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per cent.

service has been that in five years, 1911 to 1916, where the mortalit from causes due to maternity in the United States has practicall stood. stationary, the mortality of the company has reduced 12

Miss RANKIN. Is this a charity or a part of the business?

Mr. FRANKEL. The service is paid for out of the premiums of the policy holders. It is everything but a charity. It is a service to policy holders.

Miss RANKIN. Your work in that respect is not in connection with your work for the American Public Health Service?

Mr. FRANKEL. None whatever.

Miss RANKIN. How is this executive committee of the National Public Health Association formed?

Mr. FRANKEL. It is elected by the organization. This executive committee was elected at the meeting held in Chicago in December last.

Miss RANKIN. Is that a representative committee or is it a small committee from New York ?

Mr. FRANKEL. The committee is a committee elected out of the board of directors by the board of directors, the board of directors being elected by the association. The board of directors has representatives in practically every State of the Union. The executive committee is elected out of that composed of officers and certain particular members elected to serve on the executive board and to act for the board of directors in the interim between meetings.

Miss RANKIN. How many men would compose a quorum at this executive committee meetings?

Mr. FRANKEL. I think five or seven.
Miss RANKIN. Are there any women on that board ?
Mr. FRANKEL. To my recollection there are none on the board;

There are women, of course, represented in the membership: Miss RANKIN. You speak of eleven States where they have child welfare work done; could you name those States ?

Mr. FRANKEL. I have here a list of nine. I was only notified of this hearing yesterday by telegraph. They are Connecticut, Florida, Illinois, Kansas, Massachusetts, New Jersey, New York, Ohio, and North Carolina. You take the State of North Carolina, for example. I do not know of a State that is doing a better piece of work at the present moment than North Carolina's health department along the lines of rural hygiene. They are quite advanced and have a very efficient State health officer, Dr. Rankin. They have gone so far as to organize dental clinics for the population of the State. and altogether their child hygiene is a distinct contribution, particularly along educational lines among women and babies, in the United States. It would seem a pity to me to go into that State and create a new agency that would take the work from them.

Mr. Robinson. Right along that line is a letter which you can make a part of your remarks.

Mr. RÁNKEL. This letter is addressed to Mr. Robinson. I will read it:




Raleigh, N. C., January 24, 1919. Hon. L. D. ROBINSON, United States Congress,

Washington, D. C. MY DEAR Mr. Robinson: I desire to direct your official attention to House bill 12634 which makes a Federal appropriation conditioned upon supplemental appropriations from States for infant hygiene in rural communities. The bill provides, as I understand it (not having seen a copy of it) that this Federal general appropriation shall be expended through some new agency to be created in the State government.

Infant hygiene work is strictly public health work and it seems to me that the public health work of the United States Government should be carried on under the United States Public Health Service and not through the Department of Labor.

I have not attempted to argue that side of it at all because I do not think it has any bearing on this particular bill.

In other words that this entire measure should come under the Public Health Service and not under the Federal Children's Bureau.

Moreover, I am opposed strongly to the idea of creating a new division of the State government to look after certain health interests, reproducing within the State the mistake of the Federal Government in dividing its health work between a number of agencies or bureaus. I would appreciate very deeply your giving your attention to this bill, and using your influence partciularly against the provision of the bill that creates a new agency within the States for public health work.

Thanking you for any consideration you give this matter, I am, with the highest esteem, Very sincerely, yours,

W. S. RANKIN, Secretary. Miss RANKIN. Let me ask this question. How could it interfere with any work done in North Carolina ?

Mr. FRANKEL.. It would mean practically one thing or the other, if I may give my own personal views. If the Federal Government is to go into the subsidy and the State is to cooperate in getting a suhsidy, it means the creation of a new agency who are going to look after infant hygiene and maternal hygiene. That work is to-day being done by the States.

Miss RANKIN. Just in New York State ?

Mr. FRANKEL. As a practical case of what I mean, in North Carolina.

Miss RANKIN. They have done work for maternal aid ?
Miss RANKIN. In what way?

Mr. FRANKEL. They have not, of course, gone to the extent this bill contemplates, of actually furnishing hospital care, for example, and medical care for pregnant women or for the care of the baby during or immediately after confinement, but they have taken up the whole educational side of infant welfare and child welfare work by the distribution of pamphlets and leaflets by sending nurses and physicians into the homes; hy having the whole State organize public health nursing service with a supervisor traveling through the State attempting to organize in every community public health nursing work through cooperation of the communities with the State board of health, and they have taken the State from one end to the other. It has been largely rural work, for the reason that there are comparatively few cities of any size in the State of North Carolina.

Now, their work has simply been a phase of their general health work, and after all you can not detach or separate the care of the mother and the baby from the general health work of the community. It ought not to be separated. The health work of the community ought to be considered as one great big problem, a study which primarily should come under the consideration of the State board of health. If that is well organized, I can not see any reason why the things contemplated in this bill should not be efficiently carried out.

Miss Rankin. May I ask, then, if North Carolina is doing such excellent work, then it would have no need of availing itself of the opportunities given under this bill and could simply give that much money to some State where the health board is not doing anything?

Mr. FRANKEL. North Carolina is not a rich State; it is a poor State. It has very limited resources at its disposal. It is due to the fact that they have a very efficient State board of health with a very efficient secretary. I mention this because I happen to know the conditions in North Carolina very well. They could use this fund and very materially extend the work along the lines you propose. They would probably be enabled to authorize every woman in the State to have proper maternity care if they had hospital facilities and to give subsequent postnatal care to the baby, if they had larger funds, and could probably induce their State immediately- I speak, of course, purely from my own viewpoint-to meet the requirements of a bill of this kind, and the work in North Carolina would be immediately doubled, enlarged, and improved upon. In a maternity board, such as is contemplated in this bill, covering all the State, with representatives of the State board of health and three or four other people representing other interests in the State, who are to be the administrators, you at once take away from the State board of health its opportunity to do that work, and the work done by the State board of health inevitably disappears and vanishes. In this case it means your taking away from the State board of health and placing in the hands of an independent body work which would legitimately, logically, and legally be performed by the State board.

Miss Rankin. Then you would take from 37 States where they have done nothing and prevent their getting anything rather than interfere with 11?

Mr. FRANKEL. I know of nothing that would encourage other States. They would go ahead and do the things planned themselves.

Miss RANKIN. You are not in favor of this bill?

Mr. FRANKEL. 'I beg pardon. I am not in favor of a particular provision of this bill.

Miss RANKIN. The States that have a State board of health have made no efforts. There is no reason to believe they are going to make particular effort for the mother and children.

Mr. McLEMORE. They will do it to get this money.

Mr. Almon. Explain what the effect of this bill, amended as you suggest, would have on these 37 States.

Mr. FRANKEL. The effect of this bill would be this thing would be published and advertised. Almost immediately, I believe, the progressive States—I speak from the standpoint of health work-would immediately avail themselves of this appropriation. That means that their work would be vastly improved and the thing that is proposed by this bill will be done. The example that will be set by these States to other States will be bound to bear fruit almost immediately. The very organization I represent is an educational organization. Its main purpose is to develop efficient health work. One of the things that we are doing at the present moment is the attempt to organize State public health organizations and associations; that is, in each State we have attempted and have organized within the last few years seven or eight of them. Others are in process of organization throughout the country. In other words, the States that have lagged behind are the ones we are trying to jack up along lines through the legitimate organization in the States, the State boards of health. Every effort of this larger organization, this national organization, would be used through its representatives and others to encourage the lagging State to come along and avail itself of the appropriation made under this bill and to induce its own legislature to make an appropriation.

Mr. ROBINSON. Is there any good reason why this work should not be done through the State boards of health or through the health departments of the Government ?

Mr. FRANKEL. I know of none, sir. I have stated before that in the United States to-day that is the legal method and procedure for the administration of health rules and regulations of the States, that every State has a State board of health with the exception of one, that in most instances the State boards of health are very efficient bodies. If they have not gone into this phase of work particularly it is, perhaps, due to the fact that there are so many other things to be done by State boards of health and they have never had the funds. Here you come along and give them the opportunity to advance and develop infant hygiene work along the lines of this bill and place in their hands the money to do it and give the impetus and incentive for the State board of health to do this particular work.

Mr. ROBINSON. I remember that Dr. Rankin says he is in favor of this bill, but thinks it might be detrimental to the health boards.

Mr. FRANKEL. That is the attitude I am trying to represent here as vice president of the American Public Health Association. We have no objection to this bill. . As a matter of fact, the association, as I said earlier, has been the very advance guard of attempts to procure legislation protecting infant life and maternity. No one for a moment could give anything but the best indorsement to any legislation that is going to safeguard infant life and motherhood. We believe, however, that purely as an administrative proposition it is inadvisable to establish a new agency partly lay in character, and when I say law, I do not mean lay as opposed to medical, but lay as opposed to professional health organizations, such as the board of health. There is no reason why a smaller body can not be created under the State board of health, leaving the administrative control in the hands of the State board of health.

I would ask the committee to make inquiries and find what has been done in the State of Kansas. Probably you can obtain the information through the Children's Bureau here in town or from Dr. Crunbine or Dr. De Vilbis, of the State board of health out there. If a new board is created of the type proposed here, the work already done in Kansas is to be continued and will not be distinctly interfered with.

Mr. McLEMORE. Do you speak of insurance you were connected with? Would the enactment of this bill into law interfere there?



Mr. FRANKEL. In no way, except we are geneerally interested in this question of childhood, and as I have explained what is generally understood everywhere the situation we have all through the United States in maternity work, we have reduced the mortality among mothers from causes due to maternity 123 per cent in five years. In that same period the mortality in the United States remains stationary, or practically, if anything, increased. The argument that this would be as our statistics would bring out is in favor of legislation directed toward proper care of women during the period of maternity.

Mr. MÖLEMORE. I just wanted to bring out that one point because there seemed to be some misunderstanding.

Mr. FRANKEL. Nothing except our general interest in health work.



Dr. RUDE. While it is perfectly true that we have at the present time 11 State boards of health with divisions of child hygiene, you have to remember that six of them have only just been formed and are still in process of organization. Out of the five States having well-established divisions there are really only three which have been very active.

This proposed bill has a broader scope than a purely health bill. That is one of the reasons for not putting it under the boards of health, but it provides most carefully for representation from boards of health. This bill provides for a representative from the State board of health, who shall be a physician. This provision obviates the situation and States having others than physicians on State boards. For instance, a near-by State has, as president of its board of health, a printer, with a broker, a veterinarian, and four physicians as the other members. There is nothing in this bill which prevents the director of the division of hygiene in the States having such divisions, from being the person represented on this new maternity board. The bill does not say that the person has to be a member of the board of health, but a representative of this board and that he shall be a physician.

forth Carolina happens to be one of the States to which this would not apply, because North Carolina has established during the past year a division of child hygiene and has at its head a home economics person. They have as yet done no work whatever. I have a letters, written in December, to that effect. I am sure the Children's Bureau has been quite familiar with Dr. Rankin's plans. He has a wonderful plan for health work in North Carolina, but the last time I talked with him and asked how many county nurses he had in his State, be assured me he had none. He has been able to do a limited amount of educational work.

Mr. ROBINSON. I do not know whether they are designated county nurses, but I know in my home county they have a community nursis. She lives in the town and looks after especially town cases.

Dr. RUDE. That is true, in certain selected localities. Dr. Rankin has really a wonderful plan for health work, if he only could have the finances with which to do this type of work. We are all watching North Carolina with great interest.

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