Among large numbers of persons, in city as well as country, washing the body is still a matter of instinct, a bath not being taken until the body is offensive, the hands not being washed until their condition interferes with the enjoyment of food or with one's treatment by others. There is a point of neglect beyond which instinct will notpermit even a tramp to go. If cleanliness is next to godliness, the average child is most ungodly by nature, for it loathes the means of cleanliness and otherwise observes instinct's health warnings only after experience has punished or after other motives from the outside have prompted action. The chief form of legislation of the instinct age is provision of penalties for those who poison food, water, or fellow-man. There are districts in America where hygiene is supposed to be taught to children that are conscious of no other sanitary legislation but that which punishes the poisoner.
Displayhas always been an active health crusader. Professor Patten says the best thing that could happen to the slums of every city would be for every girl and woman to be given white slippers, white stockings, a white dress, and white hat. Why? Because they would at once notice and resent the dirt on the street, in their hallways, and in their own homes. People that have nothing to "spoil" really do not see dirt, for it interferes in no way with their comfort so far as they can see. Their windows are crusted with dust, their babies' milk bottles are yellow with germs. Who cares? Similar conditions exist among well-to-do women who live on isolated farms with no one to notice their personal appearance except others of the family who prefer rest to cleanliness. But let the tenement mother or the isolated farmer's wife entertain the minister or the school-teacher, the candidate for sheriff or the ward boss, let her go to Coney Island or to the county fair, and at once an outside standard is set up that requires greater regard for personal appearance and leads to "cleaning up."
Elbow sleeves and light summer waists have led many a girl to daily bathing of at least those parts of the body that other people see. Entertainments and sociables, Saturday choir practice and church have led many a young man to bathe for others' sake when quite satisfiedto forego the ordeal so far as his own comfort and health were concerned. Streets on which the well-to-do live are kept clean. Why? Not because Madam Well-to-do cares so much for health, but because she associates cleanliness with social prestige. It is necessary for the display of her carriages and dresses, just as paved streets and a plentiful supply of water for public baths and private homes were essential to the display of Rome's luxury. Generally speaking, residence streets are cleaned in small towns just as waterworks are introduced, to gratify the display motive of those who have lawns to water and clothes to show.
Instinct strengthens the display motive. As every one can be interested in instinct hygiene, so every one is capable of this display motive to the extent that his position is affected by other people's opinion. It was love of display quite as much as love of beauty that gave Greece the goddess Hygeia, the worship of whom expressed secondarily a desire for universal health, and primarily a love of the beautiful among those who had leisure to enjoy it.
Commercebrooks no preventable interference with profits, whether by disease, death, impassable streets, or disabled men. The age of chivalry was also the age of indescribable filth, plague, Black Death, and spotted fever that cost the lives of millions. It would be impossible in the civilized world to duplicate the combination of luxury and filthy, disease-breeding conditions in the midst of which Queen Bess and her courtiers held their revels. The first protest was made, not by the church, not by sanitarians, but by the great merchants who were unable to insure against loss and ruin from the plagues that thrived on filth and overcrowding. By an interesting coincidence the first systematic street cleaning and the first systematic ship cleaning—maritime quarantine—date from the same year, 1348A.D.; the former in the foremost Germantrading town, Cologne, and the latter in Venice, the foremost trading town of Italy. The merchants of Philadelphia and New York started the first boards of health in the United States. For what purpose? To prevent business losses from yellow fever. Desire for passable streets, drains, waterworks, and strong boards of health has generally started with merchants. For commercial reasons many of our states vote more money for the protection of cattle than for the protection of human life, and the United States votes millions for the study of hog cholera, chicken pip, and animal tuberculosis, while neglecting communicable diseases of men. No class in a community will respond more quickly to an appeal for the rigid enforcement of health laws than the merchant class; none will oppose so bitterly as that which makes profits out of the violation of health laws.
Table II
Cost in Life Capital of Preventable Diseases[2]
AgeEstimated Value of Human LifeMultiply by the number of deaths for each age group to learn the cost in life capital to your community in loss of life from one or all preventable diseases.0- 5 years$1,5005-10 years2,30010-15 years2,50015-20 years3,00020-25 years5,00025-30 years7,50030-35 years7,00035-40 years6,00040-45 years5,50045-50 years5,00050-55 years4,50055-60 years4,50060-65 years2,00065-70 years1,00070- years1,000
Anti-nuisancemotives do not affect health laws until people with different incomes and different tastes try to live together. In a small town where everybody keeps a cow and a pig, piggeries and stables offend no one; but when the doctor, the preacher, the dressmaker, the lawyer, and the leading merchant stop keeping pigs and cows, they begin to find other people's stables and piggeries offensive. The early laws against throwing garbage, fish heads, household refuse, offal, etc., on the main street were made by kings and princes offended by such practices. The word "nuisance" was coined in days when neighbors lived the same kind of life and were not sensitive to things like house slops, ash piles, etc. The first nuisances were things that neighbors stumbled over or ran into while using the public highway. Next, goats and other animals interfering with safety were described as nuisances, and legal protection against them was worked out. It has never been necessary to change the maxim which originally defined a nuisance: "So use your own property that you will not injure another in the use of his property." The thing that has changed and grown has been society's knowledge of acts and objects that prevent a man from enjoying his own property. To-day the number of things that the law calls nuisances is so great that it takes hundreds of pages to describe them. Stables and outhouses must be set back from the street. Every man must dispose of garbage and drainage on his own property. Stables and privies must be at least a hundred feet from water reservoirs. Factories may not pollute streams that furnish drinking water. Merchants may be punished if they put banana skins in milk cans, or if they fail to scald and cleanse all milk receptacles before returning them to wholesalers. Automobile drivers may be punished for disturbing sleep. Anything that injures my health will be declared a nuisance and abolished, if I can prove that my health is being injured and that I am doing all I can toavoid that injury. No educational work will accomplish more for any community than to make rich and poor alike conscious of nuisances that are being committed against themselves and their neighbors. The rich are able to run away from nuisances that they cannot have abated. If proper publicity is given to living conditions among those who do not resist nuisances, the presence of such conditions will itself become offensive to the well-to-do, who will take steps to remove the nuisance. Jacob Riis in this way made the slums a nuisance to rich residents in New York City and stimulated tenement reform, building of parks, etc.
Anti-slummotives originated in cities where there is a clear dividing line between the clean and the unclean, the infected and the uninfected, the orderly and the disorderly, high and low vitality. As soon as one district becomes definitely known as a source of nuisance, infection, and disease, better situated districts begin to make laws to protect themselves. A great part of our existing health codes and a very large part of the funds spent on health administration are designed to protect those of high income against disease incident to those of low income, high vitality against low vitality, houses with rooms to spare against houses that are overcrowded. To the small town and the country the slum means generally the near-by city whose papers talk of epidemic scarlet fever, diphtheria, or smallpox. Cities have only recently begun to experience anti-slum aversion to country dairies whose uncleanliness brings infected milk to city babies, or to filthy factories and farms that pollute water reservoirs and cause typhoid. The last serious smallpox epidemic in the East came from the South by way of rural districts that failed to notify the Pennsylvania state board of health of the outbreak until the disease was scattered broadcast. Every individual knows of some family or some district that is immediately pictured when terms like "disease," "epidemic," "slum," arepronounced. The steps worked out by the anti-slum motive to protect "those who have" from disease arising from "those who have not" are given on page 31.
A Country Menace To City HealthA COUNTRY MENACE TO CITY HEALTH
A COUNTRY MENACE TO CITY HEALTH
Pro-slummotives are not exactly born of anti-slum motives, but, thanks to the instinctive kindness of the human heart, follow promptly after the dangers of the slum have been described. You and I work together to protect ourselves against neglect, nuisance, and disease. In a district by which we must pass and with which we must deal, one of us or a neighbor or friend will turn our attention from our danger to the suffering of those against whom we wish to protect ourselves. Charles Dickens so described Oliver Twist and David Copperfield that Great Britain organized societies and secured legislation to improve the almshouse, school, and working and living conditions. When health reports, newspapers, and charitable societiesmake us see that the slum menaces our health and our happiness, we become interested in the slum for its own sake. We then start children's aid societies, consumer's leagues, sanitary and prison associations, child-labor committees, and "efficient government" clubs.
Rightsmotives are the last to be evolved in individuals or communities. The well-to-do protect their instinct, their comfort, their commerce, but run away from the slums and build in the secluded spots or on the well-policed and well-cleaned avenues and boulevards. Uptown is often satisfied with putting health officials to work to protect it against downtown. Pro-slum motives are shared by too few and are expressed too irregularly to help all of those who suffer from crowded tenements, impure milk, unclean streets, inadequate schooling. So long as those who suffer have no other protection than the self-interest or the benevolence of those better situated, disease and hardship inevitably persist. Health administration is incomplete until its blessings are given to men, women, and children as rights that can be enforced through courts, as can the right to free speech, the freedom of the press, and trial by jury. There is all the difference in the world between having one's street clean because it is a danger to some distant neighbor, or because that neighbor takes some philanthropic interest in its residents, and because one has a right to clean streets, regardless of the distant neighbor's welfare or interest. When the right to health is granted health laws are made, and all men within the jurisdiction of the lawmaking power own health machinery that provides for the administration of those laws. A system of public baths takes the place of a bathhouse supported by charity; a law restricting the construction and management of all tenements takes the place of a block of model tenements, financed by some wealthy man; medical examination of all school children takes the place of a private dispensary;a probation law takes the place of the friendly visitor to the county jail.
Most of the rights we call inalienable are political rights no longer questioned by anybody and no longer thought of in connection with our everyday acts, pleasures, and necessities. When our political rights were formulated in maxims, living was relatively simple. There was no factory problem, no transportation problem, no exploitation of women and children in industry. Our ancestors firmly believed that if the strong could be prevented from interfering with the political rights of the weak, all would have an equal chance. The reason that our political maxims mean less to-day than two hundred years ago is that nobody is challenging our right to move from place to place if we can afford it, to trial by jury if charged with crime, to speak or print the truth about men or governments. If, however, anybody should interfere with our freedom in this respect, it would be of tremendous help that everybody we know would resent such interference and would point to maxims handed down by our ancestors and incorporated in our national and state constitutions as formal expressions of unanimous public opinion.
The time is past when any one seriously believes that political freedom or personal liberty will be universal, just because everybody has a right to talk, to move from place to place, to print stories in the newspapers. The relation of man to man to-day requires that we formulate rules of action that prevent one man's taking from another those rights, economic and industrial, that are as essential to twentieth-century happiness as were political rights to eighteenth-century happiness. Political maxims showed how, through common desire and common action, steps could be taken by the individual and by the whole of society for the protection of all. Health rights, likewise, are to be obtained through common action. A modern city mustknow who is accountable when an automobile runs over a pedestrian, when a train load of passengers lose their lives because of an engineer's carelessness, when an employee is incapacitated for work by an accident for which he is not responsible, or when fever epidemics threaten life and liberty without check. How can a child who is prevented by removable physical defects from breathing through his nose be enthusiastic over free speech? Of what use is freedom of the press to those who find reading harder than factory toil? How futile the right to trial by jury if removable physical defects make children unable to do what the law expects! Who would not exchange rights of petition for ability to earn a living? Children permanently incapacitated to share the law's benefits cannot appreciate the privilege of pursuing happiness.
Succeeding chapters will enumerate a number of health rights and will show through what means we can work together to guarantee that we shall not injure the health of our neighbor and that our neighbor shall not injure our health. The truest index to economic status and to standards of living is health environment. The best criterion of opportunity for industrial and political efficiency is the conditions affecting health. The seven catchwords that describe seven motives to health legislation and health administration, seven ways of approaching health needs, and seven reasons for meeting them, should be found helpful in analyzing the problem confronting the individual leader. Generally speaking, we cannot watch political rights grow, but health rights are evolved before our eyes all the time. If we wish, we can see in our own city or township the steps taken, one by one, that have slowly led to granting a large number of health rights to every American.
[1]Prepared by Dr. John S. Fulton, secretary of the state board of health, Maryland, and quoted by Dr. George C. Whipple inTyphoid Fever.
[1]Prepared by Dr. John S. Fulton, secretary of the state board of health, Maryland, and quoted by Dr. George C. Whipple inTyphoid Fever.
[2]Marshall O. Leighton, quoted in Whipple'sTyphoid Fever.
[2]Marshall O. Leighton, quoted in Whipple'sTyphoid Fever.
Laws define rights. Men enforce them. For definitions we go to books. For record of enforcement we go to acts and to conditions.[3]What health rights a community pretends to enforce will, as a rule, be found in its health code. What health rights are actually enforced can be learned only by studying both the people who are to be protected and the conditions in which these people live. A street, a cellar, a milk shop, a sick baby, or an adult consumptive tells more honestly the story of health rights enforced and health rights unenforced than either sanitary code or sanitary squad. Not until we turn our attention from definition and official to things done and dangers remaining can we learn the health progress and health needs of any city or state.
The health code of one city looks very much like the health code of every other city. This is natural because those who write health codes generally copy other codes. Even small cities are given complicated sanitary legislative powers by state legislatures. Therefore those who judge a community's health rights by its health laws will get as erroneous an impression as those who judge hygiene instruction in our public schools from printed statements about the frequency and character of such instruction. Advocates of health codes have thought the battle won when boards of health were given almost unlimited power to abate nuisances and told how to exercise those powers.
A Dairy Inspector's OutfitA DAIRY INSPECTOR'S OUTFIT
A DAIRY INSPECTOR'S OUTFIT
The slip 'twixt law making and law enforcement is everywhere found. In 1864 New York state prohibited the sale of adulterated milk. Law after law has been made since that time, giving health officials power to revoke licenses of milk dealers and to send men to jail who violated milk laws. We now know that no law will ever stop the present frightful waste of infant lives, counted in thousands annually, unless dairies are frequently inspected and forced to be clean; unless milk is kept at a temperature of about fifty degrees on the train, in the creamery, at the receiving station, and in the milk shop; unless dealers scald and thoroughly cleanse cans in which milk is shipped; unless licenses are taken from farmers, creameries, and retailers who violate the law; unless magistrates use their power to fine or imprison those who poison helpless babies by violating milk laws; and unless mothers are taught to scaldand thoroughly cleanse bottles, nipples, cups, and dishes from which milk is fed to the baby. We know that these things are not being done except where men or women make it their business to see that they are done. Experience tells us that inspectors will not consistently do their duty unless those who direct them have regular records of their inspections, study those records, find out work not done properly or promptly, and insist upon thorough inspection.
Whether work is done right, whether inspectors do their full duty, whether babies are protected, can be learned only from statements in black and white that show accurately the conditions of dairies and milk shops, the character of milk found and tested by inspectors, and the number of babies known to have been sick or known to have died from intestinal diseases chiefly due to unsafe milk. Any teacher or parent can learn for himself, or can teach children to learn, what steps are taken to guarantee the right to pure milk by using a table such as Table III. Whether conditions at the dairy make pure milk impossible can be told by any one who can read the score card used by New York City (Table IV).
Table III
MILK INSPECTION WITHIN NEW YORK CITY, 1906
New YorkEach boroughStoresWagonsStoresWagonsFIELDPermits issued during 1906Permits revoked during 1906For discontinuance of sellingFor violation of lawAverage permits in force in 1906INSPECTIONRegular inspectionsInspections at receiving stationsTotalAverage inspections per permit per yearSpecimens examinedSamples takenCONDITIONS FOUNDInspections finding milk above 50°% of such discoveries to total inspectionsInspections finding adulterationWarning givenProsecuted% of adulterations found to inspectionsRooms connected contrary to sanitary codeIce box badly drainedIce box uncleanStore uncleanUtensils uncleanMilk not properly cooledInfectious diseasePersons found selling without permitACTION TAKENDESTRUCTION OF MILKLots of milk destroyed for being over 50°Quarts so destroyedLots of milk destroyed for being sourQuarts so destroyedLots of milk destroyed for being otherwise adulteratedQuarts so destroyedTotal quarts destroyedNOTICES ISSUEDTo drain and clean ice boxTo clean storeCRIMINAL ACTIONS BEGUNFor selling adulterated milkFor selling without permitFor interference with inspectorTotal
Table IV
Perfect Score 100%Score allowed ...%File No............DEPARTMENT OF HEALTH(Thirteen items are here omitted)Dairy InspectionDivision of Inspections1 Inspection No..........Time.........A. P. M. Date......1902 All persons in the households of those engaged in producing or handling milk are.........free from all infectious disease.........3 Date and nature of last case on farm.........4 A sample of the water supply on this farm taken for analysis.........190... and found to be.........
Perfect Score 100%Score allowed ...%
File No............
Dairy InspectionDivision of Inspections
1 Inspection No..........Time.........A. P. M. Date......1902 All persons in the households of those engaged in producing or handling milk are.........free from all infectious disease.........3 Date and nature of last case on farm.........4 A sample of the water supply on this farm taken for analysis.........190... and found to be.........
1 Inspection No..........Time.........A. P. M. Date......190
2 All persons in the households of those engaged in producing or handling milk are.........free from all infectious disease.........
3 Date and nature of last case on farm.........
4 A sample of the water supply on this farm taken for analysis.........190... and found to be.........
STABLEPerfectAllow5COW STABLEis......located on elevated ground with no stagnant water, hog pen, or privy within 100 feet1...6FLOORSare......constructed of concrete or some nonabsorbent material1...7 Floors are......properly graded and water-tight2...8DROPSare......constructed of concrete, stone, or some nonabsorbent material2...9 Drops are......water-tight2...10FEEDING TROUGHS, platforms, or cribs are ... well lighted and clean1...11CEILINGis constructed of......and is......tight and dust proof2...12 Ceiling is......free from hanging straw, dirt, or cobwebs1...13NUMBER OF WINDOWS......total square feet ... which is......sufficient2...14 Window panes are......washed and kept clean1...15VENTILATIONconsists of......which is sufficient 3, fair 1, insufficient 03...16AIR SPACEis......cubic feet per cow which is......sufficient (600 and over—3) (500 to 600—2) (400 to 500—1) (under 400—0)3...17INTERIORof stable painted or whitewashed on......which is satisfactory 2, fair 1, never 02...18WALLS AND LEDGESare......free from dirt, dust, manure, or cobwebs2...19FLOORS AND PREMISESare......free from dirt, rubbish, or decayed animal or vegetable matter1...20COW BEDSare......clean1...21LIVE STOCK, other than cows, are......excluded from rooms in which milch cows are kept2...22 There is......direct opening from barn into silo or grain pit1...23BEDDINGused is......clean, dry, and absorbent1...24SEPARATE BUILDINGis......provided for cows when sick1...25 Separate quarters are......provided for cows when calving1...26MANUREis......removed daily to at least 200 feet from the barn ( ... ft.)2...27 Manure pile is......so located that the cows cannot get at it1...28LIQUID MATTERis......absorbed and removed daily and......allowed to overflow and saturate ground under or around cow barn2...29RUNNING WATERsupply for washing stables is......located within building1...30DAIRY RULESof the Department of Health are......posted1...COW YARD31COW YARDis......properly graded and drained1...32 Cow yard is......clean, dry, and free from manure2...COWS33COWShave......been examined by veterinarian ... Date......190 Report was3...34 Cows have......been tested by tuberculin, and all tuberculous cows removed5...35 Cows are......all in good flesh and condition at time of inspection2...36 Cows are......all free from clinging manure and dirt. (No. dirty ... )4...37LONG HAIRSare......kept short on belly, flanks, udder, and tail1...38UDDER AND TEATSof cows are......thoroughly cleaned before milking2...39ALL FEEDis......of good quality and all grain and coarse fodders are......free from dirt and mold1...40DISTILLERYwaste or any substance in a state of fermentation or putrefaction is......fed1...41WATER SUPPLYfor cows is......unpolluted and plentiful2...MILKERS AND MILKING42ATTENDANTSare......in good physical condition1...43 Special Milking Suits are......used1...44 Clothing of milkers is......clean1...45 Hands of milkers are......washed clean before milking1...46MILKINGis......done with dry hands2...47FORE MILKor first few streams from each teat is......discarded2...48 Milk is strained at......and......in clean atmosphere1...49 Milk strainer is......clean1...50MILKis......cooled to below 50° F. within two hours after milking and kept below 50° F. until delivered to the creamery......°2...51 Milk from cows within 15 days before or 5 days after parturition is......discarded1...UTENSILS52MILK PAILShave......all seams soldered flush1...53 Milk pails are......of the small-mouthed design, top opening not exceeding 8 inches in diameter. Diameter......2...54 Milk pails are......rinsed with cold water immediately after using and washed clean with hot water and washing solution2...55 Drying racks are......provided to expose milk pails to the sun1...MILK HOUSE56MILK HOUSEis......located on elevated ground with no hog pen, manure pile, or privy within 100 feet1...57 Milk house has......direct communication with......building1...58 Milk house has......sufficient light and ventilation1...59 Floor is......properly graded and water-tight1...60 Milk house is......free from dirt, rubbish, and all material not used in the handling and storage of milk1...61 Milk house has......running or still supply of pure clean water1...62 Ice is......used for cooling milk and is cut from ...1...WATER63WATER SUPPLYfor utensils is from a......located......feet deep and apparently is......pure, wholesome, and uncontaminated5...64 Is......protected against flood or surface drainage2...65 There is......privy or cesspool within 250 feet ( ... feet) of source of water supply2...66 There is......stable, barnyard, or pile of manure or other source of contamination within 200 feet( ... feet)of source of water supply1...100