The National Board of Health
IT is curious, as an element of the study of human nature, to consider the manner in which the newly constituted National Board of Health has been received by those who have most to do with the direction of public opinion concerning public affairs, — the reporters and the frequent or occasional correspondents of the newspapers. Several influences were brought to bear upon the constitution of the board which are fair subjects of criticism, and these have not failed to exert an important influence upon some features of its work and methods. But, unquestionably, the object was a laudable one, and those selected to secure it included some of the very best men in the country for the purpose.
On the whole, as the first step taken in an important new direction, we must regard the National Board of Health as a decided success, of no little present utility and of great future promise. Many a new venture, much less praiseworthy and of much less hopeful aspect, has been at once embraced by the daily press as a great public blessing; its defects have been overlooked, and only its virtues have been held up to the public gaze. Very unfortunately, the Board of Health has met with the opposite reception,—for what reason, it would be impossible to say without more knowledge of Washington journalism than I possess. Everything concerning it has had a bad taste in the reportorial mouth from the very outset. Emboldened by the tendency thus instituted, doctors and others who should know better have not been slow to pour forth voluminous condemnation regarding it. If one were compelled to guess at the cause of this opposition, it would, perhaps, be safest to go back to the tone of the discussion of the yellow-fever question since the epidemic of last year.
Public opinion at the North, where sanitary matters have received the most attention, naturally assumed at once that the reason why Southern cities had been so devastated by this plague was that they were not kept clean. This opinion is wide-spread; whether it is entirely well founded or not, I have no means of knowing. The immunity from the epidemic which New Orleans enjoyed during General Butler’s military occupation is popularly supposed to have been due to the thoroughness with which he compelled the systematic cleansing of the city.
The Southern mind did not attach so much importance as we did, perhaps not so much as it should have done, to the matter of cleanliness and good drainage. Indeed, more than once it was reported by local committees that the worst infection often existed in the best drained parts of the town. To this suggestion I shall refer again.
The controlling opinion of the South, especially as represented at the meetings of the American Public Health Association and in Congress, held very strongly to the idea that the means by which yellow fever is to be prevented from devastating those cities again is the very palpable means of quarantine. The best knowledge on the subject seems to indicate that the disease never originates de novo in this country, but is always the result of importation from infected places. Consequently, the most obvious suggestion concerning it is to lay such an embargo upon its importation as shall furnish adequate security against it. One who has control of a powder magazine applies his chief energy and his greatest anxiety to the absolute exclusion of the least spark of fire. Southern people, knowing that they are subject, from whatever cause, to yellow-fever epidemics, naturally look first to the exclusion of the first spark of infection; and in so far they are wise. To regard quarantine as the one sure preventive, as they have done, seems short-sighted. In the case of the manufacturer of gunpowder, the storing of the explosive material is an absolute necessity. If it were possible for him to get rid of this element, the rest of his property would be entirely safe, in spite of the sparks.
Yellow fever used to prevail, sometimes very seriously, in Northern cities, and in seasons of no more severe heat than we have frequently had in recent years. Notwithstanding the well-regulated quarantine of New York, there are occasional importations of the infection; hut at no time for years past, since the radical though still imperfect sanitary improvement of the metropolis, has any case served as the starting-point of a local epidemic.
Southern physicians and experts have much more knowledge than we have concerning this disease. At the same time it seems evident that, under the influence of panic and of a determination to protect their communities by isolation, they have failed to appreciate as we do the importance of municipal and domestic cleanliness.
It is perhaps this difference of opinion between Northern writers and those Southern members of Congress who directed the Board of Health and quarantine legislation which has caused the former to take the unfavorable view that it has of the board which that legislation created. Another difficulty is to be sought in the constitutional limitations under which the legal enactments were necessarily made. The act constituting the board, approved March 3d, is simple, direct, and effective. The quarantine act, approved June 2d, which prescribed the specific duties of the board with reference to yellow fever, is by no means so clear and positive. There is evident at every point a desire to avoid raising the question of the right of the general government to interfere in any respect with local authorities. In so far as the action of the National Board has been halting or ineffective in dealing with the present outbreak (and it is in this respect that it has been most severely criticised), there is reason for Its caution and for the absence of positive action in the limited and qualified powers given to it by Congress.
In considering what the National Board of Health is and what it has done, these facts must not be lost sight of. We must regard it always with a view to the limitations by which it is restricted. Could the gentlemen constituting the board have prescribed their own authority, and done in all respects what might to them alone have seemed best, we should undoubtedly have had more prompt, efficient, and severe treatment of the question. As it is, it is fair only to consider the manner in which they have exercised their very limited powers, and to estimate the wisdom of their course by the degree to which they are endeavoring to do the most they can with their restricted means.
So far as the constitution of the board is concerned, there is no doubt that any one of us would be able to select from among the sanitary experts of the country eleven men who would be, in our own opinion, better qualified for this special work. It is possible that some members of the board ought not to have been appointed. Be this as it may, all who are competent to judge recognize the fact that the leading spirits of the board are among the very best men in the country for the work in hand. They are fully qualified to apply existing knowledge to the delicate questions which they have to treat, and they realize (as, unfortunately, the public does not) how extremely limited the existing knowledge is, and how impossible it is for any man to say with certainty that such or such treatment is most advisable. The radical trouble with the whole question is that the public has expected too much, — as it always expects too much from experts. The action of the board is now measured solely by the single standard of its treatment of the yellow-fever question, which is the only one that engages the public mind. But concerning this, knowledge may be said hardly to exist. We know, of course, something of the disease, and something of the circumstances under which it becomes epidemic; and we know pretty surely that it never originates in this country. This is about all that we do know respecting it. With such a very feeble foundation to work upon, with virtually no precedents to follow, and with very restricted powers of action, the Board of Health cannot reasonably be expected to accomplish any great practical result. They have been active in making suggestions; and the individual interest of the members in the whole question has been lively and unceasing. That they have not applied themselves to experiments which they had no legal right to make, and which they had no reason to believe would be effective, should be regarded as commendable rather than reprehensible. A calm consideration of their powers and of the knowledge which alone could justify their action must lead to the conclusion that they have done quite as much as the existing circumstances would warrant.
The board consists of eleven members: seven civilian physicians, one medical officer of the marine hospital service, one army surgeon, one navy surgeon, and the solicitor general. In the constituting act, only three duties are prescribed for them: one, to obtain information upon all matters affecting the public health; another, to advise the several departments of the government, the executives of the several States, and the commissioners of the District of Columbia, on all questions submitted by them, and in their discretion “to give such advice as may tend to the preservation and improvement of the public health; ” the third, to coöperate with a committee of the National Academy of Science, and to consult with sanitary organizations and leading sanitarians as to the recommendation of a plan for a permanent health organization, to be established by Congress at its next session. This is simple and straightforward, and there is no doubt that the work thus indicated will be satisfactorily carried out.
The quarantine act (June 2d) is much less explicit, so far as any decided action is concerned. Under it the board may request the president to detail medical officers to aid consuls in foreign ports from which the importation of infection is to be apprehended. They are to coöperate with state and municipal boards to prevent the introduction of infectious diseases from foreign ports, or into one State from another; but the means and the degree of the coöperation are neither specified nor authorized. If local provisions seem to the board to be insufficient, it is to report the fact to the president, who may order it to make rules and regulations that meet the requirements of the case. If the president approve these, the board is to promulgate them, and they are to be enforced by state authorities. If they fail to enforce them, it is left with the president in his discretion to detail an officer or a suitable person to carry them out.
The board has only a similar authority concerning the rules and regulations to be observed by vessels coming from ports declared to be dangerously infected. It has authority (and this is important) to obtain from the consuls and medical officers detailed to assist them weekly reports of the sanitary condition of foreign ports and places from which danger is to be apprehended. It is also authorized to obtain, through all accessible sources, weekly reports concerning the health of towns and cities of the United States, and it is required to publish weekly reports, giving the information thus obtained " and other pertinent information received by the board;” also to “ procure information relating to the climatic and other conditions affecting the public health.” It has the further duty of formulating and supplying information and suggesting rules and regulations concerning vessels, railroad trains, and other means of interior communication,
All this, it will be seen, is vague and limited in regard to giving the board any absolute power to do any specific act or thing to accomplish an immediate Sanitary result. So far as the treatment of the yellow-fever question is concerned, it is proper to repeat that the National Board of Health has done promptly and carefully what it seemed necessary or possible to do under its present circumstances. Not the least of the good, permanent results of its work is to be sought in its publications. In compliance with the law of June 2d, it publishes, for gratuitous circulation among those interested and influential in such matters, a weekly bulletin, containing a record of its action, and such information as from time to time it is able to gather from the various important sources within its reach. This bulletin, while it is by no means a newspaper, and while its more striking features have always been made public by the more prompt action of the daily press, constitutes an educational instrument of the greatest public value.
One of the circulars of the board recites the requirements of the constituting act, and indicates that in the performance of the duties therein specified it will furnish means and encouragement to leading physicians, sanitarians, and scientific men to prosecute scientific inquiries as to the various matters necessary for the protection of the public health. It will thus secure the performance of a most important work, for which no local organization and no private citizen would be likely to devote the necessary time and money. In its effort to obtain information upon matters affecting the public health, it will come in an authoritative way into familiar communication with the various local boards, with a view to the exchange of information and advice. This will lead to the formulating of methods, to the assimilation of systems, and to the improving of the processes of each organization by means of the experience of all, thus saving the present enormous waste of effort that is being expended by various local organizations in tentative work which others have already found to be unprofitable.
However valuable and important all of its other offices may be, we must surely look for the best result of its work in the last requirement of the constituting act. It is extremely important that there should be a permanent national organization, specially charged with the direction of sanitary matters. It is not less important that this organization should be constituted in accordance with the wisest possible discrimination and judgment. To determine what such a board may do and what it may not do, what means should be placed at its disposal and in what manner these means should be applied ; to separate it from all party and sectional interests; to make it the most efficient agency for the obtaining of knowledge and for the effective distribution of this knowledge among the people, will be a very great step in advance. We may now hope that an efficient sanitary public authority may be established upon so firm a basis that no man’s private scheme and the indulgence of no man’s whim may lead to its destruction. If we can secure for the whole country an educational influence as important as that of the State Board of Health of Massachusetts was to the people of that commonwealth, and if we can protect it from the shipwreck which has overtaken that board, we shall have accomplished an inestimable good. With this view we may well be content to regard all that the National Board of Health is now doing as purely tentative work, leading only to the exploration of a field which is henceforth to be cultivated in a systematic, wise, and effective manner. If we get, no other result than the judicious application of present experience to the organization of future work, we shall have a result compared with which no possible action in connection with any epidemic is worth considering.
It would be beyond the purpose of this paper — a purpose of illustration only — to recite and comment upon the various acts and performances of the National Board. It will not be out of place, however, as an indication of its method and its temper, to quote from its circular of July 12th: —
“ Whatever opinions may be held as to the causes of yellow fever and of the recent appearance of that disease in Tennessee and Mississippi, it is best to act as if it were a disease due to a specific particulate cause, which is capable of growth and reproduction, transportable, and may be destroyed by exposure to a temperature above 240° Fahrenheit, or by chemical disinfectants of sufficient strength if brought into immediate contact with it.
“ It is also prudent to assume that the growth and reproduction of this cause is connected with the presence of filth, in the sanitary sense of that word, including decaying organic matters and defective ventilation, as well as of high temperature.
“ The cases of yellow fever recently observed should be considered as due to causes surviving from last year’s epidemic, and not to recent importation from other countries. It follows that there is a liability to the appearance of other cases in places visited by the epidemic of last year, and that there is danger of the spread of the disease to the North and the East. . . .
“ The object of the present circular is to advise that all cities, towns, and villages be at once made clean, in a sanitary point of view. The first step toward securing this cleanliness is to obtain reliable information as to what parts of the place are clean, and what foul.
“ The results of a careful sanitary inspection of almost any city or town will show the existence of collections of decaving and offensive matters previously unknown, and which every one will admit should be promptly removed and destroyed.
“ Such inspections to be of value must be thorough, and made by persons competent to recognize foul soils, waters, and air, as well as the grosser and more palpable forms of nuisance. They should also be made by persons who will report fully and frankly the results of their observations, without reference to the wishes of persons or corporations. When the whereabouts and the extent of the evil are known, the remedy is usually almost self-evident.”
The first paragraph of this quotation indicates (which is true) that it is not now positively known that the disease is due to “a specific particulate cause, which is capable of growth and reproduction.” No sufficient scientific examination has ever been made to determine this question. He would be a rash man who should attempt to predict the time and manner of determining it. As a first step toward ascertaining it, the National Board has sent a committee of experts to Havana, with instructions to institute scientific investigation in this direction. This commission is composed of three physicians and a sanitary engineer. They are instructed to find out the actual sanitary condition of the principal ports of Cuba, how this can best be made satisfactory, and especially what can be done to prevent the infection of shipping by yellow fever; “ to add to our knowledge as to the pathology of yellow fever,” and to study the question of endemicity. They will also endeavor to “ find some means for recognizing the presence of the immediate cause of yellow fever other than the production of the disease in the human subject.” The commission is well supplied with scientific apparatus, and it is expected to make a preliminary report at the end of three months, the hope being indulged that this may indicate the best direction for future inquiries.
It is already reported by Dr. Sternberg, of the commission, that a most valuable and convenient fluid for detecting the presence of bacteria is the liquor from the interior of the unripe cocoa-nut, whose properties, he believes, will make it of great value in such investigations. It is transparent as water, is confined in a germ-proof receptacle, and when exposed to air containing bacteria and other organisms it enables them to develop with astonishing rapidity. In an experiment reported, a portion of this fluid, exposed to the air, became milky within a few hours, and was loaded with bacteria, ” and had upon its surface a pellicle containing the cells of some fungus.” Another portion, in the same room, but protected by a suitable bell-glass, remained perfectly clear.
An examination of the six copies of the Bulletin thus far issued shows that the board has by no means been idle. It has published: (1.) Rules and regulations for securing the best sanitary condition of vessels, cargoes, passengers, and crews coming from infected foreign ports. (2.) Rules and regulations recommended for quarantined ports, with special reference to yellow fever. (3.) Rules and regulations concerning the sanitary condition of vessels, cargoes, passengers, and crews going from an infected port of the United States to another port in the United States. (4.) Rules and regulations for securing the best sanitary condition of railroads, station-houses, road-beds, and of cars, freights, passengers and employees coming from a point where yellow fever exists. (5.) Rules and regulations to be observed by the health authorities of a place free from infection having communication with an infected place. (6.) The course to be adopted in a place already infected with yellow fever.
All these rules and regulations are copious, specific, and in accordance with the best ascertained knowledge and best accepted theories of the subject.
There is also a weekly report of the mortality from specific diseases in foreign cities and in the chief cities of the United States; together with an amount of general information concerning sanitary matters which is of great, and much of it of permanent, value.
In the original draft of the constituting act it was proposed that $500,000 should be appropriated, to enable the National Board of Health to pay one half of the expenses of such state boards as might be organized in accordance with a plan approved by the National Board of Health. This would have been extremely effective in securing a uniformity of methods, and would have enabled local boards to perform much more efficient service than is now possible. It is unfortunate that this provision was stricken from the bill, and it is sincerely to be hoped that it will be included in the plan of a permanent national organization.
It is quite natural that the general public should now endeavor to measure the efficiency of the board solely with reference, not to its action, but to the result of its action, in the suppression of yellow fever. Of course it can never be known to what degree the board has been instrumental in preventing the greater severity and wider spread of the epidemic; but that “ great big stupid,” the public, is sure to adjust its estimate of processes by what it sees, or thinks it sees, of results; and, for the moment, the whole question of the National Board of Health is in its mind the question of yellow fever.
The fact is that, as compared with con sumption, yellow fever is insignificant even in the years when it occurs, and that there are other diseases always prevalent throughout the country which are far more important, when measured by their fatality alone, than is this conspicuous periodic scourge, — to say nothing of the enormous amount of costly and painful sickness which stops short of death. The great good that is to be accomplished by the future national health organization is not in freeing the country from yellow fever alone, but in working towards the abolishment of the whole range of preventable diseases, in preserving health as well as life, and in adding, not only to the average of human longevity, but to the sum of human efficiency. If we realize the importance of this view of the case, we shall accept all honest present effort in the most friendly and favoring spirit, confident that the work now being done is only a first step towards the accomplishment of an ultimate public benefit, of which it would be rash now to estimate the extent.
I cannot close this paper without referring to the opinion so often expressed, and alluded to above, that in 1878 the worst infection often occurred in the “ best drained ” parts of the town. Possibly the requirements of good draining are not always properly understood. In the Bulletin of the National Board for August 16th, Dr. Palmer, sanitary inspector, reporting on the condition of Mobile, says: —
“During the dry seasons the sewers are never flooded, because the water supply is so limited, and hence they are never washed out unless the rain comes and deluges them. In the pits are emptied the refuse matter from night-vessels, and in many cases the kitchen refuse is also poured into these places. Of course, last year, when there were over two hundred cases of yellow fever here, all the deposits and vomit were emptied into these festering pits, and now, there is no doubt about it, things are very unsanitary here. When I have approached the authorities upon the subject, they have said that yellow fever will come whether you are clean or not.”
If the “ pits ” received these matters, the sewers received them also. Sewers in the condition indicated as existing in Mobile — and if in this condition no amount of care and cost in construction would help them — would probably be more injurious than the pits, because more directly in communication with houses. Filth does less harm in street gutters than in foul sewers.
George E. Waring, Jr.