should beapplied by the town, sanitary districtor other community organization:1. Draining and filling. Eliminatemosquito-breeding areas by drainage orfilling. As far as is feasible, the entiredrainage system should be planned,constructed and maintained in sucha manner as to prevent the collectionof standing water.Canals and ditches should be cut totrue, even grades, with the bottomsnarrow enough to be covered withwater during periods of normal flow.Slope the sides enough to prevent theircaving. Have the alignment straight,when it is possible to do so, and, whenchanges in direction are necessary,avoid sharp angles by putting incurves as flat as the ground and othertopographical features will permit. Installdrainage structures under roadsand streets on grades that conformwith those in the ditches. When sufficientfunds are available, place concretelinings in the bottoms of ditchesor put the system underground inpipes and culverts.Install sewers, water mains or otherpotential obstructions that cross thechannels at elevations that will notinterfere with the flow.Keep ditches and streams as freeas possible of drift, floatage and otherdebris.Cut vegetation that interferes withlarvicidal operations or obstructs theflow as often as the rate of growthrequires. Other vegetation should bepermitted to remain, as the shade

May, 1955 The Health Bulletin 13provided inhibits the growth of weedsand grass.Planning and construction of thedrainage system should be performedunder the supervision of an engineer.2. Larviciding. To destroy mosquitolarvae and pupae in their breedingplaces, petroleum derivatives, such asNo. 2 fuel oil, and DDT or otherchemicals are applied to the watersurface. Approximately 20 gallons ofNo. 2 fuel oil is required per acre ofwater surface when this material isused alone, but when 100% technicalDDT is dissolved in the oil, at therate of 6 pounds of DDT to 100 gallonsof oil, one to two gallons is enoughfor an acre. In either case, the larvicideshould be applied at ten-day intervals.In land-locked fresh water pondswhere fish are not present, or whenno consideration is given their mortality,effective control can be obtainedfor from three to six months by applyingDDT at the rate of three poundsper acre, or Dieldrin at the rate ofone pound per acre. This method isdestructive of fish and other forms ofaquatic life and should not be usedexcept in unusual circumstances.Your local health department shouldbe requested to assist in the selectionof larvicides and the equipment fortheir dispersal.3. Outdoor Space Spraying. Temporaryrelief from mosquitoes can beobtained by the application of spacesprays in the form of fogs or mists.This method of mosquito control merelykills or drives off the insects presentat the time it is applied but gives nosignificant lasting effect. With thebest space spray machines, using effectiveinsecticides and operated in thecorrect manner, kills are seldom obtainedat distances greater than 200feet. The fog which travels muchgreater distances does not kill mosquitoesbut is of some value in drivingthem out of the area. Several machinesdesigned for the disposal of insecticides,as mists or fogs, are commerciallyavailable.DDT and other insecticides are usedin space spraying. The local health departmentshould be asked to assist inselecting the insecticide and in determiningthe formulation to use.Caution: All insecticides are poisonousand should be so regarded at alltimes. The State law requires thatthose sold commercially be registeredwith the North Carolina Departmentof Agriculture. No insecticides shouldbe used other than those that areproperly registered and labeled withadequate directions concerning theiruse and precautions for safety.NOTES AND COMMENTSBY THE EDITOROUR FRONT COVER — Charles M.Cameron, III, is the son of Dr. andMrs. Charles M. Cameron of Raleigh,North Carolina. Dr. Cameron is Chiefof the Communicable Disease Sectionof the Division of Epidemiology, NorthCarolina State Board of Health, andis also Chief of our Accident PreventionSection.INFANT AND MATERNAL MORTAL-ITY—The May issue of The HealthBulletin traditionally publishes statisticaldata concerning births, infantdeaths and maternal deaths for theStates of the Nation and for thecounties of the State. On page 15 youwill find information for each of theStates of the Nation for the year,1952. On Page 16 are provisionalfigures for each county in the State,for the year, 1954.For infant deaths, the year, 1952,was a bad year for North Carolina.Not only did our infant mortality increase,while the rate for the Nationremained stationary, but several Stateswhich formerly had higher rates thanNorth Carolina made such substantial

14 The Health Bulletin May, 1955improvement that our relative positionamong the states, is even more embarrassingthan it has been in previousyears. In 1952—only five States in theNation had higher rates than NorthCarolina; in 1949—9 other states wereworse than North Carolina; in 195012 others; and in 1951—13 states hadhigher infant mortality rates thanNorth Carolina. In 1952 only Alabama,Arizona, Mississippi, New Mexico andSouth Carolina had more infant deathsin proportion to the number of birthsthan did our own State. Even NewMexico, which has had the highestrate in the Nation for years, andstill does, reduced their rate from 54.4in 1951 to 47.5 in 1952. North Carolina'sInfant Mortality rate of 32.7 in1952 is so painful to all public healthworkers that we are anxious to changeour viewpoint to 1954 when we didmuch better. Whether or not ourrank in the Nation will be improvedonly time can tell for National figuresalways trail our current provisionalrates by two years.Maternal Mortality rates, which arecomputed on the basis of 10,000 livebirths, show North Carolina in justabout as bad a light for 1952 as ourInfant Mortality rates. North Carolinawith a rate of 10.2 had only 6 otherstates with a worse record: Alabama,Georgia, Mississippi, New Mexico,South Carolina, and Tennessee. Herewe actually improved our MaternalMortality rate over the year 1951, yetwe actually lost ground on a comparativebasis for while our rate was exceededonly by 6 in 1952—in 1951 therewere 7 with higher rates than ourown.The Birth rate of the Nation in1952 was 24.7. North Carolina's ratewas 26.7. Fourteen states had a higherbirth rate than North Carolina.North Carolina's record looks muchbetter in 1954 according to our provisionaldata. Our Infant Mortalityrate is 30.0. Although our officialfigures vary slightly from the provisionalones, our official rate will notvary materially. Only one County,Columbus, had a rate higher than 50.Fourteen counties had higher ratesthan 40, 30 higher than 35. The mostencouraging fact in our 1954 InfantMortality is the fact that many ofour counties with traditionally highrates have shown marked improvement.We are particularly proud ofthe progress which has been made inOnslow County, which in 1952 andagain in 1953 had rates in excess of70, but which in 1954 came up witha rate of 27.1;—thus a county whichhas had the highest rate in the Statenow has a rate less than the averagefor the State. Other counties makingdefinite progress are Craven, Edgecombe,Granville, Halifax, Jackson,Northampton, and Pender. Certainlywe have demonstrated that we cando something about our Infant Mortalityproblem when we devote intelligenteffort in determining its causesand make a conscientious effort toreduce its prevalence. We have manycounties in North Carolina with rateslower than that of the Nation.Our Maternal Mortality rate in 1954also showed marked improvement,being 7.6 per 10,000 live births in 1954as compared with 10.2 in 1952. Althoughour 1954 rate is greater thanthe Nation's in 1952, 6.8, our comparativeposition with other statesshould not be too bad.We are making progress in NorthCarolina both in the protection of ourmothers and children born to them.This progress is Nation-wide. Unlesswe accelerate our progress, we willhave a tough struggle to improve ourrelative position among the states.We invite our readers to look overthese statistical tables. It will beparticularly helpful if you will studythe records for your own county. Ifthey are good, compliment your HealthOfficer. If your infant and Maternalmortality rates are consistently badand are showing little, if any, signsof improvement, consult your HealthOfficer. Maybe he has an explanation.If he doesn't maybe your interest willstimulate him.

May, 1955 The Health Bulletin 15REGISTERED LIVE BIRTHS, INFANT DEATHS, ANDMATERNAL DEATHS WITH RATES:UNITED STATES AND EACH STATE, 1952iBy place of residence. Births based on a 50 per cent sample. Infant mortalityrates per 1,000 live births. Maternal mortality rates per 10,000 live births)LiveBirthsIntant Deaths- 1Maternal Deaths 2AreaNumberRateNumberRateNumber.nitedStatesAlabamaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of Columbia.FloridaGeorgiaIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew Hampshire..New JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhodeIsland3,846,986 24.7 109,413 2S.4 ,611)83,140South Carolina ...South DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

16 The Health Bulletin May, 1955RESIDENT LIVE BIRTHS, INFANT DEATHS, ANDMATERNAL DEATHS WITH RATES*:NORTH CAROLINA AND EACH COUNTY, 1954**LiveInfantMaternalAreaBirthsNo.DeathsNo. RateDeathsNo. RateNorth CarolinaAlamanceAlexanderAlleghanyAnsonAsheAveryBeaufortBertieBladenBrunswickBuncombeBurkeCabarrus ..CaldwellCamdenCarteretCaswellCatawbaChathamCherokeeChowan.ClayClevelandColumbusCraven.-CumberlandCurrituckDareDavidsonDavieDuplinDurhamEdgecombeForsythFranklinGastonGatesGrahamGranvilleGreeneGuilfordHalifaxHarnettHaywoodHendersonHertfordHokeHydeIredellJackson113,8-40 | 3,411 |1,8723541347084863089707928615342,6739741,5081,2811537035111,7626173683711971,7331,4912,1275,0631631261,6013671,1752,4681,7144,0998323,0752311728185335,1741,8471.2418457086284611541,4303413730.087 7.6|

MEDICALLIBRARYU . OF N. C .CM APE L HILL, N. C .MroMffliPubliclyTAMAQMA SMflgMMflThis Bulletin will be sent free to cmij cifizen of the State upon request IPublished monthly at the office of the Secretary of the Board, Raleigh, N. C.Entered as second-class matter at Postoffice at Raleigh, N. C. under Act of August 24. 1912Vol. 70 JUNE, 1955 No. 6HEALTH OFFICERREPORTS

MEMBERS OF THE NORTH CAROLINA STATE BOARD OF HEALTHG. G. Dixon, M.D., President AydenHubert B. Haywood, M.D., Vice-PresidentRaleighJohn R. Bender, M.DWinston-SalemBen J. Lawrence, M.DRaleighA. C. Current, D.D.S GastoniaH. C. Lutz, Ph.G HickoryGeo. Curtis Crump, M.D 1 •_ AshevilleMrs. J. E. Latta • Hillsboro, Rt. 1John P. Henderson, Jr., M.D Sneads FerryEXECUTIVE STAFFJ. W. R. Norton, M.D., M.P.H., State Health OfficerJohn H. Hamilton, M.D., Assistant State Health Officer and DirectorState Laboratory of HygieneC. C. Applewhite, M.D., Director Local Health DivisionErnest A. Branch, D.D.S., Director of Oral Hygiene DivisionA. H. Elliot, M.D., Director Personal Health DivisionJ. M. Jarrett, B.S., Director Sanitary Engineering DivisionFred T. Foard, M.D., Director Epidemiology DivisionFREE HEALTH LITERATUREThe State Board of Health publishes monthly The Health Bulletin, which willbe sent free to any citizen requesting it. The Board also has available fordistribution without charge special literature on the following subjects. Askfor any in which you may be interested.DiphtheriaFliesHookworm DiseaseInfantile ParalysisInfluenzaMalariaMeaslesScarlet FeverTeethTyphoid FeverTyphus FeverVenereal DiseasesResidential SewageDisposal PlantsSanitary PriviesWater SuppliesWhooping CoughSPECIAL LITERATURE ON MATERNITY AND INFANCYThe following special literature on the subjects listed below will be sent free toany citizen of the State on request to the State Board of Health, Raleigh, N. C.Prenatal CarePrenatal Letters (series of ninemonthly letters)The Expectant MotherInfant CareThe Prevention of Infantile DiarrheaBreast FeedingTable of Heights and WeightsBaby's Daily ScheduleFirst Four MonthsInstructions for North CarolinaFive and Six MonthsSeven and Eight MonthsNine Months to One YearOne to Two YearsTwo to Six YearsMidwivesYour Child From One to SixYour Child From Six to TwelveGuiding the AdolescentCONTENTSPageChronic Diseases—A Joint Responsibility of Private Practiceand Public Health 3Departmental Reports 5

IPUBLI5MED BYTAE N»RTA CAROLINA STATE B°ARD*AEALTAIVol. 70 JUNE, 1955 No. 6J. W. R. NORTON, M.D., M.P.H., State Health Officer JOHN H. HAMILTON, M.D., EditorCHRONIC DISEASES—A JOINT RESPONSIBILITYOF PRIVATE PRACTICE AND PUBLIC HEALTH*By J. W. R. NORTON, M.D., M.P.H., F.A.C.P.**RaleighIn the long span of recorded timeon this planet fifty years is as thetwinkling of an eye, but medical progressduring this period has exceededthat of many prior centuries. For thetwenty-eighth year after the establishmentof the North Carolina StateBoard of Health, Dr. Cooper in hischronological summary for 1905 hadthis to say for a year just before thebeginning of intensified joint effortsagainst communicable diseases:"General Assembly established StateLaboratory of Hygiene; imposed watertax of $64 on all public water companies;voted $600 annually for thesupport of laboratory. Small appropriationmade it necessary for the Departmentof Agriculture to continue toassist State Board of Health. Annualappropriation, $2,000."Even the barest outline or summarythis year of public health servicesprovided by the State and the sixtyninelocal health departments servingall 100 counties would require manypages. Concurrently with the wellkncwnvast and rapid changes in theprivate practice of curative medicinehas come similarly impressive progressin preventive medicine and publichealth. Through the years a few physicianshave voiced fears that theywould have no work if preventive measureswere applied to all ills and injuriespractically preventable. Weheard such comments from a few withregard to vaccinations against smallpox,typhoid, diphtheria, whoopingcough and tetanus, against the plannedparenthood program, against the schoolhealth program, against the venerealdisease and tuberculosis control program.We hear less of these shortsightedobjections today, but there area few who would limit public healthservices to the indigent and againstonly the communicable diseases.With improved educational methodsand more widespread use of preventivemeasures, prompt diagnosis and greatlyenchanced effectiveness of treatmentprocedures, the communicablediseases have come under relativelyeffective control with the exception oftuberculosis. Recent examples are theSalk vaccine against poliomyelitis andcertain antibiotics against rheumaticfever. The former Captain of the Menof Death, tuberculosis, has droppeduntil now it is not even among the firstten killers except in limited age groups.In 1954 diseases of the heart and•Read before the Conjoint Session of theMedical Society of North Carolina andthe State Board of Health, Pinehurst,May 4, 1955.••Secretary-treasurer of the State Boardof Health and State Health Officer.

The Health Bulletin June, 1955blood vessels, cancer, accidents, nephritisand diabetes accounted for 22,623deaths out of a total of 32,072 in NorthCarolina. Mental disorders accountedfor half the persons hospitalized. Arthritiscaused an enormous amount ofdisability and hospitalization. Impropernutrition caused decreased vitality andlowered efficiency in many. All these,except accidents, are in the noncommunicablefield or area of chronicdisorders. Most medical leaders agreethat much progress could be madeagainst them by health education,early diagnosis and prompt medicaltreatment and supervision.We are now at about the stage ofmedical knowledge regarding thesechronic non-communicable disorders inwhich our predecessors found themselveswhen joint efforts of privatepractice and public health began tobe coordinated against the communicablediseases. The opportunity is affordedus to proceed humanely andcooperatively as was done so successfullyagainst the infectious diseases.When the Medical Society of NorthCarolina stimulated the establishmentof the State Board of Health and localhealth departments, medical leadersconsidered the situation with regardto communicable diseases to be intolerable.Our successful joint effortshave prolonged the life span and helpedto create the present intolerablesituation with regard to the chronicnon-communicable disorders, and ourmechanical progress has contributed,at least in part, to our deplorableaccident situation. Even such problemsas rehabilitation and stream andatmospheric pollution should be ofactive concern to physicians in privatepractice and in public health. In oneweek in December, 1952, the Londonsmog accounted for more excess mortality,even in proportion to the population,than occured during any weekof the great cholera epidemic of 1866.Our State is fortunate in that wehave an alert medical profession wellrepresented on the State and localboards of health. We are one of thefew states with full coverage by soundlocal health departments. We havemade a beginning in cardiovasculardisease diagnostic work. We have agood start in finding cancer in theearly stages when, in many cases,something can be done to control itprovided the diagnostic efforts are notdiverted too obviously into estimatingthe size of the pocketbook before proceedingwith a medical diagnosis. HarnettCounty has an excellent programof diabetes case-finding and supervision,and physicians throughout theState have cooperated in the annualweek of diabetes case-finding. CumberlandCounty has started an obesitycontrol service. Halifax, Harnett andsome of the other counties have hadlimited experience in multiple screeningtechnics. The mental health serviceshave expanded recently along linessimilar to the tuberculosis control workfor early case-finding, guidance andthen post-hospitalization follow-up toprevent a breakdown. The nutritionservice has been strengthened. A recentgrant by the Kellogg Foundation hasenabled the beginning of an intensiveprogram in control of home and farmaccidents. A cooperative program withthe Motor Vehicle Bureau has beenstimulated by Cornell University consultantsin a study of motor vehicledesign as it may contribute to, or tendto prevent, serious crash injuries. Someprogress in the treatment of arthritis,arteriosclerosis and bursitis has beenmade, and there is increasing hope ofimprovement in our knowledge regardingtheir prevention.The Rural Health and Public RelationsCommittees have contributed ina fundamental way in laying thegroundwork for a better understandingof, and a willingness and desire toproceed against, chronic disorders, andaccidents—just as was the case inearlier improved control of communicablediseases. The work of the privatepractitioner will be just as ethicaland much more satisfying as all chronicdisorders are promptly diagnosedand control efforts are increased ineffectiveness. Our State is in a strategicposition to lead the way in combating

June, 1955The Health Bulletinchronic disorders and accidents justas private practitioners and the publichealth team joined hands to pioneerin communicable disease control.DEPARTMENTAL REPORTSNorth Carolina State Board of HealthJanuary 1, 1954-December 31, 1954CENTRAL ADMINISTRATION—J. W.R. Norton, M. D., State Health OfficerThe affairs of Central Administrationare conducted under the directsupervision of the Secretary and StateHealth Officer, who serves as Directorof this Division. Working directly underhis supervision are: The PublicityOfficer, Central Files, Personnel, MailingRoom, Multilith Service, and Budgets.The State Health Officer servesin a liaison capacity between the StateHealth Department and all organizationsassociated with or related topublic health, on the national, Stateand local areas. He is president of theAssociation of State and TerritorialHealth Officers, American College ofPreventive Medicine and SouthernBranch of the American Public HealthAssociation and is associated withvarious other organizations in thegeneral group heretofore referred to.During the past year, the StateHealth Officer has engaged in manyactivities involving public relations, aswell as executive duties.Since the 1954 conjoint session theState Health Department has movedinto its new building, on CaswellSquare, in Raleigh, which was erectedat a cost of more than $900,000. Theefficiency and morals of the staff havebeen definitely increased by workingin more convenient and comfortablequarters.During the past year the publicityofficer has transcribed 52 weekly radioprograms, for delivery over stationWPTF, in Raleigh, and WWNC, inAsheville. Also, under the direction ofthe State Health Officer, he has preparednews releases and other materialdesigned to keep the public informedas to the available services, duties, andactivities of the State Health Department.He assisted in publicizing andwent on a Caribbean cruise conductedby the North Carolina Academy ofGeneral Practice, in October, 1954.The Central Files Section operationscontinued to expand with the increasingprogram activities. In this officerests the responsibility for recording,protecting, and filing all official recordsand their finding when needed.It controls the systematic retirementof records to storage and the disposalof those no longer useful. During 1954,210,008 records were received for filingand 34,590 searches for material andinformation were made. In cooperationwith the Department of Archives andHistory, a complete survey and inventoryof all the records was made. Themajority of the recommendations madehave been carried out. Prior to June1, 1954, when the new Medical Librarybegan operating, 19 new medical andPublic Health books were received and20 journals bound for permanent conveniencefor reference.During the year, the mailing roomdistributed 1,226,956 pieces of literature.The number of envelopes addressed forradio scripts was 16,792, while thenumber of copies of the Health Bulletinmailed out was 720,000. The mailingroom also sent out quantities ofmaterial for the various divisions andsections making up the State Boaidof Health.Pamphlets on prenatal care weremailed to 12,517 persons, while prospectivemothers received 19,501 leaflets.Prenatal Clinic cards mailed outnumbered 10,399 and baby feedingcards, 40,861. During the year, morethan 23,000 copies of booklets pertainingto children from one to twelve

6 The Health Bulletin June, 1955years of age and 4,607 on adolescencewere mailed.Reports for last year show that 3,-466,480 copies of various leaflets andother material were printed on theState Board of Health's multilith machine.The total number of copies passingthrough the cutting machine was1,039,175.Below is a condensed statement ofthe activities of the Personnel Section,which operates within the frameworkof Central Administration. This Sectionduring last year cooperated withthe State Merit System, the PersonnelDepartment, the Budget Office, theInstitute of Government, and otheragencies having to do with any phaseof personnel activities.In order to keep classification planscurrent and responsive to changingprograms, five new and forty-one revisedclass specifications were preparedand approved with eleven specificationsbeing deleted for both State andlocal health departments. Only sevenState salary ranges were revised, whereasfifty- three local salary ranges wererevised, the majority of the latterbeing only one or two steps upward.A simplified procedure was worked outwith the Merit System office and theState Personnel Department for establishingnew classes of positions and forrevising existing class specificationsand salary ranges. Considerable timewas spent in cooperation with theInstitute of Government in connectionwith a study of both State and localpersonnel procedures for the Commissionon Reorganization of StateGovernment, the ensuing commissionReport and proposed legislation. Vacationleave was made transferable fromone local health department to anotherif the department to w.iieb the transferis being made is willing to acceptthe leave. A new Personnel Manual preparedby the Personnel Section wasdistributed to key State personnel tofacilitate understanding of State regulations.Within the State Board of Healththere were 87 appointments, 99 separations,27 reclassifications, the majorityof which included salary increases, 201salary increments, 5 other salary increases,and 39 employees certified aspermanent. As of December 31, 1954,there were 328 employees of the StateBoard of Health and 30 vacant positions.This represents an increase of5 employees for the calendar year.In local health departments therewere 261 appointments, 267 separations,68 reclassifications, 878 salary increasesand 144 employees certified as permanent.As of December 31, 1954, therewere 1,104 employees in local healthdepartments and 40 vacant positions.This represents an increase of 17 employeesfor the calendar year.The following is a comprehensivestatement of amounts budgeted for thefiscal years of 1952-53, and 1953-54,in order to emphasize mainly thesharp drop in Federal funds.1952-53 1953-54State $2,322,048 (includes misc. receipts $2,378,845Federal 2,233,484 1,878,681Special Accounts: 120,985 201,658Local 3,643,581 (From Public Health Ser. budgets) ._ 3,902,708Totals$8,320,098 8,361,892State vouchers 17,323 16,422Special Accounts include:BeddingBeddingDentalDentalKellogg ^ KelloggReynoldsTWA-CountyIndian Service - County Indian Service - County

June, 1955The Health BulletinLibrary SectionThe Medical and Public HealthLibrary, made possible by a grantfrom the Zachery Smith ReynoldsFoundation, Inc., was opened on June1, 1954. It is situated in a large roomdesigned for that purpose when planswere drawn for the State Laboratoryof Hygiene.At the time of its opening, theLibrary consisted of about 4,000 volumes,including the private library ofDr. Charles O'H. Laughinghouse, whichNorth Carolina's late State HealthOfficer generously gave to the StateBoard of Health. Other friends of publichealth and members of the medicalprofession have made other contributions,and additional volumes are beingpurchased. The Library is growing ata satisfactory rate.It is also receiving a number ofmedical, nursing, engineering and publichealth journals. Bound volumes ofearlier issues are available for consultationin the Library itself or forleisurely study elsewhere.The Library's material is availableto all the doctors of the State. Witha few exceptions, any of this materialmay be obtained on loan for periodsup to two weeks, with the privilege ofrenewal. The librarian is eager to beof whatever service he can to themedical men and women of NorthCarolina. He will be glad to assistdoctors in locating source material insubjects in which they may be interested.LOCAL HEALTH DIVISION—C. C.Applewhite, M. D., DirectorLocal interest in and support ofpublic health in North Carolina hascontinued throughout the past year.Local appropriations for the fiscalyear 1954-1955 have increased by$322,461 over the previous year. Thisprovided the sole expansion of publichealth in the State. This fact alone isevidence that the people of the Statewant a good public health program.Also very encouraging is the factthat during the year, seventeen morehealth departments occupied newquarters. This brings to forty-two thenumber of health centers completed.Others are under construction, andstill others have been planned.The health officer turnover has continued.There are six health officervacancies created by resignation,death and transfer to other departments.Five of these have been filled,and in addition, health officers havebeen placed in four other counties.There are several other vacancies asyet unfilled.Lack of funds for training has continuedto hamper the over-all program.It is feared that unless money ismade available for this purpose theentire State will suffer, because welltrainedpublic health people are themainstay of a good public health program.Dr. Robert E. Coker, Jr., who resignedin February, was replaced byDr. B. M. Drake in June as AssistantDirector. Dr. John A. Googins, commissionedofficer of the Public HealthService, was assigned to the Divisionfor a year's experience as of July 1and has made a valuable contributionto the program.In order to better coordinate theefforts of the field consultants of thevarious divisions, plans were made forconferences of these consultants togetherwith division and section heads.This is but one example of the excellentspirit of teamwork that the LocalHealth Division has experiencedthroughout the year.Administrative SectionAs of December 31, 1954, there were1,144 full-time budgeted positions inlocal health departments with a totalof forty vacancies. Although federalfunds for local health services continuedto decrease while state fundsremained the same, the increased localappropriation was a little more thansufficient to offset the federal decrease,and thus nine of the twentythreepositions originally lost in 1953through federal cuts were restored. Itis noted that of the forty vacanciesnine were in the positions of full-timehealth officers, thirteen in public

8 The Health Bulletin June, 1955health nursing personnel and two inthe field of sanitation.The one hundred counties are dividedinto sixty-nine full-time local healthdepartments, forty-four county units,twenty-three district units and twocity units. The allocation of State andfederal funds to the local health departments,the processing of localhealth department budgets, the mailingof budget instructions to localhealth officers, the preparation ofregular reports, such as the NorthCarolina Local Health Service Budget,and compiling pertinent informationrequested by the local health departmentscontinue, for the most part, tobe the major activities of the AdministrativeSection.Within its available funds, the StateBoard of Health has for several yearssponsored, on a restricted basis, trainingprograms, but limited funds havemade it impossible to coordinate andexpand such activities to include theessential and needed personnel forour public health program. Particularlyduring 1954 all types of training havebeen greatly retarded because of drasticreduction of training funds. Therecords of the State Board of Healthfor 1954 disclose that a total of 297public health workers were given sometype of training. Of this number thirtyonewere physicians, 227 were nurses,one was a health educator, ten weresanitarians, one was a laboratory technician,fifteen were mental healthworkers, and twelve were clerks. In theabove-mentioned categories trainingranging from two days to twelve weekswas received, with the exception ofthree physicians, one health educator,and three nurses, who were awardedscholarships to attend the Universityof North Carolina.The in-service training programsconsisted of a post-graduate course incardiovascular diseases for physicians;for nurses, in addition to necessaryorientation, special fields in publichealth (cancer, heart, geriatics, tuberculosis,and mental health), pediatricnursing institutes, rheumatic feverseminar, institute on problems oftuberculosis control, two-day institutesin local health departments on prematureinfant care, extension coursesat the University of North Carolina,courses in premature infant care atDuke Hospital, venereal disease institutesand twelve-week field trainingcourses for newly employed sanitarians.A legitimate function of the Recordsand Procedures Analysts is to stimulateinterest in better records in the localhealth departments, which function includesproper recording and analysis ofhealth data.This responsibility has been carriedon routinely over a period of years,but, since there has always seemed toexist a congenitally acquired dislikefor records and reports, the programin this line has been slow. However, itis encouraging to note that such animprovement in this has been madethat it is considered worthy of commentin this annual report.In practically every health departmentthere is evidence of more interestin this phase of work. For instance,the annual report is being used moreand more for program evaluation.Rather than serving only as evidenceof work accomplished, it is being usedto determine the needs of a communityand whether or not they are being met.Another evidence that efficientrecords are being emphasized more isshown by the interest the health officerand other staff members have in sendingthe clerical personnel to the PublicHealth Records Short Course. In 1954eleven girls attended, bringing thetotal who have attended the fivecourses to seventy-seven. Of this number,sixteen have resigned from publichealth, but it is believed that thesecourses continue to be outstanding.The Film Library experienced a greatyear in 1954. All previous records infilm requests and film distributionwere broken. The only activity whichfailed to show a gain during this yearwas new film purchases. The libraryfell far short of the previous record of$10,261.05 down to $3,295.60 spent fornew and replacement prints of films.This loss was reflected in the fact that

June, 1955The Health Bulletinthe library was forced to turn downseveral hundred requests due to a lackof prints. The library was able tofilms compared topurchase only forty163 for the year 1953.More than 100 films were either replacedentirely or footage replacementwas purchased and spliced in to prolongthe life and make these filmsusable again.During the calendar year the libraryreceived more than 5,506 individual requestsfor this film service. The librarydistributed more than 12,750 films in8,416 individual shipments. These filmswere distributed to borrowers on thefollowing basis of total distribution:During the school term:1. Local health departments 26.8%2. Public schools 40.5%3. State institutions 9.2%4. Colleges (other than State) ___ 6.2%5. Hospitals (other than State) __ 7.2%6. State hospitals 2.3%7. Other (includes individuals,civic clubs, churches, homedemonstrations agents, etc.).. 7.8%During the summer:1. Local health departments 25.4%2. State institutions 27.2%3. Colleges (other than State) ___12.9%4. Hospitals (other than State) __11.5%5. State hospitals 3.8%6. Other (includes individuals,civic clubs, churches, homedemonstration agents, etc.) —19.0%The library also distributes thevenereal disease drugs furnished tothe local health departments and thefollowing amounts were distributedduring 1954.12,058 vials or 36,174,000,000 units ofpenicillin1,114 vials or 3,342,000,000 units ofbicillin473 vials or 1,419,000,000 units ofcrystacillin50 vials or 250 grams of streptomycine103 bottles or 410,000 mg. of aureomyecine522 - 100 tablet bottles or 26,100 gramsof sulfadiazine25 boxes V.D.R.L. antigen12 tubes Cortone acetate5 - 100 tablet bottles pyribenzamine6 - 1000 tablet bottles A.P.C. tablets15 boxes Frei test antigen32 boxes Ducrey vaccineIn distributing the above materials,the library used a total of $894.51 inpostage for fourth class mail only.The Film Library moved to the newState Board of Health Building, wherenew storage facilities were providedfor more efficient operation.Public Health Nursing SectionThe Section personnel consists of achief, an educational consultant whowas loaned by the U. S. Public HealthService in November for a nine-monthsperiod, and five generalized consultantswith specialities in tuberculosis, mentalhealth, industrial health and plannedparenthood. A sixth consultant, witha speciality in venereal disease, onloan by the U. S. Public Health Service,was transferred out of the State inDecember, and the district she servedwas left without a consultant. In addition,there are four specialized consultantsassigned to other sections.The Section continues to give guidance,supervision, and consultation tolocal public health nurses, to recruitpersonnel, to provide opportunities forpreparation in public health nursing,to coordinate the many activities ofother agencies contributing to publichealth nursing; and to provide in-serviceeducation for local public healthnurses. The following indicates theneed for this service: in local healthdepartments sixty-eight per cent of thestaff nurses are not prepared in publichealth nursing; sixty-nine of the countiesdo not have local supervisors;thirty-five of the counties have nopublic health nurse who has completedthe program of study in public healthnursing.To meet the needs indicated above,a committee of the Section has beengiven responsibility for in-service,activities. The opportunities offered tolocal public health nurses includedtuberculosis, venereal disease, some ofthe chronic diseases, maternal and

10 The Health Bulletin June, 1955child health, including growth anddevelopment and midwife supervision;mental health, including an orientationat the State Hospital at Raleigh; andprogram analysis and planning. Extensioncourses were planned and offeredat the University of North Carolinaand Greenville in basic public healthnursing.Well prepared public health nursesare needed. In our State two schoolsprepare graduate nurses for publichealth nursing, and three collegiateprograms are under way to preparebasic nursing students in public healthnursing. To provide field experiencefor these has required considerablelong-range planning. The Section initiatedplans to work through the manyproblems relating to field training.Public Health Education SectionThe only staff change in the HealthEducation Section was the filling ofone of the positions of health educationsupervisor, effective November 1.This brought to three the professionalstaff of the section, with one of thisnumber attached to the School HealthCoordinating Service. A health educatorjoined the staff of the Accident PreventionSection in February.Consultation service on health educationwas given to the nineteen publichealth educators working in fourteenlocal health departments and schoolsystems. Twenty-five local health departmentswere assisted with a varietyof health education activities. Assistancewas given other sections of theState Board of Health in materialspreparation, community organizationfor mass x-ray surveys, family lifeeducation, joint planning, and in-servicetraining. Personnel of the Sectionworked with other division staff membersin a team approach to localhealth departments requesting evaluationof their total public health programs.This Section coordinated the preparationof six exhibits for the NorthCarolina State Fair in October andcooperated with the TuberculosisCentral Section and the North CarolineTuberculosis Association in thepreparation of an elaborate exhibit ontuberculosis shown at the NationalTuberculosis Association meeting andthe North Carolina Public Health Associationmeeting and scheduled forother showings.Personnel of the section were activein the work of the following organizations:State School Health AdvisoryCommittee, Arrangements Committeeof North Carolina Public Health Association,State Advisory Committee onTraining, Western District of the NorthCarolina Public Health Association,Rural Health Committee of the StateMedical Society, North Carolina HealthCouncil, and North Carolina Associationof Health Educators.Orientation was arranged for newemployees, student groups, and visitorsfrom India, Mexico, Indo-China andTurkey.Mental Health SectionProgress and new ventures bestdescribes the Mental Health Section'sactivities for 1954. The first state-wideconference for mental health clinicpersonnel was held in Raleigh, January13-15; a second state-wide conferencealso in Raleigh, November 3-5.More in-service training courses wereplanned for and given to public healthnurses than in any previous year. TheWilmington and Charlotte coursesstarted in 1953 were concluded. Threenew courses were started for the publichealth nurses, one each in Fayetteville,Greensboro, and Winston-Salem.One course included eight monthlysessions; two, sixteen bi-monthly sessions.An intensive educational programwas directed to informing people ofthe need for mental health centers.For instance, a five-year plan whichsuggested the establishment of tenregional mental health centers wasprepared and included in a draft ofthe "Report on North Carolina's MentalHealth Functions and Agencies"; 10,000copies of a pamphlet "Have You Hada Breakdown?" prepared by the Sectionmaterialwere printed and distributed;was prepared for newspapers and radio.The Mental Health Section assisted

June, 1955 The Health Bulletin 11the North Carolina Hygiene Society inits educational campaign to supportthe State Health Department's legislativeprogram for ten regional mentalhealth centers. For instance, the NorthCarolina Mental Hygiene Society wasassisted in preparation of news releases,radio spot announcements, thefirst exhibit to be sponsored by theSociety at the State Fair and othereducational material. The MentalHealth Section also helped the Societyplan for Mental Health Week, May 1-7.In addition to these activities, theuse of new statistical forms for collectingclinic data was initiated July 1,1954. An institute was planned for andgiven to the people of Oxford and inDecember three committees were appointedto study mental health personnelpositions in the mental healthclinics.Except for Asheville Mental HygieneClinic, which lost three of its personnel,and Charlotte Mental HygieneClinic, which lost one, North Carolina'ssix community mental health clinicswere fortunate in keeping their presentstaff intact. In fact, by the end of theyear at least two of the clinics weremoving to expand their current staffs.School Health Coordinating ServiceThe School Health CoordinatingService of the State Department ofPublic Instruction and the State Boardof Health continued to work in muchthe same way in 1954 as was done in1953.Staff members worked primarily withschool superintendents, principals,teachers, and health department personnelbut continued to cooperate asusual with other agencies and organizationsconcerned with the health ofschool children.The health curriculum guide, entitledHealth Education North Carolina PublicSchools, having been completed,published and distributed, that changedthe work of some of the staff membersto some extent. Instead of preparingand trying out the materials for thepublication, the job became, at leastin this respect, one of getting theschools to use it to improve schoolhealth programs. Many regional, county,city, and local school meetings wereheld to "introduce" the "guide" and toshow how the materials could best beused. Health Department personnelattended most of these meetings.The School Health CoordinatingService continued to administer andsupervise the school health program,including planning and administeringthe expenditure of school health fundsin the amount of $550,000 annuallyappropriated by the General Assemblyto be allocated by the State Board ofEducation as grants in aid to city andcounty school administrative units. Theplan for allocating these funds for1954 was the same as followed theprevious year, namely: (a) Each countyand city school administrative unitwas allocated an amount equal to 50cper pupil based on the average dailymembership for the first seven monthsof the previous school year, (b) Inaddition, the sum of $1,000 was allottedto each county regardless of size.Each school administrative unit withinthe county receives a portion of the$1,000 allotment based on its percentageof the total students in the county.School health funds have been usedto pay for the correction of chronicremediable defects of children of parentsunable to pay for such services.However, reports show that the followupprograms by school and health departmentpersonnel have resulted ingetting an increasing number of parentswho could pay, to seek and payfor medical services for their children.The policies approved by the StateBoard of Health and the State Boardof Education in 1949, governing theexpenditure of these funds, were continued.Also, the State Board ofHealth continued the plan of earmarkingan amount equal to 40c perpupil for school health work. Expendituresof State Board of Educationschool health funds for the periodJuly 1, 1953 to June 30, 1954 were asindicated below:

12 The Health Bulletin June, 1955Salaries: Health Educators $31,345.68Nurses 94,583.02Dentists 12,312.95Technicians 2,825.29Travel: Health Educators 1,808.40Nurses 14,230.24Dentists 420.00Technicians 637.05Fees for Medical Examinations $ 17,803.02Correction of Defects 314,123.79Supplies 23,112.04Equipment 27,621.42TOTAL, $ 540,822.90Services of the staff of the School calendar year 1954. No attempt will beHealth Coordinating Service consisted made to point out the many improveofplanning and promotional work and ments secured in the field of environservicesto school and health depart- mental sanitation in this brief, since dementpersonnel through consultative tailed monthly reports have been subservice,field visits, planning and carry- mitted to the State Health Officering on in-service education, production and members of the State Board ofof materials, reviewing and recommend- Health, but several of the more imporinguse of materials, locating and tant ones are given mention,recommending the use of local, State Administrationand national resources, evaluative pro-Thg gtaff nQW consists of a total ofcedures, joint state conferences and33 people> including the Director, andcommittees, state and national organiconsistsof sanitary engineers, sanitarzations.ianS( entomologists and secretaries.Staff members worked with schoolsDuring the year one ^^^1 positionand health departments in the followandone ^^^^ as Bedding Inspectoring specific aspects: health instrucwereestablished . Practically the entiretion, including mental hygiene, comtimeQf the personnel was devoted tomunicable diseases, sanitation, family& program of cooperation with andliving, community health, personalassistance to federal, State, municipalhealth, alcohol and narcotic education,&nd cQunty officials and other agenciesheart, cancer, first aid and safety;concerned with sanitation problems,healthful school living, includingAg ^ the past> special assistance wasphysical and emotional environments;giyen to the Budget Bureau, the Deandhealth services, includmg prepartmentof Public instruction, theschool clinics, teacher screening, nurse-Department of Public Welfare, Stateteacher screening and follow-up, medi-Hi hway and Public Works commiscaland dental examinations, audiosion>Hospitals Board of Control, Statemeter testing, and correction of de-Department of Conservation andfects -Development, Medical Care Commis-Two staff members worked primarily Sion( priVate consulting engineers andwith elementary and secondary schools architects, municipal officials, andin in-service training of teachers in iocai health departments,physical education.Engineering SectionSANITARY ENGINEERING DIVIS- As has been the case for a numberION—J. M. Jarrett, Director of years, the engineers assisted theThe following is a brief summary of operators of municipal water and sewthemany activities engaged in by the age treatment plants with specialpersonnel of this Division during the operational problems. The Director, as

June, 1955 The Health Bulletin 13Chairman of the State Stream SanitationCommittee, participated in publichearings in connection with the classificationof the Yadkin River Basin.Staff members also assisted with theWater Works and Sewage WorksOperators' Schools and with the industrialWaste Conference. Thesemeetings are held annually and rotatebetween Duke University, Universityof North Carolina, and North CarolinaState College. The program of cooperationwith architects and school officialsin planning water and sewerage facilitiesfor the many new consolidatedschools, which were built during theyear, has continued. The location ofnew well sites, which is carried on incooperation with the State Geologist'sOffice, was also of considerable valueand assistance to a number of thetowns. Considerable improvement inwater and sewage facilities was notedduring the year, and a number ofadditional projects were reviewed andapproved, but work was not startedduring the calendar year. However,there were 37 water improvement projects,which included new systems andextensions and new plants and renovationsamounting to $4,794,176. Therewere 34 sewerage projects relating tocollecting systems and the constructionof new sewage treatment plantsamounting to $4,305,205, and there were8 combined or non-classified projects,which contained both water and sewerageamounting to $1,293,584, or a totalof 79 projects for which contracts wereawarded for water and sewer improvementsamounting to $10,392,965.Cooperative work with the U. S.Geological Survey Laboratory has continued,and information was furnishedthis office for distribution to interestedcitizens regarding the chemical characterof public and industrial watersupplies. This Laboratory also assistedwith the control of fluoridation of publicwater supplies. During the yearfour towns began the fluoridation oftheir water supplies, making a total of19 towns in the State which are nowadding fluoride to their public watersupplies.Surveys and inspections were madeof all interstate carrier watering pointsand water supplies, and reports werefurnished the U. S. Public Health Service.Matters relating to the formation ofsanitary districts were investigated andduring the year one district was formed.Considerable time was devoted toassisting towns concerned with watershortages due to the drought of thelast two years. The following townswere seriously affected by the droughtduring 1954: Apex, Bisco, BlowingRock, Bryson City, Gastonia, Greensboro,Kings Mountain, Lenoir, Lexington,Lincolnton, Marion, Mocksville,Ramseur, Reidsville, Thomasville, Roxboro,Sanford, Selma, Troy, Valdeseand Wilson. Because of "HurricaneHazel" and the damage done to coastalareas in North Carolina, the engineersdevoted considerable time to emergencywater supplies and sewage disposalproblems, as did the sanitarians, andin assisting public officials. Work wasalso carried on in connection with theState Department of Civil Defense inassisting these towns to secure federalaid for the rebuilding of their damagedor destroyed facilities. Special workwas carried on in connection with theState TB Sanatorium and consultingengineers in determining the degree oftreatment necessary for sewage dischargedfrom this institution. Specialattention was also given to the sudyof wastes from small abattoirs. One ofour engineers was given a specialcourse of training in atomic wastedisposal at the Public Health ServiceCenter at Cincinnati, and he also tookpart in the Public Health Service programof checking radioactive fall-outparticles at the A-Bomb testing groundin Nevada.SanitationSectionA large number of special activitieswere engaged in in the field of environmentalsanitation. Considerable timeduring the year was devoted to assistingthe State Prison Director in a studyof foodhandling facilities in Stateprison camps and in planning for

14 The Health Bulletin June, 1955future improvement of these facilitiesin line with a master plan developed.One man was transferred to thisacitivity and has devoted about half oftime to prison work.In the field of Milk Sanitation,special investigations were completedwith regard to bulk milk dispensers, asreported last year, and recommendationswere made to the State Boardof Health that the use of bulk milkdispensers be approved when operatedin accordance with certain sanitaryregulations. One of our engineersserved on a committee with the StateDepartment of Agriculture in the studyand approval of these dispensers. Timewas also given to the study of bulkmilk tanks used on farms. This workis continuing. Also in the field of milksanitation, special meetings were heldwith local sanitarians throughout theState in connection with the interpretationof code requirements with particularreference to the testing of equipment.The usual milk surveys for thecertification of interstate milk supplieswere carried on by two menassigned to this activity. The programof certification of local milk laboratories,in cooperation with the StateLaboratory of Hygiene, was carriedforward during the year, and considerableimprovement has been noted inthe methods and equipment of localhealth department laboratories doingmilk work.Two films dealing with food poisoningand foodhandling procedure weremade in North Carolina by the CommunicableDisease Center of U. S. PublicHealth Service, in cooperation withthis office. Considerable time was devotedby two of our sanitarians to helpingwith the preparation of the scriptas well as the actual filming of thepictures. These films will be availablethroughout the United States for usein connection with training coursesfor foodhandling personnel. The programof foodhandling courses for employeeshas also gone forward duringthe year but not as actively as in 1953because of time consumed by othernecessary activities. The usual amountof time was devoted to helping secureand train sanitarians for local healthdepartments. This field training activityhas become one of our major functionsin the field of sanitation. The localsanitarians requested and received permissionfrom the local health officersto hold three district meetings peryear. These meetings will be devotedto in-service training. The programswill be developed by the Departmentof Field Training of the School ofPublic Health at the University ofNorth Carolina and this office. Ourmen also assisted with a Dairy Fieldman'sCourse at State College andtook part in a course in radioactivityat the University of North Carolina.We also were the host State for theInterstate Sanitation Seminar whichwas held in Chapel Hill during theyear, and much time was given topreparation of this program. Our sanitariansalso participated in a numberof shellfish conferences, including theNational Shellfish Conference in Washington,D. C. A representative also appearedbefore the Medical Society'sRural Health Conference to discussenvironmental sanitation. Thus ourtraining and educational program wasnot confined to the field training ofsanitarians, although two courses weregiven at the University of North Carolinaand in the field training counties.Insect and Rodent ControlAssistance was given to local healthdepartments throughout the State inconnection with the ratproofing ofbuildings, rat eradication, DDT dustingfor ectoparasites and mosquito and flycontrol. In addition to this, a surveillanceprogram was carried on to correctlyestablish the existence andlocation of diseases caused by insectsand rodents. Also during the year,considerable attention was given topest mosquito control in the easterncounties. Areas particularly affectedwere Dare County, along the beaches,Beaufort and New Hanover countiesand Carteret County. Information wasgathered regarding the cost of pestmosquito projects in other states in aneffort to advise local citizens regarding

,_-i.June, 1955 The Health Bulletin 15the cost of such projects.The vector demonstration controlproject at Fayetteville operated forseveral months during the year. Thisproject was carried on in cooperationwith the U. S. Public Health Serviceand the Cumberland County HealthDepartment. Our engineer and entomologistalso assisted the vocationalagriculture teachers in Robeson Countyand assisted with the field trainingof sanitarians. The impounded waterprogram continues to develop, as alarge number of ponds are being constructedas a soil conservation measureand to enable the farmers to havestock watering ponds. Some are beingused for irrigation.The bedding inspection work wastransferred to the Insect and RodentControl Section during the year foradministrative purposes, and an additionalbedding inspector was employed.Our entomologist and engineer alsospent considerable time with the U. S.Corps of Engineers in connection withthe John H. Kerr Reservoir and in anattempt to secure proper control measuresand also worked with the VirginiaElectric and Power Company regardingthe construction of the damson the Roanoke River in Halifax County.The work on the promotion ofsanitary landfills also went forwardand considerable attention is beinggiven to this activity as a propermeans of disposal of garbage andrefuse.ConclusionsOne of the most significant accomplishmentsin the field of sanitationconcerned the moving of the StateBoard of Health into decent officequarters. The old quarters which wehave occupied for a number of yearsgave visitors a very unfavorable impressionof our sanitation and publichealth programs. It was most difficultfor us to promote proper environmentalsanitation and enforce laws, rules andregulations and at the same timehave our visitors refer to us as beinghoused in one of the dirtiest Statebuildings in the city of Raleigh. Approximatelytwo months' time of severalmembers of the staff of this officewas devoted to the moving of theoffices, but much has been accomplishedwhich will enable all of us to carryon a much better program and in amore efficient manner in the future.The following is a numerical tabulationof some of the major inspectionaland supervisory activities.NUMERICAL SUMMARY OF ACTIVITIESEngineeringi :;Public water supply inspections 595Well sites examined and approved 62Water samples collected and examined 242Special investigations conducted (water supplies) __, 74Sewerage system inspections 302Plant site investigations 82Special investigations (sewerage systems) j.j^, 61Sand analyses 36Water supply plans approved 39Sewage works plans approved 38Swimming pool plans approved - 9Sewage plant plans furnished 105Swimming pool plans furnished 8Outdoor bathing places investigated _^___ 24Sources of water supply examined for interstate carriers ___ 22Watering points examined 35FHA developments investigated ,__ __; 28FHA cases processed i. 1,455FHA Subdivisions processed 31

16 The Health Bulletin June, 1955VA cases processed 52VA Subdivisions processed 14Special conferences with engineers, city and county officials 760SanitationMilk plant inspections 154Dairy farm inspections 1,151Milk surveys completed 24Milk plant plans reviewed 6Special investigations (milk) 12Milk samples collected 42Conferences regarding milk 353Food handling establishments inspected 1,573School lunchroom inspections 139Abattoir and meat processing plant inspections 292Meat market inspections 398Frozen food locker plant inspections 47Poultry plant inspections 55Plans reviewed for food handling establishments 325Food handler schools held 5Private water supply inspections 1,052Private sewage disposal inspections 394Privy inspections 1,269Summer camp inspections 18Institutions inspected 371Hospital plans reviewed 44Public school inspections 90Swimming pool inspections 38Hotel and tourist camp inspections 153Complaints general sanitation 148Special investigations 11Special meetings 421Shellfish packing plants inspected 889Retail seafood markets inspected 121Patrol inspections of restricted waters 112Plans distributed - 59Number of court cases 12Insect and Rodent ControlCommunities assisted in planning or supervising landfills 7Applications received for permits to impound water 1,147Impounding permits granted 761Mosquito surveys made 26Arthropods identified 319Communities assisted in planning or supervising insect control 7Impounded water inspections 532Residual spraying inspections - 9Inspections of refuse storing, collection or disposal 75Inspections of bedding factories 5,953Inspections of retail bedding establishments 1,968Pieces of bedding removed from sale and/or condemned 2,025Municipal and county board meetings attended _ 6

June, 1955 The Health Bulletin 17EPIDEMIOLOGY DIVISION—Fred T.Foard, M. D.,DirectorIn 1954 the organizational structureof the Division of Epidemiology consistedof the following seven sections:Public Health Statistics, Industrial Hygiene,Tuberculosis Control, VenerealDisease, Veterinary Public Health,Communicable Disease Control, andAccident Prevention. A review of theactivities of the group discloses thateach made very satisfactory progressin its field in 1954. A brief resume ofthe work of these sections during theyear is presented by the Division Director,followed by the more detailedreport of each section.ResumeIn addition to collecting, processing,and analyzing birth and death records,the Public Health Statistics Sectioncontinued its studies of special projectsfor eleven non-State Health Departmentorganizations. Also during theyear all laws relating to collecting andhandling of vital records were reviewedin cooperation with the Institute ofGovernment, University of North Carolina,and many amendments to thepresent laws were drawn for submissionto the 1955 State Legislature, withthe purpose of clarifying and simplifyingoperative procedure in processingsuch records.Of wide interest is the fact that thecrude birth rate in 1954 was higherthan in 1953, while the death ratetrend was downward for all communicableand infectious diseases.The Industrial Hygiene Section operatedwithout a medical director for almostthe entire year. The principalactivities were confined to conductingchest x-rays of employees of the dustytrades. Sixty-nine plants were surveyed,a total of 3,308 employees surveyed, and3,268 work cards issued. More than6,800 industrial employees in non-dustytrades were x-rayed. Engineering serviceswere extended to 199 industrialplants, and consultation service wasprovided to twenty-four local healthdepartments.In 1954 the Tuberculosis ControlSection's tuberculosis case-finding program,as carried out under the State'smass chest x-ray program, conductedcounty-wide mass surveys in eightcounties, and special group surveyswere made in twenty-two individualcommunities. During the year 301,216persons received free chest x-rays bythis service. The number of tuberculosiscases discovered each year throughthe mass chest x-ray program is rapidlydecreasing, and the cost per casediscovered is proportionately increasingto the extent that in the nearfuture it will be economically advisableto confine this important service tospecial groups. So far, however, thecontinuation of the program has beendeemed advisable so that progress alreadymade in the control of tuberculosismay be retained.The report of the Venereal DiseaseControl Section shows that the prevalenceof venereal diseases has decreasedmaterially in recent years;however, to maintain this reduction, itis necessary to intensify epidemiologicalinvestigation of known casesand contacts to cases as well as toexpand selective blood-testing activities.In 1954 medical consultant servicein venereal disease control was extended,on an increased basis, to localhealth departments, private physicians,hospitals, and medical officers at theseveral military installations in NorthCarolina. Venereal disease investigators,varying periodically in number,were supervised directly by the Sectionin 1954. The number on duty at anyone time varied from seven to eightteen.Also thirteen locally employedfull-time investigators, cooperatingwith the State Board of Health, werereduced in 1954 to seven, totaling fromfourteen to twenty-five investigatorsavailable at any time in the year tocover the one hundred counties in theState.Accomplishments in the veterinarypublic health field in 1954 include theinstitution of measures to controldiseases of animals transmissible tomen. In rabies control, stray dog controlprograms were begun in twelve

18 The Health Bulletin June, 1955more counties. Dog wardens are nowappointed and dog pounds constructedin thirty-eight additional counties. Theanti-rabie vaccination program fordogs has been accelerated. Only onehuman case of rabies occurred in NorthCarolina in 1954. Special investigationsof leptospirosis outbreaks in six countieswere also made. The blood offorty-three humans was found positivefor various species of leptospira, adisease primarily of dogs but spread tohumans chiefly through infected water.Psittacosis was widely prevalent amongparakeets and other psittacine birds,with several human cases definitelytraceable to infected birds. Investigationshowed that a dairy herd owner,whose herd was infected with tuberculosis,had advanced tuberculosis oflong standing. He was immediatelyplaced in a sanatorium.In communicable disease control,prompt and expanded epidemiologicalinvestigation of disease outbreaks byDepartment personnel, cooperating withand at the request of local healthofficials, was reflected by decreasedmorbidity and mortality rates fromacute communicable diseases. To a considerableextent, this intensified fieldservice was made possible by theassignment of a trained epidemic intelligenceofficer of the U. S. PublicHealth Service to this Division for ayear. Investigations included the gastro-enteritisoutbreaks (200 cases atDavidson College; 500 cases at Washington,N. C), an explosive outbreakof eleven poliomyelitis cases in ClayCounty, an outbreak of several meningococcusmeningitis cases in Pittsbcro,an outbreak of leptospirosis (one fatalhuman case occurred), and small outbreaksof typhoid fever in Bladen,Guilford, and Halifax-Warren (Littleton)counties.In 1954 the trend among more importantcommunicable diseases wasdownward. Poliomyelitis reports decreased21% under 1953. Infectioushepatitis cases reported showed a decreaseof 30% under 1953.Early in 1954 the Accident PreventionSection completed recruitmentand began full-scale operation. It maderapid strides in bringing to the attentionof North Carolinians the importanceof preventing home and farmaccidents, the annual death toll fromwhich exceeds that from deaths dueto all communicable disease. In relativeimportance in the prevention ofdisability and death, accident preventionranks high among preventivemeasures long since recognized as importantfunctions of state or localhealth agencies.This program was made possible inAugust, 1953, by a grant of funds fromthe Kellogg Foundation to finance athree-year demonstration project. Theprofessional staff consists of a medicaldirector, one engineer, a public healthnurse, and a health educator. It isone of eight similar projects in theUnited States financed by the KelloggFoundation and included as routinehealth programs in state health departments.Public Health Statistics SectionThis Section performed practicallyall of the statistical services for theState Board of Health in 1954. This involvedcollecting, processing, tabulating,and analyzing various activitiesfor the health programs carried on bytwelve sections of the department. Alsospecial studies were continued or begunfor various health and medical groupsduring the year. Agencies participatingwith the State office in studies includedthe Americal Medical Association,American Dental Association, theMaternal Welfare Committee andAnesthesia Study Committee of theN. C. Medical Society, and three medicalschools, the School of PublicHealth, Motor Vehicle Department,Cornell University Medical College,National Office of Vital Statistics,and Children's Bureau.During the year, 115,775 regular and17,500 delayed births, 32,070 deaths,and 2,374 childbirths were recorded.All indications point to an all-timehigh in number of births for the year.In 1954, a total of 30,790 certifiedcopies was issued and 6,852 verifica-

June, 1955 The Health Bulletin 19tions were made in order to prove thefact of birth or death. There were1,046 legitimations and 1,488 adoptionsprocessed, resulting in new birth certificatesbeing issued.Resident birth and death certificatesreceived for 1954 indicate that thecrude birth rate will be higher thanin 1953, whereas the death rate willbe lower. The provisional rates, basedon all certificates of residents receivedin 1954, with no regard to year ofoccurrence, are 27.1 live births and7.5 deaths per 1,000 population.Since 1925 diseases of the heart havebeen the leading cause of death. Eachyear a greater proportion of all deathsis due to this cause. In 1925 the heartdisease death rate was 123.5 per 100,-000 population; in 1954 the provisionaldeath rate from this cause was 255.9.The other leading causes of death,with provisional rates per 100,000population and number of deaths (indicatedin parenthesis), are as follows:vascular lesions, 100.6 (4,295); cancer,90.4 (3,859); influenza and pneumonia,26.7 (1,142); non-motor vehicle accidents,33.5 (1,431); motor vehicle accidents,26.0 (1,110); immaturity, 19.2(820).The provisional infant mortality ratewas 30.5 per 1,000 live births in 1954.The provisional maternal mortalityrate was 0.8.In promoting registration of vitalevents, administrative contact wasmaintained with registrars, doctors,midwives, undertakers, registers ofdeeds, hospitals, and health departmentpersonnel. In an effort to obtainmore prompt and complete registrationof certificates, tabulations byattendant, showing time lag in filing,were made for the counties with theworst records.The consolidation of four morecounties was made with the healthofficer serving as local registrar forthe collection of all vital events, makinga total of sixty-four consolidatedcounties. The remaining thirty-sixcounties are served by town and townshipregistrars. The ultimate goal is toconsolidate all one hundred counties.Industrial Hygiene SectionSince August 1, 1954, this Sectionhas operated under the direct supervisionof the Division Director becauseof the resignation of the Section Chief.Below is a statistical summary of theSection's activities in 1954:Dusty trades plants surveyed 69X-rays taken 3,308Employees issued work cards 3,268Employees refused work cards 40X-rays taken in non-dusty trades 6,821Pre-employment x-rays read 1,309Case histories and supplementssubmitted to Industrial Commission72Case hearings attended 37Engineering services were extendedto one hundred and ninety-nine industrialplants and twenty-four localhealth departments. This was performedwith a skeleton staff of two engineersduring the first four months ofthe year and with only one during theremaining eight months. The types ofindustry served were: cotton textile,asbestos textile, insecticide remixing,mining, quarrying, granite cutting,boiler manufacturing, brick and tile,light-weight aggregate and mineralprocessing.Tuberculosis ControlSectionActivities during 1954. Communitywideor mass x-ray surveys, using fourto six mobile x-ray units, were conductedin eight counties or districts.Special surveys, using one or twomobile x-ray units, were conducted intwenty-two communities. During specialsurveys special groups selected byhealth officers, as well as the generalpopulation, were surveyed. Thesegroups included state mental institutions,colleges, industrial plants, tuberculosiscontacts, and persons who requirehealth cards.Work Accomplished. The Section'smobile units examined 251,762 personsduring the year, which was an increaseof 1,210 persons, as compared to 1953.A detailed comparison of work accomplishedin 1953 and 1954 is tabulatedbelow:

20 The Health Bulletin1. Persons examined by Section units (miniature film) __2. Persons examined by Section units on loan (miniaturefilm):a. Baptist Hospital, Winston-Salemb. Duke University Hospital, Durhamc. Union County Memorial Hospital, Monroe3. Miniature films interpreted in Central Office forcounties and institutions:a. Forsyth Countyb. Cabarrus Countyc. Stanly Countyd. State Hospital, Goldsboroe. Cumberland CountyGrand Total 291,268

June, 1955 The Health Bulletin 21Organized stray dog control providedby a dog warden is essential to aneffective rabies control program. Progressalso was made toward improvingdog immunization programs. As a resultof these activities, the number ofhuman antirabic treatments dispensedby the State Laboratory has beensignificantly reduced. One humanrabies death was investigated duringthe year.The tremendous increase in the saleof psittacine birds (parakeets) has resultedin an increased incidence ofhuman psittacosis. Reports of humancases have been investigated in eightcounties. Regulations relating to thecontrol of pssitacine birds have beenrevised. Birds in known infectedaviaries have been destroyed. A surveyis being made to determine whether ornot psittacosis is also present in domesticfowl, especially turkeys.Several requests that the State Boardof Health supervise the inspection ofpoultry for wholesomeness were receivedfrom one large health departmentoutside North Carolina. ThisSection has assisted county health departmentsand local poultry processorsin providing consultation relative topoultry inspection. The introduction ofan enabling act in the 1955 GeneralAssembly to permit inspection is beingconsidered.Assistance often has been given tolocal health departments in developingmore effective meat inspection programsand in investigating numerousdiseases of animals transmissible toman.Leptospirosis, a disease of man andanimals having its reservoir in animals,is being recognized more frequently byphysicians. Numerous human andanimal cases have been investigatedduring the past year. A reliable diagnostictest has been made availableto physicians and veterinarians during1954. This test is essential for a differentialdiagnosis, as leptospirosisresembles several other infectiousdiseases and conditions in men andanimals.In 1954 the Section Chief preparedtwo papers on veterinary public healthfor publication and gave several lecturesat the School of Public Healthand North Carolina's three medicalschools.Communicable Disease Control SectionContinuing a trend established in thepast two decades, the acute contagiousdiseases decreased in prevalence andseverity in North Carolina in 1954. Allthe contagious diseases, includingtuberculosis, considered as a group,ranked as the seventh leading causeof death in the State, and no singlecontagious disease, cosidered separately,caused sufficient deaths to rankamong the ten leading causes.Conditions such as tuberculosis, diphtheria,typhoid fever, syphilis, influenza,and others, which once numberedtheir victims among the thousands,now claim lives in the hundreds orthe dozens. With many diseases, thedeath rates no longer can serve as anindex of their severity, and one mustrefer to disability rates, both temporaryand permanent, loss of efficiency,and other such factors in orderto characterize the magnitude of theacute disease problem.The task confronting private physiciansand public health workers inthe field of communicable disease controlis now largely a matter of surveillanceto insure that once vanquisheddiseases do not recur. Activities leadingto a high level of mass immunityhave been fostered in addition to acceleratedendeavors in the area of investigationof unusual or suspiciousoutbreaks of disease.Additional studies regarding theepidemiology of these diseases aboutwhich knowledge is still incompletehave been undertaken. Encephalitis,blastomycosis, leptospirosis, infectioushepatitis, and psittacosis, all have receiveddetailed study to this end.There is a continuing responsibilityfor the forthright education of thepublic as to the true severity of diseaseproblems. As an example, poliomyelitiscontinues to strike terror in the heartsof many persons in the State, while

22 The Health Bulletin June, 1955in reality during the past five yearsNorth Carolina ranked thirty-ninth inthe nation in the number of poliomyelitiscases reported per 100,000population.An enlightened citizenry, both professionaland lay, have within itsgrasp the tools for the further reductionof suffering and anxiety causedby the communicable diseases.Accident PreventionSectionAccidents continued as a majorcause of deaths, injury, and permanentdisability in 1954 in North Carolina.Motor vehicle accidents have receivedwide publicity and attention, but onlywithin the past two years have homeand farm accidents been recognized asa major health problem.For the past five years, for everyone hundred highway accident deathsthere have occurred from seventy toseventy-five accident deaths in thehome and on the farm to rank theseaccidents as the second most importantsingle type of accident in the State.Beginning in 1953 and continuing in1954, the North Carolina State Boardof Health has taken pioneer steps inthe development of home and farmsafety activities as one of eight statesin the United States selected by theW. K. Kellogg Foundation to initiatesuch activities under a special grantfrom the Foundation.The professional staff engaged indeveloping this program is directed bya trained epidemiologist, and thisgroup inaugurated activities with astudy of the epidemiology of home andfarm accidents. Based on these significantfindings, a program of public informationand education has beenstarted, utilizing, to a large number,the local health departments in theState.In addition, cooperative relationshipshave been established with more thana score of safety agencies, each activein some field of accident prevention,as well as with state and local professionalsocieties and lay groups.It is the philosophy of the StateBoard of Health that, while statelevelsafety activities may make greatprogress in focusing attention on theproblem, the prevention of accidentscan be achieved only at the communitylevel, and every step has been takento bring safety education to everycounty, city, home and family in theState.ORAL HYGIENE DIVISION—ErnestA. Branch, D.D.S., DirectorThe Division of Oral Hygiene recognizesthe continued need and urgencyof finding and promoting the mosteffective measures for improving thedental health conditions of the people,especially the children, of North Carolina.Surveys show that approximately85 per cent are in need of dental attention.Teeth decay is our number onephysical defect. The average personat age 16—has 16 decay sites involving7 teeth. Dental authorities agree thata losing battle is being waged againsttooth decay and that prevention offersthe only solution. It is generally concededthat this can best be accomplishedby providing dental health educationprograms for children and theirparents. It is our belief that such aprogram should include.1. Education to appreciate good dentalhealth and to know the acceptedprotective measures.2. Motivation to assume personal responsibilityfor dental health.3. Early detection and correction ofdental defects.4. Promotion of preventive measures,such as the fluoridation of municipalwater supplies and the topicalapplication of sodium fluoride tothe children's teeth.Before giving a report of the Division'sprogress in 1954 toward the accomplishmentof these objectives, somethingof the modus operandi shouldbe pointed out. The Division of OralHygiene has a staff of public healthdentists who go into the elementaryschools to conduct mouth health educationprograms. When a dentist is sentto a county he reports to the CountyHealth Officer and works as a memberof the local health department staff.

June, 1955 The Health Bulletin 23The counties share in the expense ofthe program. In each local healthbudget there is an item for dentalservices which, in all but the sixcounties having full-time dentists,means for participating in the servicesoffered by the Division of Oral Hygiene.Each county defrays approximatelyone-half of the expense of the programin that particular county, and theState Board of Health takes care ofthe balance. Each county has a localpracticing dentist as one of the membersof its County Board of Health.During the year 1954, the staff ofthe Division of Oral Hygiene consistedof the Director, an average of 13school dentists, an educational consultant,an artist, 2 puppeteers, andclerical help. Mouth health programswere conducted by the staff dentistsin 44 counties.In presenting the following statisticalreport we note with satisfaction andgratification the upward trend innumbers of children receiving the services.Indeed, it appears that 1954marks a definite turning point afterthe difficult and discouraging decadebetween 1942 and 1952. It has beenimpossible to maintain a staff of dentistsadequate in numbers to meet theneeds and demands for the services.During the past two years, however,our efforts in the area of recruitmenthave been more fruitful, and indicationsare for continued success.SUMMARY OF CORRECTIVE AND EDUCATIONAL WORK BY DENTISTSNumber of schools visited 567Number of children — mouths inspected 106,780Number of underprivileged children receiving dental corrections 40,832AMOUNT AND CLASS OF TREATMENT ITEMIZED AS FOLLOWS:Number amalgam fillings 14,580Number cement fillings 2,732Number silver nitrate treatments 51,750Number teeth extracted 29,997Number children — teeth cleaned 25,792Number sodium fluoride treatments 4,084Number miscellaneous treatments 7,323TOTAL NUMBER OF OPERATIONS 136,258Number of teeth extracted that were six year molars 5,571Number of teeth filled that were six year molars 11,026Number of children referred to local dentists 57,760Number lectures on Mouth Health 2,875Total attendance at lectures 107,272In analyzing the foregoing report wecall especial attention to the classroominstruction by the school dentistsand the attendance on these lecturesby 106,780 children. Not only havethese children received valuable informationfrom the person best qualifiedto give it to them, but they have alsobecome acquainted with a dentist andhave learned to consider him as theirfriend. The corrective service for theunder-privileged children is termeddemonstrative teaching. It must alsobe remembered that these are childrenwho, otherwise, would not havehad dental attention—over 40,000 in1954. It would be impossible to estimatein terms of prevention the benefitsreceived by this group of children.Of particular significance is the numberof six year molars filled. These11,026 six year molars may be regardedas that many permanent teeth saved.The 5,571 six year molars extractedtell another story. But even these lostteeth tell a story of the relief of painand the prevention of even moreserious ills through the removal of

24 The Health Bulletin June, 1955sources of infection.An important group represented inthe report is that of referred children,57,760 in number. These are thechildren whose parents are financiallyable to take care of their needs. Eventhe privileged need reminders. Theseare the children who can and shouldbe motivated to accept personal responsibilityfor their own dentalhealth. The Division of Oral Hygienestrives constantly to develop on thepart of the public the appreciation ofgood dental health and good dentistryand the awareness that there is a definiterelationship between an unhealthymouth and systemic disease.While the services listed in the 1954statistical report are, of necessity,limited to the counties and schools inwhich the staff dentists conductedprograms, other services of the OralHygiene Division are available to allcounties and schools.A major service of the Division ofOral Hygiene is the preparation (writing,illustrating, and printing) and distributionof dental health educationmaterial for use in the schools. Thisis available, upon request, to the teachers.We are glad to report that manyadvantage of thisappreciate and takeservice. Approximately 1,000,000 piecesof literature were distributed duringthe year, 1954. It is noteworthy thatthe material is dispensed only inresponse to requests.The 19th consecutive year of LittleJack's puppet show was most successful.The show was presented to morethan 150,000 children during the year.We believe that this visual educationproject is effective in supplying gooddental health information and motivation.The activities of the Division as wellas its dental health message have beenpresented to professional groups andto the general public through talks bythe director and other staff members,newspaper articles, radio programs,and exhibits. Exhibits were presentedat annual meetings of The NorthCarolina Dental Society, The NorthCarolina Public Health Association andThe Rural Health Conference and atthe North Carolina State Fair. Exhibitswere also loaned to county health departments.We realize that, in spite of our increasedefforts and activities in thefield of dental health education, thereis still a wide gap between needs andservices. Evidence continues to pointto the fluoridation of public watersupplies as an effective means of preventingtooth decay and, thereby, reducingthe needs for dental service. Itis with regret that we note someopposition to this measure, in spite ofthe unqualified endorsement of itssafety and efficacy by well qualifiedand authoritative scientific groups.During the year 1954, four North Carolinatowns joined the ranks of thosein which fluoridation is in operation.This brings the total to 19 cities witha combined population well over the600,000 mark. In many other towns thematter is under consideration. To aidthe communities in securing popularacceptance of fluoridation, the Divisionof Oral Hygiene has published literature,a booklet and a leaflet, on thesubject. These are available upon request.The North Carolina State Boardof Health recommends fluoridationand stands ready to assist local groupsin promoting it. However, it must alwaysbe kept in mind that fluoridationis only one preventive measure. Wemust continue in our program ofmouth health education to provide informationand motivation to the endthat our people will appreciate andstrive to attain good dental health.PERSONAL HEALTH DIVISION—A.H. Elliott, M. D., DirectorHeartThe program has in the past consistedprimarily of physician and layeducation and secondarily of trying toput patients whose screening tuberculosisx-rays indicated abnormalityof the heart or great vessels in touchwith their family physicians.Education: The Section providedthree-day refresher courses in cardio-

June, 1955 The Health Bulletin 25vascular disease at Bowman Gray forapproximately thirty rural generalpractitioners in June and again inOctober and provided two courses forapproximately the same number ofpractitioners at Duke in the fundamentalsof electrocardiography in Juneand January. The June course is strictlyfor beginners and the January coursefor more advanced training. Otherforms of education consisted of providingsubscriptions to the HEART BUL-LETIN for all general practitioners,internists and cardiologists of the StateMedical Society and for all coloredphysicians. Another one consists ofsound films and leaflets in the fieldof heart disease.Consultation service was providedfor three special studies of rheumaticfever in school children in Durham,Wilmington, and Lenoir. During theyear the Heart Section relieved theCrippled Children's Section in supplyingpenicillin for rheumatic fever patients.CancerOne new detection clinic was startedduring the year, and one was closedfor lack of attendance, leaving thenumber of detection-diagnostic and detectiononly at six each. The case findingprogram examined 9,806 personsin 3.3 per cent of whom cancer wasfound, (327 cases) ; 774 biopsies and 38diagnostic X-rays were provided.Smears are done routinely on adultfemales and examined in the StateLaboratory. Referrals to private physiciansaccounted for 198 biopsies, 47diagnostic x-rays, 111 dilatations andcurettages and 446 non-cancer operativeprocedures. X-ray therapy wasrecommended for 55 patients. Underthe three-day hospitalization for diagnosisprogram, 473 patients were handledat a cost of $21,735.33. The cancertreatment program for the indigenthospitalized 351 patients at a cost of$72,453.48. Both the hospitalization programshad to be discontinued for afour-months period because of the exhaustionof funds. The gastric cancermobile unit continued to do routineannual x-rays on manageable inmatesof the State Hospitals. Approximately4,000 of these were done. The radiologistsare processing the summary oftheir findings and evaluation of thestudy on the first 10,000 patientshandled on this unit.Maternal and Child HealthA thoroughly trained obstetric consultantwas added to the staff duringthe year. Our pediatric consultant resignedto take a position with theChildren's Bureau in the Chicago area.Several new M&I clinics were opened.An intensive three-day refresher coursein pediatrics and obstetrics was givenat Bowman Gray for thirty-odd cliniciansand health officers who conductM&I clinics. Prenatal care was providedthrough these clinics for 31,610patients, and well baby care was providedto 51,158 babies. A special studyinto the possible causes of miscarriages,stillbirths and neonatal deaths occurringin the three hospitals associatedwith the medical schools was put intooperation. The usual immunizing materials,vitamins and literature weresupplied to the local health departments.A two-week refresher coursewas given 36 midwives. In addition tothis number, 5 midwives who hadattended previous courses acted asgroup leaders. At the same coursepublic health nurses from the countiessending midwives helped with theteaching and prepared themselves fora better followup of midwives in theircounties. A three-day course in thepublic health nursing aspects of themidwife program was conducted for18 nurses.The premature program continuedon its routine basis of teaching,demonstrating and paying for thehospitalization of a certain numberof very small infants of low-incomeparents at the six primary centers.Hospitalization of 389 infants was paidfor by our program. Eight secondarycenters are operating under theguidance, but without the financialsupport, of the MCH Section.

26 The Health Bulletin June, 1955Crippled ChildrenThe staff lost the services of onephysical therapist but was able toemploy another on a part-time basis.The demands on this program are sogreat that the budget cannot possiblytake care of them. Because of inadequatefunds, the rheumatic fever programat North Carolina MemorialHospital was discontinued December31, and only emergency or special caseshave been accepted since the first ofthe year. Plans for speech and hearingdefect program are complete, but lackof funds prevents activation of thisprogram. This section, with the helpof the School of Public Health and theState Board of Health's consultantnurses, conducted four strategicallylocated workshops for public healthnurses in the care of children, especiallythose with handicapping conditions.These workshops were extremely wellreceived. Approximately 40 clinics ona monthly basis were operated duringthe year. Service was provided 10,220children, and 1,418 children wers hospitalized.NutritionBecause of limitation of trainedpersonnel, the nutrition program continuesto work primarily on a requestbasis, though the staff is larger atpresent than ever before. Nutritionistswork chiefly through local health departmentpersonnel, school personneland various and sundry civic groups.An appreciable amount of work is deneon an individual basis with personsreferred from organized clinics andindividual private practitioners. A fewstatistics on the activities of this sectionare as follows: the nutrition consultantsconducted in-service trainingprograms for 943 nurses, 2,316 teachers,167 welfare case workers and, 2,818adults in community programs. Theygave consultation service to 1,367 professionaland 1,617 non-professionalpersons. They attended 42 orthopedicclinics, 130 prenatal clinics, 48 wellchildclinics, 21 preschool, 15 overweightclinics and 12 diabetic clinics, with atotal of 2,970 patients referred for individual'diet instruction. They surveyed208 children in seven schools.The dietitians serve as consultants inmost of the State hospitals and prisonsand for quite a number of local hospitals.Personnel in this Section joinwith the North Carolina Hospital Associationin putting on an institute forfood service managers in small hospitals.The Nutrition Section worked veryclosely with the Director of Prisonsand did some special studies, one ofwhich resulted in working out a cannedpreparation to be used in theprison for prisoners in solitary confinement.The idea is to provide a dietthat will sustain health but likelywould become extremely monotonousand at no time could be consideredpalatable. The nutritionists cooperatedwith public health officials in in-servicetraining programs for operators ofboarding homes, particularly those forthe aged. They also participated inworkshops for school lunch supervisors.In a limited number of cases, thenutritionists, with the help of publichealth nurses, provided special consultationservice, followup, etc., for reducingclasses for persons referred byphysicians. One of the most importantfunctions has been systematic in-servicetraining programs for public healthnurses and short refresher courses innutrition for school teachers. The PublicHealth Service has had considerablymore requests than could be grantedfor field training of nutritionists anddietitians referred by a number ofuniversities and schools of publichealth nutrition. The fact that nutritionis relatively new as a specialty inpublic health, and the fact that progressis being made in this field isexpressed in the following paragraphfrom Dr. Bosley's annual report:"The Nutrition Section of the StateBoard of Health has frequently encounteredboth resistance and indifferenceto the idea that nutrition isan important factor in health and,therefore, an essential part of a publichealth program. There is evidence thatinterest in nutrition is increasing

June, 1955 The Health Bulletin 27among public health people and they, refresher course to thirty rural generalin turn, are encouraging others to im- practitioners at Bowman Gray Medicalprove their food habits. Eventually, College on October 7-8 and also enthere should be some concrete evi- June 15-17. It gave one primer anddence among the population groups of one more advanced course in electrotheeffectiveness of its application. It cardiography at Duke Medical Collegehas been well-established in the plant to thirty general practitioners onand animal industry. It can, and will, January 22-24. It subscribed to thesome day, be equally well-established Heart Bulletin for all white generalfor the human race when man decides practitioners, internists and cardiotoforego some of his accustomed logists and to all the colored physihabitsand make use of known scienti- cians.fie facts that promote better physical In an effort to put patients whoseand mental health."tuberculosis screening x-rays indicatedpossible heart or blood vessel diseaseHeart Section in touch with their physicians, theThe Heart Section gave a three-day form letters were mailed out as follows:Number of letters to patients in regard to their chest x-rays 1,620Number of letters to the family physicians of these patients 1,620Number of cards and letters from doctors and patients sayingthe patient had reported to his doctor 1,241Number of letters to patients who did not give the names oftheir doctors, enclosing cards for this information 43Number of patients who died before they received our letters 5Number of final reports made to County Health Officers of thework done in their counties: Alleghany-Ashe-Watauga,Avery-Yancey-Mitchell, Burke 3Cancer Section ment, making a total of 7,444 referralsOne new Cancer Center was opened to physicians. These referrals representduring 1954. This Center, known as 75.9% of total examinees,the Wake County Cancer Detection During the year 327 cancers (involv-Center, opened at Rex Hospital in ing 3.3% of all examinees) were diag-Raleigh on October 5. nosed in the centers. Some types ofThe Halifax County Cancer Detec- pathology were found in 7,229 othertion Center closed in April, 1954; and, instances, with only 2,250 (22.9%)therefore, the total number of centers completely negative examinees reportinoperation in the State remains at ed.twelve. To aid in making diagnoses, theseThe six Cancer Detection Centers, centers did 774 biopsies and 38 x-rays.only, are in Burlington, Lincoln Hos- The Center staffs recommended topital in Durham, Sylva, Elizabeth City, the private practicing physicians thatNorth Wilkesboro, and Raleigh. Detec- an additional 198 biopsies and 47 diagtionand Diagnostic Centers are in nostic x-ray studies be made. They alsoAsheville, Watts Hospital in Durham, recommended that 55 patients receiveRocky Mount, Greensboro, Wilming- x-ray therapy, that 111 D & C operaton,and Rutherfordton. tions be performed, and that 446 otherA total of 9,806 detection examina- operations be done. Smears were donetions were made in these centers dur- by the State Laboratory,ing the year. Of this number, 5,480 The hospitalization programs for thepersons were referred directly to their treatment of medically indigent canpersonalphysicians. Another 1,964 cer patients and for the diagnosis ofexaminees were referred to a Diagnos- possible cancer in the medically inditicCenter for further study and then gent were in operation for as much ofto their personal physicians for treat- the year 1954 as funds were available.

28 The Health Bulletin June, 1955A total of 351 new cancer cases wereapproved for treatment, and bills paidtotaled $72,453.48 (State funds). Forthe same period 473 new cases wereapproved for hospitalization not toexceed three days in order that adefinite diagnosis could be made. Billspaid under this program totaled $21,-735.23 (Federal funds). As a result ofa lack of money, both of these programshad to be closed for four monthsof the calendar year.The Gastric Cancer Mobile Unit continuedits program in connection withthe State Hospitals during 1954, andapproximately 4,000 patients receivedx-ray studies of the stomach andesophagus on this Unit.Crippled Children's SectionIn June, 1954, the Section lost aphysical therapist by resignation. Theentire load of clinic attendance andlocal aid to physical therapy hasdevolved upon the two remaining fulltimetherapists, with the aid of a parttimeassistant who is paid on the basisof clinic attendance. Every effort hasbeen made to procure another fulltimetherapist, without success.In December of 1953 we declared$35,000 as a probable excess of appropriationand authorized the Children'sBureau to retain that amountof the last quarter's appropriation. Theend of the fiscal year found us inarrears by approximately that amount,and the necessity for maintaining aclose record of encumbrance was verydefinitely pointed up.During the first six months of thecalendar year it began to be apparentthat requests for service were graduallybut steadily exceeding our appropriationability to serve. This became veryapparent in the last month of thefiscal year when service was accordedto a large number of children immediatelyafter the close of school. Thisresulted in rapid dissipation of ourfunds, and encumbrances for the periodhad to be supported through fundsappropriated by the State for the newfiscal year, inasmuch as Federal fundsappropriated for service in one yearcannot be used to pay for servicecompleted in the year past.The demands for service during thefirst six months of the new fiscalyear (the last six months of thecalendar year) failed to either plateauor taper off, as we had presumedwould be the case, and in Decemberit was definite that significant retrenchmentwas indicated. The AdvisoryCommittee was called to a meetingon December 19 and approved ofmeans to accomplish this retrenchment,as follows:(1) Reduction of surgeons' fees.(2) Restriction of authorizations forservice to those of urgent oremergent character.(3) Close check and limitation ofhospital days.(4) Program support of but half thecost of appliances.(5) Reduction of validity of authorizationsto thirty days.(6) Retreat from the field of supportof treatment of some of the recentlyaccepted ultra special entities.(7) Discontinuation of support of theRheumatic Fever Center of theUniversity of North Carolinaand North Carolina MemorialHospital.These measures, with the exceptionof the last-mentioned, became effectiveretroactive to December 1, while(7) above became effective January1, 1955.The Section initiated a system ofencumbrance recording aimed at keepingexpenditures within the limits ofallotted income for each month andquarter.The office has added one filing clerk.Periodic bulletins of informationhave been published and distributedabout once a quarter, and work hasbeen initiated on the composition of anew operating manual. A new planwas submitted to the Children's Bureauin July and was accepted. Included inthis plan was a section for service onspeech and hearing defects. This hasnot been initiated because of a lack

June, 1955 The Health Bulletin 29of funds. long-term illness and handicappingThe nursing consultant component conditions. These seminars of fourof the Section, with the School of days' duration were well attended andPublic Health and the generalized very instructive.consultants of the State Board of Service statistics for the calendarHealth, conducted workshops in four year 1954 were as follows and reflectedareas in the problems of children with a definite increase over those of 1953:Number Treated Visits or Days CareClinic Service 10,220 20,587Hospital In-patient 1,418 18,169Other service by physicians(Out-patient, office, home etc.)__ 1,288 849Total unduplicated count of children who received physician services: 11,093(one or more specified in lines 1 to 4)Entities most frequently treated (First 10 of 41 conditions)(1) Polio 1,866(2) Diseases bones and joints other thancongenital, tuberculous, osteomyelitis,or others specified 1,296(3) Clubfoot 1,146(4) Flatfoot 1,143(5) Cerebral Palsy 785(6) Congenital other than clubfoot, hip, face,spinal and others specified 762(7) Miscellaneous diseases, injuries or otherhandicaps 693(8) Accidents, poisonings, violences 545(9) Curvature of spine other than congenital oreffect of polio or tuberculosis 303(10) Cleft palate and lip 246With constant increase in requests State) to support such service, thefor essential service for handicapped „ ., . .. ........ . ... .... . . program for aid to these children canchildrenand with no significant increasein appropriations (Federal or not be more than half effective.M&I CLINICS1954Total number of clinics conducted 5,009For white only 726For colored only 1,209For white or colored 3,074For Maternity patients only 856For infant and preschool only 1,686For maternity or infant and preschool 2,467Attendance — Maternity patients 31,610Infant and preschool 51,158Nutrition Section activities of the local health depart-The activities of the Nutrition Sec- ments with which it works,tion have been carried on within the The plan of operation of this Secframeworkof its (1) objectives; (2) tion differs somewhat from that ofpersonnel and (3) the objectives and other sections in that, since local health

30 The Health Bulletin June, 1955departments have not been able toemploy full-time nutritionists for theirstaffs, they request direct as well asconsultant service from the NutritionSection. The Section, therefore, hasdeveloped a plan which allows its consultantsto maintain regular monthlyschedules of work in the local departments.This means that, through jointplanning with a local health departmentstaff the nutritionist becomesadministratively responsible to thelocal health officer and regularlyworks in specific clinics, such as prenatal,well-baby, overweight, diabetic,and orthopedic. This regularity in visitsto the local health department alsomeans that the consultant is ableto assist the staff of a departmentwith its planning and participation innutrition services and activities withother community agencies and groups.The advantages in this plan areobvious, since local health departmentpersonnel is limited. Local health departmentsreceive assistance in thenutrition component of their basicpublic health programs (both directand indirect) and in their cooperativecommunity programs. This is important,for there are few communitiesin the State with access to the servicesof a trained nutritionist. Such aplan gives a department assurance ofcontinuity of service in programdevelopment.There are disadvantages, too, sincethe local departments have requestedand need more help from the nutritionistthan is now available. Thereare too few days in a month to providemore than minimum service toa portion of the counties in the Statewith the present number of consultants.When there are vacancies on thestaff, as there were for part of thispast year, the services are curtailedto include only requests with somedegree of urgency. This has the effectof reducing the possible achievementof the objectives of the Section programand the nutrition objectives ofthe local departments.During the year three vacancies onthe consultant staff were filled byMisses Helen Meadors, Mildred Barryand Vera Kerstell, thus permitting theSection to have a consultant for nineof its ten districts for the first timein its history. It has not, as yet, beenpossible to fill the position of PrincipalNutritionist left vacant by the resignationof Miss Gladys Strawn in April,1954. There were no changes in thestaff of dietery consultants.This report, therefore, represents theactivities of a partially complete staffworking in 71 counties as time wouldpermit.The nutrition consultants conductedin-service training programs for 943nurses, 2,316 teachers, 167 welfare caseworkers and 2,818 adults in communityprograms. They gave consultation serviceto 1,367 professional and 1,617non-professional persons. They attended42 orthopedic clinics, 130 prenatalclinics, 48 well-child clinics, 21 preschoolclinics, 15 overweight clinics,and 12 diabetic clinics, with a total of2,970 patients referred for individualdiet instruction. They surveyed 208children in seven schools.The dietary consultants visited 15State institutions 46 times. They gaveconsultant service to 42 hospitals and11 county homes. They reviewed plansfor renovation or construction of newkitchens for 49 hospitals. They providedin-service training for 542 non-professionaland professional personnel.There are similarities in activitiesthroughout the State, but the specificneeds of certain departments andinstitutions result in an interestingvariety of services.The Section staff participates in anumber of special projects. During thesummer the second annual institutefor food service managers was held inChapel Hill for hospital administratorsand food service managers from smallhospitals. This was sponsored jointlyby the North Carolina Hospital Association,the North Carolina DieteticAssociation, and the North CarolinaState Board of Health. This three-dayinstitute was attended by 35 personsrepresenting 28 hospitals.A project of special interest was a

June, 1955 The Health Bulletin 31study made at the request of thePrison Director of the diets served toprisoners. The review of the kinds andamounts of food served over a threemonthperiod in eight prison campsand the Central Prison providedessential information. The results ofthis study are being used by thePrisons Department in the developmentof its agricultural, food purchasingand food service programs.One other project carried on for thePrison Department was the developmentof a formula for a diet to beserved to prisoners in solitary confinement.This project, which is a type ofliver mush, of high nutritive value,provides a monotonous but adequatediet which may be served for an indefiniteperiod of time. The Sectionreceived invaluable assistance in theprocessing of this product from thelaboratory of the American Can Company.It canned two different formulassent to it by the Section, to determinethe necessary techniques to be followedand the feasibility of canning theproduct for distribution to the camps.The company cooperated further bysending consultants to the Prison tosupervise the canning of the livermush in the prison cannery.In conjunction with the State Boardof Public Welfare, nutritionists anddietitians participated in in-servicetraining programs held throughout theState for operators of boarding homesfor older people. The nutritionists alsoparticipated in the two workshops forschool lunch managers sponsored bythe school lunch supervisors and theState Department of Public Instruction.In four counties of the State, thenutritionists participated in groupweight control programs initiated andsponsored by civic groups in the counties.The devlopment of this type ofprogram has not been encouragedexcept when satisfactory arrangementscan be made with members of localmedical societies in the community forreferral of their patients to the groups.Physicians and psychiatrists haveparticipated in these projects, alongwith nutritionists and other persons.The problem of weight control is sufficientlycomplex to be approachedonly after careful planning, particularlywith reference to the follow-up. Itdoes, however, permit emphasis upona nutritionally sound diet which shouldbe followed by all persons for themaintenance of good health.One health department has establisheda clinic for overweight patientsreferred by physicians. This clinic(only 14 months old) originally plannedfor once a month grew so rapidlythat there are now two regular monthlyclinics. At present it is staffed bya nurse and a district nutritionist. Thenurse obtains the history and otherpertinent data, such as blood pressure,etc. The nutritionist advises all patientson their diets. The nursing staffchecks these patients on home visitsin their districts. The program appearsto be meeting with success and pointsout the importance of planned followupand individual guidance.Referrals for nutrition instructionfrom orthopedists still show a preponderanceof the cases in the categoryof overweight, but increasing numbersof patients are being referred forproblems such as child feeding, adequatefor children in families with lowincomes, anemia, undernutrition andhigh vitamin diets.The nutrition consultants have continuedtheir in-service training programson a quarterly basis for publichealth nurses and the short refreshercourse in nutrition for public schoolteachers. Both educational programsrequire continuous follow-up servicefor effectiveness. Since these twotraining programs have been in operationfor ten years, the follow-up programhas become extensive. It isgratifying, however, to see the publichealth nursing supervisors and thecounty educational supervisors initiatemore educational programs and assumemore responsibility for continuingthe work started by the nutritionist.The Nutrition Section receives anumber of requests from schools of

32 The Health Bulletin June, 1955public health and universities, trainingnutritionists and dietitians for publichealth, to supervise field training fortheir students. It was not possible toaccommodate all of the schools in1954, but five students did receive fieldtraining under the direction of theNutrition Section staff. One of thesewas a public health dietitian fromTeachers College, Columbia University.The four nutritionists were sent bythe School of Public Health, Universityof North Carolina; Penn State Collegeand the School of Public Health,University of Pittsburgh; the Universityof Tennessee and the HarvardSchool of Public Health. The studentfrom the latter school is studying forhis Doctor's degree in Public Health.The other students were receivingMaster's degrees.For the past few years dietetic internsfrom Duke Hospital have beenreceiving a two-week field trainingprogram each in the Durham CountyHealth Department under the supervisionof the Health Department staffand the district nutritionist. This hasbeen greatly appreciated by the Schoolof Dietetics at Duke University buthas meant supervision for a period ofabout six months each year, sincethere are approximately twelve studentseach year.During the past year Charlotte MemorialHospital arranged for a threeweekfield training period for eachof its dietetic interns with the CharlotteCity Health Department and thedistrict nutrition consultant. This hasproved to be a highly rewarding planfor both the hospital and the HealthDepartment.Members of the Nutrition Section,along with members of the CrippledChildren's Section, have continued toparticipate actively in the operation ofthe two camps for children withorthopedic handicaps at Washingtonand at Salisbury and the camp forchildren with speech defects at Salisbury.Assistance is given in menu planningand guidance of the food servicemanager in the operation of thekitchen and the preparation of food.The Nutrition Section of the StateBoard of Health has frequently encounteredboth resistance and indifferenceto the idea that nutrition isan important factor in health and,therefore, an essential part of a publichealth program. There is evidencethat interest in nutrition is increasingamong public health people and they,in turn, are encouraging others to improvetheir food habits. Eventuallythere should be some concrete evidenceamong the population groups ofthe effectiveness of its application.It has been well established in theplant and animal industry. It can, andwill, someday, be equally well-establishedfor the human race when mandecides to forego some of his accustomedhabits and make use of knownscientific facts that promote betterphysical and mental health.An excerpt from a recent publication,reprinted in the North CarolinaMedical Journal is aptly phrased:"Nutrition and Food. The nutritionistdidn't have an easy task at first inhis educational efforts. On the oneside he was opposed by the critic whoadvanced that many years ago a lotof people were healthy who took nopains to balance their diet. True, theydidn't take any pains, because theirdiet was naturally balanced; it wasbalanced by tradition and by experience.What the new knowledge toldus was why these people were healthyin spite of taking no pains. But therewere many more less fortunate folkwho were not healthy but we did notknow why. Children were stunted andmothers died in childbirth, or couldnot stand up against the strain ofnursing; and now we know why. Thenagain, it was difficult to get the newknowledge across to the individual. Totell a 15-stone man that he was overweightbut undernourished took agood deal of explaining and even theReaders' Digest didn't help in caseslike this".—Horder, L.: Fifty Years ofMedicine, New York, PhilosophicalLibrary, 1954, p. 23.The Nutrition Section's objectives,stated in past reports, will be continu-

June, 1955 The Health Bulletin 33ed for the furtherance of better health crease our serological service in theof North Carolinians. field of Virus and Rickettsial activity.We now have antigens and are per-LABORATORY OF HYGIENE DIVIS- forming complement fixation tests forION—John H. Hamilton, M. D., Direc- six of the Neurotropic Virus infections,tor six for the Viral and Rickettsial in-From some aspects the year 1954 fections showing pulmonary involvelookslike just another year of useful ments, and 3 of the Rickettsiel infecservicefor the State Laboratory of tions with skin manifestations. DuringHygiene, but a closer scrutiny shows the first half of the year we made 410that the year's work has certain of these complement tests and duringcharacteristics which made it different the second half 923, a total of 1,333.from all the other 46 which have pre- Of this number, 47 gave reactions ofceded it.sufficiently high titer to be significant.There was a reduction in the total Many of these specimens were pairednumber of examinations made during specimens, the first being taken in an1954. This is due entirely to the cur- early stage of the disease and thetailment of syphilis serology made second being taken some 10 days, twonecessary by the withdrawal of Federal weeks or even longer after the first.Funds for this purpose in 1953, which When we are supplied with pairedwas explained in our 1953 Report. Dur- specimens of this sort, we can giveing the first half of 1953 we could much more worthwhile informationmake all serological tests for syphilis than when only a single specimen iswhich were requested. During the examined. A rise in titer is indicativesecond half of 1953 and all of 1954 we of a current infection; whereas, acould not make serological tests for single laboratory test of significantsyphilis for Selective Service—neither titer can only mean that the patientcould we participate in case finding has in all probability at sometime insurveys, but limited our work in this the past had an experience with thatfield to the examination of specimens particular virus or Rickettsia,sent in by physicians as an aid to A new acivity of the Laboratory indiagnosis and those specimens sent in the field of serology which has rebylocal health officers for epidemio- vealed worthwhile information duringlogical studies. In 1953 we examined the current year is Agglutination Tests339,501 specimens of blood. In 1954 for Leptospirosis. For years we havethis number was 292,973. On all these realized that Weil's Disease of Leptospecimenswhich gave a positive re- spirosis icterohaemorrhagiae was occuraction we diluted serum and made ring in the State, but, until we had atitered tests which numbered 23,210. human death from a Leptospiral infec-We made serological tests on 2,520 tion, identified as the Canicola variety,specimens of spinal fluid. Of this we had little information about thenumber there was sufficient quantity prevalence of other types of Leptospiraremaining after the serological tests in the State. When we began to lookfor syphilis were made to do total pro- for and test for other varieties andtein determinations on 2,209. sources, we found them widely seat-When funds for serological tests for tered throughout the State. During thesyphilis were decreased, it was decided year we have tested 211 specimens ofthat we would decrease our serological blood from humans; 9 from dogs, 96tests for syphilis and not jeopardize from cows; 3 from mules; 6 from goats,other activities of the laboratory; con- Significant reactions were obtained assequently, we have been able to in- follows: PositiveLeptospira autumnalis strain 1 humanLeptospira canicola strain 6 dogs, 48 humans, 1 muleLeptospira icterohaemorrhagiae 7 human, 1 dogLeptospira pomona strain 8 human, 1 mule, 48 cows, 2 goats

34 The Health Bulletin June, 1955We doubt very much if Leptospirosisis a new infection in the State. It hasprobably been existing for years andhas been mistaken in most instancesfor infectious hepatitis. In the futurea physician seeing a patient withjaundice has an addition to make tothose conditions considered in a differentialdiagnosis.Weil Felix—In 1953 we made WeilFelix tests on 4,692 specimens of blood— 32 showing sufficiently high agglutinationtiters to be important; whereas,in 1954 tests were made on 4,164specimens with only 20 specimens givingrelatively high titers. Whether thisdecrease is due to early antibiotictreatment or to actual reduction inthe prevalence of Rocky MountainSpotted Fever and Endemic Typhus isproblematical, although the reportedcases of these two infections have decreasedmarkedly.Undulant Fever—There has been anincrease in the number of AgglutinationTests for Undulant Fever. In 1954we made 3,086 of these—only 4 ofwhich gave agglutination titers of importance.Tularemia—During the year we made2,205 tests with 18 positives, as comparedwith 2,378 and 32 positives in1953.Typhoid Fever—Agglutination testsfor typhoid fever decreased from 3,085in 1953 to 1,323 in 1954. On only 27 ofthese was the titer sufficiently highto be of any significance, and someof these could have been due to previousexperience with typhoid vaccine.For years we have called attentionto the importance of blood culture asan aid to the diagnosis of any bacterialinfection in which the organisms occurin the blood stream. Although agglutinationtests can be performed morerapidly than cultural procedures, apositive blood culture gives the physicianmuch more important infirmation.In 1953 we made cultures on 2,052specimens of blood finding the typhoidorganism in 12. In 1954 we cultured2,050 specimens, finding Salmonellatyphi in 12 and other Salmonella in 3.Feces cultures were made on 2,047 in1953 and on 2,747 in 1954—240 of theserevealed either Salmonella typhi, otherSalmonella or Shigella. Many of thesefeces cultures were made in the searchfor carriers.Gonorrhea— In 1953 we examined3,328 urethal smears—while in 1954 weexamined 3,411. The number of specimensin which characteristic organismswere found was greater in 1954 thanin 1953. In the field of gonocoocus cultureswe had less than half as manyspecimens in 1954 as in 1953—145 ascompared with 328.Rabies—This continues to be a verytroublesome problem There was anincrease in the number of animalheads sent in for examination in 1954— 941 as compared to 796 in 1953. In1954 there were 168 giving evidencetypical of rabies, as compared to 130in 1953. Of the 168—there were 148dogs, 10 cats, 5 cattle, 1 goat and 4foxes. In 128 animals on which wecould find no evidence of rabies frommicroscopic examination, we inoculatedmice. In 8 of these—rabies developedin the mice.Tuberculosis—The years 1953 and1954 were almost identical so far asthe number of specimens of sputumexamined microscopically for tuberculosiswas concerned—21,025 for 1953and 20,942 in 1954. The number ofcultures made in 1954 almost doubledthe number in 1953—4,473, as comparedwith 2,257 in 1953. In this largernumber cultured there were 17 morepositive cultures than in 1953—156 ascompared to 139.Diphtheria—In this field work wasalmost the same for both years— 1,484for 1953 and 1,438 for 1954. In 1953—80 showed diphtheria organisms andonly 52 in 1954.Malaria—We completed another yearwithout finding malaria parasites.There were 284 specimens examinedwith only the month of April failingto supply specimens.Sanitary Examination of Water1— Ouroldest activity showed the largest percentageof gain. In 1953—13,952 specimenswere examined—in 1954, 22,460.Most of this increase we could attribute

June, 1955 The Health Bulletin 35to the fact that many communitiesfound it necessary to provide emergencywater supplies because of theextensive drought during the summer.Also a substantial number of newwater supplies were added to our list.Stream Sanitation activities increasedduring the second half of the year.During the entire year 1953 we made1,440 examinations for the StreamSanitation Committee. The first halfof 1954 was about at this rate. However,during the period July 1 toDecember 31st there were 4,504 examinationsmade.Cancer Cytology—The total of 10,239specimens examined in 1954 was slightlylarger than the number examinedin 1953—9,787. In 1954—132 specimenswere considered to show evidence ofcancer with 106 suspected; whereas in1953 135 were considered to be fromcancer patients with 104 suspected.Intestinal Parasites—The number ofspecimens examined for intestinalparasites was 18,601 in 1953, and 18,231in 1954—3,094 or 16.6% of which showedsome intestinal parasite in 1953, and2,749 or 15.2% showing intestinal parasitesin 1954. These specimens originatedfrom 70 counties. Hookworm infestationwas found in 2,107; Ascarisin 415; Oxyuris in 86; Trichuris in 51;Hookworm- Ascaris in 50; and 50 showedmiscellaneous parasites.Shellfish—Our examinations of shellfishwere conducted in our laboratoryat Morehead City, which is staffed byone bacteriologist. The total numberof 6,933 examinations were made1,499 of which were for shellfish; 524were for crab meat; and 4,910 wereother examinations, principally waterfrom shellfish habitat.Approved Laboratories—For LaboratoriesApproved for the Making ofSerological Tests for Syphilis, we havecontinued our activities, with 168laboratories now on the approved list.Milk Laboratories—During the yearwe inaugurated an approval system formilk laboratories which would becertified as meeting the requirementsof the United States Public HealthService for the examination of milkfor interstate shipment.Biological Products distributed bythe laboratory show several significantchanges; for instanceTriple Antigen—Diphtheria and TetanusToxoid combined with PertussisVaccine, is rapidly replacing the singleantigens formerly used to immunizeagainst Pertussis, Diphtheria, andTetanus. Enough triple antigen for182,450 injections was distributed in1954. For the year 1953, the numberwas 159,630.Tetanus Toxoid—There is a substantialdemand for Tetanus Toxoid, ofwhich we distributed 24,470 injectionsin 1954.Diphtheria Toxoid—North Carolinacan properly take pride in its immunizationprogram, although we must admitthat it is not as good as it shouldbe—nevertheless, it is sufficiently effectiveto decrease the demand fordiphtheria toxoid—only 410 10,000-unitpackages and 607 20,000-unit packageswere distributed during 1954.Typhoid Vaccine—We would havehad a substantial reduction in 1954 hadit not been for emergencies created byHurricane Hazel in October.Smallpox Vaccine—Sufficient vaccinewas distributed in 1954 to inoculate173,980 individuals. Since this is substantiallyin excess of our birth rate,we seem to be maintaining our defenseagainst this loathsome disease.Immune Serum Globulin—In spite ofthe fact that there was no great ballyhooabout the value of Immune SerumGlobulin in the prevention of poliomyelitisduring 1954, we actually distributedmore of this product—84,394cc, and 75,172 in 1953. Most of thiswas used for the modification ofmeasles and the prevention of infectioushepatitis, both diseases in whichGamma Globulin has demonstrated itsvalue. In fact, several epidemics of infectioushepatitis were apparentlybrought under control during the yearby the judicious use of this biologicalproduct.The State Laboratory of HygieneFarm is continuing to demonstrate itsvalue, in spite of changes which the

36 The Health Bulletin June, 1955antibiotics have caused in the controlof infectious diseases. On this farm weproduced all of our own small animalsand produced our own rabies vaccineand smallpox vaccine. In addition ourlarge animals produced all of the bloodneeded in the operation of a modernlaboratory.Although we are operating on a verytight budget, we have not found itnecessary to increase the price of anyof our supplies or products. We havebeen able to meet all of the paymentswhich we are obligated to make inretiring the bonds which were issuedfor the purpose of constructing ourpresent Laboratory Plant. The last ofthese bonds will be retired during theyear 1957.The year was saddened by the deathof our Mr. Ross Martin, who for 29years headed an important group ofour workers in the Laboratory. ForMr. Martin's devoted and conscientiousservice, members of our staff hold himin fond remembrance. Countless physiciansand their patients throughoutthe State are unknowingly indebted toMr. Martin for the honest and capablehelp which he has given them.We have had fewer changes in ourstaff during 1954 than we have hadduring any similar period in the past10 or 12 years. This has enabled us toincrease the competency of our workers—adesire which is ever before us.Their loyalty and devotion to serviceis commendable. We look forward tothe future in anticipation of our beingable to play our part in making NorthCarolina a better place in which to live.

MEDICAL LIBRARYU. OF N. C.CHAPEL HILL, ». c.mmTKis Bulletin will be servtfree to anil citizen of the State upon requestIPublished monthly at the office of the Secretary of the Board, Raleigh, N. C.Entered as second-class matter at Postoffice at Raleigh, N. C. under Act of August 24, 1912Vol. 70 JULY, 1955 No.RECEIVEDJUL 27DIVISION OfHEALTH AFFAIRS UBRAttH. LEE LARGE HEALTH CENTERROCKY MOUNT, NORTH CAROLINA

MEMBERS OF THE NORTH CAROLINA STATE BOARD OF HEALTHG. G. Dixon, M.D., President AydenHubert B. Haywood. M.D., Vice-PresidentRaleighJohn R. Bender, M.DWinston-SalemBen J. Lawrence, M.DRaleighA. C. Current, D.D.S GastoniaH. C. Lutz, Ph.G HickoryGeo. Curtis Crump, M.DAshevilleMrs. J. E. Latta Hillsboro, Rt. 1John P. Henderson, Jr., M.D Sneads FerryEXECUTIVE STAFFJ. W. R. Norton, M.D., M.P.H., State Health OfficerJohn H. Hamilton, M.D., Assistant State Health Officer and DirectorState Laboratory of HygieneC. C. Applewhite, M.D., Director Local Health DivisionErnest A. Branch, D.D.S., Director of Oral Hygiene DivisionA. H. Elliot, M.D., Director Personal Health DivisionJ. M. Jarrett, B.S., Director Sanitary Engineering DivisionFred T. Foard, M.D., Director Epidemiology DivisionFREE HEALTH LITERATUREThe State Board of Health publishes monthly Tm Health Bulletin, which willbe sent free to any citizen requesting it. The Board also has available fordistribution without charge special literature on the following subjects. Askfor any in which you may be interested.DiphtheriaFliesHookworm DiseaseInfantile ParalysisInfluenzaMalariaMeaslesScarlet FeverTeethTyphoid FeverTyphus FeverVenereal DiseasesResidential SewageDisposal PlantsSanitary PriviesWater SuppliesWhooping CoughSPECIAL LITERATURE ON MATERNITY AND INFANCYThe following special literature on the subjects listed below will be sent free toany citizen of the State on request to the State Board of Health, Raleigh, N. C.Prenatal CarePrenatal Letters (series of ninemonthly letters)The Expectant MotherInfant CareThe Prevention of Infantile DiarrheaBreast FeedingTable of Heights and WeightsBaby's Daily ScheduleFirst Four MonthsInstructions for North CarolinaFive and Six MonthsSeven and Eight MonthsNine Months to One YearOne to Two YearsTwo to Six YearsMidwivesYour Child From One to SixYour Child From Six to TwelveGuiding the AdolescentCONTENTSPageMemorial To Dr. Joseph A. Morris 3Our Historic Heritages In Public Health 4Remarks at the Rural Health Conference In Greenville, N. C. .__ 8Latest Chemicals and Procedures Used In Insect Control __. 9

!l§dMbIPU6LI5AED BYTAE N°RTA CAROLINA STATE B°ARD-*AEALTA| |i£Vol. 70 JULY, 1955 No. 7J. W. R. NORTON, M.D., M.P.M., State Health Officer JOHN H. HAMILTON, M.D., EditorMEMORIAL TO DR. JOSEPH A.By ERNEST A. BRANCH, D.D.S.MORRISDEDICATION OF HANCOCK MEMORIAL HEALTHJune 19, 1955CENTERI deem it a great honor and privilegeto pay tribute to one who was yourfriend and my friend, Dr. Joseph A.Morris. It is particularly fitting that, asthis beautiful new Health Center is beingdedicated to the service of the peoplein Granville County, we pause inmemory of one who devoted not onlyhis years but also his heart and hismind and his strength to the healthand welfare of his people. We know thathe is here in spirit this afternoon.You will recall the thrilling and dramaticstory of another great physician,David Livingston and his request that,at his death, his heart be buried inAfrica, where it was during his life. Inour day and generation, Dr. Morris wasa physician and a Christian gentlemanwhose heart was truly in his work. Itwill remain among the people whom heloved and served.Dr. Morris was closely identified withGranville County. He was born here in1863. Except for the years he spent inpursuing his education—first at theUniversity of North Carolina, fromwhich he graduated in 1887, then atVanderbilt University, from which hereceived his degree as Doctor of Medicine,and later a year's postgraduatestudy of Medicine in New York City—and three years in the practice of Medicinein Texas. Dr. Morris lived out hisfour-score years and twelve right here.He was identified not only in years ofresidence but also in interests and experiences.I am sure that the six yearshe spent as farm agent brought himcloser to the people and gave him adeeper understanding of their needsand problems. When he became CountyHealth Officer in 1919, Granville Countyand public health in North Carolinawere indeed fortunate.Dr. Morris was diligent, conscientiousand painstaking in the performance ofhis duties. He was a stickler that thingsshould be just right. He expected ofhimself and of others that all the "I's"should be dotted and all the "T*s"crossed.Though he lived most of his life inthis one county, he was in no senseprovincial. He was a well read and alearned man. I am sure that you recall,as I do, his delightful use of the Englishlanguage, both as to vocabularyand enunciation. He was a man whowas interested in and who could discussintelligently many subjects. All of theseaccomplishments he brought to bear onthe chief burden of his heart—the welfareof the people whom he loveddearly.I am speaking from experience becausemy association with him in publichealth was close. I have gone with himthroughout this county, from center tocircumference, in the schools and out.

The Health Bulletin July, 1955We have walked through new ground,scrambled up ditch banks, gone throughplowed fields and climbed lot fences inorder to talk to county commissionersand school board members about publichealth or to parents about the healthof their children. He knew the importanceof presenting the problems of thepeople and enlisting their cooperation.One of my favorite public healthstories is about my experience in helpingDr. Morris put on an exhibit at acommunity fair at one of the tobaccowarehouses here in Oxford, about 25years ago. He was particularly disturbedbecause there had been two deathsfrom typhoid fever and three fromdiphtheria, and he wanted to impresson the people just what the HealthDepartment could and should mean tothem. We put our heads together andcame up with something which we feltsure would make an impression. Whenthe fair opened and the people streamedby the Health Department booth,they were startled to see two coffins foradults and three for children with aplacard saying, "These deaths from typhoidfever and diphtheria in GranvilleCounty this year could have been prevented.Consult your Health Department."This may have been a bit morbidand drastic for a fair exhibit, butI do not need to tell you that it got theattention of the people, and Dr. Morriswas pleased with the results.We cannot do justice, in this shortdiscourse, to Dr. Morris, his life ofservice and his great contribution tosociety. I have told you nothing thatyou, his friends and neighbors, did notalready know. This gathering today andthis very building are evidences of hisefforts and accomplishments during hisyears as County Health Officer.This portrait of Dr. Joseph A. Morriswill serve to remind us all of his unselfishand untiring service to humanityand to inspire us to emulate his example.May we, as he did, "love mercy,do justly, and walk humbly with ourGod."OUR HISTORIC HERITAGES IN PUBLIC HEALTHBy C. C. APPLEWHITE, M.D., M.P.H.Director, Local Health DivisionNorth Carolina State Board of HealthIt is deemed timely and appropriateon this occasion to pause and takestock of the magnificent public healthheritage that is inherent in and peculiarlyindigenous to the area embracedby this Association. It is one of whichall may feel justly proud. It was in theSouth that Goldberger made his outstandingdiscoveries with respect to pellagra;Carter made his observation onthe extrinsic incubation period of yellowfever by the use of which WalterReed was able to demonstrate that yellowfever was transmitted by the Aedesaegypti mosquito and Carter and Le-Prince inaugurated a malaria controlprogram which later achieved worldwideacclaim. Here, Stiles demonstratedthe presence of hookworm diseasewhich stimulated a south-wide hookwormcontrol campaign that produceda profound effect upon the entire publichealth development in this area. Inthis region, full-time local health servicefor a distinctly rural population wasinaugurated and systematically developed.Attention should here be called tothe heroic work done by members ofthe medical profession in securing legislativeenactment of measures authorizingthe development of state boards ofhealth. This work was done by thesemedical statesmen often at personalfinancial sacrifice and without anyhope of reward other than the satis-* Address at 1955 meeting in New Orleansof Southern Branch of the AmericanPublic Health Association.

July, 1955 The Health Bulletinfaction of achieving an improvement inthe health status of the citizens of thisarea. It is said in the long ago "therewere giants in the land." These physicianswho almost singlehandedly wageda successful campaign for creating stateboards of health were giants not ofbrawn but of brain, not of muscle butof mentality, not of brutal courage butof courage born of a definite convictionthat the state had a legal and a moralresponsibility to protect the health ofits citizens. Surely the epochal statementof Sir Winston Churchill that"never was so much owed by so manyto so few" is truly applicable to thosemen for their statesmanlike and heroicconduct. Through their unselfish anddevoted service, the broad and firmlegal foundation of the modern publichealth program was laid. As typicalrepresentatives of this group of pioneeringmedical statesmen, the followingnames are mentioned:Jerome Cochran of AlabamaMorgan Smith of ArkansasJohn P. Wall of FloridaJ. G. Thomas of GeorgiaL. P. Blackburn of KentuckyE. H. Barton of LouisianaJ. M. Taylor of MississippiT. F. Wood and R. H. Lewis ofNorth CarolinaJ. D. Plunket of TennesseeJames L. Cabell of VirginiaManning Simons of South CarolinaIt will be of particular interest to thissection of the Association to know thatone of the first types of health workrecommended by these pioneers was theenactment of a thorough system of lawsfor registration of births, deaths andmarriages. The following statementtaken from the recommendation to oneof the state medical associations issignificant:"The registration of births, marriages,and deaths, with the causes of deaths,will afford the means of preserving andcollecting accurate vital and mortuarystatistics throughout the state, withoutwhich all legislation looking to the promotionof public health, and the preventionof disease, must be more or lessguess work. Without such statistics, thefield for the operation of a board ofhealth will be very contracted. Registrationis a prerequisite for statistics ofany sort."It has taken years of "sweat, bloodand tears" to bring the vital recordssystem of the states to their presentstate of effectiveness. Workers in the. . .field of vital statistics, like all others,owe a debt of gratitude to those pastworkers who have labored hard andlong in this particular field.As a typical example of the longrangevision, constructive thinking, andstatesmanlike attitude of the medicalleadership at that time, the followingstatement made by Dr. J. P. Wall ofFlorida about 80 years ago is strikinglysignificant: "The duty of preservingthe health and lives of its citizens fromthe causes of disease is as incumbenton the state as is that of suppressingrapine and murder one has noadequate conception of how much sicknessand consequently death are preventable.The time is fast hasteningwhen the preservation of the publichealth will become one of primary considerationin all enlightened governments."This is a heritage that no publichealth worker today should everforget.Soon after the turn of the centurythe actual construction of a modernpublic health program was inauguratedon the firm foundation which has beenlaid by these earlier pioneers. Fortunately,in practically every state, physicianswith outstanding ability were selectedas leaders in this particular field.These men were endowed with vision,courage, persistence, determination andability for intelligent leadership. Theywere imbued with the spirit of loyaltyto the best interest of scientific medicine,actuated by determination to seethat the task was effectively done inspite of all obstacles, absolutely immuneto the seductive call of politicsand motivated by an insatiable desireto render efficient service to humanity.They were men of"Strong minds, great hearts, truefaith, and ready hands;Men whom the lust of office does

6 The Health Bulletin July, 1955not kill;Men whom the spoils of office cannotbuy;Men who possess opinions and awill;Men who have honor; men who willnot lie;Men who can stand before a demagogueAnd damn his treacherous flatterieswithout winking;Tall men, sun-crowned, who liveabove the fogIn public duty and in private thinking."To confirm the outstanding ability ofthe leadership provided at that time itis only necessary to mention the followingnames: Fulton of Maryland,Freeman and Williams of Virginia,Rankin and Cooper of North Carolina,Hayne of South Carolina, Harris andAbercrombie of Georgia, Porter ofFlorida, Sanders and Welch of Alabama,Dowling of Louisiana, Garrisonof Arkansas, Leathers of Mississippi,West and Bishop of Tennessee and theMcCormicks of Kentucky. Lumsdenand Carter of the Public Health Serviceand Rose and Ferrell of the RockefellerFoundation served during thisperiod as distinguished consultants tothe states in this area. Surely this is areal galaxy of stars in the firmamentof public health upon which all maygaze with profit and justified pride andsatisfaction. This form of leadership isa wonderful heritage of the highestorder.There could be added to this list thenames of others whose record of publichealth achievements would probablysurpass those here mentioned. They,fortunately, are still in public healthharness and are keeping the traces taut.For that reason, they are omitted forthe present.It is very significant that practicallyall of these early leaders in the publichealth field developed a strikingly similarphilosophy with respect to the waysand means of achieving the best results.Early in the period of organization theyrealized that most public health problemswere local in origin and would requirelocal machinery for their solution.The agency of choice was thelocal health department manned bypersonnel who devoted their full timeand efforts to the task of preventingdisease and promoting a state of goodhealth among the citizens. This planof organization was at an early stagedecided upon to be the one of choicein securing the most effective and lastingpublic health results. This basicallysound philosophy has been persistentlyfollowed by the successors of these earlyleaders, with the result that the areaencompassed by this Association is morenearly completely covered by full-timelocal health service than any similararea in the United States. This plan oforganization is a noteworthy heritageand is worthy of emulation in otherparts of the country.Please bear in mind that, in the inaugurationof the modern health movement,the leaders had no clearly definedprogram, no facilities for trainingpersonnel other than the school ofexperience. Funds available for publichealth purposes were meager, and theattitude of the appropriating agenciesand the general public was apatheticand sometimes hostile. The tools availablefor the construction of the newpublic health edifice were few and oftencrude. However, these leaders had faithin the worthiness of the cause thatthey espoused, faith that the medicalprofession which had laid the foundationfor the structure would give activesupport through the building era, faiththat the general public when suppliedwith the essential facts would ultimatelyrally to the support of thecause. They also possessed unboundedenthusiasm because they felt their causewas just and that they were engagedin a life-saving enterprise. With suchan inauspicious beginning against apparentlyinsurmountable obstacles, themovement was started and gained momentumand achieved results in communicabledisease control that are reallystartling. The death rates from typhoidfever and diphtheria have beenreduced more than 99%; the deathrates from pellagra and malaria have

July, 1955 The Health Bulletinbeen reduced in excess of 98%; thedeath rates from dysentery, 86%; tuberculosisdeath rates have been reducedapproximately 80%; and the infantand maternal mortality rates havebeen reduced in excess of 70% by thecontinuous application of proceduresinaugurated in accordance with theplan set up by these early leaders. As aresult of the constant and routine applicationof sound public health techniques,the present public health structurehas been provided with a soundprogram, strong financial support, goodfacilities for training personnel and apublic attitude which endorses and supportsthe public health movement withenthusiasm. This is the crowning heritageto which modern public healthworkers fall heir.It is true that public health workers,with the enthusiastic cooperation of themedical and allied professions, as wellas the general public, have achievedoutstanding results in all phases of theroutine public health program to whichtheir efforts have been applied. Notwithstandingthese excellent results,this is no time for complacency. A reviewof the vital records will indicatethat there are grave problems whichwill require the combined and consecratedefforts of all agencies keenly interestedin the progressive advancementof the human race through the practicalapplication of available scientificdata to routine usage. One look at thevital tables of any state will reveal thataccidents and the degenerative diseases,such as heart disease, diseases of theblood vessels, cancer, diseases of thekidney, and diabetes, are the real killers.In the past, health departmentshave devoted little or no attentionspecifically to these problems. It ishonestly felt that the time is at handwhen the sights of public health administratorsmust be raised and focusedon these main causes of death. Lack ofknowledge with respect to the aetiologyand methods of control with respect tothese problems has heretofore been adeterrent to definite and constructiveaction. Mental health is now generallyrecognized as one of the gravest problemsconfronting the whole nation. Itis definitely felt that public healthworkers can make a realcontributionto the solution of this problem. Whateffect, if any, nutrition and endocrinologyhave in the aetiology of the socalleddegenerative diseases and certaindiseases of the mind has not yet beendefinitely determined. It is in this fieldthat the services of well trained youngphysicians and other technicians areurgently needed in order to develop asensible and constructive public healthprogram for the solution of these problems.Notwithstanding the lack of adefinite program, it is firmly believedby forward-looking public health administratorsthat much can be done toreduce the morbidity rate and lowerthe death rate of these so-called degenerativediseases by early detection andearly treatment by competent privatepractitioners of medicine. To achieveworthwhile results in this particularfield, teamwork between the publichealth personnel, the medical and ancillaryprofessions and the general publicis absolutely essential. These problemsconstitute a distinct and worthychallenge to the modern public healthworkers if they are motivated by thesame faith and enthusiasm which characterizedthe early pioneers in the publichealth program. It is firmly believedthat through a spirit of teamwork asolution to these vexing problems canbe found. It is sincerely hoped thattoday's public health workers will graspthis wonderful opportunity and willapply themselves assiduously to thetasks ahead with the firm convictionand determination that results willcrown their efforts. This is your opportunityto make for the future generationof public health workers a real andlasting contribution and add luster tothese already resplendent public healthheritages.

8 The Health Bulletin July, 1955REMARKS AT THE RURAL HEALTH CONFERENCEIN GREENVILLE, NORTH CAROLINABy J.STREET BREWER. M.D.Roseboro, N. C.I wish to talk to you just a few minuteson the importance of a regularphysical check-up examination whichshould be done on a semi-annual orannual basis according to your age andthe state of your health. I would liketo call such an examination a healthassurance examination. You go to yourdoctor and have a physical examinationand let us say he finds you in goodhealth. Then you feel assured becauseyou have had your examination and thedoctor discovered nothing of significancewrong. On the other hand, letus suppose that he does find somethingwrong. Then the necessary steps to correctthe error or whatever disease youhave can be instituted immediatelywithout you having to wait for symptomsto warn you that something iswrong. The great value of regular annualphysical examination is in the detectionof incipient diseases, like tuberculosisand cancer and many forms ofheart disease, for example. They maybe present and operating in your bodymany weeks or months before the symptomsbecome sufficiently alarming tosend you to the doctor. In other words,they do not produce pain or distressuntil a long time after their inception.I wish to ask each individual in theaudience a question. Do you have afamily physician? Do you have thecondition of your physical body registeredanywhere? You have your carregistered, your property listed andregistered, but what about your ownbody? The place to have your bodyregistered and the condition of yourhealth noted is in your family or personalphysician's office. I wish to emphasizethat every individual shouldhave a personal physician and youshould make it your business to go tohim at regular intervals for a physicalexamination. The records in his officewill have meaning throughout your lifetime.He will refer to them from timeto time as he attempts to keep an accurateaccounting of your health. If herefers you to another physician at anytime, your history from your record canbe easily obtained and save you timeand money, as your family physiciangives the new doctor the benefit of pastvisits, treatments, illness, etc. It isoftentimes important in a given case tobe able to find out what an x-ray examination,electrocardiogram or bloodpressure reading was one or severalyears ago.After your examination, don't pressyour doctor to tell you everything aboutyour condition in detail. Often in thecourse of the examination the doctorwill find variations from normal thatare insignificant so far as life andhealth are concerned, but one notknowing too much about medicinemight be inclined to worry over them.Your doctor understands what he seesand finds, and he will tell you if thereis anything wrong that you should beconcerned about. Just follow his recommendationsand don't pester him withtoo many questions, many of which willbe irrevelant. And let me urge you tostay with your family physician. Don'tbe changing from one doctor to anotherwithout good cause. The accumulatedknowledge and understanding that aphysician acquires about a person afterseveral years of observation and studyis oftentimes a very important factorin the management of serious illness.

July, 1955 The Health BulletinLATEST CHEMICALS AND PROCEDURES USEDIN INSECT AND RODENT CONTROL*By KENT S. LITTIGCommunicable Disease Center. Public Health ServiceU. S. Department of Health, Education, and WelfareAtlanta, GeorgiaINTRODUCTIONInsects flourished in countless numbersduring the Carboniferous period,long before the first man appeared onearth. Many of the prehistoric insectsstill exist in much their original form.Unlike the insects, man has advancedmentally, physically and spiritually. Hisintellect has explored the facets of allthe sciences in an effort to see all andto know all. Our present generationhas seen tremendous advances to insureour comfort and wellbeing, despitethe legions of insect enemies.You no doubt remember the accountin our Bible of the children of Israeltoiling in captivity under the EgyptianPharaohs. They were obliged to makebrick without straw for the granariesof Egypt. Some of the granaries havebeen explored by archeologists, andthose strawless bricks have beenbrought to light. It was also discoveredthat the granary weevil was a seriouspest of grain even in those early times.The Greeks killed insects with sulfuras early as 1,000 B.C., and records indicatethat the Chinese controlled gardeninsects with arsenic and wine about900 A.D. Nevertheless, it was not untilthe 1860's that our first modern insecticide,Paris green, was developed to combatthe Colorado potato beetle. Prior tothat time, Paris green had been knownonly as a beautiful but dangerous pigmentfor oil paints. This discovery stimulatedthe production of lead arsenate,calcium arsenate and other arsenicalsfor controlling chewing insects.Marco Polo mentioned the use ofmineral oil for treating camels formange caused by the scabies mite.Later, kerosene was used for killingscale insects on citrus trees and forcontrolling mosquito larvae. Even nowthe miscible oils, such as Volck, find animportant place in the control of scaleinsects and white flies on ornamentalsand fruit trees.The horseless carriage has evolvedinto our modern automobile during thepast fifty years, the radio and televisionindustries have become big business,and man has learned to split theatom. The development of insecticidesand rodenticides has been nearly asmeteoric as these other evidences ofman's progress.MODERN INSECTICIDESPoisons Derived From PlantsLong ago the natives of South Americancountries were observed to throwpulp of certain plants into streams andponds to paralyze fish. Humans couldeat these fish without suffering ill effects.It was learned that the concoctionconsisted of the crushed roots andstems of derris, cube and other plantsthat contained rotenone. Subsequenttests showed that rotenone was veryeffective in controlling fleas on domesticanimals, grubs on the backs of cattleand many garden pests.Pyrethrum was known for many yearsas Persian or Dalmatian powder. Thispowder is made by grinding the flowerheads of certain daisies of the chry-* Presented at the annual meeting of theNorth Carolina Public Health Association.Raleigh, North Carolina, September 24,1954.

10 The Health Bulletin July, 1955santhemum family. Pyrethrum is nowone of the chief ingredients of aerosolsprays used indoors, although it is tooexpensive for widespread outdoor use.You may have used Pyrenone, 1 / a commercialpyrethrum product containingPyrethrum extract, plus a synergist.This synergist is piperonyl butoxide, achemical that does not kill flies by itselfbut greatly increases the effectivenessof pyrethrum, permitting the useof very low concentrations. Some ofthe pyrethrum sprays contain only onetenthof one percent pyrethrins andone percent piperonyl butoxide.Allethrin is an artificial compoundsimilar in action to the pyrethrins thatmay be used in various types of spacesprays. Allethrin is usually employedwith a synergist to increase its potency.Nicotine is a very poisonous alkaloidderived from the tobacco plant—chieflyfrom the stems and other waste portions.This insecticide is valuable forcontrolling plant lice or aphids but istoo toxic for use in public health work.Sabadilla and ryania are two otherpoisons derived from plants. They arenot at present considered to be ofmuch value in public health operations.ChlorinatedHydrocarbonsWe are all familiar with chlorine, achemical used either as a gas or inhypochlorite for destroying bacteria inwater. We also are familiar with gasolineand kerosene, two of the hydrocarbons—substancescontaining only theelements hydrogen and carbon. Whenone of the hydrocarbons is chlorinated,the resultant chemical is known as achlorinated hydrocarbon. DDT, chlordane,lindane and many other importantinsecticides belong to this group.They consist basically of benzene ringcompounds in various combinationswith chlorine atoms. Therefore, thesechemicals are related, and, when aninsect develops a resistance to one ofthe group, it may soon develop a resistanceto other chlorinated hydro-VTrade name is used as a means ofidentifying the product. Its use does notconstitute endorsement by the U. S. PublicHealth Service.carbons. DDT-resistant house flies, forexample, soon become immune to poisoningby lindane.DDT is one of the few treasures salvagedfrom the recent world conflict.The production of this important insecticidejumped from nothing to threemillion pounds a month in less thantwo years. The incredible two-way actionof DDT produced a revolution ininsect control practice. Not only wouldDDT kill insects hit by the spray particles,but it also would cause almostcertain death to insects that walked ontreated surfaces many months later.People grew to depend upon DDT asa miracle insecticide and became emotionallyinvolved because of the knowledgethat DDT saved thousands andpossibly millions of lives in protectingpeople from malaria, plague, epidemictyphus and other diseases. It was abitter blow to human credulity whenhouse flies and north Korean lice becameresistant to DDT. Certain mosquitospecies soon developed a resistanceto DDT. Culex tarsalis, an importantwestern species, became resistantto as much as one thousand times thenormal killing concentration of thischemical. People were willing to throwDDT out the window. DDT, however,is still our most practical insecticidefor the control of a wide range of insectspecies. Related compounds, suchas methoxychlor, may be used for applicationswhere low toxicity to humansand animals is a requirement.Chlordane was developed in thiscountry during World War II and remainsone of our most valuable insecticides.Chlordane, like DDT andother chlorinated hydrocarbons, maybe formulated in emulsions, solutions,suspensions or dusts. Dieldrin and aldrinare related compounds used out ofdoors chiefly for the control of agriculturalinsects, although dieldrin is anexcellent mosquito and fly larvicide.Benzene hexachloride was developedfor industrial use by French and Englishworkers about 1942. It is a mixtureof several isomers, only one of which,the gamma isomer, is highly toxic toinsects. Lindane is the 99 percent pure

July, 1955 The Health Bulletin 11gamma isomer of BHC and has all ofthe good qualities of the parent compoundwith only a slight amount of itsundesirable musty odor. Gammexane, aBritish product, is roughtly equivalentto lindane. These chemicals kill insectseither as stomach poisons, contact poisonsor fumigants. They do not havethe long residual killing power of DDT.The Organic PhosphatesThe organic phosphates are some ofour sharpest weapons in insect control.They are toxic to nearly all insects,ticks and mites and can be preparedin all of the standard formulations.Most of these materials are too toxicto humans and domestic animals topermit extensive usage.Bladan was developed by Germanscientists during World War II forkilling aphids and mites. Americanchemists found that tetraethyl pyrophosphatewas the chief ingredient ofthis compound. This chemical is knownas TEPP, an ingredient of certain flybaits and agricultural sprays. TEPP isvery hazardous for use in the controlof public health insects. I would hestitateto recommend this material forfly control. Parathion is a similar materialused for agricultural insects butis not considered safe enough for publichealth work. Excellent control offlies has been attained in tests withparathion-treated cords used in dairybarns and hung in loops from the ceilingto attract flies. These tests are beingcontinued by the CommunciableDisease Center Technical DevelopmentLaboratories at Savannah, Georgia, inan effort to develop a safe means ofusing parathion cords.EPN, another organic phosphate, hasfound extensive use in California forthe control of Culex tarsalis larvae. Thismosquito is highly resistant to DDTand is a severe pest as well as the chiefknown vector of encephalitis in theWest. EPN is effective at dosages aslow as 0.035 pounds per acre. Suitablerespirators, neoprene- dipped canvasgloves and other protective clothing aregenerally necessary for persons mixingand applying materials of high toxicityor whose toxic properties have not yetbeen definitely established.Diazinon is another organic phosphatewhich is much less toxic to humansthan TEPP but is highly toxicto flies and certain other insects. Thismaterial should not be used unless approvedfor public health work by yourstate health department. We will knowmore about diazinon after completionof further tests of its toxicity to warmbloodedanimals.Malathion is a chemical you will allknow better in the near future. Thisorganic phosphate has a very low toxicityto humans, much like that ofDDT but is highly toxic to many speciesof insects. It will kill DDT-resistantflies readily and may prove invaluablein the control of aphids, mites andmany other pests. As a residual spray,malathion is effective for only one tothree weeks. It may be used in poisonousbaits, and further tests may proveits value in space spraying.INSECT CONTROL BY CHEMICALSThe Control Of FliesNormally well-adjusted people oftenforsake their civilized ways when besetby hordes of insolent house flies. Itseems that no insect can be more persistentin attaining its objective thanthe hungry fly. Fortunately, few otheranimals have its propensity for browsingin human and animal feces andlater visiting pastries and other humanfoods.The house fly, Musca domestica, becameresistant to DDT soon after theintroduction of this potent new chemical.The insect overcame each succeedingpoison until research workers becamefrantic and pest-control operatorshad a disillusioned clientele. Residualsprays, space sprays, poison cords, baits,electric screens and the familiar vaporizers,one by one, proved inadequate tocope with the house fly hordes. Fewpeople thought of the most logicalmeans for fly control and the controlof diarrhea-dysentery disease carriedby this enemy. We know now thatbasic fly control consists of isolationof human and animal feces from thesetwo-winged insects, storage of garbage

12 The Health Bulletin July, 1955in fly-tight cans, frequent collectionof refuse and suitable incineration orburial of refuse in a sanitary landfill.Malathion has perhaps brought abouta new era in fly control. This chemicalis related to deadly TEPP and parathion,chemicals that might play havocwith human life if used indiscriminately.Despite malathion's low toxicity toman, it is highly poisonous to resistanthouse flies. Malathion is valuable bothas a residual spray and as a bait. Oneto 2.5 percent malathion emulsion orsuspension with sugar or syrup may beapplied to surfaces where flies congregate,producing a dramatic kill. Malathion,plus sugar or molasses, may beused as a bait on pulverized oystershells or on surfaces to attract and killflies. Malathion has produced excellentresults in the fog and mist machinesand may offer promise for future spacespraying activities if approved for thispurpose. This chemical remains effectivefor one to three weeks, after whichreapplication is necessary. It will be ineffectivein the long run unless it issupplemented by sanitation measures,for an insecticide does not replace sanitationin fly control.Malathion will have to compete withtwo other organic phosphates for residualapplications. They are chlorthionproduced by the Chemagro Companyand a similar material (No. 4124) madeby the American Cyanamid Company.Whereas malathion will last one tothree weeks, chlorthion and 4124 canbe expected to last six weeks. These twolatter chemicals have not yet been approvedfor use in dairy barns; malathion,however, has this approval.Mosquito ControlDDT remains the most importantchemical for mosquito control. Lightapplications of 0.1 to 0.2 of a pound peracre in oil solution will kill most mosquitolarvae readily. Culex tarsalis, thewestern vector of encephalitis, hasdeveloped an almost complete immunityto DDT but is controlled by EPN at0.025 of a pound per acre. Some otherspecies, such as Aedes sollicitans, thesalt-marsh mosquito, and Aedes dorsalis,a marsh and rice field mosquito,have become DDT resistant. Salt-marshmosquitoes have been controlled byground applications of EPN at 1/100 ofa pound per acre, heptachlor and dieldrinat 1/40 of a pound per acre, orlindane, chlordane or malathion at 1/40of a pound per acre. Dieldrin appliedas an emulsifiable concentrate or as awettable powder suspension at the rateof one pound per acre has preventedmosquito breeding for more than a yearin small landlocked, fresh water ponds.This concentration should not be usedwhere total destruction of fish wouldbe objectionable. This same applicationto rice fields has controlled Psorophoralarvae for an entire season. Thus, theoutlook is very good for continuation ofeffective mosquito larviciding by cityand county health departments andother agencies.RODENT CONTROLOld MethodsOld methods of controlling Norwayrats and roof rats still persist in spiteof our new knowledge of rodenticidesand rat biology. Ferrets, dogs, cats,rifles, slingshots and the man with astick still engage the wily foe, althoughno permanent injury to rat populationshas been inflicted.Poisoning, another old method of ratcontrol, is still practiced, but with newmaterials and techniques. Fortunately,many of the most dangerous rodenticides,such as strychnine, arsenic trioxide,phosphorus paste and thallium sulfate,are falling into disuse. People arelearning that rat killing has very temporarybenefits, as it eliminates competitionand stimulates the survivors tomaintain a high population level.Trapping RatsRats may be trapped to obtain bloodspecimens for laboratory tests for disease.Combing ectoparasites from trappedrats makes it possible to determinethe prevalence of rat fleas and the resultof DDT dusting programs. Rattrapping may be employed to obtain anestimate as to rat abundance, althoughrat signs should suffice for this purpose.General rat trapping programs overlarge areas are expensive and unpro-

July, 1955 The Health Bulletin 13ductive, whereas the use of rodenticidesis cheaper and more effective. Trapsare useful in killing the last few ratsin a building after poisons have broughtthe infestation down to a low level.Traps are practical as a means for killingvery small rat populations and havethe advantage over rodenticides ofcreating no odor problem. Traps arestill weapons of choice for killing housemice. These stupid little creatures willenter cage traps readily or will take thebacon bait on a snap trap with utterdisregard for their lives. The morecrafty rat learns by experience andwill avoid baits or traps if it survivesthe first contact with them.One-Shot PoisonsRed squill, 1080, Antu, and zinc phosphideare one-shot poisons that willkill a high percentage of the rat populationin a building or block in one ortwo nights. Sometimes 1080 kills everyrat in a building during the first nightof poisoning, although repoisoning isusually necessary. Only a highly trained,cautious individual can safely usethis deadly poison. Sodium monofluoracetate(1080) is highly effective butmay be recommended only under conditionswhere it can be used with comparativesafety. It is relatively free fromobjectionable odors.Most of us will have to remain contentto use a 10-percent red squill preparationin cereal, meat or fish in foodhandlingestablishments. This shouldbe followed immediately by baiting withpival or warfarin to kill remaining ratsand to prevent future build-ups of ratpopulations.AnticoagulantPoisonsSeveral years ago it was observed inWisconsin that cattle developed serioushemorrhage after feeding upon decomposedclover. An analysis of the cloverby Professor Karl Paul Link showedthat it had a high content of dicoumarin.This chemical prevents the coagulationof blood, with a resultant lossof blood through the smaller vessels.Research workers tested dicoumarinagainst rats in an effort to producefatal hemorrhage. It was not sufficientlypotent to be effective as a rodenticide.Warfarin and pival, two very potentanticoagulants, were subsequentlydeveloped by research organizations.These rodenticides are used in greaterquantities in the United States than allother rat poisons combined.Pival is similar to warfarin in its effectupon the rat and in the way it isused. It is more resistant to insect attackand to mold than warfarin buttakes somewhat longer to kill rats.Both anticoagulants are marketed in a0.5 percent technical grade concentration.Warfarin is diluted with cornstarchcolored with lake green pigmentto identify it as a poison. Anticoagulantbait is prepared by mixing one part ofconcentrate with 19 parts of freshlyground yellow corn meal. Thus, onepound of warfarin or pival makes 20pounds of concentrate and two tons offinished bait. Most people are astoundedby this extremely high rate of dilution.Some of them make the mistakeof using a higher concentration, expectingto get a more rapid kill. This is awaste of material and is absolutely unnecessary,especially in view of thePublic Health Service tests that provea 1:49 dilution to be almost equally aseffective as the standard 1:19 dilution.When used at the latter dilution, onepound of pival or warfarin will makefive tons of bait.Pival and warfarin baits are placedin small paper plates or other containersin areas where rat signs are evident.The bait is smoothed with thehand or a knife to leave an even surface.Baits are inspected frequently andobserved to see if signs of rat feedingare present. The bait is replenished andmaintained until the rat infestation iseliminated. No bait shyness results andrats will feed on the poison even afterit begins to take its deadly effect.Rats and insects have been thorns inour flesh since man's earliest ancestorfought in his cave to keep hungercrazedrats from his dinner. We allknow that rats cannot live withoutadequate food, water and shelter. Modernman has many advantages over hisprimitive forefather in combatting rats.Removal of rubbish from our cities,

14 The Health Bulletin July, 1955proper storage of foods and the use ofrat-tight garbage cans will destroy therat. Another bonus is the elimination offilthy flies which depend upon garbage,industrial wastes and other organicmatter for their livelihood.Chemicals are valuable as stop-gapmeasures and as plugs to close the damwhile more fundamental measures arebeing taken to repair the deficienciesin our environment. Insecticides and rodenticidesat best are two-edged swordsthat often cut the hand that uses themand destroy the good as well as the bad.Nevertheless, these weapons, when usedintelligently, will do much to improvecommunity health during the long periodof years in which sanitation standardsare being brought to ultimateperfection.NOTES AND COMMENTBY THE EDITORNONPARALYTIC POLIO DIAGNOSISNEED NOT BE GUESSWORK"The diagnosis of nonparalytic poliomyelitisno longer has to be guesswork,"a Yale University School of Medicinephysician said in the Journal of theAmerican Medical Association.She said six months' experience witha relatively new method illustrates itsvalue in diagnosing polio quickly andin winnowing out illnesses which otherwisemight be diagnosed as nonparalyticpolio.The new method, a combination ofvirus-isolation and antibody-responsetests, uses monkey kidney tissue insteadof live monkeys for testing fluids frompatients.The "tissue culture" method, first introducedby Dr. John Enders, Boston,in 1949, is more rapid, less cumbersome,and less expensive than the use of livemonkeys, the author said.Diagnosis of nonparalytic polio previouslydepended much on symptoms andepidemic factor studies. Because of thesimilarity of these factors in severaldiseases, specific and rapid polio diagnostictests have been needed. The"tissue culture" method, providing forvirus isolation, lessens this confusion.The "tissue culture" method was carriedout on 9 patients at Grace-NewHaven Community Hospital, NewHaven, Conn., and was reported by Dr.Mary O. Godenne.The results of antibody response testswere diagnostically significant in 96per cent of the patients later proved byvirus isolation to have polio, the authorsaid.She said the rapidity of the method"is an encouraging and a relatively newfeature of diagnostic work."In 60 per cent of the patients fromwhom a poliomyelitis virus was obtained,the agent isolated from varioussources was recognized and typed withinseven days of the time of inoculationof the specimen. By two weeks afterinoculation these positive results wereavailable in 88 per cent."Included in the report were patientswith paralytic poliomyelitis, meningitisfor which no cause could be found,nonparalytic polio, and encephalitis, aninflammation of the brain.In 49 patients with paralytic poliomyelitis,a polio virus was isolated in44 or 90 per cent.Thirteen or 32 per cent of the 41patients with meningitis and nonparalyticpolio harbored a poliomyelitisvirus, while three of the six patientswith encephalitis had a polio virus.In discussing the "tissue culture"method, Dr. Godenne said:"It has demonstrated that the diagnosisof nonparalytic poliomyelitis nolonger has to be guesswork. ... Of thevarious tests now available, the isolation(and typing) of poliomyelitisviruses from specimens obtained fromsuspected cases is the most valuable.Furthermore, it is a test in which theresults can now be secured in a matterof days."

July, 1955 The Health Bulletin 15ADEQUATE SANITATION CANCONTROL FLY PROBLEMAlthough fly swatters and DDT maybe ineffective in controlling flies, "thereisn't the slightest need to permit thispublic health menace to continue inAmerican cities and towns," accordingto the health educator of the LosAngeles County Health Department.Writing in Today's Health, publishedby the American Medical Association,Edward R. Reinig, M.P.H., called forcommunities and individuals to cleanup fly breeding grounds, thus eliminating"one of the greatest disease carriersin history."Plies have been considered pests sincethe days of Moses. They have spreadtyphoid, dysentery, cholera, and otherserious maladies.Methods of combating them have includedfly swatters, flypaper, screening,and, finally, during World War II theinsecticide DDT. But in 1947 came thenews that flies had "met the challenge"by devleoping a resistance to DDT andother insecticides."Sanitation experts all over the worldare now convinced that man's victoryover the housefly—if it ever occurswill likely be achieved through somemeans not yet put into general practice,"the author said.And that means, according to Reinig,is based on the fly's sex life.This "helicopter loaded with misery"begins its reproductive cycle by layingeggs in some convenient fermentingmatter, such as spilled garbage, compostpile, or manure. Under favorableconditions, the eggs hatch into maggotsin 48 hours. Five days later they crawlaway and bury themselves in hardcocoons in the ground. Adult fliesemerge in about four days, force theirway to the surface, and fly off in searchof food and shelter.The way to break up this cycle istoeliminate places where flies lay theireggs, such as open dumps, trash piles,and other rotting vegetable and animalmatter."Good sanitation is the one weaponagainst which flies cannot develop resistance,"Reinig said.Controlling flies is essentially an individualresponsibility, he said, since"one careless person can be the sourceof enough flies to plague everybody inthe block. .". . No local or state healthdepartment is able to perform the jobof community fly control alone."One of the best ways to do the jobon a community-wide basis is to forma Citizen's Fly Control Committee composedof community residents and publiGofficials. ... In this way the coordinationof all sanitation and flycontrol efforts is obtained at great savingto taxpayers," the author said."The best time for the organizationof a fly control committee in a communityis now," he said. "The fly problemexhibits itself during warmweather, but the work and planningthat prevent it is a year-round business.You can win encouraging results thisseason, and your community will be ajump ahead of the enemy next spring.""Musts" for an adequate communityfly control program include daily garbagecollection from restaurants andother food establishments; twice-weeklygarbage collection in all residentialareas; enclosed garbage pickup trucks;landfill type dumps; twice-weeklycleanup and disposal of all waste atpoultry houses, hatcheries, slaughterhouses, canneries, and similar places.Others are treatment of private andcommercial compost piles with goodfumigants, and local ordinances requiringhouseholders and businesses to usenonleaking garbage cans with tight-fittingcovers.If any of these are neglected in acommunity there probably will be aseasonal fly problem.Hints for fly control by householderslisted by Reinig are:"Grass cuttings provide an excellentplace for flies to breed. Spread cuttingsout thinly for drying. Flies need moistureto breed."Manure is an excellent fertilizer forlawns but it should be properly compostedand dried before using in thisway. Dog droppings should be disposedof by burying or in sewer facilities."Clean garbage pails thoroughly aftereach collection. Make sure covers fit

16 The Health Bulletin July, 1955tightly. ... If bottom of the pail iscorroded, liquids will seep into theground, thus providing a good flybreedingbed."If garbage is buried, it should becovered with at least two feet of earth."Bury dead animals and cover themwith at least three feet of earth."Dishwater and kitchen wastesthrown in the yard create breedinggrounds for flies."Fruit under trees should be rakedup and disposed of as garbage."A.M.A.ASPIRINCOMMITTEE RECOMMENDSBOX WARNINGAll packages containing aspirin orother salicylate compounds should beara clear warning, "keep out of the reachof children," according to the Committeeon Toxicology of the AmericanMedical Association.Pointing out that oil of wintergreenand aspirin are forms of salicylatesmost often involved in childhood poisonings,a report adopted by the committeealso recommended:That the label should state "Consultyour physician on dosage for childrenunder three years of age."That individual pills be wrapped inmetal or plastic foil that cannot beeasily removed by children, or that thecontainer have a top which closes automatically.That the number of tablets in eachcontainer of children's aspirin shouldbe limited.The committee's report, published inAmerican Medical Association Journal,was originated by the committee onaccident prevention of the AmericanAcademy of Pediatrics. A similar reportwas adopted at a recent meetingof representatives of industry, medicine,and pharmacy called by the federalFood and Drug Administration.Of 113 deaths in the United Statesknown to have been caused by salicylatecompounds in 1952, 86 occurred inchildren under five years of age. Fortyoneof these were caused by aspirin,the report said."The frequency with which aspirin isinvolved in childhood poisoning callsfor preventive measures," it said.Families with small children areurged to use caution in handling salicylatecompounds, particularly flavoredaspirin.Secretary of the Committee on Toxicologyis Bernard E. Conley, M. Sc,Chicago.Members of the committee are JustusC. Ward, M. Sc, Washington, D. C,Jerome Trichter, New York, and Drs.Torald Sollmann, chairman, Cleveland;Jay M. Arena, Durham, N. C; HarveyB. Haag, Richmond, Va.; Irvin Kerlanand Arnold J. Lehman, Washington,D. C, and Edward Press, New York.INADEQUATE DIET CAUSES LESSANEMIA THAN WAS EXPECTEDAnemia in persons living in a "backwardrural area where the diet isnotoriously deficient" appears to be lessaccordingcommon than was expected,to a survey reported in the AmericanMedical Association Journal.However, the majority of 90 cases ofanemia were caused by iron deficiencyand inadequate diet.The survey was conducted by J. J.Kirschenfeld, M. D., and H. H. Tew,M.S., Fort Deposit, Ala.Most of the patients were fromLowndes County, Ala. The basic industryis farming, and the importantproducts are cotton, corn, peanuts, cattle,and wood."The economic status of a large proportionof the population is rather precarious,but improving," the authorssaid."The chief ingredients of the diet,especially in the Negro population, arecorn, pork, lard, and vegetables suchas potatoes, turnips, field peas, and collards,"they said. "Fruit is rare, andbeef, eggs, and milk are scarce. ... Toa large extent it is only in the summermonths and in the fall that fresh vegetablesare available."Ninety of the 500 patients in the surveyshowed anemia, a total of 18 percent. This compares with rates rangingfrom about 3 to 12 per cent in similarstudies conducted in recent years inother areas of the country.

MEDICALLIBRARYU. OF N. CCHAPEL HILL, N. C&sifih>& WTKis Bulletin will be sent free to dni| citizen of tKe State upon requestIPublished monthly at the office of the Secretary of the Board, Raleigh, N. C.Entered as second-class matter at Postoffice at Raleigh, N. C. under Act of August 24, 1912Vol. 70 AUGUST, 1955 No. 8RECEIVEDSEP 3 1955DIVISION OFHEAtTH AFFAIRS LIBRARYmwmHANCOCK MEMORIAL HOSPITALHEADQUARTERSGRANVILLE COUNTY HEALTH DEPARTMENTOXFORD, NORTH CAROLINA

MEMBERS OF THE NORTH CAROLINA STATE BOARD OF HEALTHG. G. Dixon, M.D., President AydenHubert B. Haywood, M.D., Vice-PresidentRaleighJohn R. Bender, M.DWinston-SalemBen J. Lawrence, M.DRaleighA. C. Current, D.D.S GastoniaH. C. Lutz, Ph.G HickoryGeo. Curtis Crump, M.DAshevilleMrs. J. E. Latta Hillsboro, Rt. 1John P. Henderson, Jr., M.D Sneads FerryEXECUTP7E STAFFJ. W. R. Norton, M.D., M.P.H., State Health OfficerJohn H. Hamilton, M.D., Assistant State Health Officer and DirectorState Laboratory of HygieneC. C. Applewhite, MX)., Director Local Health DivisionErnest A. Branch, D.D.S., Director of Oral Hygiene DivisionA. H. Elliot, M.D., Director Personal Health DivisionJ. M. Jarrett, B.S., Director Sanitary Engineering DivisionFred T. Foard, M.D., Director Epidemiology DivisionFREE HEALTH LITERATUREThe State Board of Health publishes monthly The Health Bulletin, which willbe sent free to any citizen requesting it. The Board also has available fordistribution without charge special literature on the following subjects. Askfor any in which you may be Interested.DiphtheriaFliesHookworm DiseaseInfantile ParalysisInfluenzaMalariaMeaslesScarlet FeverTeethTyphoid FeverTyphus FeverVenereal DiseasesResidential SewageDisposal PlantsSanitary PriviesWater SuppliesWhooping CoughSPECIAL LITERATURE ON MATERNITY AND INFANCYThe following special literature on the subjects listed below will be sent free toany citizen of the State on request to the State Board of Health, Raleigh, N. C.Prenatal CarePrenatal Letters (series of ninemonthly letters)The Expectant MotherInfant CareThe Prevention of Infantile DiarrheaBreast FeedingTable of Heights and WeightsBaby's Daily ScheduleFirst Four MonthsInstructions for North CarolinaFive and Six MonthsSeven and Eight MonthsNine Months to One YearOne to Two YearsTwo to Six YearsMidwivesYour Child From One to SixYour Child From Six to TwelveGuiding the AdolescentCONTENTSPageMental Health Workshop 3Accident Hazards Found On Dairy Farms 5Notes and Comment 8

T^57mmIPUBLI5AED BYTAE N°RTA CAROLINA STATE B°AftD*AEALTAVol. 70 AUGUST, 1955 No. 8J. W. R. NORTON, M.D., M.P.H., State Health Officer JOHN H. HAMILTON, M.D., EditorMENTAL HEALTH WORKSHOPBy WARFIELD GARSON, M. D.Division ofEpidemiologyState Board of Health, Raleigh, North CarolinaOn June 15, 16 and 17 one of themost active and productive gatheringsconcerning mental hygiene everorganized in the State was held inChapel Hill.This unique workshop was primarilythe brainchild of the North CarolinaAcademy of Preventive Medicine andPublic Health. The uniqueness of themeeting was many-sided. In the firstplace, this was perhaps the first gatheringof its type in the State where themain spring of action came by arealization of need by common consentof four levels of State leaders in publichealth rather than being stimulated,as in the past, by outside resources.Further, the sincerity, high spirit, hardwork and genuine enthusiasm of theparticipants marked a new high indealing with this difficult problem. Althoughsome satisfying conclusionswere reached, it should not be assumedthat the final panacea of our problemsin this field was propounded.Rather, it might be said that a pathwaywas cleared over which the engenderedenthusiasm and stimulationmay be guided to advance our mutualends by continued perseverance anddedication to a better solution ofmental health problems that seriouslybeset some of our citizens.A short resume of the background ofthe meeting should be of interest tomany, as it demonstrates the breadthof concern in the minds of men in thevarious fields of activity in publichealth. It also suggests the coming ofage of a relatively new but potentiallypotent state public health organization.The Academy of Preventive Medicineand Public Health is composed ofphysicians all of whom are certifiedDiplomates of the American Board ofPreventive Medicine. Almost all areFellows of the American Public HealthAssociation and Fellows of the AmericanCollege of Preventive Medicine andPublic Health. They come from localrural and city health departments, thelaboratory, our universities and theState Board of Health and even includeofficers of the U. S. Public HealthService who are working in our State.In short, they represent the widest,most talented and experienced groupof public health physicians in the State.Coming from such a diversity of activitiesand places, they have but one"axe to grind." And that is the broaderapplication of a higher quality of publichealth practice in North Carolina.In January of this year this organization,by unanimous vote, decided todivide its members into committees tomake a study which would form abasis for planning recommended progressin the fields of mental healthand chronic diseases.This was immediately converted intoaction, and two committees were form-

The Health Bulletin August, 1955ed to cover the mental health aspectsof the problem. The first committee,under the chairmanship of Dr. FredG. Pegg, Forsyth County health officer,considered methods useful indetermining the needs of the communityin reference to services for theprevention or alleviation of mentaldiseases, including technics and indicesuseful in this regard. The second committee,under the chairmanship of Dr.Warfield Garson of the EpidemiologyDivision, State Board of Health, consideredplanning for a mental healthprogram for a community which wouldnot necessarily require a preliminarysurvey. Such questions as these wereconsidered: What clinics might beestablished? What educational methodsmight be employed? What servicesmight be rendered? How can mentalhygiene be incorporated into prevailingpublic health services?It was from the first committee,aggressively led by Dr. Pegg and aidedand abetted by Dr. Roger Howell ofthe School of Public Health at ChapelHill, that ideas for the workshop originated.Dr. John H. Hamilton, Directorof the State Laboratory of Hygiene andpresident of the Academy, wisely guidedboth committees together in a conjoinedendeavor to birth the fully formedworkshop. There are those who perhapsare not aware of Dr. Hamilton'srare talents in midwifery in suchaffairs. The confinement was not withoutoccasional discomfort, but the endresult attests to his obstetrical judgement!The cord was tied and Crede appliedwhen the State Board of Healthlent its support to the project throughDr. C. C. Applewhite, Director of theLocal Health Division, and Mr. E. S.Haswell, Chief of the Mental HealthSection, and Public Health Servicefunds were made available for the purpose.With the good offices of Dr. Howellcalled upon, an outstanding array ofpsychiatric and mental health talentwas lured to participate with us. Amongthese were Dr. Ernest M. Gruenberg,of the Millbank Foundation, New YorkCity, Dr. Robert Thomas, Director ofthe Division of Mental Health, MarylandState Health Department, Dr.John A. Fowler, Director of the Durham,N. C. Child Guidance Clinic, and,last but by no means least, Dr. RogerHowell himself.The invited group of regular participantsincluded the members of theAcademy, representatives of the N. C.Public Health Association Sections ofPublic Health Nursing, Sanitarians,Clerks and Health Educators, as wellas representatives of our mental healthclinic staff and a select group of healthofficers who had expressed special interestin, or were operating, mentalhygiene activities as part of their localprograms.A specal word of praise is in orderfor Dr. John Wright, Professor ofPublic Health Administration at theSchool of Public Health, and his coworkersfor the excellent work on localarrangements, which included makingavailable the University swimming pool,campus parking privileges, use of theCobb dormitory, the banquet in thePine Room of the Carolina Inn andother facilities that make for suchpleasant meetings that appear to bethe rule at Chapel Hill. The opportunityfor participants to remain for eveningsessions—both scheduled and "bull"—allowed for further mastication,rumination and consolidation of theusually tough work fare. It was inthese informal evening get-togethersthat people really got to know notonly each other, but the fine points ofeach other's thinking.It is perhaps difficult, if not impractical,to attempt to report in detailon the various small group andgeneral session business. It may appearanticlimatic to simplify or oversimplifythe conclusions of the workshop.There was one unanimous opinionexpressed by all the psychiatrists andmental health consultants. Their feelingwas that public health can offermost to the field of mental health bydoing more and better public health.This may sound like Gertrude Stein's

August, 1955The Health Bulletin"A rose is a rose is a rose"; but whenone considers the impact of our preventiveprograms in prenatal, birthand postnatal injury, other trauma,infection toxins, malnutrition (to mentionbut a few areas where nervoustissue is protected) and our educationaland promotional programs to preparefor predictable and unpredictable lifestresses, one can more clearly appreciatethe psychiatrists' point of view.This was a refreshing point of view,indeed, from our colleagues in thisfield. In this respect, they pointed outthat in the past forty years two of themost outstanding accomplishments inmental health were the reduction ofand control of neurosyphilis and theabolition of pellagra. In effect they saywe in public health are their main bulwarkin the primary prevention ofmental illness and in the promotionof mental health by doing just whatwe are doing. Only they challenge us todo it better.In that middle ground of "secondaryprevention" in which public health sooften administers the program andpsychiatry and its team render the service,we both have a challenge. Thisarea is the counseling and case workand out-patient treatment where weoperate hand in hand. The definitetherapeutic area of mental hygiene,that of hospital treatment, is thepsychiatrists' playground. In this areawe can return the challenge theythrow to us in the preventive area.In spite of the fact that our relationswith psychiatry were given clarityby the identification of public health'splace in the promotional and preventiveareas of the mental hygiene field,the health officers were not as completelysatisfied as the psychiatrists.Certainly they were not as happy asthe psychiatrist who insisted that uponreturn to his state he was going toput more of his money to work supportingpublic health nurses and otherpublic health personnel to improve thestatus of his mental health program.The health officers expressed a needfor more categorical services and identificationof mental hygiene in theirprograms.Further consideration and study inthis regard was thus pointed out tothe Academy for its future action.ACCIDENT HAZARDS FOUND ON DAIRY FARMSBy EDGAR F. SEAGLE, M. S. P. H.Sanitation Consultant, Accident Prevention Section,North Carolina State Board of HealthRaleigh, N. C.Protection and promotion of communityhealth through improvementsin the environment have been amongthe major fields of endeavor of publichealth agencies for the past half century.It was in the area of environmentalsanitation that the initial endeavorsof the pioneering health departmentswere centered during theearly days of the pubic health movementin the United States.This environmental focus of public•Read before the Sanitation Section, SouthernBranch, A.P.H.A. Meeting, NewOrleans, La., May 13, 1955.health activities made a significant andlasting impact on the major healthproblems during the past 20 years. Allare familiar with the role sanitationand sanitary engineering played in thecontrol of certain communicable diseases,and such workers can claim ajust share of credit for the extensionin life expectancy and improvementin the personal hygiene of living whichhas characterized the twentieth century.The time has not yet come, however,when sanitation personnel can limitthemselves to a mere surveillance pro-

The Health Bulletin August, 1955gram over conquered problems, for,with the tremendous technilogicaldevelopments of our age, have comenew areas of environmental health hazards,any of which rank as equallyserious problems as any approached todate. We hear much of the significanceof housing to one phase of the healthof a community, and additional activitieswith radiological health hazards,air and water pollution, the effect ofnoise on health, industrial sanitation,and home and farm accident preventionmust be initiated if sanitationprograms are to keep pace with thechanging patterns of community healthand sickness.It is significant to note that many ofthese new problems can be approachedonly after considerable specializedtraining; however, public health safetyspecialists have been encouraged overthe high degree of correlation betweensound sanitation practices and forcefulhome safety activities. This wouldsuggest that with a minimum of inservicetraining, existing sanitationstaffs can initiate safety activities, theimportance of which has been cited bynumerous public health authorities.Accident prevention, then, one of thenewest of public health programs,offers a most fertile tool by which tofurther sanitation. Sanitarians are notas much concerned with why peoplechoose to make improvements in sanitationas they are that they makethem. If a person changes some hazardousenvironmental condition in orderto eliminate an accident hazardand it favorably alters some conditionaffecting the surrounding sanitation,then the ultimate end is the sameas if the correction had been made solelyto improve sanitation. The importanceof this observation is that mostof the time people will be motivated tomake necessary changes if they can beshown that it might eliminate hazardsto them personally. Everyone is moreconcerned wth things that touch himdirectly rather than how his end product,for example, may effect otherpeople.To illustrate how accident preventioncan play an important role in theimprovement of sanitation, let's considersome accident-producing environmentalconditions on the dairy farm.First of all, one is likely to find uncoveredholes or slick surfaces ongraded levels around the barn thatmay result in cows' slipping and injuringtheir udders. The concrete slableading into the milking barn is agood example and is notorious forgetting worn down and slick. Thesefalls may result in mastitis. They notonly mean an economic loss to thefarmer but may also mean illness forpersons drinking the milk. However,the farmer or employee himself mayfall and break a leg in these sameholes or ditches or on the same slicksurfaces. Therefore, if some accidentprevention work is done with an eyetoward protecting the farmer, it couldindirectly improve his milk product.How closely one can measure thistype of thing as preventing sicknessand disability remains to be seen;however, it seems logical to believethat accident prevention and sanitationshow a marked correlation. Thesimilarity is obvious when thinking ofthings like discarded pit privies. Ifthese are properly filled in, thatlessens the possibility of spreadingdisease; however, it also keeps peoplefrom accidentally falling into them.When thinking of insect and rodentcontrol on the dairy farm, the StateBoard of Health in North Carolina isfurthering one project which, althoughdesigned to prevent mosquito breeding,also prevents many home accidents.This is the inspection of every homeand farm pond and stressing that alltree stumps and other obstructions becompletely cleared from the pond bed.The regulation only requires thesestumps to be a certain number ofinches below the fluctuating waterlevel so as to prevent vegetation fromaccumulating around them, with resultantmosquito breeding. However,emphasis is being placed on completeclearing of the pond bed. This is usinga double-barrel gun, inasmuch as itdoes accomplish the primary purpose

August, 1955The Health Bulletinbut also keeps children as well asadults from diving in the pond andhitting their heads on these obstructions.On some of the larger ponds itprevents small boats from being overturnedby ramming these stumps. Thepoint to stress again is that if thefarmer is reluctant to remove thesehazards from the standpoint of mosquitobreeding he may come aroundwhen he thinks that some member ofhis family may be seriously injured oreven killed as a result of these hazards.It is simply another approach oranother road to get to the same place.This approach should give the personyou are dealing with the idea thatyou are interested in him personally,and this always has a good end result.The next concern might be constructionof milking barns, milk roomsand other dairy farm buildings. Sanitarianshave long been concerned withthe construction of floor and wall surfacesfrom the standpoint of keepingthem clean. They should be of smooth,washable, nonabsorbent material, freefrom cracks, crevices and open joints.This type of surface certainly contributesto better cleaning and consequentlybetter sanitary conditions. Italso contributes to safer walking andmoving around of personnel. Thiscould also be another "selling" pointfor the sanitarian to use in getting hissanitation program across; bring outthe fact that things like floor surfaces,if properly constructed, will contributenot only to better sanitation but alsoto more safety from accidents for thefarmer. This is a prime example ofhow accident prevention can be integratedinto an already existing programand also illustrates that sanitarianshave actually been doing someaccident prevention all along but withoutrealizing what an important toolit is in furthering other programs. Thisis something that affects the milkhandler directly—it is closer to himthan contaminating the milk thatsomeone else is going to drink. This issomething for his safety, not just thesafety of the public that he serves.The ultimate end is that, for whateverreason he changes these environmentalconditions to safer and better ones, heis improving sanitation and preventingaccidents.Regulations also specify that theremust be adequate lighting and ventilationthroughout. Here again theywere primarily set up for sanitary reasons;that is, if you can see better,you can clean up better. Another importantreason for good lighting,though, is to prevent accidents. Poorlylighted cellar or back stairs need nocomment other than to recognize theirhigh potential as a source of falls resultingin serious disabilities and evendeath. Good lighting is certainly neededto properly inspect pieces of equipmentwhen they are being washed andcleaned. However, good lighting whileone is cutting, mixing or using electricmotors and other apparatus in thefarm buildings may prevent a cut fingeror hand or the loss of one by gettingit caught in a piece of equipment becausethe moving parts could not beclearly seen. Here again bringing outthe accident prevention concept tothe farmer is another prong withwhich to improve sanitation.One could also mention here storageroom space around the milking barn.Proper storage and use of poisonouschemicals is something to watch for allover the farm; however, sometimeschemicals that are harmful to milkquality are found dangerously close tothe milk, in both the milk room andmilking parlor. Frequently these arefound sitting around the rim of themilk cooler or on a shelf close to thestrainer or sediment pads. This isobviously a bad practice. However, ifit can be prevented by using a cabinetwith a good lock on it, two purposesare served. The operator is helping toprotect the quality of milk and alsopreventing children and other membersof the farm family from getting thosechemicals by mistake. In regard tomiscellaneous storage rooms, it isrecommended that articles be storedin a manner that will facilitate cleaning.If this recommendation is carriedout, things are certain to be more in

8 The Health Bulletin August, 1955order than if they were strewn on thefloor in a random manner, and consequentlythe possibility of trippingand falling over something is reduced.Again sanitation and accident preventionare going hand in hand; however,one may get more results if heapproaches proper storage from thestandpoint of preventing injury to theoperator rather than telling him hecan clean up better. Certainly bothpoints should be brought out in theconversation.Practically all of these same examplescould equally as well be appliedto restaurants, meat markets, abbatoirsand all the other food handlingestablishments subject to inspectionby the health department. I couldname specific examples for all of theseplaces, and I am sure you could alsoby merely giving thought to this helpfulapproach. Accident preventionwork for the sake of it alone is a mostworthwhile endeavor. In North Carolinastudies have shown that just onthe farm, in the home and residentinstitutions, there were 827 accidentaldeaths in 1952, 739 in 1953 and 817 in1954. The 1954 figures are not yet complete;that is, more reports are stillcoming in. This is a rate of approximatelytwo deaths per day. It has beenestimated that for each of these fatalaccidents there are 150 accidental injuriesresulting in disability for twentyfourhours or longer and that four ofthese are permanent disabilities. Anyaccident prevention activity should bepreceded by an in-service training programfor sanitarians, and a check listof home hazards should be agreed uponand approved. Armed with this knowledge,the sanitarian could then discusssuch situations on the spot andmake recommendations for the mostpractical means of elimination or correction.This type of program shouldspread to all categories of public healthpersonnel who make home and othervisits as part of their daily duties.Truly accidents are a major problem,and, when accident prevention can beso easily combined with another importantphase of public health, that ofsanitation, where both have a strongtendency to promote the other it providessanitarians with a wonderful opportunityto make their work evenmore valuable and satisfying.NOTES AND COMMENTBy THE EDITORNEWBURGH'S 10YEARFLUORIDATION*The Newburgh-Kingston FluoridationStudy in New York celebrated its10th anniversary on April 21 in ceremoniesin which it was reported that"reports confirm earlier findings thatwater fluoridation has no demonstrablesystemic or developmental effect onchildren except for the known dentalbenefits of reduction in tooth decay."Addresses were made by three staffmembers of the New York State Departmentof Health including the directorof Bureau of Dental Health,David B. Ast, D.D.S., and by Samuel•American Journal of Public Health, V.45, P. 861.Z. Levine, M.D., pediatrician-in-chief,New York Hospital, and a member ofthe State Health Department's TechnicalAdvisory Committee on Fluoridationof Water Supplies.As a part of the study, the cityauthorities of Newburgh approved thefluoridation of the city water supplywhile those of Kingston with a fluoridedeficientwater supply agreed to participateas a control area. For the sixandseven-year-old Newburgh children,who had consumed fluoridatedwater all their lives, the decayed,missing, and filled rate for permanentteeth was 75 per cent and 68 per centlower than for those for comparableKingston children.

August, 1955The Health BulletinThe total cost of the study includingthe cost of fluoridating Newburgh'swater supply has been about $300,000or about $30,000 annually. Said MortonLevin, M. D., making one of the day'sspeeches, "A reduction in dental cariesof approximately two-thirds amongchildren and the adults of the futuremakes the cost of this study and thecosts of fluoridating water supplies atruly economical practice."CARELESS HANDLING MAKESCANDY DRUGS DANGEROUSCarelessness about reading labels andstoring medicine out of reach are contributingto an apparent increase inpreschool-age illnesses and deaths fromoverdoses of candy-flavored medicines.The warning against mishandling ofpotentially dangerous drugs was madetoday by the American Medical Association'sCommittee on Toxicology,in a report in the Journal of theA.M.A.Committee Secretary Bernard E. Conleysaid that among preschool-agechildren, the group in which accidentalpoisonings is most frequent, "drugs areresponsible for 33 per cent of the fatalpoisonings." Children's death rates"from the ingestion of poisons are fourtimes higher in the United States thanin England, even though over-all deathrates for both countries are generallycomparable," he said.Most poisoning accidents are causedby "ignorance, carelessness" and unsafestorage, the report said. Many ofthese products "that are packaged andflavored to look like candy are inreality potent drugs, some of whichcan be dangerous with overdoses."Figures show that since candiedaspirin became available over-the-counterin 1948, deaths from aspirin amongchildren under 5 years old rose 500per cent above pre-war levels. Therewere 31 deaths of this kind in 1951,compared to a pre-war average of 6.While the aspirin poisoning reportsare not "conclusive evidence," they"strongly suggest that flavored aspirinhas contributed to an increase in accidentalpoisoning disproportionate to itsavailability," the report said.Another indication of danger foryoung children is in the unusually highrate of preschool-age poisonings fromswallowing oil of wintergreen, commonlyused in liniments. Sales of thissubstance have remained fairly level.So have fatalities from the oil amongmost age groups. But among preschoolagechildren the mortality rate fromoil of wintergreen is 20 to 25 timesgreater than among the remainder ofthe population. This may be due partlyto its "tempting odor," which resemblesthat of some chewing gum, candy, andsoft drinks, the report said.Labels that say "keep out of thereach of children" and special safetydevices, such as enclosing pills in strongplastic film or putting strong springcaps on containers, might make drugsharder for children to get.But safety devices are not a basicanswer to the problem, the report said.Adults must learn to pay attention tolabels and danger signals.Advertising that "states or impliesa degree of safety not associated withthe drug" is "a basic cause of carelessnessand negligence among users," thereport said. "Such advertising encouragesan easy familiarity" which toooften generates carelessness."More often than not this carelessnessis the result of a cultivated ignoranceof the dangerous capacities of adrug rather than an inherent negligenceon the part of the user," thecommittee said. "Recognition of thisfact will be a major step toward improvingthe safe use of common householdmedicaments."PHYSICIAN DESCRIBES"LITTLE STROKES"One of the commonest diseases ofman is that in which, over the courseof 10 or 20 years, a person is "graduallypulled down" by dozens of "littlestrokes." Dr. Walter C. Alvarez said inthe Journal of the American MedicalAssociation that the "little strokes"come from pluggng of small arteries inthe brain, and result in damage to

10 The Health Bulletin August, 1955brain tissue from the cutting off ofcirculation.Onset of the disease possibly can bedelayed by keeping the weight downand reducng the amount of cholesterol(a fat-like substance) in the diet.People can recover after a little stroke,and some may go for 10 or 15 yearsin good health before having another.An important factor is understandingon the part of the family, employers,or partners. Dr. Alvarez said,since the disease can cause majorchanges in personality and ability.The "little strokes" are not easy todiagnose, especially since the patientmay confuse his symptoms with otherdiseases, such as ulcers or gallstones,and may neglect to tell his physicianabout an important incident whichwould reval a history of "little strokes."However, he said the disease might besuspected whenever:"(1) A man or woman past 38 or sohas a mental and nervous disabilitythat is out of all proportion to thelittle indigestion, abdominal, or thoracic(chest) pain complained of, (2) anervous breakdown or a queer groupof symptoms come suddenly on a certainday, and (3) one learns fromthe family that after a dizzy spell,blackout, or perhaps a fall, there camedecided changes in character and perhapsan inability to work."The "little stroke" may go unnoticedbecause the thrombosis (or "plugging"of an artery) in the brain may causeonly a small shock, and may occur unknownduring sleep. Frequently symptomsdo not appear for some timeafterward. A significant sign is asudden change in character, such asthat when "a previously kind, affectionate,gentle husband suddenly beganto explode in anger over almost nothing."Loss of work ability may be a signwhich puzzles the patient and hisemployer, since even a complete physicalcheckup may reval no apparentcause. Fear of being alone, loss of oldinterests and joy in life, visual trouble,pain, arthritis, "acute indigestion,"burning and bad taste in the mouth,changes in writing, speaking, andability to swallow, and falling downsteps may be indications of "littlestrokes." Dr. Alvarez said he can makea diagnosis "as the man gets up out ofthe chair in the waiting room; he isso clumsy about it. I often make thediagnosis when I see how dull the manlooks and how much older he is thanhis chronologic age."There are several other symptoms ofthe disease, but the physician needsinformation from the patient and hisfamily about such incidents as fallsor character change. Then the family'sunderstanding is needed so they canbe "more forgiving of the patient'scantankerousness or constant complaining.""In many cases a man's employers orpartners need to know quickly that heis never likely to work again. Thenthey can retire him with a pension,"he said. "Often, when a man owns hisown business, the family ought toknow that he is not likely ever to beof any use in the office. They must thendecide quickly what is to be done withthe business and the people who workthere."Dr. Alvarez pointed out that thereare helpful methods of treatment insome cases and that one "little stroke"does not necessarily result in disability.He said he "can tell patients that Ihave seen many persons go for 10 to15 years in good health before anotherlittle stroke occurred."He added that a patient "need notfear that a third stroke will kill; thisis only an old folklore with no truthin it.""I tell my patients of some of themany persons I have seen who, aftera stroke, became remarkably well," hesaid. "I may tell of Pasteur who, for27 years after his big stroke, did muchof his best work. Interestingly, hisbarber told a friend of mine, in Paris,that through the years Pasteur musthave had 50 little strokes."LOW-FAT DIET MAY PREVENTCORONARY DISEASE PAINA low-fat diet may be useful in help-

August, 1955 The Health Bulletin 11ing to prevent angina pectoris, oneof the most painful effects of coronarydisease, two Philadelphia physicianssaid in the Journal of the AmericanMedical Association.Angina pectoris, a severe pain in thechest, which carries with it a feelingof suffocation and impending death, isusually brought on by effort or excitement.Anginal pain following meals hasbeen attributed to the increased heartwork during digestion or to heartartery constriction resulting from adistended stomach. However, the twoPhiladelphia doctors suggested thatthe cause may be too much fat in themeal.Fourteen patients with coronarydisease at the Hospital of the Universityof Pennsylvania were given a fattymeal consisting of heavy cream, flavoredwith cocoa and synthetic sweetening.Six patients had a total of 14 severeattacks of angina pectoris from threeto five hours after eating. Two otherpatients developed relatively mild andshort attacks about five hours aftereating. The patients said the discomfortwas identical to that of effortproducedangina.Blood samples taken at intervalsafter the meal showed a steady risein fat content, with the highest pointreached about the time of the attack.This slowly rising and prolonged fatconcentration might explain whyangina pectoris may occur in certainindividuals after a certain meal of theday, the doctors said. It also might bepartly responsible for angina decubitus,chest pain occurring when the patientis lying down, they said.Other tests showed changes in heartrate and a temporary deficiency ofblood in the myocardium (heart muscle)during the attack. The doctorssaid that high fat concentrations,bringing about such a deficiency duringthe attack, could have a bad effecton the myocardium in persons whosecirculation already is impaired bycoronary disease.This is another good reason forgiving a low- fat diet to patients withangina pectoris, the doctors concluded.Making the survey were Dr. Peter T.Kuo, Hospital of the University ofPennsylvania, and Dr. Claude R. Joyner,Jr., National Heart Institute ofthe National Institutes of Health.ATOMIC TEST PROGRAM GIVESMAXIMUM PUBLIC SAFETYSafety measures at the NevadaAtomic test site have reduced hazardsto the public to a minimum accordingto Gordon M. Dunning of the AtomicEnergy Commission's Division of Biologyand Medicine, Washington.After five major tests no one hasincurred radiation exposure off thesite that may be considered "anywherenear hazardous."There have been no known cases ofserious eye damage from light effectsnor any reported injury to personsfrom shock waves.Carrying out an extensive programof warnings before tests and checksafter tests are 100 full time employeesof the Atomic Energy Commission. Inaddition, many persons participate ona part-time basis throughout theUnited States.The basic consideration for the public'ssafety was shown in the selectionof the test site. It covers an area of600 square miles, with an adjacentU. S. Air Force gunnery range of 4,000square miles. These are surrounded by"wide expanses of sparsely populatedland."Preceding a test, a "warning circle"is set up and all aircraft are warnedby the Civil Aeronautics Administrationto remain out of the circle. Roadblocksare established on major highwaysin the area to alert motorists tothe approaching blast and flash oflight.The AEC and U.S. Public HealthService have cooperated in establishinga liaison program with residentsin surrounding areas. Liaison men livein each of 12 zones. Their duties includebecoming so much a part of theneighborhood that residents wouldrespect their decisions and seek their

12 The Health Bulletin August, 1955advice if needed. The men also monitorradioactivity-measuring equipmentfollowing the tests.After each blast, monitoring equipmentat the site, in nearby communities,and on mobile equipmentmeasures the radioactive fall-out.Airplanes track the clouds and plotthe fall-out pattern on the ground.Ninety U.S. Weather Bureau stationsthroughout the United States collectfall-out data, as do 10 AEC installationsin different parts of the country.Contamination of water and air inthe surrounding area was found to berelatively small after each blast, Dunningsaid.There have been no reported cases ofpeople receiving radiation burns offthe site. In 1952 some cows which were15 to 20 miles from "ground zero" receivedsome burns, as did some horsesin 1953.Damage from shock waves in nearbycommunities has totaled $44,300 fromseveral blasts. If it appears that theremay be slight damage from shockwaves, because of weather conditions,residents are warned to open windowsand doors in their homes to helpequalize the pressure.PHYSICIAN DOUBTS EXISTENCEOF "ULCER PERSONALITY"Doubt as to "the nature or even theexistence of a specific ulcer personality"was expressed by a Cleveland physician.It has become common in the lastfew years for doctors and the publicto refer to certain persons as being ofthe "ulcer type." Articles and even abook have been written on the subject.Yet investigators cannot agree onwhat goes to make up the "peptic ulcerpersonality," Dr. Harold P. Roth saidin the Archives of Internal Medicine.He found that a number of differentpersonalities were described as typicalin various studies on the topic. "Therewas no whole personality or feature ofpersonality that was agreed upon byas many as a third of the investigators,"he said.Personality traits most frequentlymentioned were drive, conscientiousness,and anxiety. "Although othertraits were described, the statementsabout most of them were contradictory,"he said.Some authors suggested that ulcerpatients had a specific type of conflict.But they did not always agree onthe nature of the conflict nor whetherthe conflict was associated with aspecific personality type.The conflict most frequently reportedwas between feelings of passivity(desire to be loved and taken care of)and feelings of activity and independence.Because this same conflict isseen in persons without ulcers, "wemust know how often this conflict canbe found in the general population beforewe can decide how significant isthe fact that it is found in ulcer patients,"Dr. Roth said."We cannot say whether the factthat a number of investigators describedthe same personality featuresis significant, for this may be due toa defect in their techniques," he said.In half of the studies no method ofstudy was outlined. Some were basedon interviews, psychoanalysis, and psychologicaltesting.No distinction was made betweenpatients wth gastric ulcer and thosewith duodenal ulcer nor between maleand female patients in many of thestudies. Yet investigators who studiedthese groups separately found therewere differences in personality."Conclusions about the ulcer personalityin the general population havebeen drawn from studies of samplesthat were not representative," Dr. Rothsaid."Usually the author did not reporthow often he found a given characteristic,such as ambition, in his patients.... Generally he reported hisconclusions, not his data," he said."An entirely satisfactory" methodfor evaluating personality has notbeen developed, nor has a method forcomparing ulcer patients with ulcerfreepersons, Dr. Roth said.

August, 1955 The Health Bulletin 13DOGS SOMETIMES TRANSMITPARASITES TO HUMANS"Man's best friend," the dog, maysometimes—accidentally—be his healthenemy.Occasionally a dog may transmit aninfectious parasite to man, two physicianconsultants said in answer to aquery from another physician in theJournal of the American Medical Association.However, they said the few cases ofinfection from dog to man probablycould be prevented by cleanliness, defleaingthe dog, and other easy methods.Some of the parasites of dogs whichmay infect man are fleas, ticks, tapeworms,and hookworms, one type ofwhich causes a skin infection called"creeping eruption" in the southeasternUnited States. Dogs with mangemay give their handlers a skin infection.Sometimes dogs and men may havethe same infection but in these casesit isn't the dogs' fault. It just happensthat they are infected by the sameparasites—which in turn came fromfleas, pigs, or fish.In fact, the physicians said, sometimeswhen dog infects man, the parasiteof the dog came from the man inthe first place.EASTER CHICKS CARRYSTOMACH INFECTIONAn unusual outbreak of a stomachand intestinal infection caught fromEaster chicks is reported in the Journalof the American Medical Association.The infection, caused by a bacterium,Salmonella typhimurium, is common inchicks and other poultry. It is beingmore frequently reported among humans,according to Arnold S. Anderson,M.D., Henry Bauer, Ph.D., and C. B.Nelson, M.D., Minneapolis. They saidthe reported outbreak indicates "apotential hazard" in distributing chicksor other small poultry as householdpets.Twelve cases of salmonellosis in 11households in Hennepin County, Minn.,were definitely traced to chicks whichwere distributed at Easter, 1954, by twofood stores.The chicks were obtained from ahatchery which had no record of infection.However, while at the stores,the chicks were crowded and were fedcereal from broken packages.No attempt was made to questionall persons who received the chicks,but 17 other persons in the 11 householdsshowed symptoms and probablyhad cases of salmonellosis.The illness began from four to sixdays after chicks were taken home.The symptoms, including fever, waterydiarrhea, blood in the stools, andvomiting, came on suddenly and lastedfrom one to five days. Treatment consistedof the usual antidiarrheal drugsand diet and antibiotics.The 12 patients ranged in age fromfour months to 35 years. Six were infantsunder one year of age.The infection is usually mild inchildren over the age of two and inadults, but so severe in infants lessthan a year old that medical help isnecessary, the doctors said.The authors explained how tiny infants,who live "in scrupulously cleancribs and seldom have anything gointo their mouths that is not sterilized,"get salmonellosis.The answer is in the behavior of thetwo to five-year-old, who handles hispets and then touches the mouth ofhis baby brother or sister. "It may bemere chance, but we suspect it is not,"that every patient under one year hada brother or sister between the agesof two and five, the authors said.TWO WORLD MEDICALGROUPS DISCUSSEDSince health is of importance toeveryone in the world, internationalcooperation in health and medicinemay smooth the way for cooperationin more controversial spheres, threephysicians said today.Two organizations which work towardworld health, understanding, andpeace—the World Medical Association

14 The Health Bulletin August, 1955and the World Health Organizationare described in the Journal of theAmerican Medical Association.Drs. Harold S. Diehl, Minneapolis,Leonard W. Larson, Bismarck, N.D., andFranklin D. Murphy, Lawrence, Kan.,said the two groups are "a team thatis making one of the greatest contributionsof our time to the improvementof mankind—a must for the preventionof the spread of communism."An accompanying editorial pointedout the importance of the organizationsas a means of exchanging information."Each country, of course, has its ownproblems, but there are many aspectsof the control of disease and the providingof medical care that should beviewed internationally," the editorialsaid. "Sometimes the view prevailingin one country is helpful when disseminatedelsewhere .... Such valueis readily apparent to everyone."Not so apparent at times is theprotection a country receives when itshealth professions can benefit frommistakes made elsewhere."Free exchange of information notcon-only can show a country how totrol malaria and other diseases, butcan point to the "inequities of somegovernmentally inspired schemes thatmay not bring health, happiness, andfreedom but instead shackles andmisery," the editorial said.The World Medical Association, aprofessional organization of physicians,developed an International Code ofMedical Ethics, sponsored the firstWorld Congress on Medical Education,and now is working in the field ofworld occupational health.The World Health Organization, with84 member nations, is within the generalorbit of the United Nations, butadministered separately. It has compiledand distributed information onmany phases of health and disease;led in the control of malaria and yaws,and assisted in training thousands ofpersons from countries without healthtraining facilities.The World Health Organization isvaluable to the U.S. "both as an armof foreign policy of our governmentand as a contributor to our domestichealth," the article said.Both organizations have worked together,collaborating on projects andexchanging representatives. "It is essentialthat these organizations continueto cooperate in order to assurethe greatest possible competence," thearticlesaid.It said the individual physician canhelp "in developing understandingwithin his own community of the importanceof the development of publichealth services in underdevelopedareas of the world as a barrier to thespread of communism."STOMACH TROUBLECHILD'SMAY BE EMOTIONALChildren have stomach ulcers andother internal disorders caused byemotional factors just as adults do,according to two staff members of theChildren's Mercy Hospital, Kansas City,Mo.Emotions "bottled up" may expressthemselves by appearing as real physicalillnesses—peptic ulcer, ulcerativecolitis (chronic ulceration in thecolon), "stomach cramps," "knots inmy stomach," and a variety of otherailments.Many cases of infantile colic alsoare thought to be largely emotional inorigin, A. H. Chapman, M.D., andDorothy G. Loeb, M.A., said in theAmerican Journal of Diseases of Children.Sometimes such disorders can becleared up fairly rapidly through atalk between the parents and thedoctor. "A small amount of extra time"to talk to the parents is often thebest treatment the physician can give,they said.Many of these illnesses begin becausechildren and infants fail to receivesufficient love or are surroundedby an atmosphere of irritability, impatience,and anger."Infantile colic" frequently developsin infants whose mothers are impatientand cross. The infant "senses theabsence of secure, affectionate mother-

August, 1955 The Health Bulletin 15ing, which is his most crucial need,"the authors said.Sometimes he expresses his sense ofinsecurity by becoming "colicky." Moreaffectionate and patient mothering isoften the best remedy, the authors said.Peptic ulcers may develop in childrenwhose needs for security and lovewere not met in infancy.Children who have ulcerative colitisoften are depressed and unable to expresstheir angry feelings. These childrenalso may not have had enoughaffection from their mothers. It hasbeen estimated that about 10 per centof all adult ulcerative colitis begins inchildhood.Once the doctor recognizes theemotional basis of these illnesses, hecan attempt to guide the parents intheir approach to the child's problemand illness. The physician not onlycan give medical treatment, but canmake specific suggestions for the behaviorof the child and his parents.PHYSICIAN LICENSINGREACHES NEW HIGHThe number of new physicians addedto the nation's physician populationreached a record high in 1954, accordingto figures released by the AmericanMedical Association Council onMedical Education and Hospitals.Boards authorized to license physiciansto practice gave 15,029 licensesduring the year, an increase of 595over the previous year. Excluding duplicationsof candidates examined inmore than one state, the actual totalof new license holders reached 7,917.The report said that deducting the3,667 physician deaths in 1954, thereremained 4,250 new physicians in practicesince the beginning of the year.This was 641 more physicians thanwere added to the population in 1953.The council's report appeared in theJournal of the A.M.A. It said that thephysician population increase occurredin 31 states. The licenses issued broughtto 222,773 the total of licenses grantedsince 1935.Registration of physicians (includingpersons licensed in 1954 who tookexams in previous years) reached alevel exceeded only by that of 1946,the all-time record year. From 1946to 1952, the numbers registered decreasedannually and then took an upswing.However, throughout all theseyears the totals were higher than inthe pre-World War II years.The report also showed that failuresof candidates to pass license exams remainedlow. Only 4.2 per cent of the5,999 American medical school graduatestaking exams last year failed toget licenses, and 4.8 per cent of the126 Canadians failed. The largest partof the failures occured among graduatesof foreign faculties, schools notapproved by the council, and schoolsof osteopathy. The total failure rateof 12.7 compares to the previous lowof 5.7 in 1930 and the previous highof 21.7 in 1908.The 15,029 licenses granted includeda number given on the basis of interstatereciprocity and other qualifications.Licenses by examination actuallywere given to 6,827 persons. Thesecandidates came from 73 medicalschools in this country and 11 inCanada. The rest were from foreignschools, unapproved schools, andschools of osteopathy.The largest number of new licenseholders came from California, whichlicensed 1,975 physicians. Next wasNew York with 1,498, followed by Illinois,Ohio, Pennsylvania, and Texaswith over 500 each; Delaware, Idaho,Nevada, North and South Dakota, andVermont with less than 50 each. Thesmallest number was 24 in Wyoming.The largest number of licenses grantedto graduates of one school was the207 given to graduates of the Universityof Illinois College of Medicine.Largest number of private school graduateslicensed was 175 from TulaneUniversity. Twenty-six schools hadmore than 100 licenses. Thirteen schoolsturned out candidate groups withouta single failure in board examinations.These were Stanford University,Georgetown University, Chicago MedicalSchool, State University of Iowa,Wayne University, Albany Medical Col-

16 The Health Bulletin August, 1955lege, and the Universities of Buffalo,Rochester, North Carolina, Utah, Washington,Southern California, and Colorado.Foreign school graduates, includingboth American and foreign born persons,took 1,642 exams in 1954, with943 of the candidates passing. Theactual increase to physician populationwas 772, bringing the total ofnew foreign-trained physicians to 2,784licensed in the past five years.PHYSICIAN WARNS AGAINSTVACATION DRIVING DANGERBeginning of vacation time brings awarning against long-distance, nonstopdriving from a Washington, D. C.physician.Dr. Carl J. Potthoff said three-fifthsof driver defects leading to accidentsare fatigue and falling asleep. Writingin Today's Health magazine, publishedby the American Medical Association,Dr. Potthoff said one-fifth of driversinvolved in fatal accidents are out-ofstateresidents but in vacation timethe proportion is much higher."Drivers who set long mileage schedulesfor each day usually are fastdrivers; speed is the leading cause oftraffic accidents and as it increasesthe injuries are greater in case ofaccident," he said."Accidents sustained far from homecause much-increased difficulty," hesaid. "Contacts are with strangers;garage service men, physicians, lawyers,police officers. Injuries may require along stay at a local hospital. It may benecessary to summons distant relatives.Police or civil action may require areturn many months later."Reasonable driving schedules protectfamily members who are passengers,precisely the ones we wish mostto protect. They provide an excellentexample to children, those we wish toteach safety, particularly with respectto driving habits."Stopover expenses in small citiesare low, perhaps less than the costsat the destination, and automobile expensesare lower when driving isleisurely."For safety's sake, vacation can beregarded as starting with the trip,rather than at the destination. A stopoverat a point of historic interest orof beauty can be found usually ....Some vacationers do not set a rigidschedule; with them every hour ofdriving is a search for the new andunusual rather than an urgent rush."MEDICINE AND INDUSTRYThe emotional and physical healthof industrial employees, executives andworker alike, needs specialized on-thejobmedical attention.Dr. Harold A. Vonachen, East Peoria,111., made his report, which appearedwith articles on mutual problems byrepresentatives of medical educationand industry, in the Journal of theAmerican Medical Association.Dr. Vonachen, Dr. Ward Darley,Denver, and Robert E. Wilson, Chicagobusinessman, agreed that medicine isa "community" concern and that industryhas an important stake in medicalprogress."The life of the worker outside ofhis employment situation may determinehis success or failure at work,"Dr. Vonachen said. "Family healthproblems may keep him off the job.Domestic conflict can cause absenteeismand accident-proneness. Alcoholism,now considered an illness, is aserious problem in some industries."He said emotional ills are at the rootof many industrial work problems. Itis said that 60 to 80 per cent of jobseparations stem from social incompetencerather than technical incompetence.Tense, hard-driving executives needa special health program. The healthof executives needs "constant guidanceand observation" to avoid losing theservices of key people through "illnessor emotional failure.""There are certain factors that constitutea particular danger to thisgroup," he said. "Their work is notmeasured by time served, but by goalsachieved; and their working day oftenextends far beyond recognized hoursof employment."

.3?Stbeoicm. LIBRAR1"• 0F N> c:N c..pufPEL HILL*til" 1 'TKis Bulletin will be sent free to tmy citizen of ft\eState upon requestPublished monthly at the office of the Secretary of the Board, Raleigh, N. C.Entered as second-class matter at Postoffice at Raleigh, N. C. under Act of August 24, 1912Vol. 70 SEPTEMBER, 1955No. 9OCT 3WHTVJOSEPHUS DANIELS JUNIOR HIGH SCHOOLRALEIGH, NORTH CAROLINA

MEMBERS OF THE NORTH CAROLINA STATE BOARD OF HEALTHQ. G. Dixon, M.D., President AydenHubert B. Haywood, M.D., Vice-PresidentRaleighJohn R. Bender, M.DWinston-SalemBen J. Lawrence, M.DRaleigh4. C. Current, D.D.S GastoniaH. C. Lutz, Ph.G _^ HickoryGeo. Curtis Crump, M.D «--- ^ AshevilleMrs. J. E. Latta Hlllsboro, Rt. 1John P. Henderson, Jr., M.D Sneads FerryEXECUTIVE STAFFJ. W. R. Norton, M.D., M.P.H., State Health OfficerJohn H. Hamilton, M.D., Assistant State Health Officer and DirectorState Laboratory of HygieneC. C. Applewhite, M.D., Director Local Health DivisionErnest A. Branch, D.D.S., Director of Oral Hygiene DivisionA. H. Elliot, M.D., Director Personal Health DivisionJ. M. Jarrett, B.S., Director Sanitary Engineering DivisionFred T. Foard, M.D., Director Epidemiology DivisionFREE HEALTH LITERATUREThe State Board of Health publishes monthly The Health Bulletin, which willbe sent free to any citizen requesting it. The Board also has available fordistribution without charge special literature on the following subjects. Askfor any in which you may be interested.DiphtheriaFliesHookworm DiseaseInfantile ParalysisInfluenzaMalariaMeaslesScarlet FeverTeethTyphoid FeverTyphus FeverVenereal DiseasesResidential SewageDisposal PlantsSanitary PriviesWater SuppliesWhooping CoughSPECIAL LITERATURE ON MATERNITY AND INFANCYThe following special literature oh the subjects listed below will be sent free to•ny citizen of the State on request to the State Board of Health, Raleigh, N. C.Prenatal CarePrenatal Letters (series of ninemonthly letters)The Expectant MotherInfant CareThe Prevention of Infantile DiarrheaBreast FeedingTable of Heights and WeightsBaby's Daily ScheduleFirst Four MonthsInstructions for North CarolinaFive and Six MonthsSeven and Eight MonthsNine Months to One YearOne to Two YearsTwo to Six YearsMidwivesYour Child From One to SixYour Child From Six to TwelveGuiding the AdolescentCONTENTSPageSchool Health Services And The Health Department 3Legislation And Policy Governing The ExpenditureOf School Health Funds 8Vocational Rehabilitation 10It's Never Too Late 12"Early Find The Peaceful Skies" 14Notes and Comment 15

IPUBLI5AED BYTAE N°r\TA CAROLINA STATE B°ARD*AEALTAVol. 70 SEPTEMBER, 1955 No. 9J. W. R. NOrrON, M.D., M.P.H.. Sute Health Officer JOHN H HAMILTON, M.D., EditorSCHOOL HEALTH SERVICES AND THEHEALTH DEPARTMENTBy B. M. Drake, M.D., M.P.H.Assistant Director,Local Health DivisionN. C. State Board of Health, Raleigh, N. C.We who have adopted the field ofpublic health as our life work havelong since accepted the fact that schoolhealth is one of the major areas ofpublic health interest in every community.The acceptance of this hasresulted to a large extent in overemphasizingschool health in terms ofhealth department time. In manyplaces as much as 50 per cent of thetime of all of the health departmentstaff is taken up with school healthwork.We have accepted the school healthproblem with mixed emotions. Wewant to do a job that will improvethe over- all health of the community.We have, shall we say, a "mandate"from our employers to protect thehealth of our people, and yet theproblem of school health is so involvedthat we feel we are beaten before westart. We see glowing statements aboutbooks such as "Solving School HealthProblems." Upon buying such a bookwe find that the author does not evenapproach the practical. We consultother authorities and are still disappointed,because even these do nothelp us.Fortunately for all of us the 6-18 agegroup is about the most healthy inour population. Most of them havebeen immunized against the communicablediseases (by one means or other).The chronic debilitating diseases havenot set in. Many of the health problemsof the school age group fall intotwo major categories:(1) sequelae of congenital conditions orearlier diseases and (2) results of unfavorableenvironmental conditionsMost authorities have broken downschool health services into several subheads:(1) Health appraisal of the children—Thiscan consist of (a) teacherscreening and observation followedwhen needed by nurse observation,with the child being seen by a physicianwhen and if needed; (b) the"examination" of large numbers ofchildren by the health officer with orwithout parents' being present; or (c)the more careful, more complete studyof the health conditions of the childin the presence of teachers and/orparent. There may be a combination ofthese three or of any two of them. Anyof them may be good, bad or indifferentdepending on the skill and interestof those doing the work.In general, it seems the best all-•Presented at Alabama Conference ofHealth Workers, Birmingham, March 2-4,1955.

The Health Bulletin September, 1955around method would be a combinationof teacher-nurse screening and observationwith the over-all appraisal bythe physician of the children at ratherwidely spaced intervals during theirschool life. Where indicated the childmight be seen by a physician morefrequently.The entire health program, if properlydone, could be made a part ofthe learning process for the children.For example, if the class is studyingthe eye, vision screening by means ofthe Snellen chart could be brought inby the teacher as a part of the lesson.Similarly, the medical history and examinationshould be an educationalexperience for both the child and theparent.As in most health department enterprises,the health appraisal is very likelyto come to nothing without a followup.This is usually done by the nursein the course of her routine homevisiting. She continues the educationalprocess beyond the confines of theschool and thus merges it into theover-all health education process inthe community. At best this type ofprogram can result in some health educationof the children and parents,in the discovery or rediscovery of certaindefects with the possible correctionof these if there is money for this.(2) The control of communicabledisease in the school population can beenchanced by a routine teacher observationprogram. An observant teacher,through her daily contacts with thechildren, has an opportunity to spotthe earlier symptoms of certain childhooddiseases and upper respiratory infections.Seeing these, she could andshould isolate the suspect and refer thematter to some higher authority whoin turn should see that the child istaken home and/or seen by the familyphysician, if need be.(3) The provision of emergency carefor accidents occurring during schoolhours and for sudden illness or otheremergency conditions is a responsibilityof the school and should not be delegatedto the health department. Insome areas contracts are made withphysicians practicing in the neighborhood.Blanket accident insurance policieswill take care of the cost in mostcases. This will generally result in amuch more efficient service than couldbe rendered by the health department,because its personnel is not geared toan emergency room type of work andbecause the nurses and doctors cannothold themselves in readiness foremergency calls that may never come.They have other vitally important worksometimes miles away from the school.(4) Health Instruction—This is ofinterest to public health personnel butshould be considered a part of theover-all instructional program. Thehealth officer, nurse, sanitarian andhealth educator should be available as"resource" people but should not attemptto do the actual teaching unlessthey are trained in teaching methodsand could do an adequate job.(5) The school enviroment is an importantfactor in the life of the childfrom several points of view. Reason (1)has pointed out that there are theemotional and physical environmentsand that both are equally importantin the growth and over-all health ofthe children. The physical environmentmay be a positive factor in theeducational process as well as the overallhealth of the school children. All ofus readily admit the need for safe andadequate water supplies, proper sewagedisposal, adequate washrooms, etc.Likewise, we see the need for goodlighting and ventilation. Regular inspectionsby qualified sanitarians followedby conferences with the principaland superintendent can result in manyimprovements at little cost.The school health situation has beencompared to industrial health. It hasbeen pointed out that it is up to theschool to provide a safe environment, asindustry has done, in order to minimizethe possibilities of accidents in oraround the schools.The emotional environment is determinedlargely by the emotional healthof the teachers and other school staffmembers. While an unhealthy emotionalenvironment may not hurt the emo-

September, 1955The Health BulletinItional development of a healthy child,a healthy emotional environment willcertainly not contribute to the developmentof emotional problems in thechildren.It should be emphasized that if andwhen possible the family physician ordentist should be utilized in the healthappraisal, in the correction of defectsand in the efforts to control communicablediseases as well as in the emergencyservices. Of course in many ofour schools there is a relatively largenumber of children from indigent ormedically indigent families. It is theresponsibility of the community to providefor the correction of defects inthis group. In most places, for example,there are the various welfareagencies. The Lions clubs usually areinterested in sight conservation andwill help with the purchase of glasses;other volunteer health agencies areready and willing to help. In somestates funds are appropriated whichmay be used to supplement welfareand volunteer agency money and aidin the correction of these defects. Allin all, such a corrective program coststhe community a great deal of money.With some minor differences, theseare the usual school health servicesthroughout this country. In some placesthey are administered by the healthdepartments, in some by the schoolsystems and in others by a combinationof the two. Throughout the areaswhere the load of public health workis carried by the local health departmentit is usually assumed that theschool health services will be done bythe health department. In some areasan attempt is made to get it to enterinto a program which includes indigentmedical care, first aid and a roundthe-clockconsultation service for theschool children. Unfortunately, in somecases the health department has gonealong with the thinking that this isthe "best may out.">(I would now like to go back to twostatements made earlier in this paper:(1) "We have .... accepted the factthat school health is one of the majorpublic health problems" and (2) "Manyhealth problems of the school agegroup fall into two major categories,(1) sequelae of congenital conditions orearlier disease and (2) results of unfavorableenvironmental conditions."Let us remember that we in publichealth are responsible for the healthof our community. We have a mandate—to protect health, to prevent illness.Are we fulfilling that mandate in theschool health area? If not, how can webest carry out this mission? We havetried over the years to find and correctdefects of school children—after theyhave gotten into school. By and large,this approach has failed. Why do wecontinue to use it? Has this producedthe best results for the money andeffort expended? We can hear andread statements that it is easier tocarry out a good public health programin the schools because we have a "captive"group. But what about the expenseand the results? I wonder if wehave not missed the whole point.Recent studies have indicated thatthere is a considerable amount ofquestion concerning the entire philosophyof our present school health programin some quarters. In a recentjournal (2), for example, there is a reviewof the problem in a large northerncity. Careful examination of over1,000 first grade children revealed only21 with previously unrecognized defectsand only one with a defect that couldnot easily have been detected by theteacher. The writers of this paper concludedthat the routine physical examinationas a casefinding measurewas a waste of professional time, andby implication it was brought out thatthe conditions of these 21 childrenshould have come to the attention ofthe physician before entrance to school.A study recently made by the HealthInformation Foundation (3) revealedthat there was knowledge of defectsamong a large group of children inPennsylvania but that nothing wasdone about them. Over 40% of theseschool children with remediable defectsdid not have the defects corrected.There was but little variation inthe percentage needing and not re-

6 The Health Bulletin September, 1955ceiving care in varying economic situations.The Foundation report statedthat "The medical and dental defectsdiscovered .... are being ignored inall kinds of homes." Then the studygroup attempted to see how the situationcould be corrected. They intensifiedthe follow-up work done by nurses—and the picture improved.Unfortunately, this tells us nothing.We have known for years that a goodnursing follow-up means better results—regardless of what the department isattempting. However, to me there wasone significant point brought out. Inthe groups studied the Foundationfound that the correction rate washigher among younger children.If the statement that our school agechildren are among the healthiestpeople and that most of their healthproblems are carried over from anearlier age is correct, could we notadopt the principle that it is easier toprevent than to correct? In goingthrough the accepted public healthtexts we find that it is assumed thatwe will have to find and correct defectsthat are already present in thechildren rather than attempt to preventthese defects.It has been said also that the mostneglected group in our entire populationis the one-to-six-year-old group.One wonders if a good preschool healthprogram would not eliminate many ofour school health problems. We cansee that in the six-year-old healthpatterns, both physical and emotional,are pretty well set. Nutritional habitsare fixed, and any change will be theresult of a major "battle" on the partof parents, teachers and health departmentpersonnel. Would we not doa better job by helping to set thesepatterns in the proper mold, ratherthan trying to change them? You willrecall that a leading religious organizationhas stated that if it is given achild for the first seven years of itslife, the child will believe in that faithfor the remainder of its life. This facthas long been accepted in other linesof endeavor. Why have we not awakenedto the fact that, in addition to beingdifficult and expensive, our presentschool health programs are not producingresults?We have a mandate, and there is aneed. The need can be met. How are wemeeting this need? In section V of theChildren? Charter there occurs the followingstatement, "For every child:health protection from birth ... includingperiodic health examinations,protective and preventive measures."How have we met the need? Do wenot owe at least as much time, effortand money to the infant and preschoolchild as to the school child?And, going still farther back, is not thehealth of the mother an importantfactor? We tend to forget that unhealthymothers often produce unhealthybabies.These ideas may not be in line withthe usual thinking, but it would bestimulating to see local health departmentand school system break withtradition and put on a ten-year demonstrationprogram somewhat along theselines. For such a program to be successfulthe entire staff of the healthdepartment and all of the school personnelwould have to be convinced thatin the long run it would be best forthem. Practicing physicians and dentists,the boards of health and education,the county commissioners andfinally a large majority of the citizenswould have to be made aware of theprogram and its potentialities.Such a program might be stimulatedby a grant from one of the philanthropicfoundations.Once the community and all thegroups are sold (for this will take goodsalesmanship) and financial supportobtained, the initial planning couldbegin. This should include, in additionto health departments and schools, themedical and dental professions, theP.-T.A., civic groups and other interestedpersons. This could be in the formof a Health Council, and, if there areexisting health or school health councils,they should certainly be utilized.The actual details of the program wouldhave to be worked out by the interestedgroups, with the following as a very

September, 1955The Health Bulletingeneral set of guideposts:The first step in a good school healthprogram would be good prenatal care.Education of the entire community isessential to this condition. Those whocan go to their physicians must goearly and should know enough to demandadequate care. Those who areto be cared for by midwives shouldreceive as good or better prenatal careby the health department. After thedelivery, an intensive educational effortwould be made to have the infantseen by the family physician or, ifthis is not possible, in the health department,at regular intervals for thefirst year. Between time home visitsby the public health nurse would helpkeep the parents aware of the healthneeds of their child.After the first year the child mustnot be forgotten. Two visits to thephysician and the dentist should beinsisted on during each year. At suchtimes the physician would not only doa thorough examination but shoulddiscuss all phases of the child's health,growth and development with the parentsand should correct or attempt toavoid potential defects.Attempts should be made to providethe community with a fluoridatedwater supply, and the rudiments ofgood nutritional habits should be taughtthe parents in order, insofar as possible,to avoid such defects as dentalcaries and nutritional deficiencies. Ithas been stated that about one tothree per cent of our school childrenhave developed rheumatic fever. Ifthis could be found in the earlier stagesand preventive measures instituted, theamount of cardiac damage among ourschool children and adults would bereduced.Orthopedic difficulties could be foundearly, when correction is less of aproblem. Mental health problems shouldbe recognized as such by the familyphysician or health department andsteps taken to correct these before itis too late. There is no longer anyexcuse for communicable diseases suchas diptheria, whooping cough or measlesin our schools, if the health departmentis on the job. The entireprogram would include a complete,careful examination of the immediatepreschool child, followed by a goodteacher observation program using agrowth chart such as the Wetzel grid,which would, in most instances, predictany marked change in healthstatus of the child. When such a situationis noticed, the child could be takento a physician for a complete checkup.Finally toward the last of the juniorhigh period, there might be anothercomplete examination of all the children.It is felt that, if we would spend asmuch money on prevention as we dofor correction and cure, we would haveenough to carry out the program Ihave outlined and have a large savings.In the matter of environment, muchmay be done, even with the limitedresources of most of our school systems.Light meters may usually be borrowedfrom the local power company office.Then, with the help of personnel fromthe state health department, the seatsin the room may be arranged so asto take advantage of all available light.Cleanliness, per se, is not expensive.Arrangements may be made to improveheating and ventilation problems.Imagination and willingness to try canturn a poor, unattractive, unhealthyschool environment into one that isclean, healthy and a good example tothe householders of the community. Ingeneral, our sanitation and accidentprevention programs have made wonderfulprogress, but they are limitedby housing, both private and forschools. These factors are, in turn,limited by economic factors which, inturn, are limited by the health (or lackof health) of our people. An unhealthygroup of school children produces anunhealthy group of adults, who are notwage earners and taxpayers.first-classWe find ourselves in a vicious circle.Can we not find someone with enoughfaith, enough courage to attempt tobreak out of this circle of poor economy,poor schools, poor health? Rememberit would not take much money,

8 The Health Bulletin September, 1955and we in public health have a mandateto protect the health of our people.References(1) Maxcey, "Rosenau Preventive Medicineand Hygiene" PP684-85 Appleton,N. Y. 1951(2) Yankauer, A. and Lawrence Ruth,"A Study of Periodic School MedicalExamination" Journal A.P.HA.45; 1, P 71 Jan. 1955(3) Health Information FoundationPamphlet 1955—New York "Rx ForHealthier Children."LEGISLATION AND POLICY GOVERNING THEEXPENDITURE OF SCHOOL HEALTH FUNDSBy Charles E. SpencerDirector School Health and PhysicalandEducationCo-director School Health Coordinating Serviceof theState Department of Public Instruction and theState Board of Health, Raleigh, N. C.The 1955 North Carolina GeneralAssembly reduced the appropriation tothe State Board of Education for schoolhealth from $550,000 for each year ofthe biennium to $425,000.REPORT OF THE ACTION OF THEJOINT APPROPRIATIONS SUB-COMMITTEE APPOINTED TO STUDYAND MAKE RECOMMENDATIONSTO THE JOINT APPROPRIATIONSCOMMITTEE OF THE 1955 GENERALASSEMBLY"Child Health Program, line item 664:Your Sub-Committee made considerablestudy of this program and recommendsthat use of the funds be morelargely restricted to the purpose ofcorrecting chronic remediable defectsof medically indigent school children.It was found that last year only $314,-124 (or 58%) of actual expendituresfrom the fund were used in paying forsuch corrections. Your Sub-Committeewas of the opinion that an appropriationof $425,000 per year for the nextbiennium would, under the proper restrictionsas to use, result both inlarger expenditures for actual correctionsof physical defects and makepossible a budget reduction in thisitem of $125,000 per year. The recommendedrestrictions are incorporatedin a proposed amendment to the AppropriationsBill."SEC. 18.2 OF THE BUDGET AP-PROPRIATION BILL FOR THE BI-ENNIUM 1955-57That appropriations made to theState Board of Education under TitleTX-I for the Child Health Programshall be expended for diagnosis andthe correction of chronic remediablephysical defects of public school childrenthrough the Child Health Programof the State Board of Education inthe following manner:(1) Upon discovery of the defect, ifit appears that the expenditure ofschool health funds will be requiredfor correction through providing spectacles,prostheses, or other correctionof chronic remediable defects, the appropriateschool official shall forthwithnotify the county superintendent ofpublic welfare of the county in whichthe child resides. Thereupon, the superintendentof public welfare shall makesuch investigation as necessary andonly upon his certification of financialneed shall funds be expended for thispurpose: Provided, however, that incase of minor dental defects involving

September, 1955 The Health Bulletin 9expenditures not in excess of $10.00,school and health department personnelmay determine financial need.(2) Child Health Program funds asdefined in this section shall be expendedin accordance with a uniform Statewideschedule of fees and costs, andonly to provide spectacles, prostheses,and other correction of chronic remediabledefects of public school children:Provided that a reasonable amount ofthe total appropriation may be expendedfor case finding, health education,and intensive follow-up services.STATE BOARD OF EDUCATIONREDUCES ALLOTMENT AVAILABLETO CITY AND COUNTY SCHOOLADMINISTRATIVE UNITSSince the General Assembly reducedthe amount of the annual appropriationof funds from $550,000.00 to $425,-000.00 it was necessary for the StateBoard of Education to reduce the allotmentsavailable to local school administrativeunits. The reductions madeare as follows:a. In 1954-55 each county and cityschool administrative unit was allottedan amount equal to 47.95cents per pupil based on the averagedaily membership for the firstseven months of the previousschool year. For the year 1955-56the allotment available is reducedto 35 cents per pupil.b. In 1954-55 the allotment to eachcounty regardless of size was$1000.00. For the year 1955-56 theallotment available to each countyis $775.00. As in previous years,each school administrative unitwithin the county will receive aportion of the $775.00 allotmentbased on its percentage of thetotal students in average dailymembership in the county.POLICY GOVERNING THE EX-PENDITURE OF STATE BOARD OFEDUCATION SCHOOL HEALTHFUNDSIn order to carry out the intent ofSection 18.2 of the Budget AppropriationAct for the Biennium 1955-57under Title IX-I for the Child HealthProgram, the State Board of Educationand the State Board of Health herebyadopt the following policy:1. The health officer of each localhealth jurisdiction and the superintendentof each administrative unitin each such jurisdiction shall submitfor approval to the School HealthCoordinating Service a joint planand budget, based on need, for theexpenditure of the funds available toeach administrative unit. The SchoolHealth Coordinating Service personnelwill, upon request, provide assistanceto schools and health departmentsin preparing plans and budgets.2. A minimum of 80 per cent of theschool health funds available to eachschool administrative unit may beexpended for diagnosis, case finding,health education and intensivefollow-up services. Included underthis provision are such services as:a. General physical examinationsb. Eye examinationsc. Hearing testingd. Nurses' services in inspecting, andhelping teachers inspect, schoolpupils to detect signs of deviationsfrom normal and follow-up servicesin connection with the correctionof defects.e. Health education for the improvementof health instruction andeffective use of available healthservices.4. School administrative units showingneed for the allotments available inaccordance with items 2 and 3 aboveshould request the State Board ofEducation to certify such funds andfurthermore should notify the SchoolHealth Coordinating Service. Allotmentswill be made in terms ofactual needs.5. School health funds shall be expendedfor correction of chronic remediabledefects only upon certificationof financial need by the superintendentof public welfare: Provided,however, that in cases of minordental defects involving expendituresnot in excess of $10.00, school and

10 The Health Bulletin September, 1955health department personnel maydetermine financial need.6. School health funds for prostheses(including spectacles) and correctionof other chronic remediable defectsof public school children shall beexpended in accordance with a uniformState-wide schedule of fees andcosts to be set up by the State Boardof Education and the State Board ofHealth.7. School health funds may not be used:a. To purchase any types of suppliesand equipment or for in-serviceeducation.b. To pay salary or travel of healthofficers, sanitarians, nutritionists,clerks, psychologists, psychometrists,special education teachers,physical education supervisors,athletic directors, teachers andschool or other administrativepersonnel.c. To pay transportation of schoolchildren for examinations or correctionof defects.VOCATIONAL REHABILITATIONBy H. E. Springer, Chief of Rehabilitation ServicesState Department of Public InstructionWhat do we mean by vocational rehabilitation?It is a service that thegovernment provides, by law, to helpdisabled men and women qualify toearn their living.State and Federal governments haveplanned this kind of help for all disabledpeople.Such services as schools, health centers,fire and police protection are providedby the State or local governmentin every town or county. Think ofvocational rehabilitation in the sameway. It is not charity. Such services areplanned as a legal right for all whomay need them.Many thousands of disabled peoplehave been helped to get jobs thatthey can do well. The purpose of vocationalrehabilitation is to help all otherdisabled people build up and use theabilities they have left so that theycan make a living.Most of the people who work in vocationalrehabilitation are called counselors.The counselor works with disabledpeople as a friend and helper. He seesto it that they get the help they need.SERVICES OF REHABILITATIONWhat services are available? Thiswill be decided on the basis of factsabout the needs and abilities of thehandicapped person. The rehabilitationpeople get these facts in several ways:1. They obtain a medical examinationto learn what the client's physicalabilitiesare.2. They interview the client and givehim tests to determine work skills andinterests.There is no charge for diagnostic servicesto the disabled person. The factsfrom the medical examination and theinterview and tests are studied. Thenthe disabled person and the vocationalrehabilitation counselor make a planto help the disabled person to build uphis skills and abilities so that he canwork and make good on a job.There are a number of services whichmay be needed in the plan for vocationalrehabilitation which the counselorand the disabled person set up:1. Medical help to bring back or improvethe person's ability to work.Doctors and other medical people doeverything they can to make the disabledperson strong enough and wellenough to work. They give the disabledperson an operation if he needsone. Or they give treatment if he needsthat kind of help to work. Medicalhelp may be given in hospitals, homes,offices or other places. The Divisionof Vocational Rehabilitation pays the

September, 1955 The Health Bulletin 11bill if the disabled person cannot pay.Sometimes the Division pays part ofthe bill and the disabled man orwoman pays what he can. The counselorassists the disabled person to getany medical help he needs.2. Physical aids such as braces, trusses,artificial limbs, and hearing devices.The counselor helps the disabledperson get the kind of aid he needsand helps get used to using it. If thedisabled person can pay for the aid,he pays. If he can't pay, the Divisionof Vocational Rehabilitation will payall or part of the cost.3. Advice to help the disabled manor woman to pick out the right kindof work and to get ready for that kindof a job. If people become disabled,they may have to change the kind ofwork they do or they may have tolearn to work for the first time. Thecounselor can help them very muchwith his advice and in other ways.There is no charge for the counselor'shelp.4. Training for the right job. If adisabled person needs to learn howto do some kind of work, the counselorwill help him get the right kind oftraining. This may be given on the job,in a trade school or in many otherplaces. Some people are trained athome. The Division ofVocational Rehabilitationpays for training costs.5. Board and room and travel duringrehabilitation. If the disabled personneeds it, the Division of VocationalRehabilitation may pay for his boardand room and other necessary expenses.Or he may pay part and the Divisionmay pay part. If he has to travel whilegetting in shape to work, the Divisionmay pay the cost or part of it. Board,room and travel help are given onlywhile the disabled person is beingmade ready for work or while he isbeing helped to find a job.6. Job finding. When the disabledperson is ready for work, the counselorwill help him find the right job. Thecounselor knows where to get help infinding jobs. The State EmploymentService finds jobs for many disabledpeople and the counselor works withthe Employment Service. There is nocharge for this help.7. Tools and licenses. If a disabledperson needs tools or a work licenseto get the right job and make good,the Division of Vocational Rehabilitationwill help him get what he needs.If he cannot pay, it may pay all orpart of the costs.8. Help on the job. When the disabledperson goes to work, he mayneed some help to "iron out" troublesor to learn some things about the job.The counselor helps him withoutcharge.Some people will need all of the serviceslisted above. Some will need onlyone or two of them. But they are allthere, and the counselor will help eachdisabled person get those that he needs.All the information that the vocationalrehabilitation people get from aperson is kept confidential.WHO CAN GET REHABILITATION?Any man or woman of working agemay get vocational rehabilitation if heor she is disabled in mind or body sothat he or she cannot work or must takea job which would be harmful for himor her. Vocational rehabilitation servicesare for those with unseen handicapsas well as for those who havehandicaps which show. A few unseenhandicaps are tuberculosis, deafness,mental illness, arthritis, rheumatismand heart disease. There are manyothers. There are a great many handicapsthat can be seen, too, such as anamputation, paralysis and palsy. Thereare many more of these also. The kindof disability does not count in decidingwhether a person can get vocationalrehabilitation. It can comefrom an accident, disease or birth. Itdoes not have to be a disability thatcomes from getting hurt on a job.In other words, ANY disability thatkeeps the person from using his bestability to earn a living—or that interfereswith his making a living—wouldmake him eligible for vocational rehabilitation.

12 The Health Bulletin September, 1955HOW TO ASK FORREHABILITATIONAll vocational rehabilitation serviceis given through the State agency.Therefore, application for it should bemade to the Division of VocationalRehabilitation, in care of the nearestlocal office. Offices are located in Asheville,Charlotte, Salisbury, Winston-Salem, Greensboro, Durham, Raleigh,Greenville and Wilmington.THE DISABLED CAN WORKMany handicaps, physical and mental,can be removed or reduced throughvocational rehabilitation services. Whenhis best abilities have been discoveredand developed and when the disabilityhas been properly treated, the disabledperson gets help in finding theright job for him. When the right jobis found, he can do that job as wellas anybody. Records of thousands ofphysically and mentally handicappedpersons in wartime and peacetime haveproved this. That is why vocationalrehabilitation people say: "It is notwhat a man has lost, but what he hasleft that is important!"IT'SNEVER TOO LATEBy Sarah E. Walker, Senior Public Health EducatorandAlice N. Blackwelder, Senior Public Health NurseCabarrus County Health DepartmentThe girl, small for her age, satacross the desk from the counselor.Looking into her eyes, one could notescape recognizing that her problemswere far beyond the strength of herfifteen years. Facing up to motherhoodwithout the sanction of marriage isnot easy at any age at any time."Looking back, now, do you feelthat there is anything that your schoolmight have done that would havehelped your having to face this problemtoday?", the counselor asked.Quick as a flash came her reply,"Yes, they didn't tell us enough."They didn't tell us enough! Werewe failing in our responsibilities to ouryouth by not providing the factual informationwhich would help them tocope more effectively not only withthe current problems of living, butwith the persistent life situations involvingthe wide gamut of human relationships?If the health education program ofthis high school with an enrollmentof 390 students could include a specialemphasis area in "Developing WholesomeLife Relationships", would theschools be meeting more adequatelythe unmet needs of youth? The schoolhealth education team, the superintendentof schools, the principal, the facultyhealth committee, the public healthnurse, and the health educator shareda deep-running conviction that sucha program would provide many opportunitiesto give factual information.But factual information, we recognize,is not the whole answer; understandings,feelings and attitudes are basic,too, in influencing behavior. Contactswith concerned parents intensifiedthese convictions.We were all in agreement that theproblems could best be met by integratingthe information in variousareas of the curriculum. However, itseemed that if we were going to doanything during the current year forall the boys and girls, a plan wouldhave to be devised wherein all thestudents could be reached.As we explored the possibilities together,in conferences, and in committeemeetings, these questions cameinto focus:1. What factual information concerningphysical and emotional growthshould be included?

September, 1955 The Health Bulletin 132. How could this information be presentedin order to best help the studentssee that the understanding ofself and others is essential in understandingwhy certain kinds of behaviorare acceptable?3. Could we be objective and at thesame time create an atmosphere whichwould be conducive to student-participation?4. Where could we find resourcepeople to help us in the various areas?The high school principal suggesteda schedule arrangement making it possiblefor all the students in a givenclass to meet for five one-hour periodson consecutive days. The commiteeeagreed on the following outline asgeneral suggestions for the discussionperiods:I. THE FAMILYII.III.1. Development of Family Life2. What Is A Good Home?3. Family Relationships4. Your Home of the FutureECONOMICS OF FAMILY LIFE1. Cost of Individual Living2. Getting the Most for YourMoney3. Budgets4. Economic Values of Education5. Cost of Establishing andMaintaining a Home6. Cost of Babies—Moral andLegal ObligationsHOW TO GROW UP EMO-TIONALLY1. How Emotions Grow1. Learning to Handle our Feelings3. Channels for Creative Energy4. Importance of Sex Drives5. Power of Reason6. Growth in Social Skills7. What it Takes to be ReallyGrown-up8. Choosing a Life MateIV. ANATOMY AND PHYSIOLOGYOF REPRODUCTIVE SYSTEM1. Physical Maturity2. How Conception Takes Place3. Reasons for ContinenceV. QUESTION-AND-ANSWERSESSIONThe following persons readily andwillingly agreed to lead the variousdiscussion groups: a local minister, acollege professor of economics, a healtheducator in an adjoining county whohad a rich background of experiencein working with boys and girls and alocal physician.This plan was initiated with thesenior class and carried through thejunior, sophomore and freshman classes.During the discussion the studentswere encouraged to participate by askingquestions and expressing their viewpointsand opinions However, to encouragethem to ask any questionswhich they might hesitate to ask inthe group, a sealed box was availablefor them to place their unsigned andunidentified questions throughout thefour discussion periods. At the conclusionof the last session, the questionbox was opened and the questionsdivided into the following categories:social, emotional and physical, andassigned to individual panel members.The panel was composed of the publichealth nurse, the health educator,member of the faculty health committeeand two class representatives.The questions were very revealing inidentifying the attitudes, concerns, interestsand problems of the students.As we moved from the senior to thefreshman class more and more of thequestions had to do with physical aspects.Approximately 75% of the questionsasked by the freshman class werein the area of physical functions andboy-girl relationships.A climate of mutual respect and understandingof the purpose of thesediscussions prevailed. The studentswere encouraged to aid their feelings.Although there were often conflictingopinions in the student discussions, thepanel felt that their inquiries weresincere and that answers were honestlysought. The adult panel membersfelt, too, that in addition to serving asdiscussion leaders and giving factualinformation, they had definite responsibilitiesthroughout the discussions for

14 The Health Bulletin September, 1955anchorage along these lines:1. Trying to develop understandingsof why certain kinds of behavior areacceptable2. That accurate information is oneof the basic guides for acceptable behavior3. That conforming to the moral codewill pay dividends in personal living4. To develop a sense of individualresponsibility in management of emotions,and to realize that the individualhas a responsibility for the welfare ofothers.The adult panel members had madeone commitment to the students, thatany question they placed in the boxwould be discussed and answered tothe best of their ability. We were ableto carry through with this promise andare confident that we were able topinpoint these values through this kindof discussion:1. That problem discussions can becarried on in an objective manner andthat adults are sincerely interested inhelping teenagers with their problems.2. That talking things over is onestep in problem solving and that individualcounselling can often help tosolve a personal problem.Because of the crowded schedules ofthe persons involved, it was not possibleto adequately evaluate the program.This year the school health educationteam plans to work with theentire faculty, high school and elementary,in studying the needs of boysand girls in human relationships andthen try to see where and how theschool curriculum can help meet theneeds. The school health educationteam feels that this program had amarked degree of success. There aresome tangible evidences: the commentsof the students, the favorable reactionof the community and certainly thesatisfying experiences which come tothose who have an opportunity to workcooperatively in trying to build for themore abundant life.Some of the intangibles, we hope, arein the minds of the boys and girls, wholistened, who questioned, who sharedtheir thinking, and who through thegroup process, extended their thinkingand deepened their values.'EARLY FIND THE PEACEFUL SKIES"By R. M. Fink, Ph.D.School Health Coordinating Service o f theState Department of Public Instruction and theState Board of Health, Raleigh, N. C.Ay, soon upon the stage of life,Sweet, happy children, you will rise,To mingle in its care and strife,Or early find the peaceful skies.—Daniel Clement ColesworthyFor the past eight years the SchoolHealth Coordinating Service has aidedthe public schools in programs for themaintenance and improvement of themental health of school children.During the past school year twentysixschool administrative units wereaided in planning and executing meetingsor work sessions on mental health.In these units 1768 teachers and administratorsparticipated in programstotalling from two to twelve hours.Some of the topics for these sessionswere:Emotions and BehaviorFeelings of InferiorityFeelings of HostilityFear and AnxietyUnderstanding and Helping theSubmissive ChildSchool systems were also aided infifteen meetings attended by about2200 parents. Some topices for thesesessions were:

September, 1955 The Health Bulletin 15What Are Junior High StudentsLike?Healthy Emotional EnvironmentsIn The HomeExpectations and ResponsibilitiesWithin The FamilyOne experimental program was developedand used with school administratorsin a large county. The programwas designed to increase productivityand morale and to reduce tensions.Illustrated lectures, films, discussionsand rule-playing were used to aid administratorsto improve relationshipsbetween administrative personnel, withteachers, and with the public.During the school year 1955-56schools will again be aided to developprograms based on local problems. Inaddition, four topics have been foundto be profitable for local use:Maintaining and Improving MentalHealth In Our SchoolsUnderstanding and Helping theSubmissive ChildUnderstanding and Helping theHostile ChildUnderstanding and Helping theWithdrawn ChildDetailed plans for these programs aredesigned in cooperation with administratorsand teachers according to theirdesires.NOTES AND COMMENTBY THE EDITORREPORT ATOMIC RADIATIONAFFECTED PREGNANCY OUTCOMERadiation from the atomic bomb explosionsover Nagasaki, Japan, in 1945had considerable affect on the outcomeof pregnancies of women in thecity who were pregnant at the time.Among 30 pregnant women with majorsigns of radiation injury, therewere three miscarriages, four stillbirths,three babies who died within the firstmonth of life, three infants who diedwithin the first year of life, and onewho died at two and one-half years.Four of the surviving 16 children werementally retarded.Drs. James N. Yamazaki, Stanley W.Wright and Phyllis M. Wright, LosAngeles, found this evidence in a studyof pregnant women exposed to theatomic blast at Nagasaki and their offspring.Their report appears in theAmerican Journal of Diseases ofChildren,published by the American MedicalAssociation.The pregnant women studied weredivided into two groups—98 who werewithin the radiation area, 30 of whomshowed what the physicians termedmajor radiation injury signs, and acontrol group of 113 pregnant womenwho were outside the radiation area ofthe city at the time of the bombing.The over- all morbidity and mortalityof the outcome of pregnancy amongthe 30 women who suffered majorradiation injury signs was approximately60 per cent, as compared to10 per cent among the 68 other pregnantwomen within the radiation area,and about six per cent among the 113women outside the radiation area, thedoctors stated.In the group of 68 women who werewithin the radiation area but sustainedno major signs of radiation injury,there were one miscarriage, two stillbirths,three babies who died withinthe first month of life, and one case ofmental retardation.In the control group of 113 pregnantwomen outside the radiation area,there were two miscarriages, one stillbirth,one baby who died within thefirst month of life, and three infantswho died within the first year of life.In addition, the study disclosed thatchildren born to mothers with majorsigns of radiation injury were retardedin growth and development, the doctorsstated. These children were signifi-

16 The Health Bulletin September, 1955cantly smaller in height and head circumferencethan those children bornto mothers in the control group."It is difficult to evaluate the effectof radiation of this mortality andmorbidity, since other factors, such astrauma, burns, infections, etc., mayhave a deleterious effect on the fetus,"the doctors stated. "The evidencestrongly suggests, however, that radiation,either directly to the fetus or indirectlyas a result of its effect onthe maternal tissues, was of considerableimportance in determining theoutcome of these pregnancies."The physicians are associated withthe Laboratories of the Atomic BombCasualty Commission, Hiroshima, Japan,and the Department of Pediatrics,University of California Medical Center.WARNS AGAINST CARELESSUSE OP CLEANING FLUIDSCleaning fluids can be poisonous.Too often labels on cleaning fluidbottles do not list potential dangers ornecessary precautions for the solution'suse—precautions necessary becausemany such fluids contain a very toxicchemical called carbon tetrachlorideaccording to Dr. Albert V. Myatt, NewOrleans."Carbon tetrachloride is a clear fluidchemically related to chloroform," Dr.Myatt wrote in Today's Health magazine,published by the American MedicalAssociation. "It evaporates quicklywhen exposed to air, causing fumeswith a pungent odor. Both the fumesand the liquid are capable of causingpoisoning. Carbon tetrachloride is usedas a solvent, a dry cleaning solution, agrease remover, and a fire extinguisher."Deaths from inhalation of fumes oringestion of the chemical have beenreduced as a result of modern methodsof therapy. However, poisoning bycarbon tetrachloride causes a lingeringillness of one to three weeks, duringwhich the kidneys shut down, the liverenlarges, and the bile backs up into theblood stream, causing jaundice."For some reason, people who habituallydrink alcoholic beverages are muchmore susceptible to poisoning by carbontetrachloride than those who donot drink," he pointed out. "Otherswho are more susceptible than normalto this poisoning are malnourished peopleor those suffering from diseases ofthe heart, stomach, kidneys or liver.Anyone who has once been poisoned bycarbon tetrachloride is more likelythan usual to be affected by it again."That one has been using carbontetrachloride with no precautions allhis life without difficulty does notmean he can continue doing so. Thenext careless use may cause illness."Dr. Myatt listed six precautions tobe taken when dry cleaning solutionsare used:1. Read the label carefully to determinewhether the solution will burn.If it is flammable, use it outdoors, awayfrom sources of flames and sparks.2. If the solution is nonflammable,look for the ingredients on the label.If ingredients are not listed, assumeit to be carbon tetrachloride, and actaccordingly. Use carbon tetrachloridesolution in a well-ventilated room or,preferably, outdoors. Do not breathe thevapor. If you must work inside, openwindows and doors, and vacate theroom as soon as possible until theodor and fumes vanish. Garmentscleaned with the solution should beplaced outdoors to dry.3. Mark "POISON" on the label ofcleaning fluid containers and storethem out of reach of children.4. Never put carbon tetrachloridesolution in a soft drink or whiskeybottle or other beverage container, asit may be mistakenly consumed.5. Do not use carbon tetrachloridesolution if you are ill, or if you havedrunk alcoholic beverages within 24hours, or if you are a chronic user ofalcohol.

MEDICAL LIBRARYU. OF N. C.CHAPEL HILL, M. C .PublisKedbv^(0btti3SCBKUNA 5B0EKffli])»flEAlTAI TKis Bulletin will be sent free to fljVU citizen of the 5tctte upon request jPublished monthly at the office of the Secretary of the Board, Raleigh, N. C.Entered as second-class matter at Postoffice at Raleigh, N. C. under Act of August 24, 1912Vol. 70 OCTOBER, 1955 No. 10ALLEGHANY COUNTY HEALTH CENTER, SPARTA, NORTH CAROLINARECRVEDm*CT29 msfrf%*'WSIQN OFAtfAIRS LIBRA"ATTENTION PLEASE—Since the General Assembly of 1955 reducedappropriations for printing, The Health Bulletin must absorbits fair share of this economy. Some of our issues therefore must beeight pages, some sixteen—with probably a twelve page Bulletinafter our present paper stock isexhausted. You will note a changein our make-up. If you no longer wish to receive The Health Bulletin,please notify us and thereby help us to economize.J.H.H."

MEMBERS OF THE NORTH CAROLINA STATE BOARD OF HEALTHG. G. Dixon, M.D., President AydenHubert B. Haywood, M.D., Vice-PresidentRaleighJohn R. Bender, M.D Winston-SalemBen J. Lawrence, M.D RaleighA. C. Current, D.D.S GastoniaH. C. Lutz, Ph.G HickoryGeo. Curtis Crump, M.D AshevilleMrs. J. E. Latta Hillsboro, Rt. 1John P. Henderson, Jr.. M.D Sneads FerrvEXECUTIVE STAFFJ. W. R. Norton, M.D., M.P.H., State Health OfficerJohn H. Hamilton, M.D., Assistant State Health Officer. DirectorState Laboratory of Hygiene, and Editor, Health BulletinC. C. Applewhite, M.D., Director Local Health DivisionErnest A. Branch, D.D.S., Director of Oral Hygiene DivisionA. H. Elliott, M.D., Director Personal Health DivisionJ. M. Jarrett, B.S.. Director Sanitary Engineering DivisionFred T. Foard, Director Epidemiology DivisionList of free health literature will be supplied by local Health Departments or onwritten request.CONTENTSPageDiabetes In A Public Health Program 2New Plan For Hospitalization Of Public Assistance Recipients 4Home Treatment Of Tuberculosis, The Progress Of AndThe Future Responsibility Of Local Health Departments 6DIABETES IN A PUBLIC HEALTH PROGRAM*By M. T. FOSTER, M.D., F.A.C.P.M.Cumberland County Health Department, Fayetteville, N. C.DEFINITION: Diabetes mellitus is ahereditary metabolic disease characterizedby high blood sugar levels andexcretion of sugar in the urine. It isassociated with a relative insulin insufficiency.In diabetes there is a faultystorage of sugar in the liver, overproductionof sugar by the liver andapparently diminished utilization ofsugar by the tissues. The result is anincreased concentration of sugar in theblood and subsequently the appearanceof sugar in the urine. When carbohydrateutilization is sufficiently impairedfat metabolism becomes disturbedin such a manner as to produce ketosiaand finally coma. The most characteristicsymptoms are the passage of largeamounts of urine, increased thirst andexcessive appetite, accompanied by lossof weight and strength.PREVALENCE: Surveys made by theU. S. Public Health Service indicate*Read before N. C. Academy of PreventiveMedicine, September 8, 1955.

October, 1955The Health Bulletinthat in certain areas surveyed 1.7% ofthe population were diabetics. Assumingthat this rate is applicable to thecountry as a whole, it can be estimatedthat more than two million persons inthe United States have diabetes, andabout one million of them are unawareof the disease. It has been estimated byothers that from one to two per centof the population are diabetics.PREDISPOSING FACTORS: Hereditarysusceptibility to diabetes hasbeen known for a long time. The incidenceof diabetes is several times higheramong parents and siblings of diabeticsthan among the parents andsiblings of non-diabetics. The marriageof known diabetics to one anothershould probably be avoided, since thedisease would most likely appear intheir offspring. While heredity determinessusceptibility to diabetes, theactual occurrence of the disease amongadults is correlated with obesity. Obesitymay be the basis for the highincidence of diabetes in the adultgroup.PREVENTION: Prevention of diabetesis a difficult task, as there areno specifiicmeasures that can be employed.All of us require insulin, and, ifwe cannot manufacture what we needin our own pancreas, we are now fortunatein that we can secure it by purchaseor gift. No one knows the quantityrequired to maintain health andstrength. Nature regulates the supplywith surprising accuracy, balancing itsproduction with the carbohydrate consumedand adjusting its output to themomentary demands of exercise orrest. Since certain known factors predisposeto the disease, these knownfactors might be controlled in an effortto prevent the disease. Avoiding obesityand reducing overweight individuals isone of our best weapons in the preventionof diabetes. The second mostimportant tool is the education of thepublic to avoid intermarriage of diabetics.High incidence of diabetes mayalso be attributed to familial patternsof living, such as excessive eating,especially of carbohydrates. As in otherdiseases, in order to find diabetes early,periodic examinations for the presenceof urine sugar and high blood sugarlevels should be recommended. The detectionof diabetes in its earliest stagesbefore the onset of typical symptomsand continuing good care are basicelements in the prevention of disabilityand death from diabetes.OBJECTIVES: The objectivesinfinding and treating diabetes are numerous.Approximately 50% of diabeticsdiscovered early can control theirdisease by diet alone. The diabeticpatient must be taught the nature ofdiabetes, how to take advantage of dietand the use of insulin, if necessary.He must be instructed in the properuse of exercise and how to prevent oicombat the common complications ofthe disease. If the diabetic follows therules of treatment and presents himselffor check-up examination three orfour- times a year, there is no reasonwhy most diabetics should not live aslong as the non-diabetic.The principal method for the earlydiscovery of diabetes is urinalysis. Communitysurveys utilizing the bloodsugar screening method and the urinalysistogether have shown that aboutone out of three diabetics escapes detectionif dependence is placed upon asingle urine specimen. Both blood andurine sugar tests should be used formaximum benefits. As in the case ofother diseases, a successful attack ondiabetes requires the cooperation of thepublic, medical and allied professions,voluntary health agencies and healthdepartments. The chief objective is todiscover diabetes in its early stagewhen it can frequently be controlledby diet alone and offer a hope forrestoration of pancreatic island formation.I quote in part from an editorial inthe August issue of the AmericanJournal of Public Health: "The Americanpeople are becoming increasinglyaware of the vast economic and socialproblems posed for our national life bythe existence of millions of chronicallyill and disabled persons in our midst.The problems will become more seriousas a result of the aging of our popula-

The Health Bulletin October, 1955tion. These problems of chronic illnessand disability constitute a communityhealth responsibility of the first magnitude.Health departments have begunto recognize their vitally importantroles in meeting these problems withinthe framework of community effort."Diabetes, along with many other chroicdiseases, is now receiving attentionby many health departments in variousways. Public health education plays avital role in most health work, and inthe field of diabetes much can be accomplishedby informing the publicconcerning this disease.The American Diabetes Associationsince 1940 has carried on an educationalprogram concerning the prevalence ofdiabetes and the necessity of earlydiscovery and proper treatment. Forseven years this Association has conducteda public education and casefindingdrive through the local affiliatesand committees on diabetes of countyand state medical societies, with assistancefrom public health groups.Activities are conducted throughout theyear, but the greatest effort is madeduring observance of Diabetes Week,which is the third week of November.The American Diabetes Associationuses all mass communications media,while the local affiliates and health departmentsobtain the support of newspapersand radio and television stationsin their areas. The Associationstrives to educate the public as to thewisdom of periodic examination fordiabetes and the importance of earlyrecognition of the disease. It also seeksto distribute accurate information tothe general public by literature, meetingsand other appropriate means.Health departments could adopt theprogram of the American DiabetesAssociation in whole or in part andconduct diabetes educational programsthroughout the year integrated withtheir general public health educationprograms.Most diabetics receive their instructions,treatment and follow-up fromtheir family physicians. Diabetic clinicshave been established in some outpatientdepartments and in some healthdepartments where needed for indigentpatients. I believe, however, it isgenerally agreed that the health departmentin most cases should limitits activities concerning diabetes toeducation pertaining to prevalence,early case finding and the importanceof medical supervision and treatmentof the disease. Health departmentsshould refer patients to physicians ortreatment clinics whenever possiblediagnosis and treatment.forNEW PLAN FOR HOSPITALIZATION OFPUBLIC ASSISTANCE RECIPIENTSBy EDWIN S. PRESTONState Board of Public Welfare, RaleighUnder provisions of a 1955 amendmentto Chapter 108 of the GeneralStatutes of North Carolina, the StateBoard of Public Welfare was authorizedto establish a State fund for thehospitalization of recipients of publicassistance. These include recipients ofold age assistance, aid to dependentchildren and aid to the permanentlyand totally disabled.The new plan will make it possiblefor six dollars per day to be paid immediatelyout of funds from Federal,State, and county sources toward thehospital bills of these recipients. Previousto this plan such payments couldonly be made in small monthly installments,the amount depending upon thesize of the assistance grant.Under the new plan, counties will

October, 1955The Health Bulletincontinue to deal directly with the hospitalswith which they work out agreements.The determination of the needof hospitalization will be made in thecounty upon medical advice, the hospitalbills will be approved by thecounty department of public welfareand the check, made out in the Stateoffice, will be sent to the county departmentfor payment to the hospital.Details of the new hospitalizationplan were developed in cooperationwith representatives of the State Associationof Hospital Administrators,the State Association of County Commissioners,the Medical Society of theState of North Carolina, the StateAssociation of County Superintendentsof Public Welfare and the Bureau ofthe Budget.Any recipient is entitled to hospitalizationwhen it becomes necessary uponmedical advice. The per diem rate tobe paid to the hospital from the Statefund will be determined from time totime by the State Board of PublicWelfare; at present it is six dollars.The medical consultant of the StateBoard for the aid to the permanentlyand totally disabled program will alsobe the medical consultant for theState plan for the hospitalization program.Payments will be made only tohospitals licensed by the North CarolinaMedical Care Commission.The State fund for the hospitalizationof assistance recipients will be maintainedby the State treasurer in accordancewith the provisions of the act.The fund will consist of monthly paymentsfrom Federal, State, and countyfunds. These monthly payments will beadjusted from time to time in orderto keep the fund solvent and to maintainrates for each category sufficientto provide funds to cover expendituresfor recipients in each category. Futurerates will be determined on the basisof experience.When an authorization is made inaccordance with the plan, it creates anobligation for payment of hospitalizationat the six dollar per diem rate tothe hospital to which the recipient isadmitted. Any obligation to pay morethan this per diem rate is to be determinedby agreement between the countyand the hospital, and payments willnot come from the State fund.Under no circumstances is an assistancerecipient expected to apply hisassistance money payment or any partof it to his hospital bill, either directlyto the hospital or indirectly throughrefunds to the county. The monthlyassistance payment to the recipient isintended only to cover the recipient'susual living expenses. If they are reducedbecause of hospitalization, theassistance payment will be reducedproportionately, provided he is to be inthe hospital for a sufficient length oftime to justify such action. When therecipient is released from the hospital,the payment is reviewed in terms ofhis needs as determined through theuse of the standard public assistancebudget.If a church, relative or other interestedparty contributes any amountto the recipient's hospital bill, it is tobe credited to any balance charged thecounty for the recipient's care in excessof the six dollars to be paid from theState fund.Each county determines annually inconsultation with each hospital usedby the county department of publicwelfare the total rate per day to bepaid for the hospitalization of assistancerecipients.No payment from the State fundwill be made for more than 180 consecutivedays of care. It will be thecounty's responsibility to make provisionsfor a patient who requires alonger period of hospitalization. If experienceindicates that it is necessaryin order to protect the State fund forhospitalization, the number of daysmay be reduced.No payment will be made from theState fund for a recipient who is hospitalizedbecause of a diagnosis of psychosisor tuberculosis, since the recipientwho is hospitalized because of thistype of diagnosis will not continue tobe eligible for assistance while in thehospital. This statement does not applyin the case of a recipient who is hos-

The Health Bulletin October, 1955pitalized because of some other diagnosis,even though he may also bepsychotic or have tuberculosis.Payment from the fund will be madeonly for hospitalization rendered toan individual recipient in a month forwhich a payment in his behalf wasmade into the fund. Payments to thehospital, however, may be made aftereligibility for assistance ceases toexist.All agencies participating in the planwill benefit by the improved administrativeprocedures which it provides.Furthermore, better services to clientsshould be a direct result.HOME TREATMENT OF TUBERCULOSIS,THE PROGRESS OF AND THE FUTURE RESPONSIBILITYOF LOCAL HEALTH DEPARTMENTSBy H. F. EASOM, M.D.*Wilson,North CarolinaThe tuberculosis hospital is as importantas it ever was in the diagnosis,treatment and control of tuberculosis.Newly discovered cases still know littleabout how the disease should be treatedor how to keep from spreading it.There are just as many contacts peractive case as ever, and, although overcrowdingand poor nutrition are lessthan in the past, they are still aserious problem in many homes in thisState. Mass x-ray surveys and the increasein the number of diagnosticx-ray units used by private physiciansand hospitals have resulted in thefinding of many early cases of tuberculosis,but you will be surprised tolearn that only seven per cent of thecases admitted to the Eastern NorthCarolina Sanatorium between July 1,1954, and July 1, 1955, were classifiedas minimal. Some of the far advancedones died within a few days after enteringthe hospital, even though theywere admitted as soon as the diagnoseswere made. Nine such cases admittedduring the past year died within thefirst thirty days.The treatment of tuberculosis hasundergone great changes during thelast ten years and has become muchmore effective and more complex. Priorto 1945 treatment consisted of bed restand good food for all cases andpneumothorax, pneumoperitoneum,phrenic paralysis and thoracoplastyfor selected cases. Excisional surgerywas seldom done because of the highcomplication rate. The average lengthof sanatorium treatment was morethan eighteen months and the readmissionrate was probably as high as 25per cent. Pleural effusion and empyemaoften complicated pneumothorax andmade it difficult or impossible to expandthe lung. In some cases it was necessaryto obliterate the air space bymeans of an extensive thoracoplasty,but in others the patient had to keephis unexpandable lung and fluid orempyema, with the ever-present dangerof infection and bronchopleural fistula.Phrenic nerve paralysis was very popularfor many years. When it was firstused the nerve was evulsed, causing apermanent paralysis, but later on mostcases were done by crushing the nerve,thereby causing paralysis for about sixmonths. Unfortunately, about 20 percent of these proved permanent, whichwas undesirable, because it resulted inindigestion for some and in reducedAssociate Superintendent and MedicalDirector Eastern North Carolina Sanatorium,Wilson, North Carolina. Presentedbefore Health Officers Section, NCPHAConvention, Winston-Salem, September 22,1955.

October, 1955The Health Bulletinpulmonary function for all cases.Phrenic paralysis was used mainly tosupplement pneumothorax or pneumoperitoneum.Pneumoperitoneum waswidely used in the South and wasgradually being accepted in the northernstates when drugs came on thescene. It offered something to thebilateral cavitary case who could nottake pneumothorax. It had the advantagesof being relatively safe toadminister and of causing few latecomplications. Thoracoplasty was thechief form of surgery. It was usedmainly on good chronics and proved tobe very safe and effective. The sputumconversion rate following this operationwas about 80%.Health departments and privatephysicians were, until about one yearago, forced to administer home treatmentto new cases. This was due mainlyto the lack of sanatorium beds. Itwas therefore necessary to isolate, educateand treat patients at home forperiods of eighteen months or more,while they were waiting for admission.In spite of the best medical and nursingefforts, the results were poor. Aboutone-third of the Negroes died whilestill on the waiting list, and in manyother cases the disease became progressivelyworse at home. Now that wehave more hospital beds and a shorteraverage length of stay, the waitingperiod has been eliminated, thus doingaway with the need for home treatmentprior to hospitalization and reducingthe spread of infection tofamily and friends. However, you willhave responsibility for home care afterthe patients go home from the hospital.All of them need extra rest and a gooddiet, and many are advised to continueone or more drugs for several months.About ten years ago streptomycinwas discovered and, after carefullycontrolled animal and human studies,was shown to be very effective in thetreatment of tuberculosis. It was soonfound, though, that it could causedizziness, deafness and other toxic reactionsand that tubercle bacilli did becomeresistant to it in a large percentageof cases. Soon afterward paraaminosalycilicacid, better known asPAS was discovered, and, although itproved to be a weak bacteriostaticdrug when used alone, it did, when givenwith streptomycin, delay the developmentof resistance. By means of severallarge studies on chemotherapy it wasfound that a regimen of streptomycingiven in a dose of 1 gm twice weeklyand PAS 12 gms daily gave best results,with least evidence of toxicity.The use of pneumothorax, phreniccrush, thoracoplasty and pneumoperitoneumrapidly diminished, and therewas a remarkable increase in the useof excisional surgery. In 1952 isonicotinicacid hydrazid, commonly known asINAH, was discovered. It has proven tobe the best of the three drugs nowavailable, but, like the other two, itmay cause symptoms of toxicity, andtubercle bacilli do become resistant toit. It should usually be given in combinationwith streptompcin or PAS. Sincedrugs have been available we have entirelydiscontinued the use of pneumothoraxand phrenic crush, and weseldom try pneumoperitoneum.Thoracoplasty is still occasionally used.Excisional surgery performed under theprotection of chemotherapy has comeinto use on a scale which was notpossible prior to the era of chemotherapy.Any discussion of home care versushospital care must take into considerationthe requirements and complexitiesof modern diagnosis and treatment oftuberculosis. First of all, a definitediagnosis must be made, and this isextremely difficult to do in some cases.Cancer and other non-tuberculous conditionsmay look exactly like tuberculosison an x-ray. Once drugs havebeen started, it is even more difficultto establish a diagnosis. Good diet,an opportunity to rest without interruptionby visitors or family andseparation from children are basictreatment requirements. Even thesecannot, in most cases, be provided athome. It is helpful for a patient tohave some knowledge of tuberculosis inorder that he may protect others andso that he may have a better chance to

drugs8 The Health Bulletin October, 1955get well and remain so. This trainingis more likely to be gained in a tuberculosishospital than at home. Thedrug treatment of tuberculosis is nota simple matter. Any of the three mostcommonly used ones may cause toxicreactions, some mild and others quiteserious. It goes without saying thatthese problems can best be handled ina hospital. There is also the matter ofdrug resistance, the determination ofwhich is a complicated laboratory procedure.The results may influence thechoice of drug combinations and maybe even more important at the time ofsurgery. Surgery is frequently employedand it must, in most cases, be precededby a period of medical treatment andoften by such special studies as themaking of planigrams and sensitivitydeterminations. Such an integrated,specialized program of treatment canbe carried on only in a hospital It istherefore my belief that practically allactive cases of tuberculosis should havea period of sanatorium treatment.Selected cases of active primary diseasein children where the home conditionsare above average and where there areno open adult cases can do well onhome treatment. There are some whonow favor giving isoniazid to all youngchildren having positive skin tests, andof course this can be done at home.There are a few old people living ingood home environment and not exposingyoung people who can take drugsat home from the beginning. However, itis essential that these patients havevery close medical supervision.In summary, it can be said thathealth departments and private physicianshave always supervised hometreatment of tuberculosis cases beforeand after their sanatorium treatment.Pre-sanatorium treatment has beenextremely unsatisfactory in spite ofyour best efforts, and, although the resultshave been better since drugs havebeen available, they have not been goodenough to eliminate the need for sanatoriumtreatment. A number of sanatoriumshave been closed recently, butthis does not indicate that home treatmentis taking the place of sanatoriumtreatment. It is the result of the useof more effective forms of treatmentwhich have resulted in the shorteningof the average patient's stay in thehospital. Now that the sanatorium cantake your cases as soon as tuberculosisis suspected I conceive of your responsibilityfor home treatment to be aboutasfollows:1. Some children with active primarydisease and a few old persons can haveail of thsir treatment at home underclose rredical supervision.2. Mj nv patients can continue extra1resc an. at home after an adequate...od of sanatorium care. Manyof these can stop drugs at the timeof discharge or within a few monthsafter going home.3. Patients who leave the hospitalagainst advice will have to be readmitted,treated at home, or sentenced toprison as health law violators.4. Many patients who have no chanceto get well are being kept alive bymodern methods. Some of these havenegative sputum for long periods andcan be discharged to their homes tocontinue treatment there under strictmedical supervision.5. Some nervous, maladjusted patientsare discharged earlier than usualand advised to continue their treatmentat home in the hope that theywill do better there.

MEDICAL LIBRARYU. OF N. CCHAPEL HILL, N. C .Vol. 70HisiDiin>Publish^ byJRlNmMm 5HER!AKD^EALTAThis Bulletin will be sent free to dni| citizen of iKeSfate upon Request ?IAN \X 1Published monthly at the office of the Setfmafy of the Board, Raleigh, N. C.Entered as second-class matter at Postoffice at Raleigh, N. C. under Act of August 24, 1912NOVEMBER-fiftsiJU,i^ftfcR^No -U

MEMBERS OF THE NORTH CAROLINA STATE BOARD OF HEALTHG. G. Dixon, M.D., President AydenHubert B. Haywood, M.D., Vice-PresidentRaleighJohn R. Bender, M.D Winston-SalemBen J. Lawrence, M.D RaleighA. C. Current. D.D.S GastoniaH. C. Lutz, Ph.G HickoryGeo. Curtis Crump, M.D AshevilleMrs. J. E. Latta Hillsboro, Rt. 1John P. Henderson, Jr., M.D Sneads FerryEXECUTD7E STAFFJ. W. R. Norton, M.D., M.P.H., State Health OfficerJohn H Hamilton, MJX, Assistant State Health Officer, DirectorState Laboratory of Hygiene, and Editor, Health BulletinC. C. Applewhite, MJD., Director Local Health DivisionErnest A. Branch, D.D.S. , Director of Oral Hygiene DivisionA. H. Elliott, M.D., Director Personal Health DivisionJ. M. Jarrett, B.S., Director Sanitary Engineering DivisionFred T. Foard, Director Epidemiology DivisionList of free health literature will be supplied by local Health Departments or onwritten request.CONTENTSOf ThePageTuberculosis Control In North Carolina ActivitiesTuberculosis Control Section, Division Of Epidemiology 2The North Carolina Tuberculosis Association Reports AndLooks To The Future 14Conference 8, 9, 10 December—Special Education OfHandicapped Children 16TUBERCULOSIS CONTROL IN NORTH CAROLINAACTIVITIES OF THE TUBERCULOSIS CONTROLSECTION, DIVISION OF EPIDEMIOLOGY1—GENERALBy William A. Smith, M.D.State Board of Health, Raleigh, N. C.creased markedly.The disease, tuberculosis, is as old as It appears remarkable that in thisrecorded history. It was described by country there was no concerted effortHippocrates, the Greek Physician, in the to control tuberculosis until about 1904.5th century, and was probably more Fifteen years earlier, however, a Philprevalentthan leprosy up to the thir- adelphia physician announced that,teenth century. After the thirteenth "tuberculosis is a question for ourcentury the prevalence of leprosy de- municipalities to deal with". In 1892 a

November, 1955The Health Bulletinsociety to oppose tuberculosis wasorganized in Pennsylvania and in 1898the leader of this society suggestedthat a national association be formed.Although there was little enthusiasm tothis suggestion, interest in preventionand treatment continued and by 1904the National Tuberculosis Associationwas organized.In this state in the same year Dr.Richard Lewis, Secretary, North CarolinaState Board of Health, devotednearly half of his annual report to theState Medical Society to the tuberculosisproblem. Dr. Lewis cited the needfor more education of the public mindon the subject and the establishmentof a society specifically organized tofight the disease. Following are excerptsfrom the report of Dr. Lewis:"Tuberculosis continues to be ourmost fatal disease. Experience hasdemonstrated that much can be donefor its prevention. We should thereforemake an earnest effort to checkits ravages as far as possible. But howto accomplish this in actual practice tomore than a superficial extent is thequestion. The answer to this questionis by the thorough education of thepublic mind on the subject."The methods usually resorted to forthe education of the public sentimentare tuberculosis congresses, the organizationof antituberculosis societies, publicaddresses, newspaper articles, thedistribution to the individual of literaturebearing on the subject and theestablishment of special sanatoria".At that time in the entire UnitedStates there were only 9,000 hospitalbeds for the treatment of this disease.During 1904 there were 150,000 deathsfrom tuberculosis in the United States,and an estimated one million fivehundred thousand active cases. Thenine thousand beds for the treatmentof this large number of cases was apitiful number for the treatment ofover a million persons.Our own statistical records are inaccuratefor the 1904 period and it wasonly in 1916 that North Carolina wasaccepted in the death registration area.In 1916 there were 3577 deaths from take trailer.tuberculosis in this state. Case reportingat that time was not complete butit is estimated that there were at least35 thousand active cases in the State.It can readily be seen that in 1904when Dr. Lewis made his report to theState Medical Society, tuberculosis wasthe most fatal disease and that theproblem was a grave one.Since 1916 there has been a steadydecline in the number of deaths.Prior to 1908 sanatoria for the treatmentof tuberculosis were principallylocated in the mountainous areas andprincipally around Asheville. The firstState sanatorium was built at McCainand opened on November 3, 1908. Atthe present time there are 1,945 Statebeds and these are sufficient for presentState needs. The State PrisonDivision is constructing a building with139 beds at McCain. In the VeteransAdministration facilities there are 1,009beds and in mental institutions 339.The people of this State are wellserved by hospital facilities as well asby facilities for chest examination.There are three four-year medicalschools in the State and each with awell-staffed out-patient clinic. Three ofthe four state sanatoria have outpatientclinics and the fourth isorganizing a clinic.There are sixty-nine county or districthealth departments and 32 ofthese have tuberculosis clinics. X-Rayservices for making the 14 by 17 X-rayplate are available in 73 of the 100counties, but not available in 27. In thecounties with no facilities for takingthe large plate, such plates are eithertaken at local hospitals or at the districtheadquarters of the health department,provided the county is a partof a district. At most of these healthdeparments there is no charge for thisservice. In addition mobile X-ray unitsare operated by 12 counties and twocounties have a portable machine whichis used particularly for industry. TheState Board of Health operated sixmobile X-ray units and a mobile 14 by17 retake trailer up to January 1955and now operates five units and a re-

The Health Bulletin November, 1955Since 1904 when Dr. Lewis broughtattention to the severe tuberculosisproblem there has indeed been progressboth in hospitalization and case finding.2—TUBERCULOSIS CONTROLPROGRAMIn order to be effective, a tuberculosisprogram must have available certainservices. They are case rinding, clinical,nursing, hospital, health education,laboratory, rehabilitation, vital statisticsand welfare. All these services areavailable in many of our communities;many do not have such services ashealth education, local laboratory serviceor a tuberculosis clinic which isattended by a specialist in tuberculosis.The lack of X-ray facilities in thosecounties which do not have suchfacilities is a handicap to case findingfor the X-ray is the most efficient andwidely used apparatus for findingtuberculosis.The Board of Chancellors of theAmerican College of Radiology hasmade these recommendations:"Chest X-Ray Surveys for the detectionof communicable pulmonarydisease are in the public interest. Theyshould be conducted as part of a programto control and eliminate pulmonarytuberculosis."Routine admission hospital surveyx-ray examination of the chest is desirableas a protective measure in largegeneral hospitals, mental institutionsand other domiciliary units in whichadults are housed in close propinquity,providing the x-ray reports reach thepatients' charts promptly, and theattending physicians take suitable stepsfor prompt completion of diagnosis andnecessary treatment."Three major sources of case findingare recognized. First, the discovery ofthe case by the physician in privatepractice; second, the routine examinationof contacts either by the familyphysician or out-patient clinics orhealth departments; third, mass orcommunity wide chest x-ray surveys.Tuberculosis cases are detectedthrough:a. Examination of hospitalin-patients 44%b. Outpatient clinics and officesof physicians 28%c. Mobile x-ray surveys 18%d. Routine x-ray of contacts 6%e. Death reports 3%f. All others 1%(From Health Dept. Minneapolis,Minn.)3—PERSONS TO BE X-RAYED—EMPHASIS ON CERTAINECONOMIC GROUPS.In our x-ray surveys we have emphasizedcertain groups for examination.These are the older age group, theNegro population and the low economicgroup. Such groups have been emphasizedfor the reason that thesegroups have shown a consistently highprevalence. As our standard of livingcontinues to rise, crowding will be lessand this should be followed by an improvementin tuberculosis morbidity inthe low economic group.In surveying the population, however,the higher economic populationshould by no means be overlooked. Ina chest x-ray survey of a large midwesterncity the number of deaths inthe area surveyed suggested there wouldbe approximately 20 times as muchtuberculosis in the lowest economicgroup as in the highest; and knowncases in the area suggested there wouldbe three times as much, but the finalanalysis showed the estimated distributionof undetected cases to be only oneand a half times as much.In our health education activitiesprior to and during a survey we endeavorto reach all the population.Each year it is estimated that about13,000,000 people in the United Statesreceive chest X-ray examinations forthe purpose of determining if chestdisease, particularly tuberculosis of thelung, is present. In North Carolina over500,000 persons, not including thosepersons examined by private physiciansand hospitals, had such examinationsin 1954. The persons examined by ourmobile units are persons who stop bythe unit casually, or through health

November, 1955The Health Bulletineducation measures conducted duringthe survey visit the unit.The tuberculosis case found by mobileX-ray unit is generally in a less advancedstage than is the case whichseeks medical treatment. The followingobservations were made by the UnitedStates Public Health Service. In surveycases:37% were minimal47.4% were moderately advanced15.6% were far advanced.In non-survey cases:21.7% were minimal45.5% were moderately advanced32.8% were far advanced.It was also found that the chance ofa survey case dying within four yearswas 1 out of 10, whereas the chance ofa non-survey case dying was 1 out of 3.The three methods of case findingalready mentioned are independent ofeach other; neither can replace theother; each is an important part inthe general case finding procedure.4—MISSION OP THE TUBERCU-LOSIS CONTROL SECTION.The mission of this section is essentiallythat of tuberculosis case finding.We also maintain close liaison with theHeart and Cancer sections of the StateBoard of Health. A daily report isfurnished the Heart section showing allabnormal cardio-vascular findings detectedin our chest surveys, and a reportshowing tumor suspects is periodicallyfurnished the Cancer section.These reports give the name, address,age, sex, of the patient, and the nameand address of the family physician.In addition to conducting chest X-raysurveys, this Section also furnishes onloan certain X-ray equipment to healthdepartments and other agencies.X-ray machines are on loan at theDuke Medical School hospital, Durham;the Baptist hospital, Winston-Salem; and the Union Memorial Hospital,Monroe. These machines are usedfor the purpose of making chest plateson hospital admissions and clinic cases.Equipment other than X-ray machinesis on loan at health departmentsin Charlotte, Winston-Salem,Raleigh, and at the State Hospital,Raleigh.Personnel and Equipment.Personnel consists of: Part time Fulltime1. Doctors, one Director full time; two film readers,part time 2 12. X-ray technicians, full time; one Chief - 83. X-ray technicians, dark room, part time 14. Clerks, field 2; central office 2, full time - 45. Health educator, part time 16. Consultant nurse, part time 17. Others, supporting services as statistical, mailingroom, office of Chief nurse, part time 5Total, full time and part time 10 13Equipment owned by the Section is:TOTAL— 23Mobile X-ray units, tractor trailers, 5 active and stand-by 1 __. 6Office trailer — 1Follow-up trailer with 14 by 17 X-ray unit - 1Carry all 1Photoroentgen units 70 mm. on loan 3Other miscellaneous equipment such as: 4 by 5; 70 mm. and 14 by 17view boxes to county and State agencies and two 4 by 5 cameras on loan.

6 The Health Bulletin November, 1955Due to inadequate funds it has beennecessary to reduce the number ofmobile units on active service from 6 to5. It is hoped that the 6th unit, nowbeing used as a standby unit can beused actively during the coming year.The loss of one unit means a reductionof 30 to 40 thousand persons for x-rayduring a 12 month period.5—ACTIVITIES DURING THEFISCAL YEAR 1954-1955During the fiscal year our field unitsmade 241,055 70 mm. chest plates andabout 3% of persons examined requireda 14 by 17 plate to confirm the diagnosismade from the miniature film. Thosepersons examined by our mass x-raygroup were re-examined by our followuptechnicians, and those who had theminiature plate made during specialsurveys were re-examined by healthdepartment personnel. About 3% of thepersons x-rayed with the miniaturefilm are requested to return for reexaminationand hence during theperiod about 7,000 persons returned forthe 14 by 17 plate.During the fiscal year 1953-1954250,968 persons were x-rayed and thedecrease of 9,913 persons during thefiscal year 1954-1955 shows the resultof the loss of one unit for the sixmonth period from January 1, 1955 toJune 30, 1955.The 1955 schedule is particularlysevere and a heavy demand on ourpersonnel which is just sufficient tooperate the five units and follow-up14 by 17 trailer. During the fiscal year1954-1955 mass surveys were conductedin six counties and special surveys wereconducted in 26 counties; two colleges;schools in the Washington-Tyrrell districtand also in two State mental institutions.The schedule for surveys has beenprepared for 1956-1957 and 7 countiesand districts have been scheduled forspecial surveys in 1958. It is our desireto schedule counties routinely year inand year out and the 7 counties scheduledfor 1958 have expressed a wishfor such surveys.Since our surveys began in July 1946,we have conducted 2 separate mass surveysin 22 counties and 3 separate surveysof this type in 3 counties. Edgecombecounty was surveyed for thethird time in January 1955. The thirdsurvey was particularly interesting inthat the number of persons found withlung pathology was much greater thanthe number detected with lung pathologyduring the 1951 survey. A tabulationcomparing the surveys follows:sEDGECOMBE, MASS CHEST X-RAY SURVEYSNumber days in surveyNumber units usedNumber persons X-rayedWhite people X-rayed195124514,1287,909Per cent White people X-rayed 56.0Negroes X-rayed 6,204Per cent Negroes X-rayed 43.9Number persons recalled forfurther examination (14x17 plate;—result of miniature filmfindings 405Recalls, per cent 2.86Number recalls who did not returnfor re-examination 40 (9.9%)Persons showing lung pathology 57 (36-White(21 -Negroes)195524313,6258,18560.15,39039.63962.906 (1.5%)141 (69-White; 67-Negroes;5 records incomplete)

November, 1955The Health BulletinActive and probably active tuberculosisof the lung 22 (ll-White)(11-Negroesja. "New" active cases—19 (White-10)(Negroes-9)b. Known active cases 3 (White-1)(Negroes-2)41 (20-White; 21-Negroes)38 (18-White)(20-Negroes)3 (2-White)(1-Negro)22Inactive pulmonary tuberculosisand suspected tuberculosisNon-Tuberculouspathology31 ^24-White)(7-Negroes)4 Tumor susp. (3-N.)Undiag. (1-W.)4187 (47 -White)(40-Negroes)8 Sarcoid3 (3-N.)Tumor suspect 4 (4-N.)Undiag. 1 (1-W.)New and hitherto unknownpulmonary tuberculosis casesrecommended for hospitalOld or known cases pulmonarytuberculosis11 (White-5)(Negroes-6)1 (Negro-1)16 (White-6)(Negroes-10)12 (White-1)(Negroes-11)3The survey included Edgecombe county less the city of Rocky Mount. Whitepopulation of county 48.1%, Negro population 51.9%.Pertinent findings in 1955 as comparedto 1951 are:A decrease of 503 persons examinedin 1955 as compared to 1951.16 new hospital cases as compared to11 in 1951.141 persons showed chest pathologyas compared to 57 in 1951.38 new active cases as compared to19 in 1951.87 inactive and suspected tuberculosisas compared to 34 in 1951.3 sarcoid cases, two brothers and 1other case; none in 1951.In the 1951 survey 40 persons of the405 recalled for 14x17 X-ray plate examinationdid not respond and in the1955 survey only 6 persons did not respond.The follow-up in 1951 was 90.1%and in 1955 98.5%. Had the 40 personsreturned for re-examination in the 1951survey and all 40 had shown chestpathology the total "suspects" in 1951would have been 97; and if the 6 personsin the 1955 survey had shownchest pathology the total "suspects"would have been 147. There would stillhave been 50 more suspects in 1955 ascompared to 1951.In 1951 the health department washeaded by a part time health officer,and in 1955 by a full time healthofficer. The publicity campaign in bothsurveys was thorough but was apparentlymore effective in 1955. The 1955publicity program as submitted by thehealth officer consisted of:a. Motion picture films on tuberculosis;these were shown to 6,000 to7,000 persons.b. Film strips shown to about 9,000persons.c. Television appearances by thehealth officer, 1 time.d. Radio talks and spot announcements,55.e. Press releases, 30.f. Meetings with persons interestedin tuberculosis control, audience 3,000.g. Letters to citizens with reference

8 The Health Bulletin November, 1955to the survey and home visits tofamilies, 11,000.h. Pamphlets concerning tuberculosisdistributed in the county, 15,000 andposters distributed 300.The findings of both surveys indicatethat the older age group responded,Chart No. III.6—MORBIDITY AND MORTALITY.A. General Dr. James E. Perkins,managing director, National TuberculosisAssociation, in the Bulletin of theAssociation, recently pointed out that:"100,000 new cases of active tuberculosisoccur each year."400,000 active cases are living today,250,000 of these are registered andknown."150,000 cases are still unknown butare projected on the basis of accuratesurveys, etc."1,200,000 cases of significant tuberculosisstand in the need of observation;these include the 400,000 activecases."The death rate has dropped markedly."The morbidity (case) rate is at astandstill in some areas it has fallenonly slightly in most. (Chart No. I &II)."Finally about 50 million people stillreact to tuberculin, that is they harborthe tubercle bacillus within their bodies—a situation safe for the most partbut explosive under conditions of strainand stress. Out of such a group ofpeople a great many cases of tuberculosiswill eventually emerge."In 1954 there were 311 deaths fromtuberculosis in North Carolina. In theUnited States (Continental) there were16,920 deaths. The number of deathsas well as death and case rates forNC and US as a whole are tabulatedbelow:TUBERCULOSISPOPULATION:UNITED STATES AND NORTH CAROLINA, 1916-1954.UNITED STATESNUMBERYEAR DEATHS 100,0001916 101,396 141.61946 50,911 36.4DEATHS (ALL FORMS) WITH RATES PER 100,000RATE PER1947 48,064 33.51948 43,833 30.01949 39,100 26.31950 33,959 22.51951 30,863 20.11952 24,621 15.81953 19,870 12.61954 16,920 10.5The North Carolina death rate has beenlate 1930's. The North Carolina death ratestates are:MaineRhode IslandSouth DakotaCaliforniaMassachusettsOklahomaVermontColoradoOhioGeorgiaMontanaSouth CarolinaTexasNew YorkNew JerseyIllinoisLouisianaWest VirginiaMississippiDelawarePennsylvaniaVirginiaNORTH CAROLINANUMBERDEATHS Rate Per 100,0003,577 142.31,182 32.51,128 30.4949 25.0972 25.2748 18.4630 15.3543 13.0402 9.5311 7.3below the National rate since theis lower than 31 other states. TheseMissouriNevadaNew MexicoMarylandAlabamaArkansasKentuckyTennesseeArizona

November, 1955 The Health Bulletin 9The number of deaths is no longerconsidered an accurate measure of theimportance of the tuberculosis problem.The number of reportable cases occurringin a given area over a givenperiod is considered a better index. In1954 there were 1459 active tuberculosiscases of the lung reported in NorthCarolina. In the US as a whole 79,097new active tuberculosis cases, all forms,were reported.In North Carolina in 1945, 1079 activecases of the lung were reported. Ourmobile x-ray surveys began in July1945 and a year later were intensified.It is of interest to note that beginningwith this activity there was a steadyrise in active cases reported, showingthat mobile X-ray surveys are of considerablevalue in case finding. Activetuberculosis cases of the lung and thetotal number of tuberculosis cases reportedto the State Board of Health byphysicians and clinics from 1945 to andincluding 1954 are shown below:NORTH CAROLINA 1945-1954No. activepulmonarytuberculosis Total casesYear cases reported reported1945 1079 33921946 1129 34661947 1163 35911948 2029 32741949 2123 34021950 1923 36531951 1743 31051952 1430 23261953 1350 2001(Min. inact.not reported)1954 1459 2013The Negro death and morbidity(case) rates still remain high. In 1954the white death rate of 4.7 persons per100,000 population compares with thelowest death rate among States in theUS. In 1953 the 5.0 per 100,000 rate inNC compared with:Wyoming 3.9Iowa 4.6Idaho 4.8Kansas 4.9North Dakota 5.0The Negro rate for 1954 is 14.7 whichis 7.5 per 100,000 lower than 1953, anda 33.8% decrease over 1953. The whiterate of 4.7 is a 6% increase over 1953.The morbidity (case) rates andmortality (death) rates for the past 5years are noted below:MORBIDITY—NORTH CAROLINATUBERCULOSIS cases, all forms1950-1954Year No. Rate White Rate Other Rate1950 3653 89.9 2072 69.5 1581 146.61951 3105 75.3 1870 61.6 1235 113.51952 2326 55.7 1346 43.7 980 89.41953 2001 47.4 1136 36.4 865 74.41954 2013 47.1 1088 34.4 925 83.3MORTALITY—NORTH CAROLINATUBERCULOSIS deaths, allYear No.1950-1954formsRate White Rate Other Rate1950 748 18.4 297 10.0 451 41.81951 630 15.3 264 8.7 366 33.61952 543 13.0 208 6.8 335 30.61953 402 9.5 157 5.0 245 22.21954 311 7.3 148 4.7 163 14.7From this tabulation it will be seenthat in the last five years there havebeen a total of 13,098 cases of tuberculosisreported to the State Board ofHealth for the first time and of these7,905 were active or hospital cases orrequired close observation. Many of theinactive cases undoubtedly becameactive cases and were either hospitalizedor received home treatment.Records from county health departmentsshow that 73,426 nursing visitswere made in behalf of tuberculosiscases, suspects and contacts, and thetotal number of visits to diagnosedtuberculosis cases was 28,031 also thatthe total number of diagnosed tuberculosiscases visited during the year was9,107.The new tuberculosis drugs are savingmany lives. Deaths in the past tenyears have decreased from 1262 to 311,but the yearly number of new casesindicates that there must be no relaxationin efforts to combat this disease.There is no effective vaccination suchas there is for small pox, typhoid, or

10 The Health Bulletin November, 1955diphtheria. A poor economy, bad housing,poor hygiene, indifference in thesupport of the services which are engagedin control could result in aspread of this disease.7—STJMMARY.The Tuberculosis Control Section hasnow been in operation since January1945. Chest X-ray surveys began July1945 and for the fiscal year 1945-46operations were limited. However, beginningJuly 1946 operations were acceleratedthrough aid given by theFederal Government. For the 8-yearperiod ending June 30, 1954 over twomillion four hundred thousand personshave been X-rayed and over ten,thousand persons have shown X-rayevidence of lung disease. Had the follow-upof those persons, who showedevidence of lung disease, from theminiature film, been 100% the numberof tuberculosis cases as diagnosed bythe large or 14 by 17 film would havebeen greater, probably by ten or fifteenper cent.Fifty-two per cent of the tuberculosiscases we find through chest x-raysurveys show active or probably activedisease.Several tuberculosis authorities haveexpressed opinions as to the value ofchest X-ray surveys. Dr. Robert J.Anderson, United States Public HealthService, in the Journal American MedicalAssociation, February 23, 1952, says,"Since the aim of mass chest X-raysurveys is to find significant tuberculosisin the screened population, thequestion of how much active tuberculosisfound is fundamental .... theinformation we have indicates thatabout one out of every 1,000 personsscreened will have active tuberculosisthat is clinically recognizable. Our experienceindicates, too, that many ofthose found with inactive and questionablyactive disease will later proveto have definitely active tuberculosis."Drs. Jacobson and Adler, AmericanReview of Tuberculosis, June 1954 notedthat "One of the greatest benefits ofthe mass survey has been to demonstrateto both the medical professionand the public the existing high prevalenceof tuberculosis and the need ofa continuous, efficient case finding programin each community."Our policy is to continue chest x-raysurveys and to emphasize the x-rayexamination of all the population, andto particularly stress the importance ofthis type of examination to thosegroups who show a high prevalence,and such groups are those persons whoare subjected to crowding; also theolder age group and Negro population.To conduct a tuberculosis controlprogram effectively, cooperation amongservices is necessary and adequatefunds must be available to support services.Cooperation among services hasalways been of a high order, but presentfunds are not adequate to employthe full field personnel to operate allour x-ray equipment and also conductother case finding procedures. Thepresent number of male technicians isnot sufficient to move all transportationfrom one location to the other atthe same time, and whenever there isa change of survey locations transportationmust be moved in sections. Sucha movement requires several days. Ourmale technicians not only take x-raypictures on the mobile trailers but alsooperate the tractor-trailers.During the fiscal year 1953-54 thecost of the examination of one personwas sixty-one cents. This cost includesall services, but does not include depreciationof equipment. The amount,sixty-one cents, is about the cost of alarge x-ray plate which is sixty cents.Our endeavor is to make every dollarof the public money count.

November, 1955 The Health Bulletin 11CHART INEWLY REPORTED TUBERCULOSIS CASES ANDTUBERCULOSIS DEATHS, UNITED STATES, 1930- 1954200,000r100,00080,000-NEWLY REPORTEDTB CASES60,00040.000\\TB DEATHS\20,0000.0005,°?930 1935 1940 1945 1950 1954Tuberculosis Progrom, Division of Special Health Services, February 1955

•12 The Health Bulletin November, 1955CHART IITUBERCULOSIS CASES AND DEATHS PER 100,000 POPULATIONNORTH CAROLINA, 1930-1954mon i-'oj lurtmyi fc e ; „HSOURCE ANNUAL REPORT OF THE PHSS, PART I 9 IIP-SS ^ 17/54

November, 1955 The Health Bulletin 13CHARTAGE SPECIFIC TUBERCULOSIS SUSPECT RATES PER 10.000 PERSONS X-RAYEDEDGECOMBE COUNTY TUBERCULOSIS SURVEYS , 1951 AND 1955HINUMBER OF SUSPECTSDER 10,000 PERSONS X-RAYED. r-f10 .IV C I4 4 t I 'unlcr .- 2.0 2 5 jo v V « g £ 2 g £ JyfR15 19 £4 29 3439 44 49 04 59 64 69 '•* J«mAGE GROUPpHSS 9-55

14 The Health Bulletin November, 1955THE NORTH CAROLINA TUBERCULOSIS ASSOCIATIONREPORTS AND LOOKS TO THE FUTUREBy C. Scott Venable, Executive Director,North Carolina Tuberculosis AssociationLegend has it that Janus, the godfor whom January is named, had twofaces—one looking forward into thenew year and the other backward intothe old one. This mid-century point inthe history of the North CarolinaTuberculosis Association offers opportunityfor a similar feat—to look backover the first fifty years and forwardinto the future.Historically, tuberculosis associationswere based upon the principle of freeand direct participation by the peoplein designing their own welfare. It wasbelieved that, if the people were sufficientlyinformed about tuberculosis,they would demand and easily obtainwhatever was necessary for its preventionand control.Looking backward, we see this faithin the people rewarded. In the earlyhistory of the North Carolina TuberculosisAssociation are accounts of itsmembers' promoting the establishmentof a state sanatorium and the passingof legislation requiring isolation oftuberculous prisoners and of their producingmaterials designed to furtherinform the public about the disease.This was merely the beginning. Anall-out campaign followed immediatelyto organize local committees in all thevarious sections of the State. Even thenthe value of local organizations dealingdirectly with the people was recognized.As the Association's income increased,appropriations were made accordingly,making available certain necessaryitems and demonstrating the valueof specific services. Some of the earlyappropriations were: for the productionof a film on TB; for a study oftuberculosis in a designated area of theState; for an X-ray machine in theState Sanatorium; and for publichealth nursing in the State. Not onlywas public health nursing demonstratedby the Association, but it also employedthe first health education workersand a consultant clinic physicianto work out of the Sanatorium.Significant in these early demonstrationsis the fact that, as soon as thevalue of an activity had been proved,it was taken over by the official agency,thus releasing the Association's fundsto explore new fields. This policy, begunyears ago, continues to serve thebest interests of the people and theagencies involved.With this type of cooperation, outstandinggains have been made. TheAssociation's emphasis on preventionand control has helped in achieving aphenomenal reduction in the deathrate. The people's knowledge of thedisease has been greatly enhanced.There is better and more widespreadreporting, and larger sums are pouringinto research.At the present time the North CarolinaTuberculosis Association is chieflyconcerned with organization, fact-finding,rehabilitation, case-finding andhealth education.The NCTA's organizational policy isto organize every area in the State intounits for controlling tuberculosis. Committees,where feasible, are developedinto associations and county associations,where practical, are consolidatedinto district associations. Every opportunityis grasped to strengthenexisting organizations.A program of tuberculosis controlmust be based on facts. This fact-findingis continuous, not only to get additionalinformation but also to keep thebasic information up to date. It is onlywhen the facts are in and analyzedthat a constructive program can beplanned.

November, 1955 The Health Bulletin 15Rehabilitation is a responsibility ofthe community and State. It is accomplishedthrough teamwork amongagencies interested in the welfare ofthe patient. In rehabilitation the NorthCarolina Tuberculosis Association iscontinuing to work with agencies andto concentrate on such objectives as:promoting a better understanding ofwhy rehabilitation is so important in aTB control program; encouraging affiliatesto initiate conferences amongcommunity agencies for the purpose ofclarifying their programs and limitationsin working with problems of TBpatients and families and furtheringcooperation in meeting patient needs;promoting State and local participationin the annual rehabilitation institute,co-sponsored by eight agencies;and seeking appropriations from theNorth Carolina Legislature when neededto improve rehabilitation programsthe State.The policy and program regardingcase-finding are to continue to promotemass X-ray surveys in cooperation withthe N. C. State Board of Health, withspecial emphasis on high prevalenceareas and among selected groups. Withthe cooperation of other agencies, theassociation is stressing the developmentof additional hospital admissionX-ray programs and attempting to improvethe effectiveness of existing ones.The NCTA, in cooperation with otheragencies, will participate in a communitywidetuberculin-testing programin one of North Carolina's counties.This emphasis on case-finding willcontinue as long as the estimate of unknowncases remains so high and certainlyuntil the newly discovered casesare found in an early stage.The area in which tuberculosis associationshave made their greatestcontribution to tuberculosis control ishealth education.Tuberculosis is both an individualproblem and a community responsibility.For this reason the Association'sendeavors are aimed toward motivatingpeople to act on individual healthproblems toward obtaining communityaction and cooperation in solving pub-tinlic health problems concerned with theprevention and control of tuberculosis.Great advances made in all areas oftuberculosis control testify that peopledo demand action and cooperate oncethey become aware of the needs andproblems. In its health education programlast year the Association providedconsultation for improvement of TBprograms; intensified interpretation ofprogram to boards of directors; promotedcommunity organization forsolving health problems; aided inteaching basic facts about tuberculosisto adults and school children by promotingthe "Inside Story" program andthe School Press Project; intensifiedefforts to keep physicians informed ofnew developments in tuberculosis; encouragedthe use of educational materialsstocked by the NCTA and suppliedat cost; helped plan in-servicetraining programs on tuberculosis andhealth for teachers; emphasized theuse of radio and television as media forinterpreting the tuberculosis controlprograms; supplied interested collegeteachers with materials on tuberculosisand health for classroom use; and furnishedunits of work, supplementaryaids and consultation to high schoolsupon request. It is to its educationalprogram with its varied aspects thatthe State Association owes most of thecredit for a steady movement of progress.As the first step is taken into thesecond half-century it is notable thatan unfinished task has been left forcompletion. In 1882 Koch discovered thegerm that causes tuberculosis. Almost75 years later there is still no specificdrug that destroys the germs withinthe body without damaging body tissueand no specific immunizing agent. Theneed for continued research is thusthoroughly established.Last year in North Carolina 2,013new cases of tuberculosis were reported.The five-year average from 1950 to1954 was 2,620. This means that withinthe last five years 13,100 new caseshave been reported. Each person infectedwith tuberculosis germs is apotential patient. Because X-rays do

16 The Health Bulletin November, 1955not determine the number of personsinfected, the arrow of the future pointsto large-scale tuberculin testing todetermine the extent of the tuberculosisproblem.The future program of the NorthCarolina Tuberculosis Association willbe keyed to the present and futureproblems. Changing trends demandchanging emphasis. One requisite foreffective functioning is that the organizationremain unhampered in itsefforts to explore new fields anddemonstrate new methods and techniques.Listed below are the amounts expendedto carry out the 1954-55 programactivities of the North CarolinaTuberculosis Association:EXPENDITURES BY SERVICEHealth Education $29,742.21Rehabilitation 6,781.99Administration 14,154.55Seal Sale 7,013.87Organization 17,855.95-Total Expenditures __-*- $75,548.57When listed as specific items, theNCTA financial statement shows adisbursement of $36,043 on professionalsalaries; $14,552 on clerical salaries;$12,331 on travel; $1,664 on publications,news letters, printing and disseminationof information. Otherbudgeted items were expended fortraining institutes, program conferences,the NCTA annual meeting,scholarships, payment on and maintenanceof the NCTA headquarters,telephone, postage and express, duesand subscriptions, office supplies andequipment, repairs, audit, insuranceand bonding, bank exchange, SocialSecurity, health insurance and annua)physical examinations for employees.CONFERENCE 8, 9, 10 DECEMBERSpecial Education of Handicapped ChildrenO'Henry Hotel — GreensboroSponsored by:Division of Special EducationN. C. Department of Public InstructionThe North Carolina Health CouncilNemours FoundationN. C. Federation of the InternationalCouncil for Exceptional ChildrenGreensboro City SchoolsNational and State specialists as speakers,consultants and panel directors.Purpose of the Conference1. To study the characteristics of handicappedchildren2. To study the needs and problems ineducating handicapped children3. To appraise the educational andmedical services available in NorthCarolina to handicapped children4. To plan ways of coordinating educationaland medical services for thehandicapped childern of the State5. To develop understanding, interest,and support necessary to provideeducational services for all handicappedchildren

m.MEDICAI LIBRARYU. OF N. C .CHAPEL HILL . N. r. .K] bwm"Krs Bulletin will be sent free to dnu, ciiizen of tne State upon requestPublished monthly at the office of the Secretary of the Board, Raleigh, N. C.Entered as second-class matter at Postoffice at Raleigh.. N. C. under Act of August 24, 1912Vol. 70 DECEMBER. 1955 No. 12JAN 4 1956DIVIS10!H AFFAIRS LtBRARiHAYWOOD COUNTY HEALTH CENTER, WAYNESVILLE, NORTH CAROLINA

MEMBERS OF THE NORTH CAROLINA STATE BOARD OF HEALTHG. G. Dixon, M.D., President AydenHubert B. Haywood, M.D., Vice-PresidentRaleighJohn R. Bender, M.D Winston-SalemBen J. Lawrence, M.D RaleighA. C. Current, D.D.S GastoniaH. C. Lutz, Ph.G HickoryGeo. Curtis Crump, M.DAshevilleMrs. J. E. Latta Hillsboro, Rt. 1John P. Henderson, Jr.. M.D Sneads FerrvtEXECUTIVE STAFFJ. W. R. Norton. M.D.. M.P.H., State Health OfficerJohn H. Hamilton, M.D.. Assistant State Health Officer, DirectorState Laboratory of Hygiene, and Editor, Health BulletinC. C. Applewhite, M.D., Director Local Health DivisionErnest A. Branch, D.D.S. , Director of Oral Hygiene DivisionA. H. Elliott, M.D., Director Personal Health DivisionJ. M. Jarrett, B.S., Director Sanitary Engineering DivisionFred T. Foard, Director Epidemiology DivisionList of free health literature will be supplied by local Health Departments or onwritten request.CONTEXTSPageHighlights From The Early History Of TheNorth Carolina Tuberculosis Association 2The Elimination Of Tuberculosis From NorthCarolina In The Next Seventy-Five Years 5Notes and Comment 7HIGHLIGHTS FROM THE EARLY HISTORY OF THENORTH CAROLINA TUBERCULOSIS ASSOCIATIONBy Dr. Lynwood E. Williams, President,North CarolinaTuberculosis AssociationDuring this fiftieth anniversary year of the State were considered particular -of the North Carolina Tuberculosis ly suited to this purpose, fulfilling allAssociation it seems fitting to point up the then-known concepts of treatment,some of the highlights in its early his- History also records that the Indianstory and to pay homage to some of the set aside the region around AshevilleState's leaders who were pioneers in as a neutral ground to which theythe movement for tuberculosis control, brought their sick. It is not surprisingAccording to this history, tubercu- then that as early as 1800 the whitelosis work in North Carolina may be man began to take advantage of thissaid to have had its beginning in the healthful climate. This set the stagesanatorium movement. The mountains for a movement which made the area

December, 1955The Health Bulletinthe mecca toward which the faces ofmany who were afflicted have beenturned.It was in this region in the early1870's that a sanatorium for the careof the tuberculous was established. Itwas the first such institution in thiscountry. Although this pioneer sana*-torium movement has received littlerecognition by historians of the greatbattle against tuberculosis, it neverthelessaroused hope in the hearts andminds of men the country over andperhaps served as a model for others.There is no doubt that it helped to inspirethe medical men, particularly inNorth Carolina, to continue their workin tuberculosis and to keep the campfireburning brightly, until such a timeas they were able to organize themselvesinto a society whose specificobjective was to conquer tuberculosis.Despite the early sanatorium movement,there was still a lack of facilitiesfor the proper treatment of tuberculosisand a lack of knowledge of thenature of the disease on the part of thegeneral population as well as on thepart of general practitioners. It becameimmediately obvious that, if theterrible death toll from the disease wasto be cut, drastic educational measureswould have to be undertaken.Thus, in 1904, Dr. Richard H. Lewis,secretary of the North Carolina StateBoard of Health, devoted nearly half ofhis annual report to the tuberculosisproblem, citing the need for more educationof the public mind on the subjectand the establishment of a societyspecifically organized to fight thedisease. This report was delivered tothe joint session of the North CarolinaState Board of Health and the NorthCarolina Medical Society at theirannual meeting in Raleigh in May,1904. The joint session adopted a resolutionasking every member of theSociety and the Board of Health andevery physician in the State to useevery effort, professional and personal,to promote the fight against tuberculosis.Dr. Lewis was delegated to launchan educational campaign at once, directedto the general public,disease.about theImpetus was given to the emphasisbeing put on tuberculosis in NorthCarolina when in the same year (1904)tuberculosis experts held a meeting inWashington, and a meeting to discussplans for the organization of a nationalsociety to fight tuberculosis was heldin Baltimore. Some of the medical menof the State attended the Washingtonmeeting and were prominent in thenational organization movement inBaltimore. They continued to fan theorganizational flames at home.On May 30, 1906, their dreams wererealized. A committee, appointed byDr. Edward G. Register the previousyear to consider the advisability offorming a State Society for the Preventionof Tuberculosis, made its report,stating that it was ready toorganize. A report of the organizationalmeeting which took place that sameday follows:Pursuant to a call issued by a committeeappointed by the presidentof the State Medical Society, underresolution offered at the 1905 session,a number of the medicalgentlemen in attendance on thefifty-third annual meeting of theSociety at Charlotte, N. C. May 30,1906, met together and organizedthe above named association (theNorth Carolina Association for thePrevention of Tuberculosis.)A constitution was adopted and directorselected. On the following afternoon,the directors met and elected Dr.M. L. Stevens president and Dr. Ben K.Hayes secretary. Dr. Charles A. Julianwas elected first vice-president and Dr.Albert Anderson second vice president.Thus was launched the first organizedattempt in North Carolina to controltuberculosis.The intensified work of medical menand the educational campaign so recentlylaunched began to have theireffects in 1907. The General Assemblythat year enacted a bill establishing aState sanatorium, which opened itsdoors to patients on November 6, 1908.

The Health Bulletin December, 1955The Legislature also passed a bill requiringisolation of tuberculous prisoners.At the meeting in 1908 the group wasconcerned about the lack of effectivework being done by the Association.The need for leadership was becomingapparent, and the Association, throughthe State Board of Health, asked the1909 General Assembly for enablinglegislation permitting them to have apaid worker. The Legislature ratified abill giving the State Board of Healthauthority to name as a special assistantto the state health officer thesecretary of the State Association forthe Prevention of Tuberculosis.As the newly employed worker ofthe Association, Dr. Julian became thisspecial assistant. He made an inspectionof the new State sanatorium and foundit to be in such an unsanitary conditionthat, as a result of his report tothe State Board of Health, the institutionwas closed and did not open againuntil the following year.Events now followed in rapid succession.During the year 1910 a resolutionwas adopted asking the 1911 GeneralAssembly to appropriate more moneyfor tuberculosis work. A special campaignto organize local associations wasundertaken. In Dr. Julian's letter tophysicians asking them to form committees,he advised them to place asmany laymen on the committees aspossible. Thus lay participation wasinitiated. Also during the year educationalpamphlets and bulletins werepublished and distributed by the StateDepartment of Public Instruction, andthe first campaign for the Sale ofChristmas Seals was begun.Apparently the State Association forthe Prevention of Tuberculosis laggedin its activities from 1911 until 1923. Itwas then that a group known as theState Red Cross Seal Commissionappeared and assumed the responsibilityfor conducting the seal salethroughout the State. Mrs. C. C. Hooksof Charlotte was chairman of thegroup and Dr. McBrayer was electedexecutive secretary in 1914.There was a steady yearly increase inthe proceeds from the seal sale, andin 1917 the directors met and made thefollowing appropriations: (1) $1,250.00for the development of a tuberculosisfilm to be worked out in conjunctionwith the Sanatorium; (2) $1,000.00 towardsa study of tuberculosis in RoanokeRapids; (3) $500.00 on the salaryof a director of public health nursingfor the State; (4) $2,500.00 to purchasean X-ray machine for the Sanatorium;(5) $180.00 to the nursing service inRaleigh. Other funds were authorizedto be paid to towns where public healthnursing service could be established.In 1920 the name of the organizationwas changed to the North CarolinaTuberculosis Association, and it was incorporatedas such on July 5.So goes the early history of theNorth Carolina Tuberculosis Association.Listed among its organizers andsupporters are such names as Mrs. GordonFinger, Charlotte; Mrs. Charles R.Whitaker, Hendersonville; Dr. L. B.McBrayer, Sanatorium; Mrs. C. C.Hooks, Charlotte; Mrs. Cuthbert Martin,Wilmington; Mrs. W. N. Hutt, Candor;Mrs. T. D. Jones, Durham; Dr. W. L.Dunn, Asheville; J. L. Ludlow, Winston-Salem; Mrs. Mark Quinerly, Greenville;Mrs. S. H. Brown, Oxford; Mrs.J. L. Wetmore, Arden; Mrs. R. C.Warren, Gastonia; Dr. Charles L.Minor, Asheville; and a host of otherstoo numerous to mention.As the title indicates, this has beenan attempt to highlight the early historyof the Association. Many importantevents from 1920 to 1955 have notbeen mentioned, and neither is the historycomplete. It continues each day asits work progresses. There are thosewho believe that the greatest pages inthe accounting of its work are yet tocome.Be that as it may, I am aware thatthe striking reduction in the numberof deaths from tuberculosis has notsolved the tuberculosis problem. In thesame year that North Carolina wasproudly recording a death rate of 7.3per 100,000, it admitted to its four

December, 1955The Health Bulletintuberculosis hospitals 1,984 patients(the fiscal year ending June 30.)To think of what this means inhuman terms is not a pleasant pastime.It means mental anguish for not onlythe 1,984 patients but also for themembers of their families. It meansbroken homes, men unable to supporttheir families, women unable to carefor their children, cherished dreamsthwarted, vocations interrupted or discontinued.Yet, as pathetic as this canbe, tuberculosis must not be consideredonly in terms of its cost in lives andin human misery. Its cost in moneymeans a serious loss in the economiclife of the community.I do not have the total bill fortuberculosis in North Carolina, but thefigures from the State sanatoriums fortreatment are quite striking and revealing.It does not take a mathematicianto conceive that at a cost of $7.58per day for 1,984 patients, the bill fortuberculosis mounts rapidly. That doesnot include patients outside the hospitalsin county sanatoriums or aid topatients'families.Even a brief summary of the situationreveals that tuberculosis is clearlya problem today, to which there is noone simple solution. However, if theefforts of the Association in the pastare any indication of what can be expectedin the future, the North CarolinaTuberculosis Association will beamong those that will stand to becounted when victory in the eradicationofthe disease has been achieved.THE ELIMINATION OF TUBERCULOSISFROM NORTH CAROLINA IN THE NEXTSEVENTY-FIVE YEARSProfessor ofBy David T. Smith, M.D.Bacteriology and EpidemiologyDuke UniversityDurham, N. C.The North Carolina Tuberculosis Associationwas founded fifty years ago.At that time the public believed thattuberculosis was inherited and that toplan its control was a Utopian dream.The national death rate in the deathregistration area was nearly 200 per100,000, with the major part of thedeaths in infants and young adults. Inthe northeastern states nearly 100 percent of the population had a positivetuberculin test by the age of 20. Therewere only a few thousand beds forpatients with tuberculosis in the entireUnited States. The X-ray technique forfinding tuberculosis was undevelopedand case-finding clinics as we knowthem today were non-existent. Therewere only two encouraging factors:deaths from tuberculosis had been almosttwice as frequent 50 years before,and a new organization had dedicateditself to the elimination of this dreadfuldisease.It is probable that the death ratefrom tuberculosis in the midwest wasnever as high as in the northeast. Therethe standard of living was higher andthe opportunity for infection was lessthan the more crowded northeasternstates.By 1920 in the midwest there wereenough sanatorium beds to isolate andtreat most of the known active cases.However, many cases were missed untilthe X-ray method had been perfectedand a larger segment of the populationX-rayed.There are no accepted criteria fordetermining when tuberculosis is under

6 The Health Bulletin December, 1955control in an area. It is suggested thattuberculosis be considered under controlwhen the death rate is five orless per 100,000 of the population andfive per cent or less of the schoolpopulation have positive tuberculintests. Wisconsin is approaching thisgoal of control; the death rate for1952 being 6.5 and tuberculin tests inschool children in 1950 five per centpositive. The other midwestern statesare approaching the status of control.When tuberculosis is under control,then we can begin to plan for its eradication.To consider the crude overalldeath rate alone is misleading. The ageand sex groups which harbor the remainingreservoirs of infection mustbe known.The most striking feature of the 1950figures is the steady rise in the Wisconsindeath rate for men from a lowof 0.1 at the age of 12 to 61.2 at theage of 85. The chief reservoir of tuberculosisinfection is now in males over40 and females over 60 years of age.This is the seed bed from which thenext generation will be infected unlessall of the active cases are detected,isolated and treated.Almost as many new cases are beingfound now as were being found whenthe death rate was four times as high.Indeed, one may conclude that thepresent death rate is an artificial conditionbrought about by early diagnosisand better medical and surgicaltreatment and is not the result of anatural decrease in either the prevalenceor severity of tuberculosis. Iftreatment should continue to improvewe might find ourselves in an anomaloussituation in which there were nodeaths but with a continuing heavyload of active cases in our hospitals.The greatest defect in our presentmethods of control is the lack ofspecific information in regard to thenumber, age and sex distribution ofindividuals who have been infected.The percentage of positive tuberculinreactors is an indirect measure of theamount of undetected open tuberculosisin the community. A positive tuberculintest pinpoints the individuals inthe group in which new active caseswill develop. A recent conversion froma negative to a positive tuberculin reactionmeans that there is an activecase among the converter's associates.There is a rough correlation betweenthe percentage of the population withpositive tuberculin reactions and thenumber of clinical cases and the numberof deaths from tuberculosis.In 1950 in Wisconsin there was anaverage rate of 1.7 deaths per 100,000for the age group under 20 and 26 per100,000 for the ages of 50 to 80. Theschool children in Wisconsin have fiveper cent positive tuberculin reactors,and it is assumed that the older groupshave a tuberculin rate of 50 per cent.The corresponding data from Minnesotafor the year 1952 show a deathrate of 0.7 per 100,000 in the age groupunder twenty years of age and in theage group of 50 years and older a rateof 19.4 per 100,000. The tuberculin ratein school children in Minnesota is nowabout three per cent in contrast to 50per cent for adults over 50.Larger samples of tuberculin testsespecially among adults of differentages are needed. When the data areavailable it may be possible to predictfrom the percentage of positivetuberculin reactors the expected annualnumber of new cases and of deathsfrom tuberculosis.As the program for the eliminationof tuberculosis progresses, intensive X-raying of certain segments of thepopulation will probably replace generalmass X-ray surveys. Repeated annualX-rays on males over 40 and femalesover 60 would yield many active casesof tuberculosis, of carcinoma of thelung and of heart disease. Ideally eachindividual with a positive tuberculinreaction should be X-rayed every year.The key to the elimination of tuberculosisis the tuberculin test which tellsus which individuals have living virulenttubercle bacilli in their bodies. Anannual X-ray of tuberculin reactorsshould detect the disease early enoughto cure the patient before the infection

December, 1955The Health Bulletinof others. Routine annual X-rays, withouttuberculin tests, should be continuedfor the heavily infected group ofindividuals who are now 40 years of ageor over.Some may be shocked by the suggestionthat 50 years would be requiredto eliminate tuberculosis from the midwesternstates. This is a conservativeestimate based upon assumptions suchas: no disturbance in our present highstandard of living, no catastrophic waror social upheaval, an increase in casefindingprograms and a maintenanceof the present sanatorium system withits expensive medical and surgical treatment.The long incubation period for thedevelopment of clinical tuberculosis explainsthe long time required. To thismust be added the prolonged persistenceof tubercle bacilli in the bodiesof those who have been treated and areapparently well. All physicians can recallinstances where a person has"cured" in his twenties and has remainedwell until he relapsed in hisseventies. Even more disturbing is theyoung child who is infected and doesnot develop clinical tuberculosis untilold age.Leprosy is the only other humandisease which has a comparable, longincubation period and a comparablelong period of infectivity. Leprosy waseliminated from Europe between 1300and 1600 A.D. by an intensive programof isolation. It required 300 years toeliminate leprosy from Western Europe.It did not disappear spontaneously andpersists even today in tropical countries.NOTES AND COMMENTBy THE EDITORThe thousands of chemical productsdeveloped to make life simpler mayonly complicate it unless used withcare and intelligence.The Committee on Toxicology of theAmerican Medical Association has saidthat there are about a quarter ofa million brand name chemical productswhich may be used in the home,farming, and industry.All of them may be useful—buthandled improperly they may becomekillers, cripplers, and destroyers ofproperty.Understanding of the uses and thepotential dangers of the wealth of productsavailable is needed to prevent theestimated 3,300 accidental poison deathswhich result each year from misuse ofchemicals.The array is so large and so manycombinations of chemicals are possiblethat no complete catalogue of all availableproducts has been made, the committeesaid.As part of its campaign to spread informationabout these products andtheir hazards, the committee will sponsora symposium on health hazards ofchemicals Dec. 29 during the annualmeeting of the American Associationfor the Advancement of Science, inAtlanta, Ga.Bernard Conley, Ph.D., secretary ofthe A.M.A. Committee on Pesticideswill be moderator for the symposium.He said the purpose of the meeting isto interpret new knowledge of chemicalproducts to scientists in various fields,so they may in turn use and spread theinformation.The committees are working towarddevelopment of more intelligent use ofchemicals so that their advantages maybe enjoyed without dangerous results,Conley said. They do not mean to implythat potentially dangerous chemicalsshould not be used at all."The problem of health hazards hasincreased with the wider household useof chemicals once found only in industry,"he said. "This makes misusemore serious and the necessity forwidespread knowledge more urgent."There are several thousand basicchemicals used in available products;

8 The Health Bulletin December, 1955these can be mixed in an infinitenumber of combinations and sold underan infinite variety of fanciful names.The products can be changed in compositionwithout notice and even patentoffice records don't necessarily showthe present composition. Thus, a listingof the contents of all brand-name productsis impossible to make."Conley said while no one may knowall about all of these products, thedanger of poisoning would be greatlyreduced by wider understanding of theproblem, reasonable care in using anychemical, and careful attention to labelinstructions.On the AAAS meeting symposiumdevoted to the problem in the home,agriculture, and industry will be LesterM. Petrie, M. D., director, preventablediseases service of the Georgia Departmentof Public Health, Atlanta; WaylandJ. Hayes, M. D., chief of the toxicologysection of the CommunicableDiseases Center, U. S. Public HealthService, Savannah; Irvin Kerlan, M. D.,associate medical director of the federalFood and Drug Administration,Washington; and Mrs. Veronica Conley,assistant secretary of the A.M.A.Committee on Cosmetics, Chicago.Dr. Vonachen, who is medical directorof Caterpillar Tractor CompanyPeoria, 111., described how this companypreserves the health of managementand worker. Besides widespreadmedical attention to workers and ageneral health education program forall, there is a special program forexecutives.Physicians and psychologists watchover executives for even slight signs ofmental or physical illness. Each year,complete voluntary physical examinationsare given to executives, withspecial attention paid to minor changesin weight, blood pressure, tensionheadaches, indigestion, and fatigue.Executives get medical counseling onhealth and job attitudes, family life,and even religious affiliations andrecreational habits.For overweight executives, there iscompulsory membership in the "FatMan's Club." Members are droppedfrom club lists when company scalesregister a suitable drop in weight.Executives are kept healthy, too, byenforced annual vacations.Executive participation in the healthplan has been 99.9 per cent due to"the close kinship developed betweenthe executive and the examining physician."Dr. Darley said the trend towardpreventive medicine may make industryand the community "the near perfectlaboratory" for showing the effectivenessof preventive work.Medicine and industry together canhelp keep "the gap between what isknown and what is done as narrow aspossible," he said. "To me, this muchis certain: the continued help andinterest of industry and business isessential if we are to do our job."The "shift in emphasis" by managementtoward "recognizing values andresponsibilities" is "one of the mostsignificant achievements of the Americanbusiness community in the past 20or 25 years," Mr. Wilson said."Business cannot and should notshoulder the main responsibility foraid to education in general or formedical education in particular," hesaid. "However, we should certainlyexamine the needs, and then, with allthe wisdom and judgment at our command,assume our fair share of responsibilityin solving this tremendousproblem so important to the healthand welfare of our nation."t>