Current Preoccupations of Health Officers

THE MOST IMPORTANT MATTERS before health officers at present seem to group themselves under 3 main headings¹: the paramount problem of budgets in this period of economic uncertainty²; the need for careful evaluation of public health practices for the purpose of eliminating less profitable services and strengthening those of major health importance; and³ a practical program which will bring the members of the medical profession into active participation in the community-wide application of personal hygiene. Please note the word practical, for there has been a lot of theory and lip-service in this matter.

A consideration of the first and second of these major preoccupations of the health officer might well go hand in hand, for during the golden decade from 1920 to 1930 health department budgets were almost constantly on the increase. Much of what was asked for was appropriated, and there was little or no necessity for pruning or eliminating wasteful practices or age-old inheritances that did not produce results commensurate with their costs. City, county, and state health budgets have recently been cut, in some instances by 20% or more. To be compelled to go through such an experience may, I believe, be an intensely profitable one for a health department. The gains resulting from such budget cutting, if not continuous or excessive, are sometimes unexpectedly helpful.

A health officer faced with a major appropriation reduction at first feels that it simply cannot be done. After the first shock is over, he sets himself resolutely to the task of pruning, which proves in the end to be a test of himself, of the department, and of its relationship to the governmental administration. Happy is the man at such a time who has the whole-hearted support of his superior officers and their genuine interest in preserving a fundamentally sound and efficient public health service. He is either free or not free to make the adjustment in the best interests of the community. He is either instructed to make the slashes himself or it is done for him by the budget authorities. To submit health department budget requests for 1933 with slight reductions from the figures for 1932, in my estimation, is a wise procedure because of the present financial situation that makes necessary every possible retrenchment in governmental expenditure. Within the limits of public safety, no health department can now afford to ignore the importance of this necessity.

Reductions in health department appropriations, where they have occurred, have made imperative the careful evaluation of public health practices in order that services which were eliminated or reduced in volume might not be those producing a major health return. Not only is it a question of what activities should go by the board, but more difficult yet, which members of the staff can best be spared. Problems of civil service and tenure of office for personnel arise to plague the health officer's midnight hours that should be given to restful sleep.

Fortunate are the health departments which have already been able to turn their major attention toward modern public health practice, which centers in the personal health of the individual citizen. In many places there are dead weights that must be lifted from the health machinery, weights that have been inherited from a program that often centered in complaint work and nuisance abatement.

The splendid services of protecting city water and milk supplies and providing proper community sewage disposal have become foundation stones which are now accepted and on which future progress in public health will be built. Nothing must interfere with their continued and efficient functioning but primary attention should now be focused on personal hygiene. This will make available on a large scale known methods of health protection for the individual. The wide application of such personal hygiene is now recognized as essential for any advance in civic health. The thoughtful health officer is preoccupied in determining which of the inherited services of the past he can profitably eliminate or reduce and what other activities he must embrace or strengthen if he is to avoid the risks of stagnation and well founded criticism.

In this change of emphasis many things will come to your mind. The need for better industrial hygiene, which is perhaps the most important of the untilled fields of public health; added emphasis on prevention of illness in the older age groups; increased attention to the mounting death rates for cancer, heart disease, diabetes, and accidental deaths; a new focus on methods of integrating mental hygiene with the community health service; and back of all, a proper emphasis on the need for public health education to bring about the desired results–all these and others come into the picture of evaluating present health practices for the purpose of sound future development.

Leadership in health promotion is the function of a health department. It should organize and coordinate official and nonofficial agencies and make possible a far-reaching health machinery. No health department can do its job along modern lines without the active support of the medical profession. This support is needed and is expected by up-to-date health officers. Such work as the eradication of diphtheria, the reduction of the venereal diseases, and the adequate care of expectant mothers and of young children must rest largely in the hands of the practicing physicians. A health department can do much to teach the public to seek such keep-well services from the medical profession. It should never hope to have a staff or clinic service large enough to carry on the needed volume of work itself. The practicing physicians are the outposts on the firing line in the modern battle for better health and they should be considered by all as veritable public health agents.

This brings me to the third major preoccupation of the health officer and that is the establishment of practical methods for bringing the members of the medical profession into a more active participation in the community-wide program of personal hygiene. There has been a great deal of theory and lip-service in this matter during recent years. Nearly everyone recognizes the desirability of having the practicing physicians feel that they are playing a real part in the modern health crusade. As a matter of fact, they are doing just that in a large portion of their private practice day by day, but they have received very little recognition for their contribution. In certain places where community sanitation, including water and milk control, sewage disposal, and nuisance abatement vie with communicable disease control in occupying the major attention of the health administrator, the need for a more closely knit working arrangement with the local medical profession has not received due consideration.

George Huntington Williams, circa 1940.

Courtesy of the Alan Mason Chesney Medical Archives, The Johns Hopkins Medical Institutions.

Until recently some leaders in the medical profession have felt that public health was distinct and apart from private and personal hygiene and that the latter should be left entirely in the hands of the medical profession. Rather naturally those who are engaged in the great tasks of social welfare are somewhat impatient with any delay in the application of known preventive measures among large groups of citizens who are not able to take the initiative, or who will not, in the health protection of their own families… . There can be no more vital problems confronting the medical profession and public health authorities than their mutual relationships and fields of activity.

Sir Arthur Newsholme has published a valuable discussion on the topic in a recent issue of the Journal of the American Medical Association and in his latest volume Medicine and the State.^1,2 Dr. William H. Welch, on the occasion of the celebration of his 80th birthday in Washington, in 1930, referred to this same problem and said:

Something of the lack of adjustment of the average man to rapidly changing social, economic, and political conditions of our complicated modern civilization, may be reflected in a certain temporary maladjustment between curative medicine and preventive medicine, which should stand in harmonious relations.³

The adjustment needed to bring about smooth-running cooperation will perhaps be achieved when medical schools give the proper emphasis in their curricula to the teaching of the practice of preventive medicine; when dispensaries, clinics and health centers serve as foci for postgraduate medical instruction along preventive lines, and when health departments become fully awake to the valuable assistance which they may receive from the medical practitioners who are leaders in their own areas. Medical educators should keep ever before them the dictum of that statesman, Sir George Newman, Chief Medical Officer of the British Ministry of Health, who has said: “The first duty of medicine is not to cure disease, but to prevent it.”

I keep thinking of an almost ideal situation where a health officer I once knew served as the chairman of the public health committee of his own county medical society. You may well imagine that cordial relations were almost inevitable in such a hook-up. It does not often occur. This rather dual personality would write himself letters from time to time, from the health department requesting the approval and assistance of the local medical fraternity on a particular health project. In due course of time the letter would be referred to the public health committee and he would send himself a reply assuring the health department of the desire of the local medical profession to do its best to assist in the particular activity under discussion. Some such working basis between health authorities and the medical profession is possible of achievement wherever it is sufficiently desired and where any preexisting causes for distrust or suspicion have been removed. Many of you know of places where just such satisfactory relationships have been worked out, by conference, by communication and by a little application from time to time of the Golden Rule.

It is my feeling that health departments must bring to the attention of the medical profession the fact that they, the health departments, are by statute required to do their utmost for the health protection of the public but, at the same time, that they desire to afford to the medical profession every opportunity of participating in the program and advising in the many details that will go to make it successful.

These details affect, in a very genuine way, the activities of workers in all of the sections of the American Public Health Association who are represented here today. After all, the health officer is merely the general family physician for the community who must call in the aid of specialists in the fields of laboratory work, of maternal and child hygiene, of communicable disease control, public health education, nutrition, and many other particular branches of service. In almost every instance what these specialists would like to see in wide application impinges directly upon the private practice of medicine in any given locality. The Committee on Administrative Practice states that satisfactory public health work requires among other things the support of the medical profession.⁴ This support cannot be had merely by wishing for it, but must be earned as a result of careful and unselfish planning.

In closing, may I say that health officers have no right to take themselves too seriously, that like others they must be able to give and take if their work is to succeed. If they are blessed with a lively sense of humor and a good digestion it is almost certain that their major preoccupations will not weigh too heavy upon them.