TH

NEXT STEPS IN PUBLIC HEALTH

HOMER FOLKS

Secretary of the State Charities Aid Association

HE health department differs markedly from most other city departments in one important particular. While the others have some one rather definite, measurable, concrete thing to do, the health department has an unlimited and increasing number of indefinite and unlimited things to do. It is and always will be impossible to say that the health department performs a hundred per cent or fifty per cent or any other particular per cent of all the work which ought to be done, and which might practically and advantageously be done to protect the health of the community. At the present moment there are all ready and waiting to be done, in applying to the life of the city the things that we know how to do for the saving of life and the prevention of sickness, at least ten times the number of things that the department can possibly undertake. Furthermore, in these days of institutes of medical research, whenever the scientific men in the laboratories discover a new germ, or a new way of controlling an old germ, in substance they add, or should add, a new bureau to the department of health. With the advance of sanitary science, moreover, it is surprising how much we unlearn. The department of health rests upon a science which is only in its beginnings, which is constantly changing its emphasis and bringing new and unforeseen elements into the situation. For that reason the most difficult problem of the health department is to decide which of the numerous things that it might do it actually will undertake.

The various possibilities fall into two general classes or categories. One proceeds by direct attack upon infection itself. It tries to stamp out or dam up or neutralize or destroy the germs that cause so many of the diseases which shorten our lives. There are many different ways of doing that,-direct attack and indirect attack,— as many ways as a fighting army has in the field. Then there is the other general plan of increasing our resistance to these germs so that not so many of us will succumb to them, and not so quickly and completely.

Among the means of increasing resistance, we might note a few: First, education. The largest function of public health education and the most difficult, as it is the most underlying and fundamental, is that of

changing the attitude of all of us in regard to the possibility of control of sickness and death. For countless thousands of years we have drawn what little consolation we could from placing the responsibility upon others and upon Providence. Hence it is exceedingly difficult, even for the most thoughtful of us, to face the fact that we are the arbiters of our own fate in this particular as in others. The moment the community as a whole really, seriously, actually believes the motto of the New York city health department that "public health is purchasable," it will be purchased, and in increasing quantities. Very few of us really believe that as yet, although we may give it a half-hearted acquiescence. It has not become a conviction upon which action is born. The second means of increasing resistance is periodic physical examination, especially of the very young and of those past middle life. I should put third the matter which is so largely under the control of Commissioner Murphy, the conditions under which we live at home; fourth, the hours and conditions under which we work; and last, our means of recreation. All these different things we might take up advisedly, advantageously, and effectively, but which of them shall we actually do?

In only one respect should I register a difference of opinion from Commissioner Goldwater. He indicated that he thought we might continue for a series of years to reduce the expenditures of the department of health. I think he accomplished a miracle in leaving a balance of one hundred seventy thousand dollars last year; I greatly mistake the facts if we do not see, instead of a reduction, a very large increase in the expenditures of the department of health in the next decade, and the more competent the commissioner we have and I only hope we may retain our present one for a long time yet to come-the larger that increase will be, because public health is one of the increasing functions of government. We are spending only three million dollars for health and eighteen million dollars for police,-that is, just to keep ourselves in order. If we would spend a part of that in finding the relatively small number of the mentally deficient and the incorrigible, and would provide for their care, we might devote a large part of that eighteen million dollars to more fruitful results. What could be more useless in these modern times, during the daytime at least, than the policeman walking up and down the streets looking for nothing in particular? I confidently expect to see the appropriations to those two departments reversed, three million dollars for police and eighteen million dollars for public health in the city of New York.

From my observation of the work of the state health department, which has been a good deal closer than that of the city department, it

seems to me that the immediate things to be done would come something in the following order:

In the first place, the control of whooping cough. What an indictment it is that we should allow a disease like whooping cough to remain one of the large factors in mortality, responsible for 279 deaths, one-third of one per cent of all the deaths in the city! It is a serious disease among infants, and is susceptible of control by measures now perfectly well understood. I would spend some of the additional millions of dollars in clinics and hospitals and sanitary supervision of whooping cough.

Measles, that insignificant disease, is the deciding factor in 560 cases, or nearly one per cent. It also is subject to control by measures no less perfectly understood.

Diphtheria has not been banished by the discovery of the anti-toxin; there were 1,492 deaths from that cause last year. The mere application of our present knowledge and a proper use of the anti-toxin would cut down that number by hundreds per year.

Tuberculosis is almost the largest, if not the largest, cause of death. Excellent work is being done, admirable progress is being made, all of us feeling a little uncertain about relative values and not knowing just exactly which is the most important of the various things we are trying to do. My suggestion is the creation of a department for the elimination of tuberculosis, with a commissioner appointed for ten years at ten thousand dollars a year.

I should put next the control of the venereal diseases. A promising start has been made in the health department through private aid, through contributions coming not from the city government, which was not able to provide them, but from that terribly tainted source, a foundation. I think it is about the best thing that is being done in the city of New York; but to how slight an extent are we as yet availing ourselves of the opportunities for making a diagnosis of these diseases and for their treatment! Think of the wonderful treatment for syphilis which was recently discovered and the slight extent to which as yet, taking the population of the city as a whole, it is used. In this particular the present activities of the health department ought to be multiplied by twelve instantly unless someone else does it. If the private agencies of the city will come forward and do it, well and good; but the main thing in this as in all other lines of health work is that it be done, that we do not think so much about who is to do it that the job goes undone. Get it done. The city is the residuary legatee, as I see it, of the things that other people do not take up and do.

We are quite a long distance yet from the control of typhoid. Several hundred lives a year can be saved in the city of New York by a more comprehensive, closer, sharper, keener dealing with that disease.

Leaving the things that have to do with the control of communicable diseases, and turning for a moment to the things that look farther ahead, especially the public education work, these seem to me the things to be emphasized. I was much struck in looking over Poor Richard's Almanac the other day to see that in 1747 Benjamin Franklin said, "Nine men in ten are suicides." I think he might change it and say that nine men out of ten are suicides or homicides; that is to say, the death of perhaps nine persons out of ten occurs when it does now either because of some fault of the man, something that he did that he should not have done, or left undone that he should have done, or through the fault of someone who had some close and vital relation to him, his parents in the course of his childhood or his associates. To make that fact enter into the daily consciousness of the community, to make it a vital element of our knowledge, a part of the mental furniture to which we become accustomed, a part of the underlying assumptions out of which our conduct springs,— that is the big thing. To destroy confidence in-I was almost about to say medicines-nostrums such as our ancestors had, to get over the idea that the medicine man and the dance and incantation would cure disease-to do that we have to recover from a great many of our underlying assumptions. A confidence should be created in the realities of personal hygiene. People should be led to believe that all this talk about air and ventilation and food and rest and sleep really does mean something after all; for most of us do not take any stock in it. We think we do and we say it over and over again and talk it to our children, but we go on and do just as we did before; whereas, if we really believed in it, we would pay some attention to it. We are not yet convinced that personal hygiene has a real bearing on sickness and on death.

Public education as to the methods of infection so that they may be avoided, and lastly, public education that is addressed to the medical profession itself, should be given more time and thought. A fair percentage of all the physicians in this city are already on the staff of the health department, but all of them actually, inherently, inevitably, unofficially, are members of the department of health. Perhaps its most difficult task is to socialize the medical profession-not in any hard and fast way, and not necessarily by making it a part of a public department in any outward fashion, but by reaching it and getting its attention turned toward the tasks of public health, instead of letting it do so much of what it now does that is practically not worth doing at all.

POLICE ADMINISTRATION

ARTHUR WOODS

Commissioner of the Department of Police

HE police force in New York city numbers just short of eleven thousand men, and the cost to the city yearly

to support it is about eighteen million dollars. The force is divided, roughly, into two departments: the uniformed force and the detective bureau.

The detective bureau is used primarily, as its name indicates, to detect criminals. It comes into operation after the crime has been committed-in other words, after a criminal has outwitted the patrolling force and, in spite of them, has managed to commit a crime. The duty of the detective bureau is to apprehend the criminal, and to recover stolen property.

There are, and probably always will be, discussions as to the amount of centralization or decentralization which should govern the organization of a detective bureau. In England the tendency is toward decentralization; in Germany the detective forces are highly centralized, although there seems to be a movement now toward relaxing the highly centralized organization in favor of local subdivisions. In New York we have a combination of the two systems, in the effort to adapt the best features of both to the local conditions here. Our detective bureau proper comprises about six hundred men. They are divided into nine branch. bureaus; four in Manhattan, one in The Bronx, two in Brooklyn, one in Queens and one in Staten Island. Each one of these branch bureaus is a complete organization in itself, and handles crime that occurs in the locality which it covers.

Besides these local branch bureaus divided geographically there are also operating from police headquarters a number of squads made up of men who are skilled in the particular kind of crime which they are assigned to work on. These special men working from headquarters operate in all parts of the city. There are special squads, for instance, dealing with homicides, with habit-forming drugs, with loft burglaries, with pickpockets, with