Chapter 42

PRESENT ORGANIZATION OF SCHOOL HYGIENE IN NEW YORK CITY

Many of the elements of the machinery outlined in the preceding chapter already exist in New York City. All of them brought together, either by amalgamation or by proper coördination, would present a very strong front. Unfortunately, however, there is not only unsatisfactory team work, but the efficiency of individual parts is seriously questioned by the heads of the health and school departments.

The inspection for contagious diseases, the examination for physical defects, the follow-up work by nurses and physicians, are in charge of the department of health. Physical training and athletics for elementary and high schools, winter recreation centers, and vacation playgrounds are under directors and assistants employed by the board of education. Heretofore inadequate powers and inadequate assistance for training or for research have been given to the physical director.

The city superintendent of schools, in his report for the year 1907, presented to the board of education in January, 1908, declares that the "present arrangements have been inadequate.... In only 248 schools--less than half the total number--were any examinations for possible diseases made. In these 248 schools not more than one third of the pupils were examined. It is only a few months since any examinations for physical defects were made outside of the boroughs of Manhattan and The Bronx, and then only on account of the New York Committee on the Physical Welfare of School Children."

As is so often the case, it is difficult to decide the merits of a method that has not been efficiently executed. The department of health has not hitherto done its best in its school relations. The commissioner of health, in a public interview, expresses resentment at the strictures by the school authorities. Yet in 1907 he permitted to accumulate an unexpended balance of $33,000 specifically voted for school inspectors, and repeatedly tried to have this amount transferred to other purposes. The interest of the Bureau of Municipal Research in municipal budgets that tell for what purposes money is voted and then prevent transfers without full publicity, preserved this particular fund. Moreover, the discussion that prevented its diversion from physical examinations strengthened the health department's interest in this important responsibility. Neither physicians nor nurses have been adequately supervised. Instead of seeing that defects were removed, the department of health sent out postal cards like the following:

+-----------------------------------------------------------------------+ | "This Notice Does NOT Exclude This Child From School" | | | | DEPARTMENT OF HEALTH | | THE CITY OF NEW YORK | | | | _Oct. 2, 190_6_ | | | | The parent or guardian of ___________________________________________ | | of____________________________________attending P.S.__51___________ | | is hereby informed that a physical examination of this child seems to | | show an abnormal condition of the ___________________________________ | | ___Eyes, Nose, Throat and Teeth______________________________________ | | _____________________________________________________________________ | | Remarks__Is Anaemic__________________________________________________ | | _____________________________________________________________________ | | | | Take this child to your family physician for treatment and advice. | | Take this card with you to the family physician. | | | | THOMAS DARLINGTON, M.D., | | Commissioner of Health. | | | | HERMANN M. BIGGS, M.D., | | General Medical Officer | +-----------------------------------------------------------------------+

From 118,000 such notices sent out only 9600 replies were received, of which only one in twenty stated that attention had actually been given the needy child. The department had been satisfied with evidence that family physicians had advised parents properly, as in the case of the child above reported:

+----------------------------------------------------------------------+ | TAKE THIS CARD TO YOUR PHYSICIAN | | | | The Physician in charge is requested to fill out and | | forward this postal after he has examined this child. | | | | I have this day examined ___________________________________________ | | of P.S. __51______________ and find the following condition: | | | | __As reported, Also enlarged (unclear) glands_______________________ | | and advised as follows:__operation for adenoids and tonsils_________ | | _____Dental treatment at Cornell. Fresh air ________________________ | | _____outing at Sea Breeze Eyes wait.________________________________ | | | | Respectfully yours, | | _______P.L. OB___________ | | Date __Oct. 9, 1906______ _________________________ | | | +----------------------------------------------------------------------+

For a candid, complete criticism of the medical examination work up to June, 1908, consult the report of the Bureau of Municipal Research, presented to the Washington Congress of Public Education Associations in October, 1908, by Commissioner of Health, Dr. Darlington. The bureau's study is entitled _A Bureau of Child Hygiene_, and, in addition to the story of medical examination in New York City schools, gives the blank forms adopted for use in September, 1908. Important as are the facts given in this study, its greatest value, its authors declare, is in its account of "the method of intelligent self-criticism and experiment which alone enables a public department to keep its service abreast of public needs."

The Bureau of Municipal Research made its study for the purpose of learning whether the disappointing results emphasized by the school authorities were due to "dual responsibility in the school--that of the board of education and that of the department of health"--and to "lack of power or inclination to compel parents to remedy defects," or to _deficient administration_ of power and inclination by health officials. Coöperating with school physicians and nurses in three schools, 1442 children were examined, of whom 1345, or 93.2 per cent, had 3458 defects that needed treatment. The postal-card notice was followed by an interview with the parent either at school or at home. Only 4.2 per cent of the total number of parents refused to act, 81 per cent secured or permitted treatment for one or more defects, while 15 per cent promised to take the proper steps at the earliest possible date. Three fourths of the parents acted after one personal interview. "The net average result of a day's work by a nurse was the actual treatment of over five children, three of them completely, and two of them for one or more defects,"--sixty cents per child!

Having established the willingness--even eagerness--of parents to do all in their power to remove defects that handicapped their children, it was obviously the duty of the health department so to organize its work that it could insure the education of parents. The new Bureau of Child Hygiene gives foremost place to instruction of parents in care of babies, in needs of school children, and in the importance of physical examination when enlisting in the industrial army. Whether this work is well done is learned by result tests applied at headquarters, where work done and results are reported daily and summarized weekly. No longer will it be possible, without detection, for one physician to find only eye trouble and to neglect all other defects; for two inspectors examining different children in the same school to report results differing by 100 per cent; for physicians in different schools to find one 18 per cent, another 100 per cent with defects; for two inspectors examining identical children to agree on 51 out of 101 cases of vision, on 49 out of 96 cases of adenoids, or 3 out of 10 cases of skin disease.

So conclusive were the results of follow-up work efficiently supervised by the department of health, that school officials are, for the present, inclined to waive the demand for the transfer of physicians and nurses to the board of education, and to substitute education for compulsion with parents who obstinately refuse to take proper remedial measures for their children when reported defective.

This present plan requires the entire working time of inspectors and nurses for school work. Thus New York has for the present definitely abandoned the plan of having the district inspection for contagious diseases done by school physicians. The purpose of the change is not to reduce danger of infection, which was negligible, but to increase the probability of scientific attention to school children.

Before a final settlement is made for New York City there should be tests showing what the school authorities would do if physicians and nurses were subordinate to them. It is conceivable that one physician working from nine to five would accomplish more than six physicians working the alleged three hours a day. So imperative are the demands of school hygiene that it seems probable that in New York and in other large cities school physicians, whether paid by the board of health or the board of education, must be expected to be at the service of school children, subject to the call of school officers, during as many hours of the day as teachers themselves must give. It is even conceivable that effective use of the knowledge gained by physical examinations of school children, and by those responsible for school hygiene, will require evening office hours or evening visits to homes, and regular Saturday office hours and Saturday visits by school physicians and nurses. Finally, it must be expected that the programme for school hygiene will need the special attention of physicians and nurses during the summer months, and other vacation periods when children and parents alike have time to receive and to carry out their instructions.

One danger in New York City is that the board of education, like the board of health, when compelled to choose between so-called standard, necessary, traditional duty and school hygiene, will sacrifice the latter. The school authorities, without any more funds and without physicians and nurses, could already have made, had they desired, eye tests and breathing tests sufficiently accurate to detect the majority of children needing attention. The outcome of the discussion as to the jurisdiction of the two boards will undoubtedly be to interest both in their joint responsibility for children's welfare, and to increase the attention given by both to the physical condition of the child when he presents himself for registration as a wage earner.