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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

RANKIN 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 organ


ization. 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 à 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 in advisable 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. 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?



If a very active.

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 124 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. MOLEMORE. 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. STATEMENT OF DR. ANNA E. RUDE, DIRECTOR, DIVISION OF


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

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.

North 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 letter, 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, he 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 nurse. 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.


Mr. ROBINSON. I am glad my State is so progressive.

Dr. RUDE. Regarding State boards of health, I think the fact that we have to-day only five States which have Child Hygiene divisions actually in operation a very good demonstration of how slowly State boards of health act.

Mr. ROBINSON. Hasn't the main trouble been, Doctor, they haven't had the means to act with the public has not been educated up to the point of providing funds for the work.

Dr. RUDE. That is perfectly true. That is what this bill provides for. It is primarily an educational extension bill. I can not see that it will do anything but assist the States that have undertaken this work by giving them Federal aid, and it is true that wherever work has Federal approval, it does carry more weight than where it has not.

Mr. ROBINSON. There is no doubt about that.

Dr. RUDE. There is something in the psychological effect of governmental approval. A State will go ahead and do work that otherwise it couldn't accomplish.

I didn't finish my first point regarding the personnel of this new board. The bill also provides for a public health nurse as a member. The majority of the public health nurses who are employed in States, are employed under boards of health, so that really the balance of power on this new board would be representative of the board of health, with a physician from the board of health and a public health nurse employed by them. I feel that the State boards of health were given very generous recognition in the formation of this new maternity board. The other member is to be a teacher from the State college or agricultural college. In many States it has been shown that appropriations are much more easily obtained where a State college is represented. I can not in any way see how this bill can be considered as retarding child welfare work. I am a little surprised to find myself a member of an association-American Child Hygiene Association-which feels that a bill such as the proposed one could possibly effect retardation of welfare work among children.

. Dr. BAKER. May I use a personal privilege, if I may, in the record for the stenographer. If he will read the things I stated, that I appeared for the executive committee of the American Child Welfare Association, that is stated there; nor am I opposed in any way to the purpose of the bill. We have gone on record heartily in favor of the bill.

Dr. RUDE. Kansas is quoted as one of the States doing excellent work and was one of the original States having a child hygiene division. That division at the present time consists of a director, who is a physician, and three stenographers. They have been able to do some educational extension work but not the type of Statewide work such as this bill provides for.

Those are my points. Have you any questions?

Mr. ROBINSON. Is there any reason why this work should not be carried on through the recognized boards of health? I am inclined to favor the purpose of this bill, and think I do, but is there any good reason why this work should not be carried on through the established boards of health where they have them, and where they have not provide that it be carried on through boards of health of the several States, and let them establish a board of health before they can get the benefits of the provisions of this bill.

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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.

The United States Public Health Service in a recent report states: “Two other basic problems, tuberculosis and infant welfare, are 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.



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

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