Chapter 43
OFFICIAL MACHINERY FOR ENFORCING HEALTH RIGHTS
The argument for _getting things done_ presumes adequate active machinery, official and private, for _doing things_ that schools are being urged to do. The chapter on Departments of School Hygiene suggests local, county, state, and national machinery necessary (1) to protect the child from injuries due to school environment, school methods, and school curriculum; (2) to getting those things done for the child at home and on the street, need for which is disclosed by physical and vitality tests at school. It is unreasonable to confine the school to the activities above outlined unless health machinery, adequate to the demands placed upon it by school and other community needs, is devised and kept in order.
Generally speaking, adequate health machinery is already provided for by city charters and by the state laws under which villages, townships, and counties are organized. Quite as generally, however, machinery and methods of adequate administration are undeveloped. How much machinery has already been set to work by New York City is shown by the accompanying chart. A useful exercise for individuals or school classes wishing to study health administration would be to chart in this way the machinery actually at work in their locality, county, and state. Even for New York it should be remembered that this chart does not include national quarantine, the state protection of the port, the state dairy and health commissions, or the state and national food inspection. To get an idea of the vast amount of attention given to health in New York City there should be added to this chart the work of many departments other than the department of health. The building bureau, tenement-house department, board of water supply, sewage commission, street cleaning, public baths and comfort stations, the department of water, gas, and electricity, and finally the department of hygiene and physical training in the public schools.
Five elements of adequate machinery are generally lost sight of:
1. The voter.
2. The nonvoter, subject to health laws and often apt to violate them.
3. The mayor, governor, or president who appoints health officers.
4. The council, board of aldermen, legislature, or congress that enacts health laws.
5. The police courts and the judiciary--police, circuit and supreme--that decide whether society has suffered from violation of law and what penalties should be inflicted for such violation.
Legislative bodies have hitherto slighted their responsibilities toward public health. The chairman of a committee on public health of a state legislature was heard to remark, "I asked for that committee because there isn't a blooming thing to do." If voters, nonvoters, and health officials will follow the suggestion of this book to secure school and health reports that will disclose community and health needs, it will be increasingly difficult for legislators to refuse funds necessary to efficient health administration.
To the courts tradition has required such deference that one hesitates to find out in how far they have been responsible in the past for the nonenforcement of health laws. Yet nothing is more obstructive of sanitary progress than the failure of magistrates to enforce adequate penalties for truancy, adulteration of milk, maintaining a public nuisance, defiling the air with black smoke, offering putrid meats for sale, running an unclean lodging house, defying tenement-house or factory regulations, working children under age and overtime, spitting in public places, or failing to register transmissible diseases.[16]
The appointing officer cannot, of course, be held responsible unless voters and nonvoters know in how far his appointees are inefficient, and in how far he himself has failed to do his utmost to secure funds necessary to efficiency. Too frequently appointments to health positions have been made on political grounds, and catastrophes have been met by blundering incapacity. The political appointee has been made the scapegoat, and the appointing officer, whether mayor, governor, or president, has regained public confidence by replacing an old with a new incompetent.
In order to have health machinery work properly, the appointing officer should not be allowed to shift responsibility for failure to his subordinates. For example, it was recently found in New York City that while the tenement-house commissioner was being condemned for failing to enforce the law, he had turned over to the corporation counsel, also appointed by the mayor, for prosecution ten thousand "violations" to which no attention whatever had been paid!
The voter, nonvoter, appointing officer, legislative officer, and judicial officer determine the character and purpose of machinery and are analogous to the surveyors, stock-holders, directors, and constructors who provide railroads with tracks and with running stock. The actual running force of health department or railroad is what is meant by its official machinery. What this machinery should be depends, of course, upon the amount of business to be done, and differs with the size of the district and the character of population to be served.
Local health machinery should guarantee protection against the evils mentioned in preceding chapters. In general, one man is better than three to execute, although three may be better than one to legislate. Where small communities do not wish to have the entire state sanitary code rigidly administered, they can adopt New York's method of a legislative board of three members, headed by an executive, whose business it is to act, not talk; to watch subordinates, and to enforce rigidly and continuously ordinances passed by the board. The National Bureau of Census places under the general heading Health and Sanitation the following activities: health administration, street cleaning and refuse disposal, sewers and sewage disposal. Sanitarians generally emphasize also the health significance of efficient water service.
A community's health programme should be clearly outlined in the annual budget. Where health work is given funds without specification of the kinds of work to be done, serious evils may be overlooked and lesser evils permitted to monopolize the energies of health officers. Again, after money has been voted to prevent an evil, records should be made of work done when done, and of money spent when spent, so that any diversion will be promptly made known. The best present guides to budget making, to educational health reports, and to records that show efficiency or inefficiency of health administrators are the budget and report of the department of health for New York City, and the story of their evolution told in _Making a Municipal Budget_, by the Bureau of Municipal Research.
To find out whether local machinery is adequate, the reader must enumerate the things that need to be done in his community, remembering that in all parts of the United States to-day there are sanitary laws offering protection against dangers to health, excepting some dangers not understood until recently, such as child labor, dangerous trades, lack of safety devices. Adequate local protection, however, will not become permanent until adequate state machinery is secured.
State health machinery should be of two kinds,--fact-gathering and executive supervision through inspection. The greatest service of state boards of health is to educate localities as to their own needs, using the experience of all communities to teach each community in how far its health administration menaces itself and its neighbors. In addition to registration of contagious diseases, facts as to deaths and births should be registered. State health boards should "score" communities as dairies and milk shops are now being scored by the National Bureau of Animal Industries and several boards of health. When communities persist in maintaining a public nuisance and in failing to enforce health laws, state health machinery should be made to accomplish by force what it has failed to accomplish by education.
States alone can cope adequately with dangers to milk and water sources and to food. The economic motive of farmers has developed strong veterinary boards for the protection of cattle. Similar executive precaution must soon be taken by cities for the protection of babies and adults of the human species. It is far more economical to insure clean dairies, clean water sources, and wholesome manufactured foods by state inspectors than by local inspectors. At present the task of obtaining clean milk and clean water falls upon the few cities enlightened enough and rich enough to finance the inspection of community foods. Once tested, it would be very easy to prove that properly supported state health authorities will save many times the cost of their health work in addition to thousands of lives.
County or district machinery is little known in America. For that reason rural sanitary administration is neglected and rural hospitals are lacking. In the British Isles rural districts are given almost as careful inspection as are cities. Houses may not be built below a certain standard of lighting, ventilation, and conveniences. Outbuildings must be a safe distance from wells. Dairies must be kept clean. Patients suffering from transmissible diseases may be removed by force to hospitals. What is more to the point, rural hospitals have proved that patients cared for by them are far more apt to recover than patients cared for much more expensively and less satisfactorily at home, while less likely to pollute water and milk sources or otherwise to endanger health.
With national machinery the chapter on Vital Statistics has already dealt. We shall undoubtedly soon have a national board of health. Like the state boards, its first function should be educative. In addition, however, there are certain administrative functions where inefficiency may result in serious losses to nation, state, and locality. National quarantine, national inspection of meats, foods, and drugs are administrative functions of vital consequence to every citizen. Authorities are acquainted at the present time with the fact that the sanitary administration of the army and navy is unnecessarily and without excuse wasteful of human energy and human life. In the Spanish American War 14 soldiers died of disease for 1 killed in battle; in the Civil War 2 died of disease to 1 killed in battle; during the wars of the last 200 years 4 have died of disease for 1 killed in battle. Yet Japan in her war with Russia, by using means known to the United States Army in 1860, gave health precedence over everything else and lost but 1 man to disease for 4 killed in battle. Diseases are still permitted to make havoc with American commerce because the national government does not apply to its own limits the standards which it has successfully applied to Cuba and Panama.
"The Japanese invented nothing and had no peculiar knowledge or skill; they merely took occidental science and used it. The remarkable thing is not what they did, but that they were allowed to do it. It is a terrible thing that Congress should choose to make one of its rare displays of economy in a matter where a few thousand dollars saved means, in case our army should have anything to do, not only the utterly needless and useless loss of thousands of lives, but an enormous decrease of military efficiency, and might, conceivably, make all the difference between victory and defeat."
FOOTNOTES:
[16] The technic and principles of municipal engineering have been treated in detail in _Principles of Sanitary Science and the Public Health_, by William T. Sedgwick, and in _Municipal Sanitation in the United States_, by Charles N. Chapin, M.D.