commodity. When the State legislature in 1908 enacted a law making possible county hospitals, we immediately took advantage of this and in 1912 opened for use the first such county-owned public hospital in the entire United States. This hospital has cared for 24,000 patients (April 1, 1943). It was recognized early that such a hospital had a definite function and duty to the people who provided it; that is, it should serve as a public health center and we should be able to reach the fundamentals of public health and the public responsibility therefore.

Gradually many people over the country became interested and saw the need for a more extensive organization. In 1924, it was possible, with the aid of Rockefeller money to establish a rural county health unit-again the first in Iowa. After various ups and downs it was not until 1936 that this county health unit became firmly established. To tell the story of what happened in the 12 preceding years is merely to restate things which you all know. Political expediences, indifference, inadequate knowledge and irresponsibility and plain contariness or cussedness caused much trouble but those who were in the lead were not discouraged, kept the fire burning and when the auspicious time came, we were ready and had many friends.

It might be interesting to tell that at this time quite a group of interested people called upon the board of supervisors and urged the adoption of this county health plan under the Social Security Act of 1935. I would like to say that I had nothing directly to do with this committee visit but it did show that the laven was working and this demonstrated the active interest of many people. A few days later another group called on the board objecting to the plan as it might increase taxes and it may be said that not a single on of these persons had any children to be benefited by such a plan. The county board was not impressed by this group and immediately authorized the establishment of the health unit and accepted the aid and cooperation of the Department of Health (July 1, 1936).

Over the period of 12 years prior to this time, much ground work had been done, much public education, the physicians understood and appreciated the public health problems and many businessmen also appreciated it as they had already had enough information to know that good public health meant better business; that epidemics and sickness always interfered with business. So we were at this time ready for the next step.

The opportunity was offered us to engraft on the county health unit as a maternal and child welfare program. This was accepted. Two nurses with training in maternity problems were assigned to the county-Miss Nadeau and Miss Brouillette. It was the duty of these nurses to come in contact with expectant mothers, this being accomplished through cooperation of the physicians. Visits were made to expectant mothers explaining or assisting them in all ways possible to prepare them for the coming event and they were urged to visit their physician regularily for the necessary check up of their condition, the nurses were very careful to explain to the women why such observation and examinations were necessary; and in suitable cases, that is, where the family was unable to employ a special nurse and if the woman did not go to the hospital one of these nurses was present at the delivery.

After a few months' work it seemed necessary that I go to Washington City and explain our plan to the proper agency in the Children's Bureau, and to attend a Conference on Child Welfare at the White House. It might be of interest and to keep the record straight to say here that at this conference Dr. Martha Eliot, whom I had not yet met, announced at this meeting that the doctor who was responsible for this work and who was doing it in his own county some years before the Government took it up, was in the audience and she further announced that he was from Washington County, Iowa. We went over our plans with Dr. Eliot and Dr. Edwin Daily, our work was approved and we were advised to return home and continue as we have been doing. The point that we made at that time was that if this plan was to succeed and be worth while we must include all low-income groups in the delivery service, not limiting it to the indigent. Our plan was approved wholeheartedly, I might also say here to any who fear government intervention of medical practice, that we never have been told to do anything. We have repeatedly been asked if we could do certain things (which will be mentioned later) if and when we said we could do it we were given the opportunity to demonstrate our plans. I have never feared State medicine so long as the medical profession kept ahead of the procession and delivered a high type of medical care.

For a number of years the number of babies born to residents of the county has been about 375, the last 2 or 3 years there have been 25 or more from outside

the county coming to the local hospital, more come into the county than those who go out. From the beginning we felt that the home deliveries should be as nearly aseptic as possible, so we prepared maternity packs which contained basins, soap, gauze, cotton, gloves, mask, sheets, gowns, towels, etc., in fact everything needed except ether and instruments. These packs are sterilized and kept at a central location where a doctor can pick up one whenever he needs it. We are sure that the use of these sterile packs has prevented any possible infection, at least no such case has developed in the years since we have had this plan. The doctors are requested, and a request with which they have wholeheartedly complied that they keep comprehensive records which would be available if required.

Comparative figures may be of interest.

Prior to the adoption of this program, 21 percent-one fifth-of the expectant mothers went to their physicians before the third month. During the first year of this program, 43.4 percent reported to their physician (last year 47.6 percent). Before the program 46 percent reported before the sixth month, and during the first year, 71 percent-2,343 reporting before this time (last year 95.5 percent). These figures have gradually and consistently increased as people have become better acquainted with the plan and for the last 2 or 3 years it is shown that 97 percent of the expectant mothers see their physician and have advice of a nurse by the eighth month. Seventy-seven percent by the fifth month; 92.5 percent by the end of the seventh month. Deliveries in the hospital have increased from 38 percent prior to the adoption of the plan to 59 percent of all county births at the present time. Counting both hospital deliveries and those at which the maternity or other nurses assist, the percent has grown from 78 percent the first year of the plan to about 97 percent the past 2 or 3 years. The first year the maternity nurses assisted at 58 births, last year 124. All deliveries have been attended by a physician. We have two or three osteopaths who do some obstetric work. They attend 6 or 7 deliveries a year or less than 2 percent of the total. Their patients receive the same prenatal and postnatal care as do those of the medical men. The maternity nurses always make postnatal visits whether the delivery has been in the hospital or not. Extra visits are made at the request of the physician. During the 61⁄2 years that the program has been in effect, from July 1, 1936, to January 1943, there have been 2,583 deliveries. There have been but 2 maternal deaths during this time, 1 due to hemorrhage and 1 due to eclampsia. The State death rate in 1941 was 2.73 per 1,000 live births, about 1 mother in 500 is lost. Whether our figures of only 1 death to each 1,300 mothers means anything or not as to the value of the prenatal care and the delivery care is for you to judge.

For more than 10 years the infant death rate in this county has been far below that of the State as a whole which was in 1941, 35.83 per 1,000 live births and for 11 months of 1942, 33.8, that is 1 infant in 29 did not live to its first birthday, in our county the figures were 1 in 62. In all of these 10 or more years, the infant death rate in our county has been less than one-half of the State as a whole. After some 2 years of operation of the maternity unit, we found that two nurses were unable to do the work indicated and required, so a third nurse was added. The county was divided into three areas, so these nurses would not duplicate their efforts and to save time and mileage. Three prenatal and two postnatal visits are made to every expectant mother (it was not long after the beginning of this work that expectant mothers themselves sent word for the nurses to call). It happened that sometimes the nurse was called before the patient had seen her physician. The patient was urged to notify the physician. In addition to this type of work the nurses check up all county schools, investigate tuberculosis cases, communicable diseases (the director is always consulted and always sees this type of disease). The director freely consults with physicians at their request in pneumonia or any other condition which has a public health aspect.

The physicians have for some years been active in recommending vaccinations against smallpox and immunization against diphtheria and they appreciated very much the opportunity to put over onto the director of the health unit the necessary additional work to continue this. Each year there has been an active immunization and vaccination campaign and we feel that not less than 80 percent of the preschool and younger children are protected agains these diseases and a large percent of the older children are so protected (81 percent against smallpox, 78.3 percent against diphtheria). Our work has borne fruit so well that there has

not been a case of diphtheria originating in Washington County since 1929, Two or three cases have been imported during that time but there was no spread from them. Some years ago in the laboratory it was our regular custom to examine from 1,000 to 1,500 throat cultures per year checking for diphtheria. For the last 5 or 6 years we have not had an average of six per year.

For several years the Red Cross has been of material assistance to us in carrying out the immunization and vaccination of infants and young children; this organization has provided at least $100 a year to pay for immunizing of children between 9 months and 24 months. As result of this work at least more than 50 percent of the preschool children are immunized.

One of the first things done under health-unit supervision was bacteriological supervision of the water of various wells, there being 100 country schools. In the beginning it was found that the water in 66 percent of these wells was contaminated by the colon bacillus and where the colon bacillus is, its relative the typhoid bacillus might be. School directors were quick to correct this condition either by proper care of the well already in existence, or by digging new wellswhatever the sanitary engineer of the health unit advised. This kind of work spread out until a good many dozen farm wells were checked and where contamination was found, they were very quick to have it corrected. It is now very unusual for us to find a contaminated well at a schoolhouse. This work has so well borne fruit that there has not been a case of typhoid fever originating in Washington County since 1929. Of the few persons who have come home with typhoid fever, very careful supervision has been practiced and there has been no spread of this disease.

By the health unit taking the lead, with the medical society, the county super. intendent of schools and the superintendents of the various town and consolidated schools, a continual course of public-health education has been carried forward. We have our own sound motion-picture machine and films (both educational and public health) have been used freely in every schoolhouse in the county which has electricity.

The active cooperative interest has been secured and maintained of the county board of supervisors, school superintendents, business associations, PTA's, several women's clubs, the farm bureau, and such like organization. It has been our firm belief for years that effective public-health work can only be done when all of the agencies interested in such work pulled on the same rope. Having this in mind, we have for several years had charge of the Christmas seal sales and tuberculosis education in the county. This works closely with the county medical society and the health unit, the director and nurses doing all of the field work. We had the first chest clinic in our county ever held in Iowa in cooperation with the I. T. A. and the State department of health. During the last 2 or 3 years it . has seemed advisable for us to conduct our own chest clinics because we could keep closer track and have better consultation by more frequent clinics, so we have had one chest clinic per month. This has been quite satisfactory not only to the persons themselves, but to the physicians. Many of these films are sent to the State department for consultation. Although the health unit has nothing to do with raising funds for the committee on infantile paralysis, still by local agreement, the director must approve the expenditure of any money.

An editorial in the Des Moines Register of February 27 last has this to say, "In the past 15 years there have been 25 epidemics of milk-borne diseases in Iowa, verifiable as such by the State health department involving 1,365 people and 39 deaths. In all but one of these epidemics raw milk was the agent, by which the germs were spread" (typhoid, undulant fever, gastro-enteritis, diphtheria, septicsore throat, and scarlet fever). The control of milk productions and marketing should be by the State department of health.

One of the outgrowths of the public health work was the adoption by the city of Washington of the standard milk ordinance, one of six or seven in the State of Iowa. It was our contention that milk dealers and producers should not be forced to do anything but that they should be educated to do it. As a result, we had very little trouble instituting the provisions of this ordinance and have gone forward with very little friction and with, we think, greater safety to the milk consumers. We have in Washington three pasteurization plants.

Gradually there grew up under the director of health unit and with the consent of the doctors, clinics throughout the county for well children. These have been very well received. If and when any defect is found in a child, it is 88975 4623

promptly referred to the family physician. The health director does not do any treatment.

Earlier in this paper I mentioned that we were never told to do anything but were asked if we could do certain things, so a couple of years ago, Dr. Robert L. Jackson of the Children's Hospital asked us if we could conduct a cardiac clinic for children there being nothing of that kind in a rural county in the whole United States. Of course we could do it and did. Two or three times a year now Doctor Jackson with his staff comes to Washington and examines 20 to 30 children who have been referred by their family physician for actual or possible heart conditions.

Next we were asked if we could conduct an orthopedic clinic. We could do that too, so last fall Dr. Arthur E. Steindler and some of his staff spent a day with us and examined 35 children and young people, a considerable number of whom had been his patients in Iowa City. These two clinics gave our doctors consultation advice with Drs. Jackson and Steindler without having to take the patients to Iowa City and is quite satisfactory to all concerned. We expect to continue both of these clinics.

Again we were asked if the State board of health might, collect blood from recovered patients having had measles, scarlet fever, or whooping cough. We could do that too, and have had three or four such clinics already.

The director of the health unit and nurses take an active part each year with the physicians or at the physicians' request in the physical examination of the 4-H boys and girls, also materially in the examination of selective service. (The drawing of blood for Wassermann examinations). Time does not permit description of the work for pneumonia control and syphilis control.

Excellent quarters have been provided for the health unit by the board of supervisors and now with the shortage of physicians, the work of this department is greatly appreciated not only by the doctors, but by the general public. I trust that the description which has been given of the establishment and work of the health unit in Washington County has not given you the idea of any egotism. We started out with a definite plan of what we wanted to do and have, with the cooperation and assistance of first, the doctors, then the general public, been able to accomplish great results. The wider our horizon, the more opportunities present themselves. The figures which have been quoted before in this paper give us reason to believe that if a community wants good public health work, it can have it. What we have done others can do. Possibly the plans which we have used in our county would not suit very many other counties but there are other plans which would suit. It is my firm belief that no public health plan will work successfully unless some local person, necessarily a physician, is willing to take the lead, to ride the cowcatcher, to go to bat for the plans and be capable of organizing such units as are necessary to carry out this definite plan; just to provide for a health unit and expect it to run itself isn't the way. Such won't work and if you are unwilling to go all the way, don't start. You can't start at the top; start at the bottom and work up. If the physicians take the lead as they are quite capable of doing, properly encouraged by nonprofessional people, Iowa can have still better health than in the past. Lives of mothers and babies can be saved, certain diseases can be eliminated from the category of medical practice, business will not be interfered with but will be better, and Iowa will maintain its lead as an agricultural State, but will move forward to greater achievements than in the past.

The marked success which we have achieved in Washington County has been due first to interest and leadership of members of Washington County Medical Society, to the trustees of the Washington County Hospital and the County health unit, ably supported by the board of supervisors, school superintendents, PTA organizations and business organizations and women's organizations, Farm Bureau, etc. We believe public health is a community problem. Whatever success which has accrued to this work has been due to the insistence that I have been able to convince board and groups that what we were doing was for the good of the community, never have I asked for any good for or favoring the physicians. We don't keep our light under a bushel. We let the people know what is needed and how to provide the remedy, and they have not failed us.

Any community wishing to succeed in public health should know its problems, secure adequate leadership, and go to work.

Good health is a purchasable commodity.

EXHIBIT 79

[Reprint from School Life, November 1945]

HEALTH NEEDS OF SCHOOL-AGE CHILDREN AND RECOMMENDATIONS FOR
IMPLEMENTATION

The following statement of the health needs of school-age children and suggested ways for meeting them was prepared by a subcommittee appointed at a meeting of representatives of Federal governmental agencies whose programs affect the health of the school-age child.

The meeting, called early this year by Frank S. Stafford, Health and Physical Education Service, United States Office of Education, was attended by representatives of the United States Public Health Service; Committee on Physical Fitness; Children's Bureau, United States Department of Labor; War Food Distribution and Extension Division of the United States Department of Agriculture; Recreation Division of the Office of Community War Services; American Red Cross; United States Office of Education; Office of the Coordinator of InterAmerican Affairs; American Association for Health, Physical Education, and Recreation- National Education Association; School Health Section of the American Public Health Association; and the National Organization for Public Health Nursing.

The purpose of the meeting was to exchange information, study needs, and make recommendations for future action. It was felt that there was special need for cooperative planning of the activities of the Federal Government in school health, including the existing programs, the planning of any extension of these programs, the formulation of over-all policies, and the establishment of regulations governing the administration of any funds that might be available. A subcommittee was appointed to study and make a report on child health and fitness needs and to suggest methods of implementing programs which would meet those needs. Members of this subcommittee, which prepared the following statement, are Katherine Bain, Children's Bureau; Mayhew Derryberry, United States Public Health Service; George W. Wheatley, school health section, American Public Health Association; Ben W. Miller, American Association for Health, Physical Education, and Recreation; and Mr. Stafford, United States Office of Education.

The terms "health," "school health," or "school health program," used in this report include those programs designated at various times and places as health and physical education, health education, physical fitness, fitness program, school health program, school health services, healthful school living, hygiene, hygiene and sanitation, and health instruction.

(It is the intent of this report to give appropriate reference to the health needs of school-age children both in and out of school, but it seems advisable to omit discussion in the report of how the health needs of children who have left school should be met.)

Educators and health workers have for years considered the health of school children an area of prime importance to society. The draft findings of World War I and more recently the Selective Service findings of World War II have again focused the attention of the Nation on the health and fitness needs of schoolage children. Those children 5 to 17 years of age composed 21.7 percent of the total population in 1942.

The schools, because of compulsory-attendance laws, have contact with more of the children and youth for longer periods of time than any other public agency. No other agency except the home has such an opportunity to give them significant instruction and to develop child health. Less personal, less emotional, and in general more scientific than the home, the schools recognize social as well as individual values in conserving the health of children. It is here that children are first grouped together for long periods under supervision and that health changes may be first observed.

The schools are the universal agency whose unique function is education. They possess the leadership, facilities, and equipment for securing effective health outcomes during the most critical and formative period of learning. Yet America with such a strategic and universal agency as the schools has tended to over

1 Acknowledgment is gratefully made to S. S. Lifson, Health Educator, U. S. Public Health Service, District No. 1, New York, N. Y., for compiling the basic content incorporated in part I of this report.