of child mortality in the United States in the last 20 years and the reduction from diphtheria, pneumonia, and other things, as compared with 20 years ago, indicates what the value of the health departments of our States have been, a very remarkable piece of work. If they haven't handled this problem yet, it is because they have not reached it. Here is the opportunity to reach it and give them the encouragement, as Dr. Baker says, and you will find every State will avail themselves of it. I see no reason why this bill should not be amended. Instead of having section 3 delegate this to a separate State board, that this be transferred and funds given to the State, provided the State board of health organizes a division of child hygiene. The money is to be paid to the State under those conditions. Under that division of child hygiene there shall be appointed the special representatives recommended here, nurse, physician, and others. Mr. HERSEY. When you have amended that bill in accordance with your thought, what have you but simply a bill making an appropriation of so much money to each one of the State boards of health? Mr. FRANKEL. That is what you have now under this appropriation to a special board. Of course I presume a bill of this kind ought to be so tied up with regulations that this money will not be disbursed by the Federal Government and continued unless the States produce results, irrespective of the type of administration. Surely the Government is not going to continue indefinitely money appropriations of this kind, and I think there is a provision of that kind in this bill. (The following letters were offered for the record:) DR. RUDE, NEW YORK, January 14, 1919. Federal Children's Bureau, Washington. Deeply regret my inability to appear in person owing to unexpected complications here, and to speak in favor of your bill. Please present to the committee in my behalf my ardent support of the purposes of mine in the bill. Never has the need in rural districts been greater than to-day for improved oversight of expectant mothers and young children. The first and best method of accomplishing this is by a great extension of the nursing service. My hope is that this may soon be accomplished. Warm greetings. Dr. ANNA RUDE, Dr. RALPH W. LOBENSTINE. NEW YORK, January 14, 1919. Federal Children's Bureau, Washington, D. C. Twenty-five years' experience as head of the New York visiting nurse service is my authority for asserting the value not only the saving of life but the enormous importance of education of mothers through public health nurses. Our record show definite results and are on exhibition. The consistent decline in mortality from diseases incident to childbirth among policyholders of the Metropolitan Life Insurance Co. who have had the care of the public health nurses is in marked contrast to the increase in death rates from these diseases in registration areas of the United States. Federal aid to State to encourage the employment of trained nurses and doctors to instruct and care for women in childbirth would bring America up to the standard of other civilized countries in this respect. LILLIAN D. WALD, 265 Henry Street, New York. Mr. McLEMORE. If that is all, we will stand adjourned. (Thereupon, at 11.55 o'clock a. m., the committee adjourned to meet again at the call of the chairman.) Dr. RUDE. As I think I stated before, this bill is intended to be a much broader bill than a purely health bill; its real purpose is for educational extension work and that is the reason for having it under a separate board. It is true that now all of our States have boards of health, but some of them are rather feebly organized. Many of them have not a full-time health officer, which is a very great handicap, and for that reason they are not as efficient as they might be otherwise. are The United States Public Health Service in a recent report states: "Two other basic problems, tuberculosis and infant welfare, unfortunately beyond the direct reach of the one-man health officer, although it is possible and essential to stress these subjects in an educational way from every possible angle.' Mr. ZIHLMAN. It would be a Federal appropriation intended to stimulate health work? Dr. RUDE. Yes. Mr. McLEMORE. Didn't you make a statement to take one from each board of health it really gives them the balance of power? Dr. RUDE. One member of each maternity and infancy board would be a physician representing the State Board of Health, and another member would be a public-health nurse, and I have tried to make it clear here that the majority of the public-health nurses at the present time are employed by State boards of health, so that the balance of power would still rest in that board. Mr. HERSEY. If they have the balance of power, why should not they have all the power? Dr. RUDE. A person representing a State college or an agricultural college will be one very valuable means of cooperation. There you have the machinery through which to extend teaching. This bill is really broader than a simple health measure. STATEMENT OF DR. DOROTHY REED MENDENHALL, PHYSICIAN, AGRICULTURAL EXTENSION. WORK IN WISCONSIN UNDER THE SMITH-LEVER FUND. Dr. MENDENHALL. I think Dr. Rude has proved that in ninetenths of our States, at least, there is no machinery this bill would supersede. There is no well organized child welfare work done. under the State boards of health, except in a few Eastern States. I also take exception to the assertion that the State boards of health have done heretofore in the majority of our States the best child welfare work—that is, work to promote right conditions for maternity and early infancy; that the medical profession, as represented by the State boards of health, is necessarily the best profession to administer this bill or to administer it alone, and that it would not be better to have a broader administration representing three professions, for such a bill. • I shall only touch on the point of the child hygiene divisions hitherto organized. With the exception of Kansas, where there has been State-wide distribution of educational material, but where there has been no work for the teaching of mothers in the care of themselves and their babies, except through correspondence, so far as I know the child hygiene divisions of Massachusetts, New York, New Jersey, and Pennsylvania have been the only contribution to child welfare of the State boards of health. There is practically no child welfare work of any moment being done except in this eastern locality. The great West and South have developed no child hygiene work under State boards of health or are just beginning to start such divisions in five or six States. I am sure we are therefore not superseding any machinery. Now, there have been other agencies doing splendid work in many of the Western States to promote health in rural communities. I am referring to the work of the extension divisions of our State universities, through which demonstrations, lectures, and actual welfare conferences are held throughout the rural districts, especially in Wisconsin, Utah, Oregon, and Indiana, and to a lesser extent in Michigan, Minnesota, and Kansas. This work in Wisconsin has been going on for over five years, and also agricultural extension work in health has been started in our State. I do not know whether you understand what extension work is. We go out to little towns, even in Wisconsin, 25 miles or 40 miles from the railroad, and there hold institutes or farmers' meetings for both men and women, and also women's meetings, where we take up among other things the health of the mothers, the question of prenatal care, the need of good obstetrical care, and the feeding of infants and older children. In the evening, at general meetings, talks are given on the health of the community and contagious diseases. Usually, in Wisconsin, we have health conferences at the end of the day, where we actually examine children, and give advice to mothers in regard to their own health problems and those of their child. Very often this is the only chance that the mother has to consult a physician. These families will come 10 to 40 miles to these conferences, because there is no other opportunity for them to consult a children's specialist. This work has been developed in many of our Western States, and I wish to say, for the sake of the other people in this work, that this is actual service for humanity, for the community. It necessitates hard and arduous traveling out into remote places, five or six days in the week, exposure to bad weather, and the danger of getting snowed up or caught all night in a stalled train. It is indeed hard, wearing work, and unless you have a real love of humanity you will not stay very long in extension work of any sort, for the salaries are quite small, practically the ordinary teacher's salary. Appropriations to further this work have been easily obtained from the State legislatures. For instance, Utah, in 1917, was granted $5,000 by the State legislature for the child hygiene work of the extension division of the State university. The legislatures, I think, on the whole, in the Western States, the ones I know about, are glad to give funds for this extension work of the universities, while they have been less generous to State boards of health. I do not say the State board of health projects should not be forwarded, but in the West it is university extension projects that have been favored. In Iowa there is a Child Research Division for studying the conditions related to child welfare and the promotion of better health conditions for children, especially in rural districts. The State legislature, in 1917, appropriated $25,000 to start this at the State university-a very unusual example of State generosity. So much for extension. work. I am a physician, a member of both the associations which Dr. Baker and Mr. Frankel represent. It is unfortunately true in the medical profession, as in many other professions, that you rarely find the modern, scientific equipment necessary for a fine physician or surgeon coupled with a broad social knowledge, a disinterested love of humanity, and the common sense point of view, such as we used to have in the old-time practitioner. The medical profession is so exacting in its training that to be expert in branches of medicine and surgery so much time has to be devoted to professional training that the social point of view is apt to be lost. I think there are exceptions where one gets disinterested love of humanity plus that scientific medical knowledge, but I am sorry to say that in many of the States where I have worked you are not apt to find it, in rural communities or in county health officers. The State boards of health in the past have been very largely interested in combating disease, and they have not been willing or anxious to take an aggressive in attacking the fundamental causes which injure the health of the community. I believe the reason why they have not been willing to take this aggressive action and sometimes they have been asked to do it and, have refused, is because they are afraid of the small practitioner in the locality where they wish to undertake or start some health project. There are physicians, unfortunately, who consider their profession a money-making business and are not willing to see started in their community a project that may injure their pocketbooks. I have been told by health officers that they could not undertake work in certain places because the local practitioners would object and would go to the State medical association, which was backing the State board of health, and make trouble for them. I think that this has undoubtedly happened in some instances. I do not think any one profession is apt to see outside of their own particular field; a board composed of any one profession would not therefore be as broad minded or have as wide a vision as a board made up of several different professions. I want to say a word about the nursing profession. It is a very practical profession. These women will very largely carry out the measures of this bill. The nurse will go into the homes and teach the mother how to care for herself and for her child and will start the centers and conferences for mothers and children and largely carry on this important part of the work. The nursing profession, as I am sure we all realize, is a profession peculiarly disinterested, with a great desire for general public service. Nursing is also a profession of women, and I think that it is only right that women should be represented in the administration of this bill, which has to do with the instruction of mothers in regard to their care and the care of their children. For another reason, I think it is an excellent thing because the nursing profession always cooperates with the medical profession, and naturally the physicians and nurses in the State board of health would work together in the administration of this bill. The nursing profession, the public health nurse, should be represented in this board. For two reasons it seems to me that it is very much better to have the administration of this bill left as it is. One of them is that the first object of the bill is that of instruction. It is educational exten |