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In the early days in which the country was but sparsely settled, sickness, except for epidemics of such diseases as smallpox and yellow fever, was regarded as an individual affair. In recent years bacteriology and medical science have revealed the causes of many diseases and the manner in which they are spread. With a denser population and with more frequent contacts as a result of better transportation, the possibility of contagion has very largely increased and we now appreciate that the health of the family--even of the rural family--cannot be maintained without attention to the health of the community as a whole. Good health has become a responsibility of the community.

The rapid growth of cities in the last fifty years has forced them to take measures for the preservation of health, and public health administration has become a distinct branch of medical science. It is the health problems which have arisen in the congested sections of our large cities, and those which are due to a sedentary life or to unhealthful conditions of certain trades and industries, which have incited the discoveries of medical science and which have created a new attitude toward sanitation and hygiene among city people.

There has been a distinct change with regard to the attitude of society toward health. A generation or two ago many people--particularly elderly females--were not ashamed of "enjoying poor health," and a delicate physique was regarded as rather incidental to the more highly cultured. Towday, although we sympathize with the afflicted, society places a premium upon a sound physique. The importance of physical exercise, of recreation and athletics for the development and maintenance of a sound body are now much more fully appreciated than they were fifty years ago. We are coming to understand that good health is largely due to habits of personal hygiene which must be instilled by the home and the school, and that without such habits the mere knowledge of sanitation and hygiene will not be generally applied. This new emphasis upon physical fitness has naturally received larger attention in the cities on account of the more unfavorable conditions of city life, while the new knowledge and appreciation of the value of health has not been so constantly forced upon the attention of rural people.

Gradually we are coming to appreciate that we have an ethical responsibility for good health, and it is even receiving a religious sanction, for we have come to know that the cause of evil behavior may be due primarily to an unsound body rather than to a perverted soul. The church has ever ministered to the sick and has supported hospitals, but today it is commencing to advocate the prevention of disease through sanitation and hygiene, and to preach the religious duty of fostering health and preventing sickness.

One of the principal factors in the farmer's relative indifference to health measures is the fact that he has become accustomed to think that an outdoor life and isolation from other people give him an ability to withstand sickness and he has rather gloried in his ability to throw off ordinary ailments and to withstand the physical hardship which his work often demands. He can see how health conditions may need attention in the city where people are crowded together, but he is not impressed that other causes make such diseases as typhoid and malaria much more prevalent in the open country, and that bad sanitation on a farm a mile away may cause sickness in his own family. American farmers have been educated on the nature and spread of disease by their experience with animal diseases, such as bovine tuberculosis, hog cholera, and Texas fever. If they can be interested to utilize this knowledge in the care of the health of their own families, and if they will provide health facilities for their own families equal to those which they feel necessary for their livestock, health conditions on the farm will show rapid improvement. It is not that the farmer is indifferent to the health of his family, but he has been _forced_ to have his herd tested for tuberculosis, and he faces the possibility of heavy losses if he does not have his hogs vaccinated for cholera, while he has not appreciated that by preventative agencies the better health of his wife and children may be insured and the cost of remedial treatment be greatly lessened.

The purely economic aspects of sickness and disease have been a potent factor in the health movement, particularly in cities. The vast sums invested in life insurance have led progressive insurance companies into extensive campaigns for promoting public health so that their risks may be reduced. Vast quantities of the best health literature have been distributed by some of the industrial insurance companies and they have done much to demonstrate the value of public health nursing by employing nurses who visit their policy holders. The extension of the insurance method to health insurance, and the adoption of insurance by large corporations for their employees has furthered this general movement, and has revealed the tremendous economic losses due to preventable sickness and disease. The farmer has failed to appreciate the purely economic handicap under which he labors as a result of sickness and the lack of adequate medical service and efficient public health administration such as cities enjoy, because the cost of sickness is distributed and is borne by each family and he has no means of knowing the aggregate cost for the whole community. Were it possible for a rural community to secure and have brought to its attention the total economic loss due to sickness in a given year and the proportion which might be preventable with a reasonable expenditure for better health facilities, its people would doubtless become as interested in better health administration as does the employer in a large city industry, and the true economy of better health facilities would be apparent.

Few concrete studies of the losses occasioned by sickness in rural communities have been made, but one of Dutchess County,[54] New York, in 1915 well illustrates the conditions which would doubtless be found in many another rural county. This survey covered five districts of the county with an aggregate population of about 11,800--most of which was rural territory. 1,600 cases of serious illness were found to have occurred during the year. "Some 9,000 days were lost by men and women of working age (15 to 54 years). Children lost 13,700 school days. On the average this cost the community for each child at least 33 cents a day for which it received no return. These two items safely represent a money loss of $20,000 to $25,000." As a result of the study it was estimated that the total money loss occasioned by sickness in a year within the whole county would be at least $412,000. "Of the 1,600 patients whose care has been analyzed in this report, 72 percent could have been cared for adequately in their own homes had there been available medical and nursing service. The remaining 28 percent (442 patients) could not have been cared for adequately in their own homes... 24 percent of the patients secured no medical care. Many startling instances of unnecessary and indefensible suffering and misery were found.... Of the 113 women who went through childbirth in their homes, only one had the continuous care of a graduate nurse, and only 18 had any service whatever from graduate visiting nurses. 35 percent of the children born came into the world under unfit conditions and surroundings." Largely as a result of this study, Dutchess County now has an efficient county health association through which a number of public health nurses are employed, who visit all districts of the county.

One of the most serious handicaps in maintaining the health of the rural community is its frequent lack of medical service. The number of doctors practising in the open country was always inadequate, but in recent years it has decreased until now many large sections are without any resident physician. The influenza epidemic of 1918, following the shortage of doctors during the war, revealed the plight of many a rural community without medical service. The higher standards now required by medical colleges and state licensing boards has resulted in a real shortage of physicians and the young men are not going into the country to practise. A recent study made by the New York State Department of Health showed that in 20 rural counties 88 percent of the physicians had been practising over 25 years and only 3 percent less than ten years. This means that most of the rural doctors in these counties have less than ten years more to practise and that there is no indication that their places will be filled by younger men. In Manitoba one rural municipality has employed a physician on full time, and a recent act of the New York legislature makes it possible for towns to employ physicians. It seems probable that country people will be forced to employ physicians on a salaried basis if they are to secure adequate medical service. This does not necessarily mean, however, that the physician will be employed by the local government. Industrial workers are now employing physicians on a salary and farmers' organizations are employing salaried veterinarians. Why cannot a local health association be formed to employ a physician, whose job it will be to keep its people well?

Two factors prevent the larger use of physicians now available. Chief of these is the cost. Farmers handle relatively less actual money than townsmen, and their income is less frequent so that they have less on hand, while the cost of medical attendance is necessarily higher in the country. Fear of running up a bill deters many a farm woman from calling a doctor, when one call might prevent many more later on. The farm home tends to employ a physician only for serious sickness, rather than as a medical adviser who may forestall illness. Another difficulty is one of the physician's own making. The experience is far too common that in cases of immediate need when the family doctor cannot be located, doctors will refuse to attend a case on account of so-called "professional courtesy." It is time that public opinion be aroused so that such cases be brought to the attention of county medical societies with sufficient public opinion to force them to take suitable action. The ethics of every profession must be shaped to meet the needs of those it serves as well as the pocketbooks of its members.

Lack of medical attendance is most serious for the farm mother during confinement, and the mortality of rural mothers during childbirth, as shown by the investigations of the U. S. Children's Bureau, is an indictment of our supposed civilization. When we learn that in a homesteading county in Montana there were 12.7 deaths of mothers per 1,000 births, which is twice the rate for the United States as a whole, which is higher than that of fifteen foreign countries for which statistics were available in 1915, we face a condition which cannot be neglected. When we find that in Wisconsin this rate was but 6 per 1,000, and that 68 percent were attended by physicians, and in Kansas it was but 2.9 per thousand and 95 percent had physicians, while in Montana only 47 percent were attended, loss of life due to isolation and lack of medical care is apparent. In sparsely settled regions the solution of this problem seems to demand the provision of local maternity hospitals, for the difficulty is primarily one of isolation.

Since medical science has shown that sparkling spring water may carry the deadly typhoid germ as a result of distant contamination, that wells are frequently contaminated by nearby privies or barn yards, that malaria is carried by mosquitoes, and that the house fly may carry typhoid fever and intestinal diseases of infants, we have come to appreciate that isolation and pure country air do not insure freedom from infection, and that sanitation is as important on the farm as in the city. Indeed the transmission of disease by flies is much easier on the farm, for too often the manure pile where they multiply is not far from the house, while in many a city the smaller number of horses and the cleaning of manure from the streets prevents their increase. The sanitation of the farm home thus becomes a very large factor in the health of the rural community. Surveys made by health officers in recent years have shown the general need of better sanitary provisions and also the possibility of the direct benefits secured from their improvement. In Indiana the State Board of Health surveyed nine typical rural counties taking only the homes on farms and in unincorporated villages. The average score of 6,124 rural homes in these nine counties was but 56.2 percent, the average for individual counties varying from 43 to 61 percent. In 1914, 1915, and 1916, the U. S. Public Health Service made sanitary surveys of 51,544 farm homes in 15 rural counties scattered throughout the United States, but mostly in the South. Its report[55] states that only 1.22 percent of these farm homes were equipped for a really sanitary disposal of human excreta, while in one county in Alabama less than 20 percent of the farm homes had toilets of any kind. "Sixty-eight percent of the water supply used for drinking or culinary purposes was obviously exposed to dangerous contamination from privy contents"; and only 32.88 percent of the houses were effectively screened against flies. A very considerable improvement in farm sanitation has resulted from the educational campaigns conducted during the past decade, but effective rural sanitation awaits the employment of public health officials who will convince the people of each local community of their individual responsibility for the health conditions on their own farms and of their common liability for the health of each other.

With the above conditions in mind, let us now consider the agencies for health conservation in rural communities. We have already seen that the old-fashioned country doctor is rapidly disappearing. With better transportation now available it seems probable that physicians will live in the larger village centers, but with telephone communication and the automobile it should be possible to secure as prompt medical attendance. We may as well recognize that many a rural community is too small a unit to support a resident physician and that if satisfactory medical treatment is to be secured we shall have to have better hospital and clinical facilities so that the time of the physician can be economized and frequent attention can be given.

Most rural townships have a local board of health and health officer, who is charged with reporting births and deaths and with the enforcement of quarantines against contagious diseases, but it is notorious that these local health officials are rarely efficient or take any leadership in the betterment of public health. Ordinarily the health officer receives little if any pay, and is a resident physician who is not inclined to antagonize his own clients when the enforcement of health regulations would meet their opposition. Students of rural health problems are now fairly agreed that the only means of securing efficient administration of public health regulations in rural communities is by the employment of a full time county health officer, working under a county board of health, who will have the same general duties as the health officers in our cities. Local health officers would be retained, but their work would be under the supervision of the county health officer and would have the benefit not only of his support and encouragement, but also of his superior technical training. If a county superintendent is necessary for our schools, a county health officer is equally necessary for the supervision of public health, and several states have enacted legislation requiring or permitting the employment of county health officers. The county is usually the best unit for rural health administration.[56] The county health officer would have laboratory facilities for the examination of drinking water, and samples of blood, urine, or sputum for the detection of disease, and would give direction for the taking of samples which might be sent to the laboratories of the state department of health for the examination of those specimens for which his laboratory was not equipped. He would have general supervision of the medical examination of school children. In numerous ways he would promote better means for health conservation, as can be done by one who has had special training for such work and who is giving his whole time and thought to its problems.

Although the county health officer is necessary for the administration of the technical aspects of public health administration, the most important gains in the health of the rural community will come through the personal education of its people on matters of hygiene and sanitation. This is the field of public health nurses, and I believe that the records of their work in rural communities will show that they have done more for health education than any other one agency. A decade ago trained visiting nurses were practically unknown in rural communities. In 1914 the American Red Cross first organized its Town and Country Nursing Service and coöperated with a few rural communities in supervising the work of trained public health nurses, but relatively few places employed rural nurses prior to the war. The county tuberculosis societies also employed visiting nurses who worked throughout a whole county and whose work inevitably created a demand for visiting nurses for a more general service. The shortage of physicians during the war and the influenza epidemic of 1918 revealed the need for rural nurses and since the war the local chapters of the American Red Cross, which is devoting much of its attention to public health work, have employed hundreds of rural public health nurses.

The success of school nurses in the cities has led to their employment in the smaller towns, and now county school nurses are being employed in individual counties in several states, and in other states school nurses are employed by townships or jointly by several rural school districts. Wisconsin and Ohio have recently enacted laws compelling every county to employ at least one public health nurse, and a dozen or more states have passed legislation making the employment of county or local nurses optional. Under whatever auspices they are employed, rural public health nurses have found that their most effective work may be done at first in connection with the schools. Medical examination of school children is now required in many states, but unless it is followed up by some one who will see the parents and encourage them to secure the necessary medical or dental treatment, the results of these examinations are often disappointing.

A most interesting and instructive account of the work done by a county school nurse during the first year of her work in typical Minnesota county has been given by Miss Amalia M. Bengtson, superintendent of schools of Renville County:

      "Renville County is prosperous; there are few poor people, no child is underfed and no one wilfully neglected, yet our tabulated report shows an appalling amount of physical defectiveness. Out of our school population of six thousand we examined five thousand children, and found four thousand and ninety-five defective, testifying that 81 percent of the children were defective. This seems almost unbelievable, and yet it does not tell the whole story, for I could take you to school after school where there was 100 percent defectiveness, where we sent a notice to every parent in that school. Yet, as I said before, Renville County is a prosperous county, and we have every reason to believe that conditions in Renville County to-day are the same as in other counties where a health survey has been taken. The percentages of the defectiveness found were: teeth, 55 percent; nose, 40 percent; throat, 66 percent; eyes, 22 percent; ears, 17 percent; malnutrition, 16 percent; nervous disorder, 16 percent; neck glands, 14 percent; skin, 13 percent; and general appearance, 12 per cent."[57]

      In reply to the question, "What of it? What good came of the health survey?" Miss Bengtson says: "Our records show that about one thousand of the children examined were taken to see either a doctor or a dentist, or both, the first year. Parents who at first opposed the work are fully convinced that a county nurse should be a permanent worker among us when they see how much their children have been benefited by a little medical help.

      "Besides examining the children, the nurse has been a great factor in bringing about a general education for better health. In our county to-day you are behind the times if you do not know what adenoids are and the havoc bad tonsils can bring; why eye strain is so prevalent and how to prevent it; why teeth should be taken care of; why we should drink plenty of water and eat the proper kind of food; what kind of clothing is best to wear, and why we should not wear too heavy and too much clothing while indoors (we have induced some little boys to remove one coat and three sweaters while in school); why we need to be clean, etc.

      "Another great service the nurse rendered us was to bring about a veritable epidemic of school-house improvement. She proved that the physical condition of the school-house was reflected in the physical condition of the children. For example, a poorly lighted and badly ventilated school-house always housed children with eye strain and nervous disorder, and in a school-house having ill-fitting desks were children of poor posture.

      "During the summer of that first year the nurse was with us, we conducted so-called 'baby clinics' in the county, one in every township and one in each village. We urged the mothers to bring their children below school age to the clinics, and much the same kind of examination was given them as was given the children of school age. We found that 60 percent of the children of pre-school age were defective."

This is but a sample of the work and experience of hundreds of rural nurses and shows how the nurse is a health teacher in the most effective manner, for she gets into the homes and gives personal help in bringing about better health. She uses the demonstration method in health work just as the home demonstration agent does with food, clothing, and home management. Furthermore, when the nurse is devoted to her work--and most nurses are or they would not stick to so hard a job--she becomes endeared to the people just as does the family doctor, for the help she gives in cases of sickness, accident, and childbirth, when she is of invaluable service to isolated homes who can secure no other help. A slip of a girl--though a well-trained nurse--who commenced work in a nearby community was introduced to her new work with two confinement cases and an accident case the first day, for none of which was a physician obtainable. The Red Cross Nurse in my own county has spent many a night in a farm home in order to get sufficiently acquainted with parents to induce them to allow her to have needed treatment given to their children, and when the parents come to realize the benefit which their children have received from operations on tonsils or adenoids, the fitting of glasses, and similar services, and appreciate the handicap which such defects would have been to them through life, the nurse has a warm place in their hearts and they eagerly support her work.

One of the difficulties of the average country doctor is his lack of facilities for the expert diagnosis of disease and for the care of patients who need to be kept under observation and given supervised care. Medical science has become highly specialized. The human body is so complicated and wonderful a mechanism that we no longer can expect any one man to be expert on all its ailments. If one desires to secure the best medical service, he goes to a large city hospital or a sanitarium, where various specialists can be consulted and where laboratory facilities are available for their aid. In the average village or country town both specialists and laboratories are lacking and the physician is dependent on his own knowledge and resources. The well-trained physician who appreciates his own limitations and that he cannot give many of his more difficult cases the care they ought to have, sends those who can afford it to the nearest hospital, and does the best he can for the others, but he is keenly aware that he cannot always give them the treatment they should have and he envies his city colleague who can take his patients to specialists for examination.

It is a fear of this professional isolation which causes the average young doctor to start his practice in the city where he has better facilities, and which is largely responsible for the small number of young doctors in rural counties. It is, of course, impossible to have a hospital in every hamlet, but it is possible to have a good hospital and laboratories at every county seat or small city center, so that there will be at least one such medical center in a county. Legislation has now been enacted in several states making it possible for counties to support a public hospital just as the larger cities have done for many years. Here clinics may be held from time to time, to which eminent specialists may be brought for the diagnosis of different cases, to the advantage of both patient and physician. It is quite impossible for a busy country doctor to maintain a private laboratory and to provide himself with all the expensive equipment for making examination and tests of blood, sputum, urine, for X-ray examinations, etc., but the hospital may have all this equipment at his service.

One of the most important features of the domestic program of the American Red Cross is the promotion of so-called "Health Centers," a movement which is also sponsored by the American Medical Association and other national health organizations. Such a health center may include a hospital with well equipped laboratories and clinical facilities, or it may be nothing more than a room in a small village, equipped with scales for weighing children, with first aid kits for accident cases, and used for occasional clinics for the examination of babies and children of pre-school age and for classes in home nursing or first aid; but every community of any size should have some place which will be a headquarters for its local health Service, equipped as may be most practicable to meet its needs, according to the size of the community.

Curiously enough the local physicians, who would be most helped by such improved health facilities and whose practice would be benefited by them, are often their chief opponents. The leaders in the medical world, who are keen for all practicable means of improving the public health, heartily support the "health center" movement.

We are coming to the time when the maintenance of health will be regarded as a public function just as education is now provided for all the people and supported by them. That country people are alive to the need of better health facilities is shown by a resolution of the recent (February, 1922) Agricultural Conference called by President Harding at Washington. Its committee on farm population reported:

      "The safeguarding of the health of the people in the open country is a first consideration. Any program that looks toward the proper safeguarding of health must include adequate available facilities for the people in the open country in the way of hospitals, clinics, laboratories, dispensaries, nurses, physicians, and health officers. This committee endorses the growing tendency through public agencies to maintain the health of the people by means of these facilities and agencies."

The life of rural people in America is no longer threatened by the invasion of human foes, but it is constantly threatened by disease. It would seem that the first public concern would be for the maintenance of the health--the very life--of its people, but as yet we have given much less thought to health than to education. The New York State Department of Health has as its slogan: "Public health is purchasable. Within natural limitations any community can determine its own death rate." This is no longer theory, but can be demonstrated by official mortality statistics. The death rate has declined more rapidly in cities than in rural communities because the cities have given more adequate support to public health organization. The rural community has all the natural advantages in its favor and will ever have the most healthful environment, but it must recognize that if preventable disease--with all its attendant evils to the family and to the individual--is to be reduced, this can be accomplished only through education and public health agencies. Better health is a matter of the hygiene of the home and the individual, but it has also become a concern of the common life--a community problem.

Footnotes:

[54] "A Study of Sickness in Dutchess County, New York." State Charities Aid Association, New York City.

[55] L. L. Lumsden, "Rural Sanitation," U. S. Public Health Service. Public Health Bulletin No. 94, Oct., 1918.

[56] See Dr. W. S. Rankin, "Report of Committee on Rural Health," Proceedings Second National Country Life Conference, p. 93.

[57] "An Adventure in Rural Health Service." Proceedings Second National Country Life Conference, p. 47.