Headpiece for “A War Worth Waging”A WAR WORTH WAGING
Headpiece for “A War Worth Waging”
THE SUCCESSFUL FIGHT TO IMPROVE THE HEALTH OF NEW YORK CITY
(AVERAGE LIFE IN 1866, THIRTY YEARS; IN 1912, SIXTY-SIX YEARS. DEATH-RATE IN 1866, 34 PER THOUSAND; IN 1912, 14.11 PER THOUSAND)
BY RICHARD BARRY
PROFESSOR FISHER, of the Committee of One Hundred appointed to consider the problem of the national health, was laboring with Senator Works of California, the official representative in Washington of the Christian Scientists.
“Your approval, Senator,” he said, “of such measures as clean streets and playgrounds is really an indorsement of preventive medicine.”
“But,” exclaimed Senator Works, “I did not know you meant those things as being preventive medicine. I thought preventive medicine meant serums.”
“No,” said Professor Fisher, laughing; “it means mosquito-bars and bath-tubs.”
It is not only serums and bacteriology, but mosquito-bars and bath-tubs, clean streets and plenty of sewers, together with an efficient organization to perfect the operation of such things, that have revolutionized the conditions of health in New York City.
Consider what has been done for poor children alone. Recently I stood in one of the fifty-five diet-kitchens maintained by the city. A poor woman of the neighborhood entered, carrying in her arms a sickly baby. Evidently familiar with the proper course of procedure, she said to the nurse in charge, “I have given him castor-oil and barley gruel; now what shall I do?” This incident is remarkable because the woman never before had come within the reach of the Health Department. In the danger that menaced the child, she had learned to take the first essential steps not through experience or instruction, but merely through neighborhood gossip.
TENyears ago such a thing would have been impossible in New York or in any other large city. The tremendous agencies that now exist for the medical enlightenment of the masses were then unheard of. A generation ago New York was in a condition of almost primeval darkness concerning questions of public health. Canton or Constantinople is to-day little worse off than was America’s chief city then.
In 1866 the public health conditions of New York were in so low a state that the average length of life of the inhabitants was thirty years. In 1912 these conditions had been improved so that the average length of life was sixty-six years. Thus the value of human life, reckoned in terms of time alone, had more than doubled in less than half a century.
Let us go back to the year followingthe Civil War. The only paving in New York then was of cobblestones, and many streets were unpaved. All were in filthy condition, being irregularly cleaned by contractors, who shirked their work. There was no general system for the removal of ashes and garbage, and these were thrown loosely upon the streets. In three quarters of the city, cellars were in foul condition, often flooded with water and undrained. At that time, incredible as it may seem to the modern New Yorker, few houses were connected with sewers. Offensive trades, such as the boiling of bones, offal, and fat, were carried on without hindrance. There were numerous cesspools and cisterns overflowing with filth. Much of the city’s milk was obtained from cows kept in dark, crowded, ill-ventilated stables and fed upon swill from distilleries. The animals were diseased, and the milk was unclean, unwholesome, and frequently was watered.
In alleyways and back yards great quantities of manure were allowed to accumulate. Farmers sometimes bought it and carted it off for fertilizing; but if no farmer happened to come along, the stuff stayed there indefinitely. Outhouses were neglected, and never were properly cared for by the scavengers, who worked for grafting contractors. The practice of keeping swine in the built-up portions of the city was common. The slaughterhouses were in horrible condition, and the offal from these could not be properly cared for because of defective sewers.
Tenement-house conditions were as bad as they have ever been anywhere. No space was left unoccupied. Sheds, basements, and even cellars were rented to families and lodgers. The vast numbers of immigrants pouring in, and the constricted space on Manhattan Island, made rents so high that even a corner in a cellar brought an exorbitant price. Single rooms were divided by partitions, and whole families occupied each section.
In 1866 it was estimated that 20,000 People were then living in cellars in New York. Ten years before that period many of the city houses had been shaky from quick building; after the war, figuratively speaking, they had fallen into the cellars. At that time New York could hardly claim distinction as a great city. Travelers referred to it as an overgrown village, into which had been shoveled slovenly hordes of European immigrants. The annual death-rate was thirty-four per thousand, while that of London was about twenty-three per thousand. And it must be remembered that New York’s new population was composed of vigorous men and women, the cream of other localities, with what should have been healthy offspring, who had quickly centered here, ambitious and active; whereas London was an ancient city, bearing the ills of its own age. It must be remembered also that at that time the medical profession knew little of bacteriology; antitoxins were unknown; people lived like ostriches, with their heads in the sand concerning questions of sex hygiene and child hygiene; and the science of sociology had yet to be discovered.
Cities had always existed, it is true, but they had to be constantly replenished by fresh blood from the country, and most of them had space to spread out into the country, and thus absorb naturally some of the health that comes from fresh air. But here was a city that had little chance to spread. It was confined to a narrow, rocky island, and was growing more rapidly than any other city in the history of the world. “Bounded on one side by a bluff and on the other side by a sound,” it was burrowing into the earth and climbing constantly into the air to make room for its fast-growing population. It was the center of the fiercest contest for money and power, yet it failed to hold long those who came there. The men that made money went to Europe to spend it, and those that fell in the fight went to the West to recuperate. Immigrants that arrived there with money went on to the West or the South; those without money stayed.
The result was that New York did not primarily become a city of residence, but the resort of those who either through the necessity of poverty or the necessity of ambition sojourned there. Of all American cities it became the most artificial; there life came to be lived at its highest tension; there the struggle for existence became fiercest.
It is apparent that in such a city Nature cannot be left to her own devices. When man deserts Nature, she promptly retaliates by deserting man. And, in substitution of so-called “natural” living, therehas been developed the present-day mode, built up of scientific analysis, skilful treatment, and thorough organization.
THEhealth campaigns of the last forty-five years divide themselves naturally into two groups, those that came before 1900 and those that came after that year. The early campaigns were the more obvious; the later campaigns are the more subtle in their tactics, but none the less effective. Before 1900 the death-rate had been reduced by more than one third. In 1866 it was 34 per thousand; in 1900 it was 20.57 per thousand. During this period of thirty-four years wells had been gradually eliminated as sources of drinking-water, until not one was left in the principal parts of the city. Young children who never had been in the country were brought to the well in Central Park and they gazed into it as a curiosity, just as they looked at the bears and the greenhouses. At the same time the general water-supply was vastly improved. To live in cellars was made illegal, and there was a general improvement in the condition of dwellings. Street-cleaning became well organized; sewers were laid in almost all the streets, and refuse was cared for scientifically. The public supervision of contagious diseases became effective; good use was made of new medical discoveries, such as diphtheria antitoxin, and the public hospitals were improved.
Yet the advances in sanitary safeguarding since 1900 are more wonderful than those that came before. In the last twelve years the death-rate has been reduced by a quarter from its comparatively high rate at the beginning of the century. In 1911 it was 15.13 per thousand. For 1912 it was 14.11 per thousand. However, this reduction of more than six per thousand has been won with over twice the effort that was necessary to make the first fourteen per thousand. The city budget for 1912 carried an appropriation for the Department of Health of more than $3,000,000. As much more was spent the same year by the seventy-odd organizations, private or semi-public, the purpose of which is the betterment of health conditions. Besides, there has been the devoted labor of more than seven thousand physicians.
In all this vast field of effort, as diversified as the entire scope of modern science, as complex as civilization itself, two main lines stand out conspicuously. New York was a pioneer among cities in both. These concerned the treatment of tuberculosis and children’s diseases. The organized fight against tuberculosis in New York, under the latest approved scientific methods, dates only from 1904. Before that time there was no successful effort on the part of the authorities to diagnose the disease properly, nor any attempt to deal with it intelligently when it was discovered accidentally. Yet New York is as great a sufferer from the white plague as any other locality. Its congested living, its large Negro population, and its indigent foreigners, ignorant of our language and customs, make it a fertile breeding-ground for the tubercle bacillus.
Within eight years, twenty-nine tuberculosis clinics have been established, and several day camps have been built where sufferers can recuperate without expense and without leaving the city. In all these thorough blood and sputum tests are made with modern scientific apparatus. At the same time, it has been widely made known that to recover from the dread disease it is not necessary to leave the city, which, situated between two bodies of water, is swept constantly by fresh air, the chief necessity in the treatment of tuberculosis.
BUTthe really remarkable work in the reduction of the death-rate within the last few years has been done among the children. It is here that the war worth waging has been carried on most effectively. If, as Ellen Key says, this is the century of the child, New York proved it in its first decade by concentrating the health battalions on infant mortality.
“A baby that comes into the world has less chance to live one week than an old man of ninety, and less chance to live a year than a man of eighty,” Bergeron, the French authority on children’s diseases, said ten years ago. Within five years those chances have been increased by a third in New York. In 1911, throughout the United States one death in every five was that of a child under one year of age, while in New York only one death in every eight was that of a child under one year of age. Yet five years before that time New York’s average of infant mortality had been equal to that of the rest of the country. And in 1912 the infant mortality was further decreased by six per cent., a greater decrease than that of any other city.
Drawn by Jay Hambidge. Half-tone plate engraved by H. C. MerrillWEIGHING THE BABIES AT AN INFANTS’ MILK STATION IN NEW YORK
Drawn by Jay Hambidge. Half-tone plate engraved by H. C. Merrill
WEIGHING THE BABIES AT AN INFANTS’ MILK STATION IN NEW YORK
What has accomplished this result? Primarily, two causes: first, the attention of the Board of Health, whose department of child hygiene now receives a larger annual appropriation than any other (in 1913 it will have more than $600,000, a fifth of the entire budget); and, second, the work of the New York Milk Committee, a semi-public organization composed of many of the chief physicians and philanthropists of the city.
Eight years ago there was not one infants’ milk station in New York. The babies of the poor were obliged to live on what milk could be found easily for them. Few could afford and still fewer could find what is known as “Grade A” milk, which sells in the commercial market for from fifteen to twenty-five cents a quart, and which is thoroughly inspected and certified. At the close of 1912 there were seventy-nine such stations in the city. At every one Grade A milk was sold at the nominal price of eight cents a quart, so as to be in easy competition with ordinary commercial milk. Every day thousands of mothers with their babies throng these stations. However, their chief purpose is not the mere selling of pure, rich milk. They serve principally as dispensaries. The milk is used by the city as a lure by means of which ignorant mothers are brought within the reach of the physicians of the Health Department. With the milk, thorough instruction and advice as to the care of infants is given gratis. The old idea that mothers know entirely how best to care for their own children has been proved erroneous. Not all mothers in a large city know how to care for their children. Many of them are virtually as helpless as the children themselves. They have to be taken in hand, trained, and taught in the care of their offspring as completely as the children themselves are taken in hand a few years later in the public schools.
In addition to the seventy-nine dispensaries of milk and medical knowledge, the city maintains a large corps of trained nurses who make visits, especially during the summer, to the homes to complete the instruction. In the poorer districts, every child under a year old is visited by a city nurse at least once in ten days. The average cost is fifty cents a month for each child. At the same time the inspection of the general milk-supply has become thorough. The city’s inspectors now cover all farms within two hundred miles from the city hall, and the sources of supply are thus kept in proper sanitary condition.
The city also gives ice in summer to those families (with children) that are unable to buy it. In the summer of 1912, 900,000 pounds were thus distributed. This is in addition to the accepted efforts to secure better playgrounds, better ventilated schools, etc.
A decade ago the summer death-rate among children in New York was from two to three times as high as the winter death-rate. For the last four years it has been steadily decreasing, and in 1912 it was almost as low as the winter death-rate. Deaths from diarrheal diseases among children have been reduced to a minimum through the concentrated efforts of a few years. The next work to be taken up will be the winter deaths from respiratory diseases. This is a more difficult problem.
Yet the greatest problem in infant mortality has still to be solved. This is the care of the “institution” baby. As in England and in France, the largest number of deaths among New York children occur among the illegitimate and those lacking a mother’s care during the early months of life. In 1911 more than forty per cent. of the deaths of infants under one year in Manhattan occurred in institutions.
The institutions that receive foundlings are too few and too poorly equipped. One day Mr. J. Pierpont Morgan saw in the street, within a block of his home, a poor woman hugging despairingly to her breast a new-born infant. In consequence, he caused to be built the million-dollar lying-in hospital on Stuyvesant Square, which has already been the means of saving many an innocent life. But that superb hospital, large as it is, has not the facilities for taking care of more than a small number of the infants that require such an institution.
The material agencies, efficient andmarvelous as they have become, have not been the chief aid in the reduction of the death-rate, especially among children. Public education has really had more to do with it. Even those in direct charge of the work in infant mortality do not assert that the entire credit for the satisfactory progress should be given to the milk stations, the dispensaries, and the hospitals. Pamphlets, lectures, newspaper articles, and school-room instruction are at the base of the advance. Publicity has proved to be a greater force than milk inspection. Certain popular newspapers in New York have the power to achieve definite radical reforms in modes of living whenever they choose to prosecute a vigorous campaign. Just as the newspapers can expose corruption in any of the city’s departments, so almost as readily they can uproot or at least substantially lessen certain sanitary evils. A case in point is their campaign against the fly last summer. By means of wide-spread and vigorous news articles and editorials they succeeded in so rousing the mass of the people that the fly pest was visibly reduced. Health Department officials testify readily to this.
The work of the social settlements, of the mothers’ clubs, of the neighborhood nursing associations, of the diet-kitchens, all contribute to the general education that is bringing about a condition of excellent public sanitation. This work is necessarily of slow growth. Its effect is not nearly so evident as that of vaccination, of smallpox segregation, or of typhoid diagnosis. It is not so simple as establishing proper sewers or purifying the water-supply; but it is no less important.
INall this tremendous volume of public sanitary education, no one feature stands out more clearly than the work being done in sex hygiene. Prudery is passing; there can be no doubt of that. Within the last five years every public school in New York has introduced a course of teaching in its physiology or biology department the aim of which is to acquaint the growing boy and girl with the essential facts of sex life, to open their eyes to sexual evils, and to prepare them to treat with sexual diseases intelligently. Ignorant mothers, both foreign-born and native, or those whose false modesty is worse than their ignorance, are day by day being taught by their daughters of twelve and fourteen, who have learned their lessons in school or in neighborhood classes, certain essential facts of sex life, ignorance of which has brought about pitiful conditions of disease and death.
The effect of this is not yet fully apparent in a decreased death-rate, but there can be little doubt that within a very few years it will have its result. For instance, one third of the infant mortality is due to prenatal conditions, congenital diseases which afflict the child at birth, and which mean either speedy death or a lingering, crippled life. The larger part of these untoward prenatal conditions are due to sexual diseases. To eliminate them will require two sustained efforts: the further abolishing of prudery, with consequent rigorous sex hygiene, and the enactment and enforcement of laws that will require proper medical examination before marriage.
A physician told me recently that in his opinion within a decade laws will be enacted providing that every man and woman desiring to marry can do so only with a doctor’s certificate that shall carry with it a clean bill of health. Once that is done, it is confidently believed that the death-rate among infants will fall off perhaps by a quarter, and surely by a fifth or a sixth. The educational work in this field is being done for the future. With present adults there is little hope; but the fathers and mothers of the next generation will be much better equipped.
INone more campaign the immediate future seems likely to yield great results perhaps almost as important as those resulting from the discovery of antitoxin. This will be from the use of the new anti-typhoid serum, which the Department of Health in December, 1912, decided to use as extensively as possible in New York. This decision followed close on the War Department’s public declaration that the anti-typhoid serum had proved a success, virtually eliminating the disease from the army. In 1909 there were more cases of typhoid in the United States than of the plague in India, despite the fact that India’s population is two and a half timesthat of the United States. In 1907 there were more cases of typhoid in New York than of pellagra in Italy, though Italy’s population is six times that of New York. In this work, as in children’s diseases and in tuberculosis, New York is a pioneer, and yet New York is better off regarding typhoid than many other American cities, for it has a lower typhoid death-rate than Boston, Chicago, Washington, or Philadelphia; yet its typhoid death-rate is higher than that of London, Paris, Berlin, or Hamburg.
Last spring when Wilbur Wright, the aviator, died of typhoid fever at the age of forty-five, several newspapers were honest enough to speak of it as a murder—a murder by the American people, through neglect and ignorance, of a genius who, had he been allowed, might have lived to be of still more distinguished service to the world.
In the last two years the New York Department of Health has been able to trace definitely several typhoid-fever outbreaks. In nearly every instance it was found that the disease could be traced to a “carrier.” A carrier is a person who has recovered from an attack of typhoid, but who remains infected. One outbreak of four hundred cases was traced to the infection of a milk-supply by a typhoid carrier who had had the disease forty-seven years before. In another outbreak of fifty cases the contamination was traced to a man who had the disease seven years before.
Within the last few months the case of “Typhoid Mary” has received much attention. This woman has recently brought suit against the Department of Health for damaging her career as a cook. For more than six months she was kept in a sort of exile by the department. Before that time she had been a cook in many households, and wherever she went typhoid fever followed her. Although she had suffered with the disease many years before she was apprehended, the germs were said to be still very lively in her system. The authorities asserted that her blood tests revealed that she was likely to communicate typhoid to any one at any time; and therefore Mary did no more cooking.
There is no telling how many carriers are loose in New York at present, and the only known way of averting the danger is by the use of the serum which the army has found efficacious. It is estimated that about three per cent. of those recovering from typhoid become bacillus-carriers. As yet typhoid vaccination is not compulsory among the public at large, as in the army; but a strong movement is felt in the city to make it so. When typhoid-fever becomes as thoroughly controlled as smallpox, or even as diphtheria, the death-rate will drop another point or two. It will be the last of the filth diseases to go. It is asserted by competent authorities that eighty-five per cent. of the cases are preventable.
DR. LEDERLE, Health Commissioner of New York City, says that while typhoid vaccination is likely to prove of untold benefit, other specific improvements should be made. There should be a more perfect control of the milk-supply. At present there is no central testing-station. He recommends also an improved method of sewage disposal, either by treatment or by carrying it farther out to sea, thus preventing pollution of the harbor. There should be a drainage of surrounding land to do away with mosquitos; improved methods of street-cleaning that would result in the prevention of flying dust-clouds; and the open garbage receptacles and dumps should be abolished in favor of cremation of all refuse. The campaign against the fly must be carried on more vigorously every year, and immediate steps are to be taken for the protection of all foods from fly contamination. This will be an extension of the control of food, together with the proper filtration of the public water-supply. Dr. Lederle says further that increased hospital facilities for contagious diseases are needed. There will be further popular education in sanitary matters, special stress being laid on the need of fresh air in homes, schools, factories, offices, theaters, and churches; and a comprehensive publication will be made, chiefly for the aid of the poorer classes, of the comparative nutritive and cost values of foods; and further changes in the customs of the time, due to these plans and to other activities, will result in a simpler manner of living. This should render overeating less frequent and reduce the consumption of alcohol and medicines.
Finally, in addition to these efforts, which are under the direction of public officers, the health commissioner declares that if the death-rate is to be further reduced, there must be in the immediate future two changes: first, a definite advance in bacteriological knowledge; and, second, a change in the attitude toward the health of our adult population.
“Save the babies!” was the cry of the last decade. “Save the middle-aged!” will be the cry of this. The real race suicide is not in the insufficiency of births, but in the inadequate knowledge of the diseases of maturity, and in the inadequate care and prevention of these diseases. Deaths from arterio-sclerosis, apoplexy, kidney affections, stomach disorders, and cancer are continuously on the increase, and have been for ten years past. Of the 75,000 persons that died in New York in 1911, 17,000 died of “middle-age complaints.”
The intense life of New Yorkers, their intemperance in eating, drinking, and working, contributes chiefly to the increase in the middle-age death-rate. However, Bright’s disease, diabetes, and cancer are not more a mystery than diphtheria was before antitoxin was discovered. Bacteriology has its fields of further effort well laid out in those directions.
It is the contention of those that give their lives to the study of the subject that “public health is a purchasable commodity.” The struggle, then, is between the death-rate and the dollar rate. Contribute more money to the cause of public health, and the death-rate will go down. Forty thousand babies were saved in 1910 at an average cost of eighteen dollars. It would have cost more to bury them, as the cheapest sort of funeral costs twenty-five dollars.
The appropriation for the care of the public health in New York is not niggardly; it is larger than in most cities. Still, it is not enough. Where the health officers ask for a dollar and a half, they get a dollar. The excuse is that the rest of the desired money is needed to improve parks and streets, for the police and fire departments, for the city government, the water-fronts, etc. Besides, the people of this city are absolutely obliged to spend about $100,000,000 a year on automobiles, candy, theaters, alcoholic drinks, tobacco, diamonds, and such other urgent needs of life. What is left over, after those necessities are provided for, goes toward the preservation of health!
The average expectation of life for man varies in different countries in direct proportion to the application of efficient principles of hygiene and sanitation. In India, for instance, where sanitation is low and the majority of the population live, like Kim, on “the ravellings of circumstance,” the average duration of life is less than twenty-five years. In Sweden and Denmark, where life is methodical and ideals are high, and the Government takes up the ash-heaps regularly, a normal man may expect to live more than seventy years. In Massachusetts, which is the only one of our States to furnish us with reliable statistics, the average duration of life is forty-five years. Wherever sanitary science is active, the length of life is steadily increasing. In India it is stationary; in Europe it has doubled in the last 350 years; in New York, as we have seen, it has doubled within the last half-century. Despite the many obstacles, it seems likely that when the next general census is taken the death-rate of the metropolis will be down to thirteen per thousand. With such a rate, every person in the city may expect to live to be seventy years old. And most of them will say, “Isn’t that old enough?”
Tailpiece for “A War Worth Waging”