w 7 Cbe liorarp of the Division of ^eauf) affairs GJntoersitp of Jftortf) Carolina Sho AN8 L726 i960 c.l ^^^ INSTITUTE OF GOVERNMENT University of North Carolina Chapel Hill GUIDEBOOK SERIES DECEMBER, 1960 Public Health in North Carolina A Guidebook for County Commissioners by Roddey M. Ligon, Jr. Assistant Director, Institute of Government Institute of Government Staff Albert Coates, Director Clyde L. Ball Marion W. Benfield, V. Lee Bounds Robert G. Byrd George H. Esser Neal Forney Philip P. Green, Jr. Jr. Roy G. Hall, Jr. Donald B. Hayman Milton S. Heath, Jr. Henry W. Lewis Roddey M. Ligon, Jr. John Robert Montgomery, Jr. Elmer R. Oettinger John L. Sanders Robert E. Stipe L. Poindexter Watts, Jr. Warren J. Wicker Gbe m&rarp of tt>e DftWion of {,„„(, affa(rs J ■ . • ". . ■ •■ ' ' ' - 7 - The board elects its own chairman. The county health director is required to act as secretary to the board. District Eoards of jfegjj-h Under rules and regulations established by the State Board of Health, district health departments including more than one county may be formed in lieu of county health departments for each of the counties involved when the following condition or conditions exist: (l) When the funds derived from tax levy plus available State and other funds are insufficient to provide a minimum standard health department of one medical officer, two nurses, one sanitarian, one clerk, and a regular dental program, or (2) when, in the opinion of the State Board of Health, special problems or special projects arise which can be handled more advantageously on a district basis and the consolidation is approved by the State Board of Health and the board of health of each county involved. When two or more counties are combined into a district health depart- ment, the policy-making body for the district health department is a district board of health composed of three or more ex officio members and four public members. The ex officio members are to be selected by the State Health Director, and at least one must come from each par- ticipating county, and they must include at least one chairman of a board of county commissioners, one mayor of a town which is a county seat, and one county superintendent of schools. The ex officio members are appointed during the first week of December following the general election in which members of the General Assembly are elected and they serve for a period of two years. The public members serve four-year, staggered terms, with one member being elected by the ex officio members ■ ' ...•'■ ■ ■■■-■'. : vyel i ■ - ■• • ■ i " • ... ■ . . ■ ■ - .. ■ . ■ • - • • - . 8 - at an annual meeting during the first week of January of each year. One of the public members must be a licensed dentist, one a licensed physician, one a licensed pharmacist, and the other is to be any public- spirited citizen. At least one public member must reside in each county, but not more than one half of the public membership may come from any one county. If more than four counties form a district health department, an addi- tional public member may be added for each county in excess of four. No public official other than those specified above may serve as a member of a district board of health as this would constitute double office holding which is prohibited by the State Constitution. District boards of health elect their chairman, and a majority of the members of the board constitute a quorum, and the district health director is required to act as secretary to the board. Vacancies ia the ex officio membership of district boards, other than by reason of expiration of a term, are to be filled by appointments made by the State Health Director. All vacancies in membership of the public members of a district board of health are to be filled by the ex officio members at the next meeting of the district board of health following the creation of a vacancy. A member appointed to fill the vacancy of a public member must be from the same county as the member causing the vacancy. In lieu of district boards of health as above described, on approval of the board of commissioners of each county in the district, counties forming or which have formed district health departments may establish and maintain separate county boards of health, organized as prescribed for boards of health for county health departments, to perform for their respective counties the functions in relation to the district health : - 9 - department which would have been performed by the district board of health had one been created, and each such board may maintain a separate budget, A district may not, however, have a district board for some of the counties and a county board for others in the district. There must be a district board for the entire district or else county boards for each county within the district. (From Letter of Attorney General to Dr. Higgins dated 28 March 1958.) Records of the State Board of Health show that: there are currently 66 counties with a county health department; there are 5 two-county dis- tricts; there are 5 three-county districts; there is 1 four-county dis- trict; and, there is 1 five-county district. Powers and Duties of Local Boards of Health G. S. 130-17 provides that the local boards shall meet quarterly, and that the Chairman or any three members may call a special meeting whenever in his or their opinion the public health interests of the county or district so requires. At either regular or special meetings, any four members constitute a quorum. Under G. S. 130-16, the members of local boards of health may receive $8.00 per diem for each day in attendance at a meeting of the board, plus necessary travel expenses. The powers and duties of local boards of health are also set out in the general law of the State. The boards are charged by G. S. 130-17 with the "immediate care and responsibility of the health interests" of the county or district. Under the same section, the boards are authorized to "make such rules and regulations, not inconsistent with law, as are necessary to protect and advance the public health. " The power to "make such rules and regulations" as the boards deem necessary is subject to the limitation contained in G. S. 130-17 which ' -■■■:■:'' . - - ■..'.. I ■ - ■ - . | ■ ■ ■ . - - , ' ' ■ '• • . ■ • hrstroo ' ■ • . •'• - -• : " ■,'■"■ ■ ! ' v ' . ■ ' ; ...... . . ■. - ■ ; . ., - ■ I ' ..-'-. ■• ■ • '.'-.• .■ .. ■ n i ■ •'■■.''■'■'■ . - ; ■ . • i ' ■ " - . ■ ■ ' " . :.- ' r be ■>'■'-' - - | • . '' snoxd • - . . - . ■: • • - 10 - provides that lartiile the boards have power to adopt regulations applicable throughout the county or district, including municipalities located therein, the boards are prohibited from passing a special regulation covering a particular municipality only except where circumstances peculiar to that municipality require more stringent rules and regulations. The power to make regulations is, of course, also subject to the fundamental limitation that such regulations must be reasonable, and that the end sought by them must have a substantial relationship to the public health. Before the regulations become effective, they must be posted at the courthouse door or doors, and a statement indicating that they have been adopted and that a copy is posted at the courthouse door, and that a copy is on file in the health department, must be published once a week for two successive weeks in a newspaper having general circulation within the county or district. G. S, 130-203 makes it a misdemeanor punishable by a fine not to exceed $50 or imprisonment not to exceed 30 days for any person to violate or fail to comply with any rules and regulations adopted by a local board of health. G. S. 130-205 authorizes the obtaining of an injunction to prevent a violation of rules and regulations adopted by a local board of health, and G. S. 130-20U authorizes authorized representatives of State and local boards of health to enter any premises for the purpose of carrying out the provisions of the health laws or regulations. G. S. 130-17 provides that "all expenditures are to be made in accord- ance with appropriations duly made under the provisions of the County Fiscal Control Act." In summary, this means that the county board of health, working with the health director, prepares a budget statement and submits it to the county accountant after March 15 and prior to June 1, ■ : " ' - • '....■..." - ' - . J ... • ■ ■ '■■•-' ' . - ■ : -li- on a date selected by the county accountant. This budget statement must contain: (1) a statement of the amount expended for each object of expenditure in the department in the preceding fiscal yearj (2) amount expended and estimated to be expended during current fiscal yearj (3) an estimate of the requirements of the department for each object during the budget yearj and (k) any supporting information prescribed by the county accountant. The budget statement is to be in such form and in such detail as may be prescribed by the county accountant. Upon receipt of the budget statements from all departments, the county accountant prepares a budget estimate for submission to the board of county commissioners not later than the first Monday in July. This estimate contains, among other things, the county accountant's estimate of amounts necessary to be appropriated for the budget year for each of the various departments and an itemized estimate of revenue to be available during the budget year. Provisions are made for newspaper publication of the fact that the budget estimate has been filed with the commissioners and that a copy is available for public inspection. At least 20 days after the publication of the notice of the budget estimate, but not later than July 28, the commissioners are to adopt a budget resolution appropriating funds for the various departments and providing for the financing of the appropriations so made. The appropriations are to be in such sums as the commissioners deem appropriate, whether greater or less than the recommendations of the budget estimate. The appropriation to each department is to be in such detail as the commissioners deem advisable. Provisions are made for amending the budget resolution and for making interim appropriations by the commissioners. ■■ . . ■ . ■ • ■■■ ■ ■ : - ' •• -. - - ■ s.ia ' - ' - • • - ■ ■ . - :o.n ■ . . . - .- - ■ - 12 - The County Fiscal Control Act also requires that each bill of claim be approved before payment by the department head and that all warrants or orders for the payment of money be countersigned by the county accountant, certifying that a sufficient appropriation exists to cover the payment. Thus, it is the duty of the health director and the board of health to prepare the budget, but it is up to the board of county commissioners to adopt the budget under the provisions of G. S. 153-120. The board of county commissioners may make appropriations in such detail as to them seems advisable, In some counties, for example, the board makes a lump sum appropriation on the basis of the budget submitted by the health director and the board of health, leaving it to the health director and the board of health to allocate and transfer funds among the requested items in their discretion. In other counties, the board of county com- missioners adopts the budget in more detail, making specific appropriations for salaries, materials and supplies, and capital outlay, for example; in such a case, no specific appropriation can be exceeded until the health director and board of health return to the board of county commissioners and obtain approval to supplement the specific appropriation by transfer of funds from another item. In counties belonging to a district depart- ment, the board of commissioners usually makes one lump sum appropriation for the county's annual support. In counties where there is a county health department, the County Fiscal Control Act requires the creation of a separate public health fund.. County taxes levied for public health purposes would be dis- tributed to this fund, as would state and federal funds and other revenues ear-marked for public health purposes. All public health expenditures would be .•■-■. rsvor ■ . - . .: ; i - ■ • ■ - ... ^ • ■ . ... - 13 - made from this fund. The expenditures, however, would not be made until the health director, as the department head, had approved such expenditures as required by G. S. 153-131. In addition, no expenditure would be made until the county accountant had approved and countersigned, indicating that there was sufficient appropriation to cover the expenditure. In counties belonging to a district health department, a different procedure would be followed. The contract entered into between the State Board of Health and each Board of County Commissioners provides that in the case of district health departments, the district board of health shall name a disbursing agent who will receive and disburse all funds of the health department and prepare and sign all vouchers drawn on the funds of the district health department. All vouchers shall be counter- signed by the chairman of the district board of health or some other person specifically authorized by the district board to countersign vouchers. The disbursing agent shall make a surety bond of not less than $5,000, premium to be paid out of the health department budget. Therefore, in district health departments, the following procedure would seem appropriate. The district board of health would select a disbursing agent, who could be the clerk of the local health department who actually keeps the records. The disbursing agent would then give the required bond, would prepare and sign checks, and they would be countersigned, as the contract requires, either by the chairman of the district board, or perhaps by the district health director if he were designated to countersign vouchers by the board. It would be the responsibility of the counties forming the district to pay their appro- priations into the district health department, the clerk would keep all records, be responsible for all funds, prepare and sign all checks, and . •■- ■ ' - ■• ■ - . ■ ■ . ' ' . - m - have them countersigned by the chairman of the district board of health or some other person designated by the board. It would not seem appro- priate to have the county accountant of any county within the district countersign these checks (as in the case of the county departments), since he has no way of determining whether the expenditures are within avail- able funds or not. Local boards of health are subject to the provisions of an annual contract between the board of county commissioners and the State Board of Health, a copy of which is set out verbatim on page 18. The commissioners must enter into this contract in order to receive State and federal grants- in-aid. The local board of health is empowered by G. S. 130-18 to elect a county or district health director. The statutes require that he meet the qualifications prescribed by the Merit System Council, under G. S. Chapter 126. The county's contract with the State Board of Health stipulates that the local board of health shall employ a qualified health director who meets the following requirements: 13 a reputable physician holding a license to practice issued by the North Carolina Board of Medical Examiners. Is a man of good moral character, without objectionable habits. Has met the minimum qualifications established by the Merit System Council . . . , and has been certified by the Supervisor that he has complied with all require- ments of the Merit System Council. Local boards may make an emergency or temporary appointment under G. S. 130-18, when necessary, and with the approval of the State Health Director. When, in the case of a vacancy in the office of health director, -■■.■■•■■ •. ■ ■ ■ ! - - i ■ ■• ■ . ■ - 15 - the county or district board of health fails for a period of sixty days or more to elect a health director, the State Health Director may appoint a health director to fill the vacancy. The health director so appointed shall serve until the local board of health elects a health director. Relationship between Board of Health and Board of County Commissioners Although boards of county commissioners have many responsibilities with respect to various public health activities (which are discussed in this publication), the relationship between the commissioners and the local boards of health is primarily a financial relationship. It is the function of the board of commissioners to pass on the budget requests of the board of health, along with such requests from all county departments. The board of commissioners has specific authority, under G, S. 130-21, "to levy at any time a special tax for the preserva- tion and promotion of the public health, " This includes authority to appropriate monies for the maintenance and operation of a health depart- ment, and authority to appropriate public funds for the purchase, acqui- sition, erection, maintenance, alteration and repair of buildings necessary to house and quarter a health department. The statutes declare that such expenditures are necessary expenses, and grant the special approval of the General Assembly to levy special taxes therefor. Thus, there is no limit on the tax which the board of county commissioners may levy for health purposes. State Board of Health and Relationship to Local Bo ards of Health The General Statutes create a State Board of Health consisting of nine members, four of whom are elected by the Medical Society of the State of North Carolina, and five are appointed by the Governor. One ' - - - .'■■.'' . ■ ■ ! ■ - . ■ . F iij - ■ ■ ' - -. . . - - 16 - of the members appointed by the Governor must be a licensed pharmacist, one a reputable dairyman, one a licensed dentist, and one a licensed veterinarian. The members serve four-year, staggered terms. The full- time executive officer of the Board is the State Health Director. The State Board of Health is given responsibility for establishing general policies to be followed in carrying out public health programs, and is given authority to adopt rules and regulations necessary to enable the Board and its administrative staff to administer and enforce the public health laws of the state. The State Board of Health is also authorized to accept and allocate or spend grants-in-aid for public health purposes which are made available by the state and federal governments. The administrative staff of the State Board of Health is to exercise such administrative authority as may be assigned to it by the State Board of Health, including the following: enforcing the state health laws and rules and regulations adopted pursuant thereto; .investigating the causes of epidemics and of diseases affecting the public health; developing and carrying out reasonable health programs for the protection and promotion of the public health and the control of disease; making sanitary and health investigations and inspections; conducting studies and research concerning the prevention of disease, the prolongation of life and the promotion of physical health and mental efficiency of the people of the state; receiving gifts of money or any other property which may be used by the Board for the purpose of carrying out its public health program; disseminating information pertaining to public health; being the health advisors of the State, and advising State officials as to the location, sanitary construction, and health management of all state institutions; making, or causing to be made, an inspection at least once in each year, ■ ' - ' ■ • ■ - : ■■■'..■ ; ■ ■ ■ ■ - 17 * and at such other times as it may be requested to do so by the State Board of Public Welfare or other State agency or institution, of public institu- tions and facilities including those subject to license or inspection by the State Board of Public Welfare or any other State agency (this would include, for example, county jails), and to make a report as to the condi- tion of such agencies or institutions together with recommendations for the improvement thereof; being the nutrition advisors to the institutions owned and operated by the State or by a county; and, making a biennial report to the General Assembly through the Governor. The chart on page U3 shows the present membership of the State Board of Health and the present organization of the State Board. This chart is based upon information contained in a similar chart published by the State Board of Health on May 1, I960. G. S. 130-9 provides that all rules and regulations adopted by the State Board of Health e.re to be enforced by its administrative staff or by local boards of health under the authority of the State Eoard of Health. Thus the State Beard of Health may provide that employees of local health departments are to enforce certain regulations of the State Board of Health, We do not have, however, a system of direct state control over the activities of county health agencies as our local health departments are rather autonomous agencies. Indirectly, the State Board of Heal + h and its operating depart lent under the State Health Director dees exercise considerable influence in local health work, in two major ways: (l) by providing consultative and advisory services, and training and certifi- cation programs for the various specialists in local he?-lth dapartments-- largely an educational program; and (2) by allocating State and federal funds to the counties, such grants being conditioned upon an agreement - ■ - : • - ■ - 18 - by local authorities to meet the requirements set out in the contract between the State Board of Health and the board of county commissioners. (The Attorney General has expressed the opinion that the State Board of Health has ample authority to impose reasonable conditions upon the allocation of grants-in-aid to local health departments — In Letter from Attorney General to Ben Eaton, dated 5> June 1959 . ) A copy of this contract for the fiscal year beginning July 1, I960, is set out verbatim below: "CONTRACT WITH COUNTY, CITY, AND DISTRICT HEALTH DEPARTMENTS For the Fiscal Year Beginning July 1, I960 This Contract is entered into between the North Carolina State Board of Health and the County, City or District Health Department, subject to the following conditions: I. That in order to administer public health activities in the County, City, or District of , for the fiscal i n ■ i . i i ■ ii» i i " miimm ii imtJ . «^ »^n» »i *-«"' i m i i^ ^— year July 1, I960 to June 30, 1961, it is agreed that funds will be appropriated or allocated to the County, City, or District Health Department from the following sources in the amounts listed: County .$ Cities and Towns $ State and Federal . $ II. That it is understood and agreed that funds from other sources, such as Other Local, or Other Non-Local, shall be in addition to these amounts, and shall be included in the State Official Budget for Local Health Activities j III. That in counties not having a full-time public health dentist funds are to be provided in their health department budgets to defray -■;.'■ : - ■ .:: ■ . - ■ - .'•■'■' - 19 - one-half of the expense of a Dental Health Program furnished through the Division of Oral Hygiene of the State Board of Health; that for each county with a population of not more than 10,000 funds shall be provided for one-half of the expense for a minimum of six weeks' dental service; that for each county with a population of 10,000 to 25,000 funds shall be provided for one-half of the expense for a minimum of ten weeks' dental service; that for each county with a population of 25,000 to 60,000 funds shall be provided for one-half of the expense for a minimum of twenty weeks' dental service; and that for each county with a population of more than 60,000 funds shall be provided for one-half of the expense for a minimum of thirty weeks* dental service. That, inasmuch as the Division of Oral Hygiene is defraying one-half of the expense of the dental program in each county and the dentists are employed for the entire year, it is understood and agreed that at least one fourth of the allocated time in any county may be furnished while schools are not in session; and that, while the Division of Oral Hygiene cannot guarantee to deliver this service, it is impossible for the Division to employ dentists, when available, unless funds are budgeted by the counties to defray their half of the expense of the dental program. IV. That all County and City appropriations shall be paid in twelve (12) equal monthly installments to the __________ _________ County, City, or District Health Department, or paid in accordance *?ith a plan mutually agreed upon by the local governing body and the local health director; - - . - - ' ' . - ■ ■ : - - - 20 - V. That the payment of State and Federal Funds shall be based upon a constant percentage of the total salaries as budgeted in the Local Health Department's original "Annual Budget" (not the "Tentative Budget"), such budget having been approved by the North Carolina State Board of Health; VI. That the payment of State and Federal funds for the first quarter shall be made not later than July 20th, and shall equal one-fourth of the total allocation for the year; VII. That the payment of State and Federal funds for the second and third quarters shall be made not later than the 20th day of the second month of each quarter, and any adjustment which may be necessary in order to reflect the actual expenditures for approved salaries as originally budgeted for the preceding quarter shall be made in each of these payments; VIII. That the State and Federal funds due for the fourth quarter shall be made in two payments as follows: A. Two-thirds of the quarterly allotment, less any adjust- ment which may be necessary due to actual salaries in the preceding quarter having been less than the approved salaries as originally budgeted, shall be paid not later than May 20th j B. The balance due for the year shall be paid not later than June 20th after receiving the "Memorandum of June Payroll" (as stated in paragraph XXX, section A, sub- section 6 of this Contract), which is a report of the salaries which will be paid for the month of Junej IX. That these funds shall be expended only for the items in the approved budget j X. That the total State and Federal funds included in the budget shall not exceed the original allotment j ■■■'■ - g : - - 3 , T - ! ■ - ■ ■ [ - - 21 - XI. That, except in July (in accordance with a ruling by the State Attorney General), NO PAYMENT SHALL BE MADE UNTIL THE "MONTHLY BUDGET REPORT" FOR THE PRECEDING MONTH IS RECEIVED BY THE STATE BOARD OF HEALTH IN PROPER ORDER . If the "Monthly Budget Report" for any month is received after the 12th of the following month, payment shall not be made until the next regular pay period, unless a justifiable request for an exception is submitted in writing by the Local Health Directors ii i ll i ■ ii 111 iihi. ■■ >i ■■■■■■ — > ■■nil i ■ ii ii i ■ i i i i i r i in -ii i ii i mi i iii . ■ i >■ — ■■ XII. That it is further understood and agreed that any balance remaining to the credit of the _____________ ■_»_», County, City, or Dis- trict Health Department as of the close of business on June 30, 1961, whether such balance has accrued from County, City or Town, State, Federal, or other funds, shall be carried forward to the credit of the Health Department in the succeeding fiscal year: XIII. That the County, City, or District Board of Health shall employ a qualified Health Director who meets the following requirements: A. Is a reputable physician holding a license to practice issued by the North Carolina Board of Medical Examiners: B. Is a man of good moral character, without objectionable habit s j C. Has met the minimum qualifications established by the Merit System Council as provided in Chapter 378, Public Laws of North Carolina, 19 ill, and has been certified by the Supervisor that he has complied with all the requirements of the Merit System Council: XIV. That all full-time County, City, or District Health Directors, and other full-time members of the staff of the County, City, or District Health Department shall not engage in the private practice of medicine nor related activities other than the discharge of official duties; XV. That the County, City, or District Health Director as agent of the Local Board of Health, shall have sole authority to employ, direct ■ in.rj '■ - '.'.-■-.'■•... - - ■ . ■ tfg • •. - ' ] ■ - ' ' ■'.■:•■ ■ ' . . .'-. a - . ■.-.■.- ' ■ •■''-". i . • . ox - 'oO : ! ! --. '■ ■ .. :o±U It ■ | ■ -" ■ . I , ■ ■■ ' ■ f ... ■■■ '■■ ' ,VOl - - - • • ■ - - 22 - and replace all other members of the staff of the County, City, or District Health Department j such appointments shall be subject to the following provisions: A. They shall conform with the Merit System Principles as outlined in Chapter 378, Public Laws of North Carolina, 19U1, with amendments currently in force, and the rules and regulations adopted by the Merit System Council, as authorized? B. They shall be made from the qualified list, certified by the Supervisor (copy of rules and regulations may be obtained from the Supervisor of the Merit System) ; XVI. That the signature of a member of the Local Board of Health, selected by said Board, shall be on all Merit System forms relating to employ- ment or change of salary or classification of Health Department personnel to signify that the Board is apprised of and approves the rates of pay involved j XVII. That for City Health Departments, the Merit System forms shall be signed by the City Manager or Mayor; XVIII. That all requests for budget revisions involving salary increases for personnel already employed shall be made only at the beginning of the quarter in which the increase becomes effective; XIX. That revisions necessitated by new personnel, or for new budgeted positions, where delay would jeopardize securing the personnel may be made at any time; XX. That all revisions requested shall be .in the form of a letter addressed to the Director, Local Health Division, N. C. State Board of Health; XXI. That no salary supplement shall be paid on a fee basis; XXII. That any person assigned to perform certain services shall, if in the opinion of the Health Director, and the duties justify, receive a salary adjustment only when such adjustment conforms to the Compensation - "■ - ■ - ! ■ - 23 - Plan approved by the Merit System Council 5 XXiri. That salaries, travel allowances, and other official expenses of the staff of the County, City, or District Health Department shall be approved by the State Board of Healthj HIV. That all salaries shall conform to the Compensation Plan approved by the Merit System Council, as provided under Chapter 378, Public Laws of North Carolina, l°Ul, with amendments currently in force, or by special action of the Merit System Council, before approval shall be granted by the State Board of Healthj XXV. That annual leave, sick leave, and petty leave shall be granted in accordance with personnel regulations adopted by the Merit System Council, G. S. 126-11;, consistent with Merit System Rules and approved by the North Carolina State Board of Health, subject to modification by the local governing body; XXVI. That each Local Health Department shall keep a current written record of annual and sick leave on each employee on a cumulative basis, in accordance with Merit System Regulations; XXVII. That each District Board of Health shall name a disbursing agent for the District Health Department who shall: A. Receive and disburse all funds of the District Health Department; B. Prepare and sign all vouchers drawn on the funds of the District Health Department; XXVIII. That all vouchers shall be countersigned by the Chairman of the Dis- trict Board of Health, or some other person specifically authorized by the District Board of Health to countersign vouchers; XXIX. That the disbursing agent shall make a surety bond of not less than $5,000, premium to be paid out of the Health Department budget; ■ . ■ ■ - 2U - XXX. That each County, City, or District Health Department shall submit promptly the following records and reports (the composition and due dates of which it is understood and agreed are subject to change as needs arise) to the: A. STATE BOARD OF HEALTH : 1. Annual Budget - One copy (yellow). Due not later than August 1st. 2. Annual Contract - Three copies. Due not later than August 1st. 3. Annual Report - Two copies. Due January 21s*. ii i ■ i ■ i in i i iii U. Q uarterly V. D. Report - Items due as requested. 5. Monthly Budget Report - One copy. Due the 12th of each month. ' The "Monthly Budget Report" and Bookkeeping System shall be prepared and main- tained in accordance with the method approved by the State Board of Health. 6. Memorandum of June Payroll - Two copies. Due June" 17th. List all personnel to be paid in June and the salary each is to be paid. (The salaries which shall be shown on the "Monthly Budget Report" for June must agree with this Memorandum). 7. Bills for Physicians' Services at M. & I. Clinics . Copies according to instructions. Due the loth of each month. 8. Monthly Vital Statistics (consolidated counties) One copy. Due the 5th' of each month. 9. Inspection Sheets of Sanitarian s - One copy of each inspection. Due the 1st of each* month. 10. Monthly Report of Sanitation Activities - One copy. Due the 1st of each month, B. ME RIT SYSTEM COUNCIL : 1. Monthly Budget Report - One copy. Due the 12th of month, XXXI. That the records of activities shall be maintained on forms supplied or approved by the North Carolina State Board of Healthj - 1 ■ .. -. - ■ 1 - ! ■ ■ . - 25 - XXXII. That the books and records of the County, City, or District Health Department shall be available for inspection and audit by the State Board of Health at such intervals as the State Board of Health may require; XXXIII. That all items questioned by the Merit System Council shall be cleared before additional payments may be made by the State Board of Health, in accordance with a ruling by the State Attorney General; XXXIV. That the conditions of paying travel allowance shall be as follows: A, General: 1. That monthly travel statements shall be filed with the County, City, or District Health Director by each employee drawing travel allowance, reporting daily mileage and places visited; 2. That the total miles traveled and payments made shall be entered on the financial report; 3. That in the event two or more persons travel together, travel allowance shall be permitted for only one car; U. That per diem shall be allowed out of the travel allowance for official business only when employees are away from headquarters overnight, not to exceed nine dollars ($9.00) per diem, including meals, provided such allowances do not exceed the accumu- lated amount in the budget to date; 5. That each employee shall attach receipted bills to support the reported expenditures made for room rent (hotel, motel, etc.); 6. That a specified sum shall be budgeted for the official travel, including car depreciation in applicable cases, for each employee; 7. That each employee shall be permitted to draw his travel allowance at any time during the fiscal year; provided, however, that the amount drawn to date shall not exceed the accumulated amount in the budget; B. That the following method* shall be followed for the pay- ment of travel allowance: ■ ' : . ■ ■ - .- - - ■ - 26 - 1 ( , ) Method A - Thirty dollars ($30.00) per month as depreciation on the car owned and used for official business by such employee, and an additional amount to be paid at the rate of four cents (U#) per mile for official travel, excluding all mileage between the employee's residence and the office of the Local Health Department; 2 ( ) Method B - Seven cents (70 ) per mile for official travel in the employee's personal car, excluding all mileage between the employee's residence and the office of the Local Health Department; 3 ( ) Method C - If the County, City, or District Officials approve some other method in preference to Method A or Method B, there shall be attached 9 mm ~+ ■ -»■ ■ « tm ~mm i ■■■■■■ — mm i to this Contract an explanation of the method whi ch is elected for th e payme nt of travel allow - ances - such explanation shall be approved and signed by the official who executes the contract on behalf of the County, City, or District; U. That the method elected to be followed for the payment of travel allowance by the ^^^^^^^ County, City, or District Health Department is so indicated above by the proper notation; ( SIGNED)* * (TITLE) __ __ ^Select one method only **To be signed by the official who executed the Contract on behalf of the County, City, or District i . ■■ ■ : - ■ - ■ - ■ ■ 3 i - 27 - XXXV. That it is understood and agreed that in compliance with the provisions of the County Fiscal Control Act as it relates to the verification and proper accounting for receipts and expenditures that Method (1) or (2) below (please indicate) shall be followed, with the further understanding and agreement that until the County/City/District Board of Health has complied with the requirement of this method all subsequent allotments of State and Federal Funds shall be withheld by the State Board of Health: Method (1) Joint certification of each Monthly Budget Report by the Local Health Check (x) if Method Director and the responsible fiscal (1) Monthly Audit officer of the Local Governing Body selected. (i.e., County Auditor), and that each report shall be submitted to the State Board of Health not later than the 12th of the following month; -OR- Method (2) An annual audit report of the cash receipts by sources and the cash Check (x) if Method disbursements by objects for the (2) Annual Audit year ending June 30, 19 , corn- selected, pared with the approved budget (including any approved revisions) shall be submitted to the State Board of Health not later than September 30, 19^ , and that such report shall be signed by the ■ i • ■" ■ ■ ■ ' . . i i i ■. ■ ■ ad - 28 - responsible fiscal officer of the Local Governing Body who is not an employee of the Local Health Depart- ment (i.e., County Auditor), or the designated accounting firm, certify- ing the report's correctness j XXXVI. That the State Board of Health reserves the right to cancel this Contract upon 30 days written notice to the County, City, or Dis- trict Health Director if, in the opinion of the State Board of Health the provisions of this Contract are not complied with by the County, City, or District Health Department, and that each County, City, or District shall have the similar option of cancellation. APPROVED FOR THE LOCAL GOVERNING BODY: Signature: ^ Date: Chairman Board of County Commissioners, Mayor or City Manager For: County or City FOR THE NORTH CAROLINA STATE BOARD OF HEALTH: Signature: ^ Date: Director, local Health Divi- sion An additional contract, containing substantially the same provisions, is entered into between the State Board of Health and the boards of county commissioners of those counties with mental health centers under V ■ - ■ r&±[ - ..■'■■ -■■■.■ ■ - ' ■ [SVOi - • • ■ ■ i - - ■ ■ ■ - - 29 - the general administrative supervision of local health departments. This additional contract relates, of course, to the financing of the mental health center. Local Health Director and Department The local health director and his staff (see Table I on page Uk), who together make up the county or district health department, are the agents of the local board of health in discharging the board's statutory responsibility for looking after the "health interests of their county or district." They are thus required to enforce the rules and regulations of the local board, certain regulations of the State Board of Health, and the State health laws. Powers and Duties of the Local Health Director As we have noted, it is one of the conditions of the contract between the State Board of Health and the board of county commissioners that the local health director, "as agent of the Local Board of Health, shall have sole authority to employ, direct, and replace all other members of the staff of the . . . health department." All bis appointments, removals, and replacements must be made in conformity with rules and regulations of the Merit System Council, and appointments must be from a list of persons certified as qualified by the Merit System Supervisor. The contract specifies that neither the health director nor any other full-time members of the staff of the department shall engage in the private practice of medicine nor related activities other than in the discharge of official duties. The local health director has both general and specific duties imposed on him by statute. G. S. 130-19 provides that he "shall be the - . . . . . r! ■ - - - - i - 30 - administrative head of the local health department, under the local board of health, and shall devote his full time to public health work, perform- ing such duties as may be prescribed by law, by the local board of health, and by tbe State Board of Health," He is to "have general quarantine and sanitation authority, not inconsistent with State law, within the area which he serves. He shall disseminate public health information and promote the general public health." He is to co-operate with the school boards, superintendents, principals and teachers "to the end that better health will be promoted among the school children of the area served by such local health director." Under G. S. 130-20, the local health director is to initiate pro- ceedings to have abated any nuisance which, in his opinion, is dangerous to the public health. Under G. S. 130-191.1, the local health director is authorized to give or withhold consent to medical treatment or operations upon a competent prisoner when findings have been made that: the prisoner is suffering from a self-inflicted injury? the treatment or operation is necessary to preserve or restore the health of the prisoner? and, the prisoner refuses to consent to the treatment or operation. Under G. S. 130-23, the boards of county commissioners are authorized to require the local health director to serve as county physician, or they may employ some other physician to serve as county physician. Public health authorities feel that the duties of local health director and county physician should not be held by the same person as they feel that the job of being administrative head of a health department takes the full time of one person, and that the county physician is engaged primarily in curative practice whereas the health director is engaged in ■ ... - i • .■■■•■■■. : " .'.■...' ' < . ■ - . ' ' . ■ ■■ . : : : .- ' : . - ■ - ■ " I - ■ . ' -•■"''' - 31 - preventative practice. The salary of the county physician is paid by the board of county commissioners at such times and in such amounts as may be mutually agreed upon between the commissioners and the county physician. The county physician has the right to employ any other regularly licensed physician of his county to perform any or all of the duties when he deems it desirable to do so, but the terms under which he is employed must be approved by the board of county commissioners. The board of county com- missioners is to prescribe the duties, not inconsistent with law, that the county physician is to perform,, The person appointed as county physician may also be appointed county medical examiner if the county comes under the optional medical examiner system (see page 121 for a discussion of the medical examiners system). I As noted, the local health director is the administrative head of the health department and the executive officer of the local board of health. As such, he is responsible for the execution of the entire program of the department and the supervision of the personnel within the department. He prepares and submits budgets to the board of health for its approval? recommends salary changes j approves payrolls, purchases, and requests for travel expense reimbursement. Under the health director, the various division heads or section heads (where the department is organized into divisions or sections as they usually are) are responsible for administering programs and super- vising the work of the personnel of their division or section. The chart on page U8 shows the organization of the Durham County Health Department as an illustration of the organization and functions of a health department in one of our larger counties. The activities of the various divisions within a typical health department will be discussed individually later in this report. - - - • ■"■'■■ ; - -■ , ■_..■•.. . , ■ - ■ • . - - - ■ ' - ■ - 32 - Department Personnel All State and county public health personnel in Worth Carolina must be employed, classified, paid, and discharged in accordance with the Merit System. The provisions of the system are to be found in Chapter 126, General Statutes of North Carolina, and the Merit System Rule and regulations adopted by the Merit System Council pursuant to Chapter 126. (it is to be noted that the Rule and regulations, as well as changes thereto, must be promulgated in co-operation with the State Board of Health and that the State Board of Health is responsible for the allocation of local health department positions to the established classes. Requests for re-allocation from one class to another are directed to both the State Board of Health and the Merit System.) A brief description of the System shows that: (1) The Merit System Supervisor prepares, in consultation with the State Board of Health, and the Council adopts a classification plan to group positions which are similar with respect to the duties performed, the supervision exercised or required, and the minimum requirements of training, experience, and other qualifications. Each of the different classes of position has a job title, a description of duties and responsi- bilities, and the minimum requirements of training, experience, and other qualifications necessary for those holding each job. All budget positions in a county health department must be fitted into this classification plan. (2) The Merit System Council adopts a compensation plan contain- ing a salary range for each class of positions. The range is established according to the duties and responsibilities performed by people filling the position; and the salary range has a minimum rate and a maximum rate with a number of steps in between to allow for salary advancement with- out change in duty. The entrance salary for each class of positions is the minimum rate, except under special circumstances as set forth in the Rule and regulations. Salary advancements are not automatic, but . ■ [ i ■ i '.' ■ ■ : - 33 - are based on quality and length of service and the availability of funds and are made in accordance with Merit System regulations. Moreover, salary advancements may be granted only to permanent employees after they have served their probationary period. All salaries paid to personnel of local health departments must be in accordance with the compensation plan, being neither below the minimum, nor above the maximum, nor at variance with any of the steps in between. (3) Examinations are held for all persons wishing to take a posi- tion in a local health department. The examinations are required to be practical and so constructed as to reveal the capacity of the applicant for a position. Examinations are rated objectively. The examinations consist of a written portion where practical, a performance test for applicants for typing, stenographic, and office machine operation posi- tions, and an oral examination for positions involving contact with the public or important supervisory or administrative duties. The Supervisor assigns weights to each part of the examination, and includes in the rating process a rating of training and experience for professional, technical, supervisory, and administrative positions. All persons who wish to stand the examination must meet the preliminary requirements for the position for which the examination is being given, including education, training and experience requirements, and the person must be of good character and physically fit. The Supervisor rates each examination, and failure to pass any part of the examination disqualifies the applicant, A veteran's preference of 10 points is given in connection with an examination for original appointment and applies in favor of veterans, widows of veterans, and wives of disabled veterans j a similar preference of up to five points depending upon the length of military service is given in conjunction with examinations for places on promotional registers. / - - : ■ ■ ■ ' ■ ■ ' - - ! ■ - 3U - (h) On the basis of the examination grade established by the Super- visior, a register is established for the position for which the examina- tion was given in the order of the grades of the applicants who passed the examination. A register normally lasts for two years, at which time a new examination is given which must be taken by all those whose names are still on the original register and who wish their names to appear on the new register. If a register is exhausted before the end of the period, a new examination may be given or the Supervisor may make a new register from the registers of related positions. Names of persons who accept permanent appointment are removed from the registers, and names of persons who show no interest in taking positions in local health departments may be removed from the registers in accordance with the Rule. (5) When a local health director wishes to fill a vacancy in his department, he must ask the Supervisor for a list of eligibles. He may specify the race and sex of the vacant position. The Supervisor certifies to the health director a list of eligibles from the appropriate register, taking the top names on the list and certifying several more people (as provided in the Rule) for consideration than the number of positions to be filled in order that the health director may have a choice. In addi- tion, if there is a promotional register for the position, names are submitted from that register by the Supervisor as well. The health director may request that the names submitted be limited to residents of the county, or be limited to the residents of the general area. In any event, the Supervisor certifies those persons who stand highest on the register, and the health director must accept one of the persons so certified unless one such person declines the appointment or fails to answer, in which case an additional name may be requested from the Super- visor for every such person. . • ■ ■ r - ; - 35 - (6) All original appointments to positions in local health depart- ments must be made from the names on the register certified by the Super- visor in accordance with a request by the health director, exclusive of the names of those persons who decline appointment or fail to answer. If a promotional register exists, the appointment may be made from the names certified by the Supervisor from that register. If there are no persons on any applicable register and if there are urgent reasons for filling a position, a provisional appointment may be made pending the establishment of a register. The person filling the provisional appoint- ment, however, must take and pass the next examination for the establish- ment of the register in order to retain his position. In addition, provi- sion is made for temporary and emergency appointments to provide for special circumstances. Such appointees, however, may become permanent employees only through the regular procedure for original appointment. (7) Original appointments to fill permanent positions must be made for a probationary period of six months. This period is considered a part of the examination process in order to determine the capabilities of the applicant, and hence the employee may be dismissed for cause by the health director during, or at the end of, the probationary period, and the employee has no right to appeal the dismissal. Similarly, the local board of health may dismiss the health director during hie six months' probationary period, and the health director would have no right of hearing or appeal. The employee's services are to be terminated at the end of the period if his services are not satisfactory, or he shall be retained if his services are satisfactory. An employee is not entitled to receive a salary advancement during the probationary period, but an . - : ■ ■ - ■ - 36 - employee may be promoted to a position of a higher class during the proba- tionary period if the employee is eligible for appointment to such higher class, (8) The Council as well as the State Board of Health encourages local health departments to fill vacancies by the promotion of qualified permanent employees. Only those persons in the department, however, may be considered for promotion whose names appear on the promotional register for the position, and they may be considered only in case they stand high enough on the register for their names to be reached by the certification process discussed above, (9) Employees are entitled to retain their positions during good behavior, and may be dismissed or demoted only for cause. The local board of health may dismiss the health director, and the health director may dismiss any employee for negligence or inefficiency in the performance of duties, for unfitness to perform duties, for gross misconduct, for conviction of any crime involving moral turpitude (a crime which is "contrary to justice, honesty, modesty, or good morals"), or for engaging in political activities. An employee may be demoted by the health director for ineffi- ciency or other cause. An employee may be suspended without pay for delinquency or misconduct for thirty days. In the case of dismissal, demotion, or suspension, the employee affected may appeal to the Merit System Council. The Council shall hear the appeal and recommend the action to be taken. Following the Council's recommendation, the local board of health in the case of the health director or the health director in the case of other employees shall decide whether or not to go forward with the dismissal, demotion, or suspension. The deoision of the local board or the health director is final, and it is to be noted that the •• • r ■ ■ - ' ■ ' • • . ■ : - 37 - decision of the Merit System Council is advisory only. (10) The health director may release any employee when there is a curtailment of work or lack of sufficient funds to pay all employees in the department. A permanent employee, however, may not be released when there are emergency, temporary, provisional, or probationary employees serving in the same class of position in the same department. The order of separation due to curtailment of work or lack of funds is to be based upon quality and length of service under a formula to be established by the Merit System Supervisor after consultation with the State Board of Health and approval by the Merit System Council. All such separations must be reported to the Supervisor. (11) The State Board of Health is directed to establish a system of service ratings to evaluate the quality and quantity of work performed by the employees in a local department. These service ratings are to be considered in determining salary advancements and in making promotions, demotions, dismissals, suspensions, and separations. (12) Employees of local departments are prohibited from using their official authority or influence to interfere with elections or affect the results of elections. Such employees may take no active part in political campaigns, but they may vote as they please and express privately their opinions on all political subjects, (13) No inquiry may be made of prospective employees of a local department as to their political or religious opinions or affiliations, and no recommendation which involves a disclosure of political or religious opinions may be considered in connection with an appointment or promotion. (lU) No employee may hold other public office or have conflicting employment. ' - - - ' ■ ■ ., . ■ • - . - ■ ■ - ■'■•-• ■ - 38 - (15) The Merit System Council, after consultation with the State Board of Healtlj adopts regulations covering annual leave, sick leave, hours of employment, and holidays for health department personnel. At the present time these regulations include a work week of either 39 or Lj.0 hours, for the 5 l/2 or 5 day work week, respectively, annual leave of 15> days for each calendar year, petty leave for tardiness and minor absences of lU hours for each calendar year, sick leave of 12 days for each calendar year, leave without pay upon the approval of the health director and the State Board of Health, educational leave either with or without pay for attendance at schools of public health, and court and jury leave in cases where the employee appears as a juror or as a witness for a governmental unit, or attends court in connection with his official duties. Not more than 30 days of annual leave may be carried from one calendar year to the next. Sick leave is cumulative. In those counties where the board of county commissioners has adopted regulations governing these matters for other employees under its jurisdiction, the board may modify the Merit System regulations so as to make the Commissioner's regulations re these matters applicable to health department employees also. All local health department employees must be hired, paid, and fired only in accordance with the foregoing provisions. An opinion of the Attorney General indicates that failure of a county to adhere to these provisions not only makes such a county ineligible for state and federal funds to aid in financing the health program but also results in an illegal expenditure of public funds since counties have no authority to hire health workers in any other but the ways prescribed under the Bf -''..'■' - ■ - ■ - 39 - Merit System* (In Letter from Attorney General to the Commissioner of Public Welfare, dated 11 March 19h6). The Attorney General has also expressed the opinion that a local health department has no authority to raise the salaries of certain health department employees without securing the approval of the board of county commissioners as all expenditures must be made in accordance with the provisions of the County Fiscal Control Act. (In Letter from Attorney General to Mr. James McRae dated 15 August I960. ) The board of county commissioners of only a few counties have modified the regulations of the Merit System Council concerning annual leave, sick leave, hours of employment, and holidays. Consequently, the Merit System provisions governing these matters [stated in paragraph (15) above] are applicable to the employees of most local health departments. Health department employees are covered by Workmen' s Compensation as the statutes make it mandatory that counties either carry Workmen' s Compensation insurance or that they be self -insurers for purposes of the Workmen's Compensation Act, and health department employees are considered county employees for this purpose. (In Letter from Attorney General to Dr. Garvin dated 22 May 1958.) G. S. 128-23 (b) authorizes the board of county commissioners of any county (by resolution legally adopted and approved by the board of trustees of the Local Governmental Employees' Retirement System), to elect to have its employees become eligible to participate in the Local Governmental Employees' Retirement System. As of September, I960, the employees of health departments in 58 counties and one city were participating in the Local Governmental Employees' Retirement System. These counties are: • ■ ■ . '-:■£ ■ ■ : - ■ " : • - ■ ' - " • ! '■'■ ■ ■'-■ - ■ ' ' ■ - . . ~ .... . m - - Ho - Alexander, Alleghany, Anson, Ashe, Bladen, Buncombe, Burke, Cabarrus, Caldwell, Camden, Carteret, Caswell, Catawba, Chatham, Chowan, Craven, Cumberland, Davie, Duplin, Durham, Edgecombe, Gaston, Greene, Guilford, Henderson, Hoke, Jackson, Lee, Lincoln, McDowell, Macon, Martin, Mecklenburg, Nash, Northampton, Onslow, Orange, Polk, Pamlico, Pasquotank, Pender, Perquimans, Person, Pitt, Robeson, Rockingham, Rowan, Rutherford, Surry, Swain, Transylvania, Tyrrell, Wake, Washington, Watauga, Wilkes, Wilson, and Yadkin. The city health department employees covered are those of Charlotte. Counties in which coverage is pending include Avery, Mitchell, Yancey and Jones, As noted previously, the State Board of Health has established an incentive fund, from which it pays 50% of the cost of the retirement up to $1,000, to encourage the bringing of local health departments under the Local Governmental Employees 1 Retirement System. Table I on page UU, together with the footnotes thereto, sets out the personnel employed by the various county and district health depart- ments in North Carolina. The information in this table is taken from the publication "North Carolina Local Health Service Budget, Fiscal Year 1959-60", prepared and published by the State Board of Health. The authority of the board of county commissioners over salaries of health department personnel has been increased by a change in the Merit System rules. Since July 1959, beards of county commissioners have been authorized to select a six-step salary range for each of three groups of county health and welfare employees. County commissioners may select the "normal range" (which contains six steps) or a range one, two, or three steps below the normal range or a range one step above the normal range for each of the following six groups of employees: health director, superintendent of public welfare, professional employees with the health department, professional employees with the welfare ■..■■•■■ . - : . ■■ ■"' ■■•.■■■ - , ■-..".-■•■ 239^ . ' ' ...... .. ■ . ■ 6v + B ''."■■ - ■ • ■ ' . . . • .... - ' - . • . ■ , . I '■■■. ... , : ■ . - ' - •■ ■ ■ ■- - - . ■ ■ ••■ • . I ■ - ia - department, clerical employees of the health department, and clerical employees of the welfare department. The salary ranges of district health employees are selected by the district board of health. Approximately one-third of the health department employees are compensated at or above the normal range, about 20 per cent at one and two steps below the normal range, and hi per cent at three steps below the normal range. Table II on page h9, taken from the publication entitled "Trends in County Personnel Practices in North Carolina — A Survey of Policies and Salaries" by Donald B. Hayman, Assistant Director of the Institute of Government, dated March I960, shows the salary ranges selected for employees of the health and welfare departments of each county. The salary range for welfare department employees is included in this guidebook for comparative purposes with the health department ranges. Physical Facilities Most counties in North Carolina have very fine physical structures for the housing of the health department. This is due, in part, to the federal legislation known as the "Hill-Burton" Act which makes federal aid available to states and counties on a matching basis for the construction of hospitals, health centers and other medical facilities, The agency created by the North Carolina General Assembly for the purpose of administering these funds is the North Carolina Medical Care Commission. Seventy-two counties and two cities have completed new health centers with the aid of State and federal funds from the Medical Care Commission during the past thirteen years, and two other county centers are under construction. Table III on page 52, using figures supplied by the ■ - ■ c - ! ■■ : : I ■ Li - 12 - Medical Care Commission, shows the counties with health centers built with Medical Care Commission aid during the period July 1, 19li7-June 1, I960, together with the square footage and cost of each center. It should be pointed out that failure of a county to have a new health center does not mean that the county is without good facilities. Its facilities may have been so adequate that a new center was not needed. An example of this is Durham County which has facilities that are very adequate but which does not have a new health center. ■ ■ . 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I -iA m jj -Ii9 - TABLE II SALARY RANGES SELECTED FOR EMPLOYEES OF THE HEALTH AND WELFARE DEPARTMENTS November, I960 [Note: The North Carolina Merit System rules authorizes each Board of County Commissioners to select a salary range applicable for for each of three groups of health employees (health director, professional, clerical) and for each of three groups of welfare employees (superintendent, professional, clerical). The district board of health is authorized to select salary ranges applicable to district health employees. The county commissioners or dis- trict board of health may select the normal range or a range either one, two, or three steps below the normal range or a range one step above the normal range for each of the six groups of employees.] Health Health Health Welfare Welfare Welfare County Director Prof. Clerical Supt. Prof. Clerical Alamance Normal -3 Normal Normal Normal A Alexander Normal Normal Normal -3 -3 Normal Alleghany -2 -3 -3 -3 -3 -3 Anson A -3 -3 Normal -1 -1 Ashe -2 -3 -3 -3 -3 Normal Avery Normal -3 Normal -1 -2 Normal Beaufort -2 -3 -1 -3 -3 Normal Bertie -3 -3 -3 -1 -2 -1 Bladen Normal -3 -3 Normal -1 -3 Brunswick -2 -3 -3 -3 Normal A Buncombe A Normal A -1 -1 Normal Burke Normal Normal Normal Normal Normal -3 Cabarrus -2 -3 -1 -3 -3 Normal Caldwell -3 -3 -1 -3 -3 -1 Camden -3 -3 -3 -2 -1 Normal Carteret Normal Normal Normal Normal Normal Normal Caswell A -3 -2 Normal Normal Normal Catawba Normal Normal Normal Normal Normal Normal Chatham A -2 -2 Normal -3 Normal Cherokee -3 -3 -3 -3 -2 -3 Chowan -3 -3 -3 Normal Normal Normal Clay -3 -3 -3 Normal Normal Normal Cleveland Normal -3 -3 Normal -3 -3 Columbus -3 -3 -2 Normal Normal A Craven Normal Normal Normal -3 Normal Normal 1 XI .'.■■:■ - ■-."■• ' ' . . - • - • .■■ - . .... ... ■ ; ' • - . - - ■ ' . ' D • • ■ •■ £ . • - ; • - ■ - ! " \ ■ ■ ■ t! ■ : ■ ■ ! • • ' ' - ■ • • . ■ .. . ■ . - ■ • ■ ■ - ■ - " . - r. - ■ ' .' ' - 50 - Health Health Health Welfare Welfare Welfare County Director Prof. Clerical Supt, Prof. Clerical Cumberland A -2 Normal -1 Normal -1 Currituck -3 Normal -3 -3 -3 Dare -3 Normal -1 -1 Normal Davidson Normal -3 Normal Normal -1 -1 Davie Normal -1 Normal -3 -3 Normal Duplin -3 A -3 -3 -3 Durham Normal Normal Normal -2 -2 -2 Edgecombe -3 -3 -3 -3 -3 -3 Fo rsyth -2 -2 -2 -2 -2 -2 Franklin -3 -3 -3 -3 -3 -3 Gaston -3 -3 -3 Normal Normal -1 Gates -3 -3 -3 -1 -1 -1 Graham -3 -3 -3 Normal Normal Normal Granville A -3 -2 -3 -3 -2 Greene -3 -2 A A -1 Guilford A Normal Normal Normal Normal Normal Halifax Normal -3 Normal -3 -3 Normal Harnett -3 -3 -3 Normal Normal Normal Haywood -3 -2 Normal Normal Normal -1 Henderson -1 -1 -1 Normal Normal Hertford -3 -3 -3 Normal -3 Normal Hoke -3 -2 Normal -3 -3 Normal Hyde -3 -3 -3 -3 -3 Iredell -3 -3 Normal -3 -2 -1 Jackson -1 -1 -1 Normal Normal A Johnston -3 -3 -3 -3 -3 -3 Jone3 Normal Normal -3 -2 -2 Lee A -3 -2 -3 -3 Normal Lenoir Normal -2 Normal Normal -2 Normal Lincoln Normal Normal Normal -3 -3 Normal Macon -1 -1 -1 Normal Normal Normal Madison -3 -3 -3 -1 Normal -1 Martin Normal Normal Normal Normal Normal Normal McDowell -2 -2 -2 Normal Normal Normal Mecklenburg -1 Normal -2 A -1 -2 Mitchell Normal -3 Normal Normal Normal A Montgomery -3 -3 -3 -3 -3 Moore -3 -3 -3 -3 -3 -2 Nash -3 -3 -2 -3 -3 -2 New Hanover -3 -3 -3 -1 -2 -3 ■ ■ ' - . . ... . ■ - ■ ■ , • -• . . ■ ' ' • - ■ ' ' ■ • " . • . - . - • ■ ' ■ ! - ■" j . ■ ■ - ■ ' ' . ' ■• - - ■ . • ■ - ■ • . * - 51 Health Health Health Welfare Welfare Welfare County- Director Prof. Clerical Supt. Prof. Clerical Northampton Normal Normal -2 Normal Normal Normal Onslow -1 -1 A Normal Normal Normal Orange A -3 -2 Normal Normal Normal Pamlico -3 Normal -2 -2 A Pasquotank -3 -3 -3 -1 -3 Normal Pender -3 -3 -3 -2 -1 Normal Perquimans -3 -3 -3 -3 -3 Normal Person A -3 -2 A A A Pitt -3 -3 -3 -2 -2 -2 Polk -3 -3 -3 -3 -3 -2 Randolph -1 -1 -1 -3 Normal Normal Richmond Normal -3 -3 -3 -3 -3 Robeson Normal -3 -3 -3 -3 -2 Rockingham -1 -2 Normal Normal Normal Normal Rowan -3 -3 -3 -3 -2 -3 Rutherford -3 -3 -3 Normal Normal Normal Sampson -3 -3 A -3 -3 Scotland -3 -3 -3 -3 -3 Stanly- -3 -3 -3 -1 -3 -3 Stokes Normal A A A Normal Normal Surry A -l A Normal Normal Normal Swain -1 -l -l -3 -3 -1 Transylvania -3 Normal Normal Normal Normal A Tyrrell -2 -3 -2 -2 Normal Normal Union Normal -3 Normal Normal Normal Normal Vance Normal -3 A -3 -3 -3 Wake -3 -3 Normal Normal -3 Normal Warren A -2 -3 -3 -3 -3 Washington -2 -3 -3 -3 Normal Normal Watauga -2 -3 -3 Normal Normal Normal Wayne Normal -3 -2 -1 -1 -1 Wilkes Normal -1 A Normal -3 -3 Wilson Normal Normal Normal -2 -1 Normal Yadkin Normal -1 Normal -1 -1 -2 Yancey Normal -3 Normal -3 -3 -1 (From Institute of Government publication: "Trends in County Personnel Practices in North Carolina— A Survey of Policies and Salaries", by Donald B. Hayman) ■ ' - 52 - TABLE III HEALTH CENTERS IN NORTH CAROLINA BUILT WITH FEDERAL AND STATE AID FROM MEDICAL CARE COMMISSION BETWEEN JULY 1, 19l*7 AND JUNE 30, I960 COUNTY Alexander . Alleghany \ Anson Ashe Avery Beaufort Bladen Brunswick i Burke i Caldwell . i Carteret ' Caswell Catawba Charlotte (City) Chatham Cherokee Cleveland (Columbus Currituck Dare Davidson . Davie < Duplin Edgecombe : Franklin Gaston 1 Gates Graham Granville Greene Guilford (High Point) Guilford (Greensboro) Halifax Harnett (Dunn) Harnett (Lillington) Haywood Henderson Hertford Hoke /'Hyde SQUARE FOOTAGE 1,750 1,750 3,000 2,000 1,750 5,100 3,000 2,000 l*,ooo l*,ooo 2,000 2,600 l+,000 37,000 2,500 2,000 5,000 l*,ooo 2,000 1,750 l*,ooo 1,750 l*,ooo l*,ooo 3,000 9,000 1,750 1,750 3,000 2,600 5,000 10,000 5,5oo 1,800 2,200 3,500 l*,ooo 3,000 2,000 l,75o TOTAL PROJECT COST $ 28,058.71 31,78U.05 57,125.25 33,51*0.86 27,8ia.U9 61*,7l5.li* 1*5,288.33 3U, 271.23 70,7l5.9U 66,l+19.U* 38,881.29 38,539.78 65,573.81* 779,390.20 38,086.1*3 30,510.32 63, 81+8. 3U 69,027.62 39,817.35 36,773.1*9 63,555.07 29,323.23 63,239.96 68,860.1*3 1*6,51*8.86 11*1,596.1*6 32,679.83 36,785.1*1 U7,838.78 51,871.53 228,313.13 7U,883.38 32,375.35 35,31*5.55 56, 21*1*. 25 80,000.00* 5o,l*5U.l*8 3l*,853.98 31*,760.33 FEDERAL SHARE $ 13,638.75 13,91*8.00 28,562.62 16,1*09.09 13,886.06 28,152.78 19,909.17 16,675.00 22,1*01.51 28,1*69.11* 18,919.07 16,658.51* 28,676.96 166,750.00 l6,50l*.00 11*, 910. 71 31,869.6U 32,675.39 17,077c79 12,308.00 27,961*. 23 11*, 306. 00 27,399.80 28,925,82 20,1*25.30 65,860.02 H*, 273.18 2l*,523.6l 20,300.16 19,809.90 75,1*62.89 30,560.38 56,695.00 29,31*8.00 10,205.10 15,552.01* 27, 3l*U. 75 1*1*, ooo. oo* 21,517.01* 16,675.00 11,551.57 STATE SHARE 8,677.25 12,1*58.10 13,138.81 11, 081*. 51* 9,305.90 17,665.51* 15,778.01* 10,205.10 21,87l*.l*2 15,168.1*3 7,930.53 15,1*1*5.10 175.52 -0- 11,299.10 8,61*3.23 11,611.08 15,31*8.61 15,362.1*6 16,51*3.1*0 13,1*73.67 8,572.10 21,019.56 11,175.89 17,31*9.86 3,1*70.30 11,021.01 3,263.1*0 15, 1*1*1*. 71 12,066.03 $ 16,675.00 18,209.10 12,186.09 10, 815 c 71* 11,156.65 9,200.00* 15,951.68 10,071.70 17,103.63 LOCAL SHARE 5,71*2.71 5,377.95 15,1*23.82 6,01*7.23 I*, 61*9. 53 18,896.82 9,601.12 7,391.13 26,1*1*0.01 22,781.87 12,031.69 6,1*36.11* 36,721.36 612,61*0.20 10,283.33 6,956.35 20,367.62 21,003.62 7,377.10 7,922.09 22,117.17 6,1*1*5.13 11*, 820. 60 28,758.72 8,773.70 72,266.11* 7,385.61* 8,998.1*0 12,093.91 19,995.60 337.1a 1*1*,565.10 151*, 91*3. 13 27,326.28 9,981*.l6 8,977.77 17,71*2.85 26,800.00* 12,985.76 8,107.28 6,105.13 ; ■ • : - J - . . , ■ - . ■ ■ i ■ ' ■ • • ■ ■•■ . ■ " , 53 SQUARE TOTAL PROJECT FEDERAL STATE LOCAL COUNTY FOOTAGE COST SHARE SHARE SHARE Iredell lt,ooo $ 59,6Wt.82 $ 29,703.16 $ 10,05U.98 $ 19,886.68 Jackson 2,000 30,603.lt9 lit, 716. 76 9,590.88 6,295.85 Johnston l+,ooo 66,335.23 28,562. 81t 22,913.30 M 5 ?' 09 * Jones 1,750 35,000.00* 19,250.00* 9,905.00* 5,81t5.oo* Lee 2,000 3U,358.68 16,675.00 700.35 16,983.33 Lenoir l+,ooo 7U,389,27 3U, 251.20 lt,826.52 35,311.55 Lincoln 3,000 U7,287.28 23,512.21 7,319.09 16,U55.98 McDowell 2,500 38,27lul6 18,772.9U 7, 330. Olt 12,171.18 Macon 1,750 29, oia. 01 12,528.52 10,936.62 5,575.87 Madison 2,000 35,5U6.26 16,675.00 11,105.55 7,765.71 Martin 2,600 53,U7U.32 22,011.00 lit, 307. 15 17,156.17 Mitchell 1,750 33,0UU.6li 16,522.32 9,979.lt8 6,51t2.8U Moore lt,ooo 58,119.82 25,186.83 12,2lt2.33 20,690.66 Nash It, 000 6U,090.8U 21,56iu£lt lit, 103. 87 28,U22.lt3 Northampton 3,000 U8, 069. lit 20,862.0lt 17,068.95 10,138.15 Pamlico 1,750 29,3U6.86 lit, 233. 28 10,07U.70 5,038.88 Pender 2,000 33,1+20.10 lit, 391. 33 11,688.37 7,3lt0.l+0 Perquimans 1,750 33,013.U6 lit, 351. 22 11,532.13 7,130.11 Person 2,500 39,922.99 13,518.67 16,301.92 10,102.UO Pitt 5,000 87,899.Ut 39,101. lit 8,5ltl.65 1+0,256.65 Polk 1,750 26,178. 5U 13,089.27 5,?85.!t5 7,303.82 Randolph It, 000 69,739.85 28,593.01 19,8l8.lt3 21,328.1tl Richmond l+,000 63,966.1+6 30,889.50 6,963.90 26,113.06 Robeson I;, 000 U9,990.33 21,930.22 15,112.61 12,9lt7.50 Rockingham 3,000 U9,It06»U8 I5,789.lt0 16,197.80 17,1+19.28 Rocky Mount (City) 3,5oo 65,196.12 23,75lt.50 9,177.88 32,263.7lt Rowan 5,500 23U,2l6.2lt ltO,353.50 12,56lt.6l 181,298.13 Rutherford )+,000 66,lt90.l+8 28,627.78 22,968.83 Ht,893.87 Sampson It, 000 66,968.05 29,093.95 2lt,666.25 13,207.85 Scotland 3,000 1+6,018.1+0 15,6U6.26 llt,633.85 15,738.29 Stanly l+,ooo 67,U89.2U 22,678.00 26,llt6.liO l8,66U.8lt Stokes 2,000 35,857.22 16,675.00 11,105.55 8,076.67 Swain 1,750 28,057.19 13,81+8.68 8,288.1+5 5,920.06 Transylvania 1,750 28,653.37 lit, 326. 69 3,951t.l7 10,372.51 Tyrrell 2,000 36,006.32 l5,81tO.OO llt,llt8.00 6,018.32 Vance 3,000 5l,68U.09 25,012.50 It, 302.15 22,369.1tlt Wake 15,000 299,000.00* 170,000.00* -0- 129,000.00* Warren 2,500 ltO,088.50 17,630.21 12,275.81 10,182.1+8 Washington 2,000 36,988.02 17,961ul7 10,063.17 8,960.68 Watauga 2,000 32,589,58 16,218.80 8,171.81+ 8,198.91+ Wilkes U,ooo 79,011.30 29,3lt8.00 22,277.80 27,385.50 Wilson lt,Uoo 59,15U.62 20,011t.08 13,7l5.5lt 25,1+25.00 Yadkin 2,000 33,lt92.67 16,675.00 11,072.20 5,71+5.1+7 Tancey 1,750 29,166.52 Ht,lt21.03 9,87lt.69 h, 870.80 Total: 80 counties j 2 cities b. $5lt71.i+93.itO $2;L60, 1+1+8, 70 $^,000,086.95 $2310,957.75 Estimated Cos" .. . . ' . ' ■' ' ■ - . . • . • ' ■ • ' . • -■ ' - ■ " - . . ■ . - s " . ' . . 1 . - ' ■ ' - - • :. ■ ■ s . . . . - . .. - . • . . ■ - : - ' • - C • :. . . : .5Y . • ! "• . - : ' '. : . ■ - • . - - ' i . -, . ■ ' 1 ■ • . ■ ■ ■ ,. ■ - - . ' ■ .' . ■ - • - " - 5U - CHAPTER III SOURCES OF FINANCIAL SUPPORT General Funds for the operation of local health departments are obtained from annual appropriations by the boards of county commissioners (by far the largest share of the departments' budgets), and from State and federal grants (allocated to the departments by the State Board of Health). Table IV on page 6l, taken from "North Carolina Local Health Service Budget, Fiscal Year 1959-60'; published by the State Board of Health, shows the total budget of each county for public health services, the local appropriation, the state allotments and the federal allotments. The total budget for all local health departments for fiscal year 1959-60 was $7,753, 210. UO, or $1.91 per capita (based on 1950 census figures). Of this amount, $6,l57,105oUO constituted local funds. Thus, 79. h% of all funds expended for local health services during 1959-60 were local funds. This represented $1.52 per capita. The state contributed $1,277,000.00 to the total local health budget ($1,132,000 regdlar grants and $lU5,000 mental health grants), which represented 16.5$ of the total budget or $.31 per capita. The federal government contributed $319,105.00 to the total local health budget ($200,000 regular grants, $109,225 mental health grants, and $9,880 special grants), which represented h.~L% of the total budget or $.08 per capita. Table V on page 65 shows that the total local health budget has steadily increased during the past twenty- three years j that the chief source of funds has been and continues to be local appropriations; that State aid has remained rather constant over the past decade and constitutes - . -- ■ ■ ' - 55 - only a small portion of the total budget; and, that federal and other aid has actually decreased over the past decade and represents a very small portion of the total budget, even less than the State aid. The charts on page 66 show the costs per capita of the total local health budget and the source of funds by percentage. County Appropriations As noted above, the bulk of the money available to local health departments comes from appropriations made by the boards of county com- missioners. Virtually all of the local appropriation was derived from county-wide ad valorem taxation authorized by G. S. 130-21. A few of the local health departments receive a small amount of funds from non-tax sources. For example, in Durham County 3.5$ of the local appropriation was derived from receipts from the issuance of certified copies of birth and death records (only Durham, Mecklenburg and Wake Counties regularly issue certified copies of birth and death certificates as this is handled by the register of deeds in the other counties), from the rental of office space in the Health Department building, and from the receipt of meat inspection fees. To use another example, the Guilford County Mental Hygiene Society and the Greensboro Nursing Council makes contributions to the mental health and nursing programs in Guilford County. Also, a few local health departments receive financial contributions from cities located within the county which the health department serves (this does not include the contribution by the City of Charlotte to the Charlotte City Health Department, and the contribution by the City of Rocky Mount to the Rocky Mount City Health Department). The Health Departments and cities which contributed to them during fiscal year 1959-60, according to State Board of Health records, were: - ' ■ ■ ■ - ■- - ' ' ' ' ■ ■ . • ■ ■ - ■ ■ • . ■ . - .- " ■ - - 56 - - Washington $ 891 - Shelby 3,600 - New Bern 17,290 - Thomasville) - Lexington ) 2,32$ 3,000 - Tarboro 1,000 - Wayne sville) Canton ) 1,200 1,200 - Wilmington 23,253 - Greenville} - Farmville ) 6,000 1,960 - Albemarle 5,3U6 - ElkLn 1,560 - Goldsboro 5,5oo Beaufort Co. Health Department Cleveland Co. Health Department Craven Co. Health Department Davidson Co. Health Department Edgecombe Co. Health Department Haywood Co. Health Department New Hanover Co. Health Department Pitt Co. Health Department Stanly Co. Health Department Surry Co. Health Department lilayne Co. Health Department Table IV on page 61 shows the amount of the total local appropriation for public health purposes during fiscal year 1959-60. Table VI on page 67 shows percentage of the total tax rate in each county which was levied for "public health" for fiscal year 1958-59, and Table VII on page 68 compares the percentage of the total tax rate levied for public health purposes for fiscal year 1958-59 with the percentage levied for other major objectives. The figures for both of these tax rate tables were derived from a survey of the tax rates of all counties made by the Institute of Government during the latter part of 1958. In using these tables for comparative purposes, it should be remembered that tax rates will fluctuate within one county from year to year (depending on such things as surpluses available to finance operations for any one year), and also that such things as revenue from ABC stores will affect the percentage of the total tax levy for various objectives. . •• - - : ■ ■ : ■ - - . ■■■• ' - 57 - State Grants As noted previously, the North Carolina General Assembly appropriates certain funds to the State Board of Health for distribution as grants-in- aid to local health departments. The amount of these state funds for fiscal year 1959-60 was $1,132,000 for general health purposes and $lU5,000 for mental health purposes. The $1,132,000 figure has been the same for the past ten years and the $lU5,000 figure has been the same for the past three years. The $1,277,000 state aid to local health departments represented 16. $% of the total local health budgets. There does not appear to be any restrictions upon the State Board of Health insofar as making conditions upon which the State funds will be allocated to the counties. Therefore, each year the State Board of Health prepares a policy for the allocation of the State aid funds to the local health departments. The State Board of Health also requires that the board of county commissioners of each county enter into a contract with the State whereby the county agrees to have performed therein certain public health programs, end agrees to follow certain procedures (the principle provisions of the contract have been discussed previously). Under the State Board of Health policy for the allocation of State and federal funds to local health departments for fiscal year 1959-60, a local health department, in order to receive the maximum allocation, must meet minimum standards approved by the State Board of Health, participate in a retirement system, maintain local funds at the current level, and carry forward any balance in the health budget remaining at the end of a fiscal year to the health budget for the succeeding fiscal year. As for the amount of State aid allotted to each local health depart- ment, the policy provides: : ■ . ■ ■-... • ■ . •. . . ■ .' 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Hro o t3 5o © P O © © 42 tM P q CO © - -l-t © SIS* - 65 - CO 03 § J3 I If . . • . ■ i : ■ . . ■ ■ - • . ■ ! ■ - _ ■ . ■ i ■ ■ 66 dl \ "^ I Oh P-, Eh CO O o " - 67 TABLE VI PERCENTAGES OF TOTAL TAX RATES LEVIED BY EACH COUNTY FOR PUBLIC HEALTH PURPOSES 1958-59* (from highest percentage to lowest) County Dare 18.75 Hoke 11.51 Madison 11.17 Mecklenburg 11.17 Pasquotank 9.81 Stokes 9.U0 Tyrrell 9.25 Alleghany 9.19 Buncombe 9.09 Onslow 8.83 Surry 8.80 Guilford 8.61 Greene 8.57 Anson 8.33 Pitt 8.06 Halifax 7.92 Edgecombe 7.86 Stanly 7.8U Swain 7.65 Gaston 7.28 Warren 7.27 Durham 7.06 Washington 7.06 New Hanover 7.0U Chowan 7.00 Cabarrus 6.82 Currituck 6.72 Caswell 6.67 Martin 6.67 Cumberland 6.U9 McDowell 6.21* Hyde 6.15 Bertie 6.11 County % County Montgomery 6,09 Macon U.38 Granville 6.08 Randolph U.36 Pender 6.0U Catawba U.12 Alexander 6.02 Davie U.12 Sampson 6.00 Union U.02 Bladen 5.93 Davidson a. oo Columbus 5.79 Graham U.oo Camden 5.71 Richmond U.oo Franklin 5.71 Lincoln 3.95 Scotland 5.63 Beaufort 3.9U Cherokee 5.53 Gates 3.82 Rowan 5.51 Yadkin 3.80 Northampton 5.50 Forsyth 3.77 Pamlico 5.38 Orange 3.7U Hertford 5.33 Lee 3.70 Jackson 5.29 Wilkes 3.66 Watauga 5.26 Ashe 3.1*5 Carteret 5.19 Wilson 3.U3 Haywood 5.11 Cleveland 3.U0 Robeson 5.00 Brunswick 3.33 Jones k.9k Caldwell 3.33 Alamance U.93 Iredell 3.33 Mitchell U.86 Johnston 3.33 Moore U.81 Rutherford 3.18 Burke U.76 Wake 2.U2 Chatham U.76 Polk 2.39 Wayne U.75 Avery 2.38 Rockingham U.68 Henderson 2.17 Vance k.Sh Transylvania 1.87 Person U.52 Clay** 0.00 Craven U.50 Lenoir** 0.00 Duplin k.hh Nash** 0.00 Harnett k.ko Yancey** 0.00 Perquimans County is not listed in this table? its levies for "public health work" and for "operation of hospital" are combined and, so combined, amount to 9.50$ of the total county tax rate. *#These counties do not make separate levy for public health. If they did raise all such funds by taxes, the levies and percentages of total tax rate would be as follows: Clay - $.07 (3.50$); Lenoir - $.06 (5.22$) Nash - $.05 (U.OOg)j Yancey - $.05 (2.78$) - ■■ ■ - - . ' . ; ■ • ' '■ : . - . - 68 - TABLE VII PERCENTAGE OF TOTAL TAX RATES LEVIED BY EACH COUNTY FOR SELECTED MAJOR OBJECTIVES 1958-59 General Fund & Hospi- Debt County Misc. Schools Welfare Health tals Service Alamance 15.26 57.93 9.09 U.93 3.21 9.57 Alexander 16.67 Uu59 27.92 6.02 .00 l*.8l Alleghany 20.00 31.35 28.65 9.19 .00 10.81 Anson 22.78 U8.89 lluWi 8.33 2.78 2.78 Ashe 19.31 29.66 29.66 3.U5 .00 17.93 Avery 3U.82 33.90 12.80 2.38 .00 16.10 Beaufort Hi. 79 50.30 10.36 3.9U 6.06 ll*.55 Bertie 15.56 3l*.l*l* 26.11 6.11 5.56 12.22 Bladen H*.8l 57. OU 18.52 5.93 .00 3.70 Brunswick 23.33 29.17 15.83 3.33 3.33 25.00 Buncombe 12.03 1*6.82 13.61 9.09 .00 18. U6 Burke 18.51* 6U.00 12.71 U.76 .00 .00 Cabarrus 21*. 1*9 1*9.53 17.29 6.82 1.87 .00 Caldwell 26.67 56.11 12.78 3.33 .00 1.11 Camden 17.71 61.1U 15.1*3 5.71 .00 .00 Carteret 17. OU 17.78 ll*.8l 5.19 .00 1*5.19 Caswell U.2U 69.70 18.79 6.67 .00 o.6i Catawba 16.1*7 67.65 11.76 U.12 .00 .00 Chatham 27.62 1*7.62 11*. 29 U.76 .00 5.71 Cherokee 16.08 1*5.73 19.60 5.53 .00 13.06 Chowan 13.00 63.00 16.00 7.00 .00 1.00 Clay 25.50 39.50 15.00 .00 .00 20.00 Cleveland 19.30 52.52 20.31 3.1*0 .00 l*.l*8 Columbus 15.53 56.8U 13.32 5.79 .00 8.53 Craven .00 67.00 20.50 U.50 .00 8.00 Cumberland 16.23 1*2.86 20.13 6.1*9 12.31* 1.95 Currituck 26.95 1*8.57 17.76 6.72 .00 .00 Dare 33.75 23.75 13.75 18.75 .00 10.00 Davidson 22.00 58.00 13.00 l*.oo .00 3.00 Davie 2U.12 U2.06 17.65 U.12 9.1*1 2.65 Duplin 1U.81 56.67 15.19 1*.1*1* l*.l*l* 1*.1*1* Durham 1U.37 1*5.29 2U.03 7.06 l*.l*8 1*.77 Edgecombe lit. 29 51.1*3 1U.61* 7.86 .00 11.79 Forsyth 15.19 6U.93 15.79 3.77 .00 0.31 Franklin 22.ll* 57.68 22.86 5.71 7.11* 5.00 Gaston 19.76 60, U6 12.50 7.28 .00 .00 Gates 3U.35 56.1*9 5.3l* 3.82 .00 .00 Graham 23.20 28.80 20.80 1*.00 .00 23.20 Granville 21.96 53.63 1U.16 6.08 i.5o 2.67 Greene 22.73 53.65 15.05 8.57 .00 .00 Guilford 21*. 10 1*7.10 18.59 8.61 .00 1.60 Halifax 16.67 58.13 16.1*6 7.92 .00 0.83 Harnett 15.72 57.86 22.01 lul*0 .00 .00 Haywood 15.93 55.52 13.83 5.11 7.07 2.51* Henderson 20.62 1*8.1*5 11.79 2.17 3.86 13.10 Hertford 20.33 1*8.00 15.00 5.33 6.6? 1*.67 Hoke 26.88 1*3.01 18.60 11.51 .00 .00 . I • ' • • ■ ■ ' ■ . . ' ' . ' . ■ . . • . . ..' , ■ ' ■ - ■ , ■ . - 69 - General Fund & Hospi- Debt County Misc. Schools Welfare Health tals Service Hyde 25.38 3U.62 18.1*6 6,15 .00 15.38 Iredell 16.00 62.67 13.33 3.33 .00 I*. 67 Jackson 16.63 37.65 19.25 5.29 0.59 20.59 Johnston 16.03 56.1*1 16.03 3.33 3.72 1*.1*9 Jones 13.65 33.99 25.06 l*.9l* .00 22.36 Lee 23.89 57.59 1U.81 3.70 .00 .00 Lenoir 3.1*8 70.1*3 15.65 .00 8.70 1.71* Lincoln 25.52 50.08 19.60 3.95 .00 0.85 Macon 19.38 53.13 13.75 1*.38 .00 9.38 Madison 28.19 35.11 23.1*0 11.17 .00 2,13 Martin 17.67 58.00 17.67 6.67 .00 .00 McDowell 16.18 68.81* 8.71* 6.21* .00 .00 Mecklenburg 18. he 1*9.62 16.22 11.17 2.1*0 2.13 Mitchell 30.81 35,68 28.65 1*.86 .00 .00 Montgomery 17.39 1*5.22 17.39 6.09 .00 13.91 Moore 1U.81 66.67 12.96 l*.8l .00 0.71* Nash 8.00 72.80 15.60 .00 .00 3.60 New Hanover 17.39 55.13 16.36 7.0U U.08 .00 Northampton 2lu60 51.50 18.1*0 5.50 .00 .00 Onslow 12.11 1*6.33 27.97 8.83 I*. 77 .00 Orange 16. UO 62.51* 11.68 3.71* .00 5.63 Pamlico Uo.oo 33.08 21.51* 5.38 .00 .00 Pasquotank 20.30 1*5.06 11*. 26 9.81 .00 10.57 Pender 30.02 1*6.69 12. ll* 6.01* l*.o5 1.06 Perquimans 2U.00 39.50 12.50 —9. 5o- il*.5o Person 16.77 1*3.23 3U. 19 U.52 .00 1.29 Pitt 10.93 1*8.1*3 2U.72 8.06 2.31 5.56 Polk 18.22 1*5.16 18.91 2.39 .00 15.32 Randolph 17.21; 5U.18 12.07 U.36 .00 12.15 Richmond 17.60 50. Uo 21.60 l*.oo I*. 00 2.1*0 Robeson 20.00 59.00 15.00 5»oo .00 1.00 Rockingham 19.36 55.95 15.09 U.68 .00 U.91 Rowan 1U.61 60.22 16.63 5.51 .00 3.03 Rutherford 21. 1*1* 39.71* 21*. 62 3.18 .00 11.03 Sampson 2U.00 1*5.67 16.56 6.00 5.56 2.22 Scotland 13.87 58.21* 20.33 5.63 .00 1.92 Stanly 25.67 1*6.02 11.30 7.81* .00 9.17 Stokes 15.03 1*1.29 16.9U 9.1*0 6.82 10.53 Surry 15. W* 55.88 18.53 8.80 .00 1.35 Swain 20.59 23.53 li*.12 7.65 .00 31*. 12 Transylvania 17.61* 56.1*2 6.27 1.87 .00 17.80 Tyrrell 25.21 1*0.57 2l*.97 9.25 .00 .00 Union 30.93 hk.70 16.1*3 1*.02 .00 3.92 Vance 1U.29 63.57 16.07 1*.6U .00 1.1*3 Wake 20.16 55.65 8.87 2.1*2 U.03 8.87 Warren 21.21 55.15 10.91 7.27 l*.2l* 1.21 Washington 12.35 1*7.06 15.88 7.06 .00 17.65 Watauga 30.53 32.63 27.37 5.26 .00 1*.21 Wayne 22.97 1*9.21* 13.98 U.75 3.56 5.51 Wilkes 17. Hi 36.26 33.11* 3.66 .00 9.52 Wilson 7.91* 72.52 15.91* 3.1*3 .00 0.17 Yadkin 2U.68 50.63 15.82 3.80 5.06 .00 Yancey 23.33 35.56 15.00 .00 .00 26.11 ' . . - . - ' . ■ • . . • • ' • . - - ' , ' ' : " ' ' - _ - . . . ■ ■ ■ ' .' : ' . - ■■ ■ •' - ■ ■ ' ' ■ ' . . ■ . ' ■ 70 - CHAPTER IV THE PROGRAMS AND SERVICES OF THE LOCAL HEALTH DEPARTMENTS Introduction The money being spent each year by the local health departments in North Carolina — about 7 3/h millions for fiscal year 1959-60 — is buying for the citizens of North Carolina a set of public health programs and services that will compare favorably with the public health programs of most states. It is the purpose of this chapter to summarize those pro- grams and services. The extent to which the basic programs and services of a local health department discussed below are carried out will vary from department to department because of many factors, the most important of which is undoubt- edly the size of staff. Some departments carry out more public health programs than are summarized here whereas others may carry out less, or carry out certain of these programs to a limited extent. Because of these variances, no effort is made to describe these programs and services in great detail but rather they are treated in a general way. It should be noted that the basic public health services discussed below are considered by public health experts as the minimal program services of a public health department, and by no means the maximum or complete range of program activities. They feel that the programs and services discussed in this chapter are required in order to maintain public health gains that have already been made, and that public health departments, while retaining these basic services, need to emphasize today other aspects of public health which are presently more serious in terms - - ■ . : - ■ ■ ■ ■ • .■ ■ ■ -70a- of sickness and death. They point out that at the time public health departments were established in North Carolina and in other parts of the country, the programs and services discussed in this chapter were stressed because the major health problems of that day were death and sickness due to poor sanitation, infectious diseases, infant and maternal conditions, and the like. However, due to the tremendous advances the public health people have been able to accomplish since public health departments came into existence, sanitation, infectious diseases and related conditions are of considerably less significance today since most sickness and death now are due to heart diseases, cancer, accident and violence, and the like. The experts therefore conclude that, while public health departments need to retain the basic or minimal services described in this chapter, they now need to plan and stress those programs dealing with the control and prevention of these more important present day public health problems. This would indicate greater emphasis on programs dealing with the control and prevention of such matters as chronic diseases, accidents, radiation hazards, air pollution, mental health and similar public health problems. In order to accomplish this transition in emphasis, they need and request the aid and assistance of boards of county commissioners as the county appropriating body, boards of health as the health department » s policy making body, and the community as the beneficiary of the health department's services. The basic work of most departments falls under the broad headings of Administration, Public Health Nursing, Sanitation, Health Education, Preventive Medical Services, Dental Health Services, Laboratory, and Vital Statistics. - ■ < .- V" * ■ • , • -71- AIMNISTRATION The health director is the administrative head of the department. As such, he is responsible for the over-all organization and administra- tion of the activities of the department. The administrative functions include the selection of personnel (see pages 32 through U2)j staff relationships j in-service training; preparation of the budget (see pages 10 through ill); interpretation of the department's activities to the board of health, to official agencies, and to the public; informing the public as to and enforcing health laws and regulations; observing State Board of Health and Merit System regulations concerning personnel employment, records and reports (see pages 32 through U2); maintenance of building; and, purchasing supplies and equipment. While a local health director must perform the administrative functions listed above, public health experts feel that the most import- ant responsibility of the health director is to scientifically deter- mine community health needs and to develop within the community the resources necessary to deal with significant community health problems. The community is considered the health director's patient. The public health specialists point out that community health needs and resources differ, just as each individual patient varies in his medical needs, and that the determination of commcajy health problems and the develop- ment within the community of prograns and activities to best handle these needs is the major tas.k facing most public health directors today. The public health experts also feel that, since this is the major task of the public health director, he needs to be a physician with specialized ! .. . . ■ ■ - - - ' ,39. ;.; ■ ■ - Z £ ' ' - oxldi'j Hon ■ h '■■■' 1 f f .' • s ■ ■• • ■ : - -71a- knowledge and training in such fields as demography, medical economics, political science, sociology, community organization and in public health. With respect to health department records, it should be noted that while most records in any governmental office are public and open to inspection at reasonable times, the health department's clinical records concerning individual patients are not public and are not subject to public inspection. (In Letter from Attorney General to Dr. Gavin dated 18 February 1958.) PUBLIC HEALTH NURSING A child is taken to the health department to be vaccinated. A public health nurse gives the shot. A psychiatrist at one of the com- munity mental health clinics needs a report on the home condition of a child receiving treatment from such psychiatrist. A public health nurse makes the report. An expectant mother goes '..to a prenatal clinic for a check-up. A public health nurse assists the doctor in rendering this service. The mother of a newborn child needs to talk to someone about such matters as proper sterilization of equipment and preparation of formula. A public health nurse goes into the home to discuss such matters with the mother. The mother of the baby takes it to a well baby clinic for purposes of examination. A public health nurse assists the doctor in the performance of such examination and renders other services to the mother. A school child leaves his classroom to go to - • ■ •- ■ -■- '. - . .. -■'•-■' • ■ - -72- another room at the school for the purpose of receiving a physical examina- tion. A public health nurse assists the doctor in making such examination. It is discovered at such clinic that the child has a defect which needs correcting. A public health nurse goes into the home of that child to discuss with his parents the need for correcting the defect, and what resources are available to assist the parents. A new school teacher needs instructions on screening children for health defects in their day to day teaching process. A public health nurse assists such teacher. The teacher also needs someone to talk to the children about health needs. A public health nurse makes such talks. The health department receives notice that an individual has been diagnosed by his private physician as having a communicable disease. A public health nurse goes into the home of such person to discuss with the family procedures for the protec- tion of other members of the family. A diabetic is ordered by his private physician to take an insulin shot each day. A public health nurse either gives the injection or teaches a member of the family the appropriate method of sterilizing the needle and giving the injection. These are typical illustrations of functions performed by a public health nurse. The clinic work of the public health nurse will be discussed in connection with the discussion of each of the various clinics. Also, the school health work of the public health nurse will be discussed in connection with a discussion of the school health program. - " - - 73 - In addition to clinic and school health -work, one of the basic func- tions of a public health nurse is to visit in the home with the mothers of newborn babies. There are two primary purposes of these visits. One is to verify the information on the birth certificate, and the second is to see if the nurse can be of any help to the mother in any way. This may include a discussion of proper feeding of the baby, proper steri- lization of equipment, the need for immunizations, etc. The nurse can discuss with the new mother the basic essentials of mental health, nutri- tion, normal growth and development, and human relationships and activities. The nurse can also advise the new mother of the availability of the well baby clinics if the circumstances are such that the mother will not be able to take advantage of the services of a private pediatrician. A nursing function of less importance today than in prior years is work with comrmini cable disease control. The State statutes require practicing physicians to report certain diseases to the health depart- ment upon making a diagnosis of such disease. Upon receipt of this report, the public health nurse goes into the home of the patient to discuss such matters as the protection of other members of the family, disinfection and sterilization procedures, travel restriction laws, how to deal with contaminated articles, etc. The State Board of Health has published a manual on communicable diseases containing forty-six reportable diseases (only four of which are quarantineable today — diphtheria, smallpox, endemic typhus fever, and whooping cough). This manual, adopted by the State Board of Health from a similar publication of the American Public Health Association, instructs the nurses as to what advice to give the family for each of the reportable diseases in order to avoid complica- tions in the patient and to protect the family. Actually, the call . . . - - . - Ik - from the physician reporting a communicable disease, such as typhoid fever, may involve six to eight of the department's staff members, includ- ing the nurse. To illustrate what might happen in such cases, take the following example: (1) Telephone operator: Accepts report from physician or family, inserts information on communicable disease report card and channels it to the health director, (2) Health Director: Channels report to supervising nurse and to communi- cable disease register clerk. (3) Clerk: Makes and files a record of the report j sends original to State Board of Health. (U) Public Health Nurse: Visits patient's home to help family understand problem and how to deal with itj investigates his home environment; determines number and type of contacts involved; collects stool specimens of family and of suspect carriers among contacts; refers contacts to family physician or health department for immunization; reports situation to sanitation division of health department, (5) Sanitarian: Visits home to investigate general environment, water supply and sewage disposal systems; collects water samples for laboratory analysis. (6) Laboratory technician: Examines water samples; reports results to sanitarian and physician; examines stool specimens and reports results to nurse and physician. (?) Sanitarian: Advises family of results of water analysis and if unsatis- factory, he advises on corrective procedures. (8) Clinic Nurse: Immunizes contacts and others from neighborhood who want it. (9) Public Health Nurse: Makes periodic visits to home; collects stool specimens at end of illness to determine if patient remains a carrier. Some health departments either have a bedside nursing program with a public health nurse going into the home to carry out a nursing procedure ordered by the doctor, or a program whereby a public health nurse goes into the home in order to teach someone in the home to carry out a nursing procedure that has been ordered by the doctor. These visits are made when requested by the family or by the family physician. The nurse either does or teaches family members to do such things as give hypodermic injections of insulin, liver extract, and other preparations, and to give baths, enemas, etc. Written doctors' orders are requested for any ■ ■ - ■ I : ; .■■-.-.- ■ ■■■ ' : : ■ - - i ■ .. ■ . - ' - • . - • . . ■ ' t. : ■ •' ' ' ■ ' .. - • . ■. . ■ - 75 - medications or treatments given by the nurse. The public health nurse encourages the family to stay under the recommended medical care prescribed by the physician. To use Durham County for illustrative purposes, the 1959 Annual Report of the Durham County Health Department listed the following activities of its Nursing Division: Type of Service Numb er Maternal Health Supervision Antepartum Period Clinic visits, by patients 2, 055 Nursing visits, to homes 1,397 Postpartum Period Nursing visits , 2,81*0 Planned Parenthood Clinic visits 131 Nursing visits ......... 210 Total Visits . 6,633 Child Health Service s Infant Supervision Clinic visits 2,532 Nursing visits k,U2U Child Health Supervision Clinic visits 1,11k Nursing visits lU,560 School Health Supervision Examinations, elementary pupils U,571 Visits to schools 2,279 Nursing visits, office and home 1,687 Total Visits 31,167 General Nursing Services Mental Health- disturbed, ill, retarded 5,585 Chronic diseases. 3,002 Tuberculosis 1,590 Acute diseases - infectious and others 912 Crippled children ., U55 Communicable diseases .... 226 Total Visits. ....... . . 11,770 Summary Total clinic visits 10,h03 Total nursing visits 39,167 Total families visited lii,036 Total not home visits 3,186 . - 76 - From this summary, it can be seen that the primary function of the public health nurse is health education. It is the nurse's duty to help each of the families in her jurisdiction to prevent disease, seek early medical diagnosis and treatment, and make adjustments to social condi- tions affecting the health of its members. Her major activities include maternal and child health work, school health promotion, communicable disease control, nutrition, and health education, Throughout the whole cycle of life, the public health nurse is on the alert for signs of ill- ness or deviation from normal. She is continually teaching and encourag- ing people to avail themselves of preventive measures such as immuniza- tions for whooping cough, diphtheria, tetanus, typhoid fever, smallpox, and polio. The Medical Care Commission administers a loan fund for students who wish to become nurses (as well as those desiring to become physicians, dentists, pharmacists, or psychiatrists) and who agree, upon graduation, to practice in a rural area of North Carolina a year for each year a loan was received. Thus the loan may be repaid by a nurse who works as a public health nurse in a rural area of North Carolina. This can include, under rules and regulations promulgated by the Medical Care Commission, working out of a health department located in an urban area so long as the public health nursing services are performed primarily in a rural area. LABORATORY Mr. Male and Miss Female are about to be married. To do so, they must obtain health certificates showing, among other things, freedom from venereal disease. The certificates must be accompanied by a report from . ''.■•'■ ■' J ■ ...■■■'■ i ' •■■■■■■ - - ' ■ • . - ■' - '■ " ' ftoqii ■• ' •' 1c ' ' ISO -..■-■■' ■■■■•-■- • ■■ -■" ■ - 77 - a laboratory approved by the State Board of Health for making serological tests showing that the Wasserman or other approved test was made. These parties could obtain this report from a health department's laboratory if it is certified by the State Board of Health for the saaking of such tests. A sanitarian collects milk samples to be analyzed for purposes of determing bacteria count, butter fat content or adulteration. A school physician wants a urine specimen analyzed for purposes of deter- mining sugar or albumen content. These analyses may be made in a health department's laboratory. They represent examples of the many types of laboratory services performed by the laboratory facilities of many health departments. These laboratories provide a wide variety of diagnostic and analytical tests of a biological, chemical, and physical character, serving the needs of local physicians, venereal disease clinics, tuberculosis clinics, health service clinics, and sanitarians concerned with the enforcement of sanitary ordinances affecting the production, processing, and distri- bution of foods, especially milk and milk products. These laboratories also make bacteriological and chemical examinations of private water supplies; prepare culture media used in tests j complete sterilization of needles, syringes, test tubes and other containers. For purpose of illustration, the work of a health department laboratory can best be summarized by taking a look at the statistics setting out the examinations made in the Durham County Health Department's laboratory during 1959. They are: Specimen Type of Exa mination Number Blood and spinal fluid Serological test's. .7 TT^WE Milk and milk products Physical and bacteriological .... 6,039 Urine Chemical and microscopic 2,728 Smears, cultures, biopsies Direct microscopic examination . . . 2,131 Water, contaminated food Physical and bacteriological .... 782 Total Examinations 25, lib b : - ■ ■■■■ - - - - 78 - In addition to the laboratories maintained by the local health depart- ments, there is a State Laboratory of Hygiene operated by the State Board of Health (see Art. 6 of G. S. Ch. 130). The statutes require monthly examinations of all public water supplies (defined as any water supply furnishing potable water to ten or more residences or places of business or combination of residences and businesses) by the State Laboratory of Hygiene, and monthly examination of samples of all water sold in the State in bottles or other package, and of all spring water maintained for human consumption in connection with any hotel, park or resort within the State (during the period that such park, hotel or resort is open to the public). The statutes prescribe an annual fee to be paid for such examina- tions. The fee is based upon the gross sales for the previous year as follows: gross sales of $2,000 or more, fee of $61* j gross sales of $1,500 to $2,000, fee of $50j gross sales of $1,000 to $1,500 fee of $l|0j gross sales of $500 to $1,000, fee of $30 j gross sales of $250 to $500, fee of $20; gross sales of less than $250, fee of $15. The fee for spring or bottled water is $15. Where water is supplied free, the fee is based upon what it would have been had the supplier charged each recipient $1 per month for the water supplied. The statutes require samples to be sent to the State Laboratory of Hygiene within five days after the receipt of sterilized containers from the State Laboratory of Hygiene. In addition, the State Laboratory of Hygiene is required to examine water specimens sent to it by a local health director or licensed physician, and is authorized to make such other laboratory examinations as the public health may require. The State Laboratory is also responsible for certify- ing other laboratories as approved to make venereal disease examinations in connection with the granting of health certificates for marriage license purposes. 1 . . 30.. •' - ■ • ■ ' ' : ■ - 79 - VITAL STATISTICS A baby is born in North Carolina, Within five days after the date of such birth, there must be filed with the local registrar of vital statistics a certificate of such birth, A person dies in North Carolina. That person may not be interred, deposited in a vault or tomb, cremated or otherwise disposed of, or removed from or into any registration district, or be temporarily held pending further disposition more than 72 hours after such death, unless a burial-transit permit authorizing a burial, removal, or other disposition thereof shall have been issued by the local registrar of the registration district in which the death occurred or the body was found. In order to obtain the bur.ial-trans.it permit, there must be filed with the local registrar of vital statistics a death certificate (except in those cases where the State Health Director, as State Registrar, by regulation provides otherwise). State statutes relating to vital statistics are contained in Article 7 of Chapter 130 of the General Statutes of North Carolina. Those statutes make the State Board of Health responsible for the registration of all births and deaths within the State, and responsible for the uniform and thorough enforcement of the vital statistics law throughout the State. The State Health Director is made the State Registrar of Vital Statistics. The State Board of Health is given authority to designate the local health director as local registrar of vital statistics for the area over which he has jurisdiction, or any fractional part thereof. The local registrar is required by law to appoint a deputy registrar and is authorized to appoint one or more suitable persons to act as sub-registrars. The deputy and sub-registrars are authorized to receive certificates and to issue burial-transit permits in and for such portions of the local regis- tration district as may be designated. -- ., . ... A ...... ... ... .-......,■ :. , .' . ■ ......... - 80 - When the State Board of Health fails to designate the local health director as local registrar of vital statistics for a county, the chair- man of the board of county commissioners of such county is to appoint a local registrar of vital statistics for each incorporated city or town of 2500 population or over (according to the latest decennial census) and for each township or any combination thereof (as designated by the State Registrar) in his county. The chairman of the board of county commissioners is to notify the State Registrar in writing of the name and address of each local registrar so appointed. Such local registrar is to serve a term of four years beginning with the first day of January of the year for which he was appointed. Any vacancy occurring in the office of local registrar of vital statistics appointed by a chairman of the board of county commissioners is to be filled for the unexpired tern by said chairman unless the State Registrar appoints the local health director as local registrar of vital statistics for said county. At least ten days before the expiration of the term of office of any local registrar appointed by the chairman of the board of county commissioners, a successor is to be appointed by said chairman. Except for local health directors serving as local registrars, each local registrar must be a bona fide resident of the local registration district for which he is appointed, and removal from the district shall terminate his appointment. In all counties except 21 the local health director serves as the local registrar of vital statistics. The counties in which the local health director does not serve as local registrar of vital statistics are: Alamance, Avery, Beaufort, Bertie, Carteret, Cherokee, Currituck, Dare, Graham, Henderson, Hyde, McDowell, Mitchell, Moore, Northampton, Onslow, Pamlico, Tyrrell, Washington, Wilkes, and Yancey. ■ .- . •■ ■" .•■''■ ' - 1 - . ■ - ' ■ ' . ■ ■ - I • ' - ■ , - ■ ■ ■ ■ " ■ ■ ' ' ' . , ' - 81 - Within five days after the date of each Live birth there is to be filed with the local registrar of the district in which the birth occurred a certificate of such birth upon a form provided by the State Board of Health. In addition, an undertaker or any other person disposing of or removing a dead body must file a certificate of death, or fetal death, with the local registrar of the district in which the death occurred in order to obtain a burial-transit permit authorizing such burial, removal, or other disposition. The death certificate is to be signed by the physician, if any, who last treated the deceased for the disaase or injury which caused death. If the death occurred without medical attendance, the statutes make it the duty of the local health director to investigate and certify the cause of death unless the coroner of the county is a licensed physician in which case the board of county commissioners may designate the coroner to perform this certification responsibility. When a board of county commissioners designates a coroner to perform this duty, the board may pay the coroner a salary or fee, for such investiga- tion and certification, in an amount to be determined by the board of county commissioners. The local registrar is to carefully examine each certificate of birth or death when presented for record in order to ascertain whether or not it has been made out in accordance with the provisions of the vital statistics laws and the instructions of the State Registrar. If the certificate of birth or death is incomplete, it is the responsibility of the local registrar to obtain the missing items of information if they can be obtained. Upon receipt of such certificates, the local registrar is to make two complete and accurate copies of each birth and each death certificate registered by him. The local registrar shall then, on the ■ • I . - . : ■ ■ - i ■ i ■ ■ . - 82 - fifth day of each month, transmit to the State Registrar all original certifi- cates registered by him for the preceding month and shall transmit to the register of deeds of the county or his agent one copy and shall retain one copy for his own files. If no birth or death occurred in any month, the local registrar shall, on the fifth day of the following month, report that fact to the State Registrar and the register of deeds of the county on cards provided by the State Registrar. The local registrar is to be paid by the county the sum of fifty cents for each birth, death, and fetal death certificate properly and completely made out and registered with him, and correctly recorded and properly returned by him to the State Registrar, as required by the vital statistics law. The State Registrar is to certify every six months to the treasurers of the several counties the number of births and deaths properly registered, with the names of the local registrars and the amounts due each. The local registrars are not to receive any fee for the issuance of burial-transit permits. Each local registrar of vital statistics, other than a local health director who is serving as local registrar, shall, on or before the fifth day of each month, deliver by mail or in person to the local health director of his respective jurisdiction such data from birth, death, and fetal death certificates filed with such local registrar during the pre- ceding calendar month as may be needed in the proper execution of the duties of said local health director, and as authorized by the State Registrar. The State Register is authorized to issue, upon request, certified copies of the record of any birth or death upon the payment of a fee of $1. In addition, the register of deeds of each county is authorized to issue certified copies of birth and death records recorded by him, for - ■ ■ ' - " . - ■ ■ ■ " . ' - . ■ - ■ • ■ ■ " ■ i - 83 - which he is entitled to a fee of 50 cents. In three counties (Durham, Mecklenburg and Wake) certified copies of birth and death records are regularly issued directly from the health department rather than rrom the office of the register of deeds . Provisions are made for the registration of birth certificates four years or more after birth under rules and regulations promulgated by the State Board of Health. The registers of deeds have certain responsibilities in connection with such delayed registration of births, and are entitled to $1 for each such registration. The register of deeds is also to receive 50 eents for each acknowledgment taken, oath administered, or notarial act performed in connection with the registration of certificates relating to births, deaths or marriages. Registers of deeds are required to issue certified copies of birth certificates free of charge to persons entering the military forces and to children entering school. HEALTH EDUCATION Health education is, of course, one of the principal functions of all of the employees of the local health departments. Many departments, however, have on their staff a person or persons who specialize in health education work. The activities of the health educators include: consultation and guidance services to staff members, coirmunity groups and organizations interested in health programs; preparation, procurement and use of educational materials; interpretation and dissemination of health infor- mation; providing information as to the Department's program, policies and functions to official and voluntary agencies, study groups, and the public; and planning and carrying out co-operative programs with official, --■'•■ .-•'■•- ' . . . - ■ - hi - - :■. '-.'■• • - -■ ■.'-'■ a . " n ■ .■ ; ■ CsJ ' ■ ■ ' - 8U - voluntary, professional and lay groups on specific problems such as nutri- tion, mental health, chronic illness, etc. For illustrative purposes, a summary of the health education activities of a health department may be seen from the activities of the Durham County Health Department (which has one health educator on its staff) during 1959 l Activity Numbe r ■ J » ■ ( 14 ■ I'll I ,-u iii mmmm** ■ • ' Films presented and discussed 15U Planned talks or group discussions led. . lU6 Professional meetings attended 108 Group meetings with emphasis on health education 91 Institutes, study courses, workshops (weeks attended) 1*0 Literature distributed (booklets, leaflets) 23,8£>0 PREVENTIVE MEDICAL SERVICES General The preventive medical services normally rendered by local health departments include: education of school children, parents, and the community on the importance of nutrition, immunization, sanitation of food and water, early diagnosis, and medical care and rehabilitation; providing clinic services for maternal and child health, immunization, school health, venereal disease, tuberculosis, cancer, mental health, crippled children, '^art conditions, and other purposes; consultation and epidemiological investigation services, and counseling and demon- stration services on patient care, nutrition, exercise and rehabilita- tion procedures. Much of the preventive medical services of any health department is carried out through the various clinics either conducted in the depart- ment, conducted with the assistance of department personnel, or conducted with funds made available to the clinic through the department. These various clinics are discussed on the following pages. - ■ . ■ ■ - qi ■ ■ • - ■ .'-..■■ . • " ' : . . . ■ : . - ■ ■■■■- ■ . - - 85 - Tuberculosis or Chest Clinics A waitress about to be employed in a North Carolina restaurant needs a health certificate showing freedom from tuberculosis, She may obtain, in most North Carolina counties, an X-ray from the health department's chest clinic in order to determine if she has tuberculosis. Parties applying for a marriage license must present a health certificate show- ing freedom from, among other things, tuberculosis in the active or communicable stage. Such parties may obtain an X-ray to determine if they have tuberculosis from a health department's chest clinic. A practicing physician has a patient that he suspects may have tuberculosis. He may refer the patient to the health department for an X-ray to determine if there is any evidence of the tuberculosis. A private citizen who desires to follow the health educator's advice to the effect that he should be physically checked periodically may come to the health department during clinic hours for a chest X-ray to determine if he has tuberculosis or some other chest disease. These are typical examples of services rendered by a health department's chest clinic. Some health departments have permanent X-ray facilities located in the health department building. Others have mobile X-ray units that travel about the county making their services available at various points in the county. County Tuberculosis Associations often assist in the tuber- culosis detection programs. The statutes relating to the public health aspects of tuberculosis are contained in Article 11 of Chapter 130 of the General Statutes of North Carolina, They provide, in summary: (l) That when any local health director has reasonable grounds to believe that any person has tuberculosis in an active stage or in a .... .. - - " • ■ - - - ■ ■ ' - 86 - communicable form, and such person will not voluntarily seek a medical examination, then it is the duty of the health director to order such person to undergo an examination for tuberculosis. The examination is to include an X-ray of the chest, a sufficient number of laboratory examinations of sputum, and such other forms and types of examinations as shall be approved by the State Board of Health. If, upon such examina- tion, it is determined that the person does have tuberculosis in an active stage or a communicable form, then it is the duty of such person to arrange for admission of himself as a patient in one of the State or county sanatoriums for tuberculosis or in a private hospital or in a ward of a private hospital maintained and operated for the treatment of tuber- culous patients. If the health director determines that there is no danger to the public or to other individuals, the tuberculous person may receive treatment at home; (2) That when it is determined that a person has tuberculosis in an active stage or in a communicable form and such person is not immediately admitted as a patient to a sanatorium or hospital, it is the duty of the health director to instruct such person as to the precautions necessary to be taken to protect the members of such person's household or the community from becoming infected, and it is the duty of such tuberculous person to follow said instructions; (3) That it is unlawful for any person to willfully fail or refuse to present himself for an examination for tuberculosis at such time and place as is fixed by the health director, or to willfully fail and refuse to present himself for admission as a patient to a sanatorium or hospital when such action is found by the health director to be necessary for the prevention of the spread of the disease, or for a tuberculous person to ■ '■- ' ■--■'' -' . - . , ■ - - - - < - - ! - 87 - willfully fail or refuse to follow the instructions of the health director concerning precautions necessary to be taken to protect the members of his household or the community. If any person is convicted of any of the violations set out in this paragraph, he is to be imprisoned in the prison division of the North Carolina Sanatorium for a period of two years. The associate superintendent -medical director of the prison division of the North Carolina Sanatorium is authorized to discharge a tuberculous person so committed upon determining that such discharge may be effected without danger to the health or lives of others. Provision is :-nade for the transfer of tuberculous persona from the prison division to another State sanatorium or to a veterans administration tuberculosis hospital under certain conditions; (U) That the county of legal residents of tuberculous persons committed to the prison division of the North Carolina Sanatorium is to be responsible for the regularly established fee for indigent or welfare patients during the patient ' s period of hospitalization; and, (£) That if the tuberculous person committing one of the crimes described in paragraph 3 above is under 16 years of age, he is not to be imprisoned in the prison division of the North Carolina Sanatorium but is to be placed in some other State, county or private sanatorium for treatment. The statutes also provide: (1) That each board of county commissioners is to provide in the jail, camp or other place where county prisoners are committed for keep- ing, separate cells or rooms or other places in which any prisoner who is committed to said place of confinement and who has been examined and pronounced to be infected with tuberculosis, shall be confined; -■ . , . ■ ' - - . - ' • ; ■ . - 88 - (2) That law enforcement officers, who suspect that a prisoner in their custody has tuberculosis, are to have such prisoner examined by the county physician or local health director to determine if he does have tuberculosis, and if so, to provide separate confinement for him. Provisions are made for transfer of sentenced prisoners with tuberculosis to the prison division of the North Carolina Sanatorium; (3) That no prisoner suffering with active tuberculosis is to be worked on any public or private aorksj (k) That every county or city physician, local health director, or other physician responsible for the medical care of city, county, or State prisoners, within his respective jurisdiction, is to make a thorough examination of every prisoner within 1*8 hours after admission of such prisoner; and (50 That prisoners suffering with tuberculosis are to receive such additional food as may be prescribed or requested by the physician in charge of any unit of the State prison system, and provision is made for the transfer from one unit of the prison system to the prison division of the Forth Carolina Sanatorium, and for transfer from the prison divi- sion of the North Carolina Sanatorium back to another unit of the prison system when the tuberculosis has been arrested. Health Service Clinics A waitress about to be employed in a restaurant is required by many local health departments to possess a health certificate. Parties about to be married must have a health certificate. These persons can normally obtain the blood test and chest X-ray required for their respective certifi- cates from the local health department. School children in certain grades - ! - I - - .. . - 89 - are normally given a physical examination. Juveniles being sent to a Training School by a Juvenile Court are usually required to have a physical examination. These physical examinations are normally given in a health department's health service clinic. A person who suspects that he has venereal disease may normally be examined (and treated if necessary) in a health service clinic or venereal disease clinic. These are a few typical examples of services performed in the health departments' health service clinics. The objective of the health service clinics is the prevention and control of communicable diseases. In an effort to achieve this objective a large number of disease-preventing and disease-finding procedures are used. The procedures include immunizations, chest X-rays, laboratory examinations, clinical inspections, interview of infected persons and follow-up of exposed individuals until infection is ruled out or treated. In the health service clinics, all of the activities relate to early detection and prevention of spread of infectious diseases. Persons coming to a health service clinic for service fall generally into four categories, according to the purpose of examination, as follows: health certificate, venereal disease, referred by official agency, and school health examina- tions (discussed in connection with the school health program). Many of the persons who come to a health service clinic for services are applicants for a health certificate, which is required in many places before employment and annually of many persons who serve the public? for example, food-handlers, barbers, beauticians, and school teachers. For each of these applicants, the services of as many as 10 to 15 staff members may be required. Using Durham County as an example, a typical application for a health certificate may involve several staff members as follows: - ! - ; 90 Telephone operator. Gives applicant information on clinic days and hours. Information desk clerk. Directs applicant to desired clinic. Elevator operator. Carries applicant to clinic floor 5 directs him to proper waiting room. Clinic clerk. Registers applicant; checks files for previous record or makes a new one; enters his name on X-ray and on blood test request forms and directs him to these stations. X-ray technician. Operates X-ray unit; developes film. Radiologist. Reads film; records finding on applicant's form. X-ray clerk. Reports findings of radiologist to clinic or physician; files applicant's record and film. Clinic nurse. Collects blood sample. Assists with other examinations, if needed. Clinic maid. Keeps clinic equipment and supplies in safe condition. Carries blood specimens to laboratory daily. Laboratory assistant. Separates identifying forms and prepares blood speci- mens for examination. Records finding; files record. Sends report to clinic or private physicians. Serologist. Prepares antigen and blood specimen for serologic testing. Reads result of test and records it on form. Clinic clerk. Enters results Of X-ray and laboratory examinations on appli- cant 's clinic record; issues health card or certificate. Records clerk. Collects, compiles and reports statistics. Clinic Director. Supervises clinic activities; compiles and analyzes statistics. Venereal Disease Clinics Many persons come to a health department's health service or venereal disease clinic because they suspect that they might have a venereal disease or have had contact with an infected person,, Such persons are usually given a clinical inspection and other diagnostic tests, in addition to a routine blood test. If the individual is found to be infected, he is interviewed for sex contacts, and he is treated or referred for treatment. The main contacts are found, requested to come to the health department's clinic for an examination, and if found infected, or if a regular contact with an infected patient, they are treated or referred for treatment. The General Statutes of North Carolina (Article 10 of Ch. 130) declare that syphilis, gonorrhea, chancroid, granuloma inguinale, and lymphogranuloma venereum are contagious, infectious, communicable, and - ■ ■■ ' - ! ; ... - : i : '■ ■ ! : - 91 - dangerous to the public health, and make it unlawful for any person infected with any such venereal diseases to expose another person to infection. The statutes also make it the duty of any physician or other person diagnos- ing a person with a venereal disease, or any superintendent of an insti- tution in which there is a patient or inmate with a venereal disease, to report such case to the local health director and to co-operate with the State and local boards of health in preventing the spread of venereal diseases. State and local health directors or their authorized agents acting under their supervision, are empowered, when necessary to protect the public health, to make examinations of persons reasonably suspected of being infected with a venereal disease, and to detain such persons until the results of such examination are known, and to isolate or quarantine persons infected with a venereal disease when it is necessary to protect the public health. The statutes make it the duty of the state and local health directors to interview or cause to be interviewed all persons infected or reasonably suspected of being infected with a venereal disease, and to investigate or cause to be investigated the source of .infection, and to co-operate with the proper officials whose duty it is to enforce laws directed against prostitution. All persons confined or imprisoned in any state, county, or city prison or jail must, within forty-eight hours after commitment, be examined for venereal diseases by the county physician or other authorized physician. If the individual is infected with a venereal disease, he is to be treated by said county physician as soon as practicable. If a person is suffering with a venereal disease at the time of the expiration of the i c ■ ■ - ■ : ;-•->.■> ■ ■ - 92 - term of his imprisonment, he may be quarantined or isolated at a hospital or clinic and treated at public expense until the disease is no longer communicable, or he may report for treatment to a licensed physician or submit to other treatment provided at public expense. Such person is not to be set at liberty until he has been treated, unless he has begun a course of treatment for venereal disease under the direction of an author- ized physician and gives a bond with satisfactory surety to the clerk of superior court of the county where he is imprisoned or confined, conditioned upon his making a personal appearance before a county physician or other examining physician and submitting to treatment for the disease. In such case, the bond is to be discharged when the examining physician determines that the disease is no longer communicable. The State Board of Health is authorized to adopt rules and regula- tions necessary for the purpose of controlling, treating, preventing and eradicating venereal disease. Every woman who becomes pregnant is required to have a blood sample taken and submitted to a laboratory approved by the State Board of Health for performing serological or other approved tests for syphilis. Any person attending or assisting in any way whatsoever ar.y newborn infant or the mother of any newborn infant, at childbirth or at any time within two weeks after childbirth, is required to report to the local health director any inflammation of the eyes of the newborn infant, and the local health director is to give to the parents or persons having charge of such infants a warning of the danger to the eye or eyes of said infant, and shall for indigent cases provide the necessary treatment at the expense of the county, city, village or town. It is the duty of the person in attendance upon a case of childbirth to instill or have instilled ■ . ■ - ■ - ■ ■•-.■.'■ - ■•■'■■■ ' ■ • - - 93 - immediately upon its birth in the eyes of the newborn baby a solution or medication prescribed and approved by the State Board of Health for the purpose of preventing infection of the eyes of the newborn. The statutes also provide that no person is to practice midwifery in North Carolina without a permit and registration with the local health director, and the State Board of Health is to furnish such registered persons with necessary directions and medication for the compliance with the laws relating to inflammation of the eyes of the newborn. Immunization Clinics A child needs a polio immunization or some other vaccination. He may receive it from a health department's immunization clinic. A private physician needs to check on the immunization status of a new patient of his. In some counties, he may obtain this information from the health department's immunization clinic file. These are two typical examples of services rendered by the health department's .immunization clinic. All local health departments provide immunization services. Articles 9 and 9A of Ch. 130 of the General Statutes of North Carolina deal with necessary immunizations. The statutes require all children in North Carolina to be immunized against diphtheria, tetanus, and whooping cough before reaching the age of one year, and poliomyelitis and smallpox before attending any public, private, or parochial school. All parents, guardians, or persons in loco parentis are required to present their child to a physician and request the physician to administer to such child preparations sufficient to immunize such child against the diseases indicated above. If the person required to present the child for immuni- zation is unable to pay for the services of a private physician or for the immunizing preparation, the child may be taken to the local health . ■ . - ■, . ...... ■ 1 ..- : as ' ■ ■ ' ■ ■■'.-'. • . Issri ■ - j : - i , .. . ■ .-.'.■ . ■ - ■ - itsti c & I :■ e ... i ■ ' - - ■ - 9U - director of the area in which the child resides, where such immunizing preparation is to be provided and administered free. The board of county commissioners is required to make available sufficient funds for the purchase of such immunizing preparation for such cases. The physician administering the preparation is to submit a certificate of immunization to the local health director and is to give a copy to the parent, guardian, or person in loco parentis of the child, and no principal is to permit any child in a public, private, or parochial school without the certifi- cate or other acceptable evidence of immunization. The statutes exempt from the immunization requirements a person whose physician certifies that a preparation required to be administered under this law is detrimental to the child's health. Also exempted are children whose parents or guardian are bona fide members of a recognized religious organization whose teachings are contrary to the practices required by this law. In those cases, no certificate for admission to school is required. In addition to the above required immunizations, the statutes authorize local boards of health to make such reasonable rules and regulations for the immunization of persons within their jurisdiction as may be necessary to protect the public health. The immunization clinics in the various local health departments provide the immunizations required by law. As noted, the law requires the individuals to obtain the immunization from a private physician unless the individual is unable to pay for such service. In that case, the service may be obtained from the local health department. A question has been raised as to the extent to which the health department must go in order to determine that the individual is unable to pay. The • • ■ ■ ■ - .■ . ■ - 9$ - Attorney General has expressed the opinion that this is primarily a ques- tion of health department policy. Ordinarily a parent's statement that he is unable to pay for the immunization is accepted by the health director unless he has personal knowledge leading him to believe that such state- ment is inaccurate. There is no requirement that the indigent parent first take the child to a private physician and then be referred to the health department. It has been estimated that any extensive investiga- tion of ability to pay would be more expensive than the immunizing agent, (in Letter from Attorney General to State Health Director dated 2\\ April 1959.) Although Juvenile Court judges may find a child neglected and order necessary medical treatment when such treatment is felt necessary by a medical practitioner and the parents refuse to consent to such treatment (in Letter from Attorney General to Mr. York dated 13 October 19kU), this probably does not apply to immunizations since children of parents who belong to religious organizations whose teachings are contrary to medical practice are expressly exempted from the immunization requirements. Maternity Clinics If an expectant mother is unable to pay for prenatal care from a private physician. She may normally obtain this service from a county maternity clinic held at or sponsored by the local health department. Most counties have such clinics available. In some instances, these clinics are held by a hospital independently of any health department participation. Even in these instances, the hospital and health department will normally co-operate with the health department making referrals to the clinic and furnishing the hospital with information concerning the home picture of - - ' ■ - - : • ■ - • ■ - ■ ■ - - ■ V - - - 96 - the expectant mother upon request. In turn, the hospital will often furnish the health department with information necessary for any home follow-up services by a public health nurse that may be desired. In other instances, a public health nurse will attend the hospital clinic and act as a con- sultant on nutrition, infant care, prenatal education, etc. In other instances, the public health nurse will actually participate by perform- ing nursing services in connection with the examination of patients, including record keeping, drawing blood, taking urine specimens, conduct- ing prenatal education classes, acting as a consultant on nutrition, infant care, etc., discussing medical resources available to indigent patients, and in general assists the patient in preparing for the hospitali- zation and birth experience. In still other instances, the clinic is held at the health department with the public health nurse and the health director, clinic director, or a private physician conducting the clinic. Information from the State Br,ard of Health shows that, for fiscal year ending June 30, I960, $55,527.91 of federal funds were paid by the State Board of Health to physicians holding maternal and child health clinics in the counties. The physicians are paid an honorarium of $10 for the first hour and $5 for each additional hour, figured to the nearest half hour. Well Baby Clinics A mother of a baby is unable to pay for well baby medical services rendered by a private physician. She can usually obtain these services from a well baby clinic in the county. These clinics are sometimes held in hospitals without any health department direct participation j sometimes held at various sites within the county under health department sponsor- ship; and, sometimes held at the health department. At these clinics, . - " ■ " - ■ .. . . ■ . . ■ • ■ ■ i ■•■ ■■ - ■ : • - 97 - the children receive a physical examination from a pediatrician and are advised as to nutrition and other matters relating to baby care by a public health nurse. The children usually receive necessary immuniza- tions at these clinics. These clinics are umially conducted by a public health nurse with a clinic director or private pediatrician performing the medical services. The federal government makes funds available to the State Board of Health to pay pediatricians a small fee for performing these services. (See last paragraph of maternity clinics discussion for information concerning maternal and child health clinic fees.) Mental Health Clinics The General Statutes of North Carolina (Art. 5 of Ch. 130) designates the State Board of Health as the State's mental health authority for purposes of administering federal funds allotted to North Carolina under federal legislation pertaining to mental health activities. The State Board of Health is also designated as the State agency authorized to establish and administer minimum standards and requirements for mental health clinics as a condition for participation .in federal-State grants- in-aid. The State Board of Health is authorized to promote and develop community mental health clinics in accordance with State policy which is stated to be: "It shall be the policy of the State to promote the establishment of mental health outpatient clinics only in those localities which have shown a readiness to contribute to the financial support of such clinics, assisted by federal and State grants-in-aid to the extent available." The statutes specify that outpatient mental clinics may also be operated by the Hospitals Board of Control or by North Carolina Memorial Hospital. - : ■ - ■ • - - . ! - - . - - 98 - Local governmental units are specifically authorized to appropriate funds for the support or partial support of outpatient mental clinics which serve such localities whether or not the facilities of the clinic are physically located within the boundaries of such cities, towns or counties, and whether or not such clinics are owned or operated by local governmental units. Such support is declared to be a necessary expense within the meaning of Article VII, §7 of the North Carolina Constitution. At the present time there are 11 community mental health clinics in North Carolina. These clinics held over 32,000 patient interviews during 1959. Forty-nine percent of these patients were under 18 years of age. These clinics are staffed with 38 full-time and 20 part-time professional persons and 20 full-time clerical persons. In addition, four lecal health departments employ psychologists or social workers. The counties in which community mental health centers are located are: Buncombe, Cumberland, Durham, Forsyth, Guilford, Mecklenburg, New Hanover, Pitt, Rowan, Wake and Wilson. Some mental health services are also provided in the counties of Gaston and Halifax where the establish- ment of a community clinic is being attempted. These clinics receive State and federal grants-in-aid from the State Board of Health. The 1959-60 State grant was $lh5,000 and the federal grant was $109,225. Each clinic with a budget less than $60,000 is pro- vided approximately $0% of its total budget from these funds. Clinics with a budget in excess of $60,000 were provided approximately $30,000 plus one-third of amount over $60,000 in the total budget. Cancer Clinics Some local health departments conduct, sponsor, or co-operate with other agencies in the holding of cancer clinics, Figures from the State : i ■ [ - 99 - Board of Health show that the State Board of Health allotted, for services rendered by the various cancer detection and detection-diagnosis clinics, for fiscal year 1959-60, $U0, h3 3. Sh» These were broken down as follows: physicians, $31, 733 J nurses $3,612; clerks, $1,829.51; pathology $3,209; and, diagnostic X-rays $50. Article 17 of G. S. Ch. 130 deals with cancer control programs. It directs the State Board of Health to administer a program for the preven- tion and treatment of cancer and authorizes the State Board of Health to promulgate rules and regulations to carry out such program. The State Board is to furnish to indigent citizens of North Carolina having or suspected of having cancer, and who comply with rules and regulations specified by the State Board of Health, financial aid for diagnosis, hospitalization, and treatment of cancer. Such diagnosis, hospitaliza- tion, and treatment must be given in a hospital which meets minimum requirements for cancer control established by the State Board of Health. The State Board is to specify the terms and conditions upon which the patients may receive such financial aid. The State Board is authorized to establish and designate minimum standards and requirements for the organization, equipment and conduct of State -sponsored cancer clinics or departments in hospitals or health departments in the State. The statutes make it the duty of every physician to notify the local health director of the name, address and such other items as may be speci- fied by the State Board of Health, of any person by whom such physician is consulted professionally and who is found to have cancer of any type. The local health director is to forward such information to the State Board of Health. The State Board is to assist hospitals and local health departments in the State in organizing and conducting cancer clinics as a part of the cancer control program. . - i . • .......... : " - . ' " ■ : , ■ • ^ ;;■ • ' ■ - 100 - Other Clinics Many local health departments either conduct or sponsor other clinics. These include planned parenthood clinics, crippled children clinics, heart clinics and others. Figures from the State Board of Health show that the State Board of Health alloted federal funds of $9U,867.38 and State funds of $66,7^0.00 (total of $161,607.38) to pay crippled children clinic fees during the fiscal year ending June 30, I960. The planned parenthood clinics are financed by State funds and are usually held by local physicians who specialize in obstetrica. For purposes of illustration, 131 patients were given contraceptive service at the Durham County Clinic during 1959, and 210 nursing visits were made primarily for planned parenthood service. DENTAL HEALTH SERVICES According to the 1956-58 Biennial Report of the State Board of Health, only six of the 100 counties have full-time dentists on the staff of the local health department. Some other counties have part-time dentists performing remedial dental care for indigent persons in the county. Most of the public health dental services in the State are carried out by the Oral Hygiene Division of the State Board of Health, The program of the Oral Hygiene Division, insofar as staff and funds will permit, includes the following services: (l) classroom instruction and dental inspection for all children; (2) dental corrections for underprivileged children; and, (3) referrals to their own dentists for the children whose parents are financially able to take care of their dental needs. These services are rendered by a staff of school dentists assigned to the local health departments on a fund matching basis. Supporting services include: the presentation of a dental health puppet show which covers the State once every two years; the preparation and distribution of dental health education ... - ■ :• - - ■■....- - - , ... ... ■ • - . . j i ■ ■ . ■ : - - 101 - materials; and the promotion of wide-scale preventive procedures, notably, the fluoridation of municipal water supplies. The Biennial Report's statistics for 1957-58 show that the Oral Hygiene Division had an average staff of school dentists of l6j that 59 counties received services from these dentists j that 650 schools were visited; that 109,678 children received mouth inspections; that 39,725 underprivileged children received dental corrections; that 50,538 children were referred to their own dentist for corrections; that 3,3U5 classroom lectures were given by school dentists; that 115,186 children attended these lectures; and, that li;3,650 school children attended the dental education puppet show of the Division. Health departments conduct a program of dental health by attempting to educate parents, teachers, and school children as to the importance of diet, mouth care, and early and regular dental care. Many of them also conduct a case finding, referral, and follow-up service. As the discussion of the school health program will indicate, in many counties most of the school health funds provided by the General Assembly are used for the correcting of dental defects of children who are certified by the public welfare departments to be medically indigent. The state statutes (Art. 19 of G. S. Ch. 130) authorize the State Board of Health to establish a fund from which loans are made to junior and senior dental students who agree, upon graduation and licensure, to join the staff of the Division of Oral Hygiene. The loan is to be repaid under such terms as may be agreed unon by the recipient and the loan committee (composed of State Health Director, dental member of the State Board of Health and Director of Division of Oral Hygiene) which is created to administer the fund. .-■".■'• ■ •" ■ . - • - - : ■ - - - 102 - SANITATION Introduction Sanitation is, of course, one of the key programs of any health depart- ment, and traditionally one of the first programs of any health department. The principal functions of the sanitarians of health departments relate to food and milk control and to the sanitation of man's environment. Pursuant to legislation passed by the 1959 General Assembly, sanitarians who are qualified and experienced, and who pass an examination prescribed by the State Board of Sanitarian Examiners, are certified as Registered Sanitarians. It is unlawful for one to represent himself as a Registered Sanitarian without such certification. Food and Milk Sanitation Activities A milkman, making his daily rounds, delivers a bottle of milk. This bottle of milk, in all probability: came from a cow that was required by the health department to receive annual brucellosis and tuberculosis tests; came from a dairy that is routinely inspected for sanitation purposes by a sanitarian from the health department j was transported from the dairy farm to the pasteurization plant to the distributor to the consumer in vehicles inspected by a sanitarian; was pasteurized in a pasteurization plant inspected by a sanitarian; was handled by personnel required to take an annual physical examination and required to exercise good cleanliness habits; was processed in equipment which is routinely inspected for cleanliness; and, it may have been laboratory tested for physical, chemical, and bacteriological characteristics. A new restaurant has been built in North Carolina and is about to begin operation. Before it can begin operating, a permit must be obtained - : i ■ - • ■ . ■ - . -;••■-.- . * --.-\ . • ■ ■ -. ■ : ' ■ ■ . ■ - : ■ ■. ■ ■ ' ■■ . ;■ ■ . • i : - - - ■ - 103 - from the local health department. Before a permit is issued, a sanitarian from the health department inspects the establishment for such matters as: cleanliness of floors, walls, ceilings, storage space, utensils, and other fac.ilit.iesj adequacy of lighting, ventilation, water, lavatory- facilities, food protection facilities, bactericidal treatment of eating and drinking utensils, and waste disposal; methods of storing, handling, preparing and serving foodj health of employees; and, such other items and facilities as are necessary in the interest of the public health. Following this inspection, the establishment (if it qualifies) receives a permit. After the establishment has been inspected, the sanitarian posts a sanitation grade of "Ay "B" or "C". The establishment is similarly inspected and graded periodically by a sanitarian from the health depart- ment. The above constitutes two typical examples of food and milk work performed by sanitarians of the various health departments. The public health objective of health department's food and milk program is to protect the public health by insuring that safe and wholesome food and milk is produced, prepared, handled, and served in a sanitary manner; and, to assure safe and clean schools, institutions, and lodging places. To this end most county boards of health have adopted, and enforce, regulations relating to food and milk sanitation, including the adoption by reference of the United States Public Health Service recommended milk ordinance. The General Statutes of North Carolina (Article 5 of Ch. 72) direct the State Board of Health to prepare and enforce rules and regulations governing the sanitation of any hotel, cafe, restaurant, tourist home, motel, summer camp, food or drink stand, sandwich manufacturing establish- - ■ - " ■ , - lOli - ment, and all other establishments where food or drink is prepared, handled, and/or served for pay, or where lodging accommodations are provided. The State Board of Health is also directed to require that a permit be obtained from said Board before such places begin operation (the permit is to be issued only when the establishment complies with the rules and regula- tions of the State Board of Health), and is directed to prepare a system of grading all such places as Grade A, Grade B, and Grade C. No estab- lishment is to operate which does not receive the permit or which does not receive a minimum grade of "C" in accordance with the rules and regu- lations of the State Board of Health. The agents of the State Board of Health are authorized to enter such food, drink or lodging establishments for the purpose of making such inspections and makes it the duty of every person responsible for the management or control of such establishment to co-operate with the agents of the State Board of Health so that a full, thorough, and complete examination may be made. It is the duty of the agent of the State Board of Health to leave with the person in charge of such establishments a copy of his inspection report and a grade card showing the grade of such place. It is the duty of the management of such place to post said card in a conspicuous place designated by the agent of the State Board of Health so that it may be readily observed by the public, and such grade card is not to be removed by anyone except an authorized agent of the State Board of Health, or upon his instruction. The statutes make it a misdemeanor to violate these provisions, and authorizes the obtaining of an injunction to prevent such violations. These provisions do not apply to private homes providing food and/or lodging to permanent house guests (defined as paying guests receiving • * ' - •" ■ ■ • : - ■ - 105 - food and/or lodging accommodations for periods of a week or longer and the visitors of such paying guests). These provisions also do not apply- to food or drink stands operated by church, civic or charitable organiza- tions for a period of one week or less, except that such establishments must meet minimum sanitation requirements (they are not subject to grading). In addition, these provisions do not apply to boarding houses having regular boarders, private clubs, picnics, camp meetings, reunions, box suppers, field trials, occasional fund-raising suppers and similar gather- ings conducted from time to time by church, civic or charitable organizations The State Board of Health has adopted rules and regulations relating to the sanitation of such establishments. They provide that the inspec- tions and grading required by the regulations may be conducted by sanitarians in local health departments designated as agents of the State Board of Health for this purpose. Article lit of G. S. Ch. 130 directs the State Board of Health to prepare rules and regulations governing the sanitation of meat markets , abattoirs, poultry processing plants, and other places where meat, meat products or poultry products are prepared, handled, stored or sold. The State Board of Health is to grade such places and no such place may operate without meeting minimum sanitation standards prescribed by the rules and regulations. These provisions do not apply to persons who raise and butcher for their own use and marketing meat and meat or poultry products. Sanitarians from local health departments make the inspections required for the enforcement of these sanitation requirements. Article li Q (b) of G. S. Ch. 106 establishes a system of voluntary inspection of meat, meat products, and meat by-products under the super- vision of the State Department of Agriculture. Article U9(a) of G. S. ■- ... . £ ■•-.■•.-. ' I : • ;. * i i ■ ■ ■ ■ • . | - <,. ! I - .... ; - ■.,.-'"■■■■ ; ; ■ :>a :-'■-;■ :.r , :is5.v'.-. •• > ■ ■ ■ I. . . 1 . . . - 106 - Ch. 106 establishes a system of voluntary inspection of poultry under the supervision of the State Department of Agriculture. G. S. 106- l6l authorizes municipal corporations to establish and main- tain inspection of meats and meat products at establishments located within their corporate limits, and authorizes county commissioners to establish and maintain inspection of meats and meat products at establishments not located within municipal corporations, but located within the boundaries of their county. The city or county governing body in providing such inspection has full power and authority to fix and collect fees necessary to cover the cost of such inspection. Also, Article \S of G. S. Ch. 106 provides that all persons, firms or corporations engaged in the business of operating meat packing plants must have the meat inspected by a licensed veterinarian if more than 1,000 beef cattle, 10,000 hogs, or 500 sheep are slaughtered therein annually. The inspector is to be selected by the governing body of the city, if located within city limits, or by the board of county commissioners if not located within city limits. Federal inspection of meat to be transported or sold in interstate commerce is provided for. In addition to the above, sanitarians doing food and milk work are responsible for such things as the investigation of food poisoning out- breaks; investigation of all types of complaints; assistance in the prepara- tion of plans and equipment layouts for establishments being remodeled or newly constructed; consultation service to the operators of all places under supervision in the interpretation of regulations and the promotion of better sanitation; and, educational activity through in-service train- ing, participation in talks, discussions, food handlers schools, field trips, and sanitarian trainee programs. - .' •• ■. ■ - ' - - ■ • ■' . ■•'■•' - ' - - •■■'•.. ■■--.' . '- - " , '' ■ : : ' - ' ■ ■ -.-■•-•• , ■•--•..' -. - 107 - Environmental Sanitation Activities A contractor is building a home in an area of a North Car where city water and sewer is not available. The residence will have to be served by a well and by a septic tank. In most counties, before the well and septic tank are installed, a permit must be obtained from the local health department, and before they may be used, they must be inspected by a sanitarian from the health department to determine if they have been installed in accordance with board of health regulations. This is an example of one of several activities of sanitarians in local health departments doing environmental sanitation work. The primary responsibilities of local health departments, with regard to environmental sanitation, include the regulation of excreta disposal, private water supplies, and garbage and refuse disposal; investigating and handling nuisance complaints ; pest control; and, making other related sanitation inspections. Most local boards of health have adopted and enforce regulations relating to these matters. With regard to excreta disposal control activities, the sanitarians usually interview the builder about his plans to determine the volume and character of the household wastes to be handled by the disposal system; visit the building site to observe the "lay of the land", soil porosity and proximity of other influencing factors; and, assist in planning a septic tank and drainfield system or other system of appropriate size and type. Sometimes several visits are made to a job before the final inspection can be made. These building sites include not only residential units but motels, restaurants, convalescent hospitals, truck terminals, schools, churches, manufacturing establishments, etc. These activities also include the maintenance of existing septic tanks and privies, the enforce- - . . . sco J-ac • • '■ , . - .. . ■---. ■ [ ! ■ ■ - - •■ - ■ • ■ ■ ■ " • ' . . . . i " --,.'■ - 108 - ment of sanitation regulations requiring connections to municipal sewage systems where public mains are extended, and the proper installation and maintenance of household and private sewer lines. The State statutes (G. S. 130-160) require all persons owning or controlling any residence, place of business or place of public assembly to provide a sanitary system of sewage disposal consisting of an approved privy, an approved septic tank, or a connection to a sewer system, under rules and regulations promulgated by the State Board of Health. Some counties have adopted a plumbing code and have provided a plumb- ing inspector to enforce the provisions of such code. The control of private water supplies by local health departments often requires the sanitarians to designate or recommend the location of wells to be drilled. In doing so, the primary concern is to provide a safe distance of separation of wells from any septic tank system, orivy, or other potential source of contamination. Sanitarians doing environ- mental sanitation work also collect specimens of water from private supplies for laboratory examinations; advise on the proper method of chlorination when the analyses indicate a need for samej and, condemn polluted wells and springs. The garbage and refuse control activities of these sanitarians often include the enforcement of regulations requiring proper garbage cans and receptacles for refuse disposal by residencies and business establishments in the county, and the maintenance of county sanitary landfills. Some counties provide a pest control program providing for such things as maintenance of streams and ditches, applying larvaciding materials to streams and ditches during the mosquito breeding season, investigating mosquito complaints and advising householders on how to control domestic ■ : - ■ - 109 - breeding j spraying pit privies, stables and animal pens as a fly control measure; setting up and maintaining bait stations to wipe out colonies of rats when rat infestations are reported in public alleys, backlots, along streams where no one individual is responsible and other places; advising individual householders and business places on rat control problems; and, enforcing the maintenance of all fish ponds. Many local boards of health have adopted regulations setting out minimum sanitation standards for trailer parks, and provide for periodic inspections by sanitarians from the health department. Many local boards of health have adopted regulations setting out minimum sanitation standards for swimming pools and other bathing places, and provide for periodic inspections by sanitarians from the health department , Many counties conduct a rabies control program under the supervision of the health department. Sections 106-36U to 106-387 of the General Statutes of North Carolina relate to the control of rabies. They make it the duty of the local health director with the approval of the board of county commissioners to appoint a sufficient number of rabies inspectors to carry out the provisions of the rabies law. In the appointment of such inspectors, preference is to be given to licensed veterinarians, and no person is to be appointed unless he is of good moral character and by training and experience is qualified in the opinion of the local health director and the board of county commissioners to perform the duties required under the rabies control law. The statutes provide that the vaccination of all dogs shall begin on February 1 and shall be completed within 90 days of that date. In ■ . "' ' ' ' ■ ■ ■ - ■ " - 110 - addition, the local health director may require the vaccination of all dogs within any area of his county when such vaccination is deemed necessary for the control of rabies. The rabies inspector is required to publish notice of the date of vaccination, and it is the duty of the owner of every dog in said county to have said dog at either of two or more points designated in the township for the purpose of having the same vaccinated. The statutes provide, in another section, that in all counties where a campaign of vaccination is being conducted, it is the duty of the owner of each and every dog over four months of age to have the same vaccinated against rabies annually, or at such intervals as shall be designated by the State Board of Health, but no more often than once in each calendar year. All antirabic vaccine is to be administered by a licensed veteri- narian or rabies inspector. At the time of vaccination the rabies inspector is to give to the person in charge of each dog vaccinated a numbered metal tag (which he obtains from the State Department of Agriculture upon the payment of a fee covering the cost of such tags) together with a certificate of vaccination. The certificate is to be issued in duplicate with the rabies inspector retaining a copy, and the metal tag is to be worn by the dog at all times. When the vaccination period has been completed, it is the duty of the sheriff, with the assistance of the rabies inspector, to make a thorough canvass of the county to determine if there are any dogs that are not wearing the metal tags. If any such dogs are found, the sheriff is to notify the owner to have the same vaccinated and to produce the required certificate within three days. If the owner fails to do so, he is subject to prosecution for the commission of a misde- meanor. If the sheriff is unable to find the owner of an unvaccinated dog, it is his duty to destroy said dog. - -■'•"■■ • • - - ■ " ; ■. ... "• • ' .... ... ■ ■ - ■ .; - Ill - The rabies inspector is to collect from the owner of each dog vac- cinated a vaccination fee in an amount to be fixed by the board of county commissioners. Any owner who fails to have his dog vaccinated on time must pay the rabies .inspector an additional $1 for late vaccination. It is the duty of the owner of any dog born after February 1 in any year or of any dog which will not be four months old on February 1 in any year to take the dog, when four months of age, or within 30 days thereafter, to a licensed veterinarian or to a rabies inspector and have it vaccinated against rabies. When a dog is brought into the State, except for exhibition purposes where it is confined and not permitted to run at large, it must be securily confined and vaccinated within one week after entrance, and must remain confined for two additional weeks after vaccination unless accompanied by a certificate issued by a qualified veterinarian showing that said dog is apparently free from rabies and has not been exposed to same, and that said dog has received the proper dose of rabies vaccine not more than six months prior to date of issuing the certificate. The local health director is authorized to declare a quarantine against rabies in any district when in his judgment this disease exists to the extent that the lives of persons are endangered, and in that event each and every dog in such district is to be confined on the premises of the owner or in a veterinary hospital, except that a dog may be permitted to leave the premises of the owner if on a leash or under the control and within sight of the owner or other responsible person at all times. When such a quarantine has been established, and dogs continue to run at large, uncontrolled by the person responsible for their control, any peace officer has the right after reasonable - * ■ . ■ . . . - ■ ■ ■ - 112 - effort has been made on the part of the officers to apprehend the dogs running at large, to kill said dogs and promptly dispose of their bodies. Every dog known to have been bitten by another animal which is known or proved to be rabied shall be killed immediately by its owner or by a peace officer, except that any dog which bos been vaccinated in accordance with the rabies laws at least three weeks before being bitten but not more than one year before, is to be closely confined for 90 days. At the end of this period, the dog may be released if declared free of rabies by a rabies inspector or a licensed veterinarian. If during the period of confinement such dog develops rabies, as determined by a licensed veterinarian, it is the duty of the owner to have such animal killed and promptly disposed of in accordance with the provisions of the rabies control law. Every person who owns or has possession of an animal which is sus- pected of having rabies is to confine such animal immediately in some secure place for a period of at least ten days. Every animal diagnosed by a licensed veterinarian as having rabies is to be killed immediately by its owner or a peace officer, except that if the animal has bitten a human being it is to be confined under the supervision of a veterinarian until the death of the animal, All heads of animals suspected of dying of rabies are to be sent to a laboratory approved by the State Board of Health. When a person has been bitten by an animal having rabies or sus- pected of having rabies, it is the duty of such persons or his parent or guardian and the person owning such animal to notify the local health director immediately and give their names and addresses, and it is the duty of the owner of the dog to securily confine it for ten days at such •.•--■ • - '• .- . . ■ ■ - - . - ■ ■ : - 113 - place as may be designated by the local health director. It is also the duty of every physician attending any person who has been bitten by an animal having rabies or suspected of having rabies, to report to the local health director the name, age and sex of the person so bitten and the precise location of the bite wound. When an animal becomes vicious or a menance to the public health, the owner of such animal or person harboring such animal is not to permit it to leave the premises on which kept unless on leash in the care of a responsible person. Rabies vaccine used in North Carolina must be approved by the U. S. Bureau of Animal Industry, North Carolina State Department of Agriculture, and the North Carolina State Board of Health. A violation of the rabies control laws constitutes a misdemeanor subject to a fine of not less than $10 nor more than $5>0, or to imprison- ment of not less than 10 days nor more than 30 days in the discretion of the court. In additon to the rabies control law discussed above, Chapter 67 of the General Statutes relates to dogs. Article 1 deals with the liability of the owner of a dog who injures livestock or fowls while off the premises of the owner; makes it a misdemeanor for any person owning a bitch to permit it to run at large during the erotic stage of copulation} makes it a misdemeanor for the owner of a sheep-killing dog, upon receiving official notice of such, to refuse to kill it and authorizes anyone to kill it if found running at large j and, makes it a misdemeanor for any person to fail to kill any dog under his control which he knows or has reason to believe has been bitten by a mad dog. Articles 2 and 3 of this chapter deal with license taxes on dogs. Article h deals with - - . - - - ' - - ■ ■ ■ . ■ - - im - "seeing-eye" guide dogs and Article 5 deals with the county dog warden. A summary of Article 5 shows that the Board of County Commissioners in each county is authorized, in its discretion, to appoint one or more county dog wardens and to determine their salary and travel allowance which are to be paid out of the proceeds of the county dog tax and, if necessary, from the General Fund or any non-tax funds. Any proceeds of the county dog tax remaining after the payment of salaries and travel are to be placed in a special county dog damage fund to be applied from time to time in satisfaction of claims for damage in accordance with the provisions of this Article. Claims are to be paid at the end of the fiscal year only to the extent that funds are available in the county dog damage fund, and any surplus in this fund may, no sooner than six months after the close of the fiscal year, at the discretion of the board of county commissioners, be paid into the county General Fund. The county dog warden has the power of arrest and is responsible for the enforcement in the county of all laws pertaining to ownership and control of dogs, and he is to co-operate with all other law enforce- ment officers operating within the county in fulfilling this responsibility. Also, in those counties having a rabies control officer, the county dog warden is to act as an assistant to the rabies control officer, working under the supervision of the health department, to collect the dog tax. In those counties having no rabies control officer, the county dog warden is to serve as rabies control officer. Although this statute refers to a rabies control officer and the rabies laws discussed above refer to a rabies inspector, it is probable that the General Assembly intended for these to mean the same thing, and an opinion of the Attorney General dated 7 February ISSl tends to indicate that in his " : ' - ■ ■ ■ - 115 - opinion that they are one and the same official. Other opinions of the Attorney General indicate that one person may not serve as both deputy sheriff and county dog warden or as ABC law enforcement officer and county dog warden as this would constitute double office holding within the prohibition of Article XIV, Sec. 7 of the North Carolina Constitution. (In Letters from Attorney General to Mr. C. L. Pemberton dated 8 October 1958 and 18 December 1958.) In each county in which a county dog warden is appointed, the board of county commissioners is to establish and maintain a dog pound under the supervision of the county dog warden, for the purpose of impounding lost and stray dogs for a period to be determined by the board of county commissioners during which time the county dog warden is to make every reasonable effort to locate and to give notice to the owners of such dogs, or if such owners cannot be located, to find new owners for such dogs. If, at the end cf the holding period to be determined by the board of county commissioners, such dogs remain unclaimed by the owners or by prospective owners, such dogs are to be destroyed in a humane manner under the direct supervision of the county dog warden. Every dog in the county where a county dog warden has been appointed is required at all times to wear a collar with the owner's name and address stamped on it or otherwise firmly attached to the collar. When the dog is listed for tax purposes, the tax authorities are to furnish the owner with a numbered metal tag to be attached to the collar as evidence that the dog has been listed for taxation. This tag is to be worn by the dog at all times. The board of county commissioners in each county having a dog warden is to appoint a board of appraisers consisting of three persons (one is - : ■ - , - - ■ i - 116 - to be chosen from among the sheep, livestock or poultry raisers j one from among the fox hunters, and one from the county at large) whose duty it shall be to determine and assess the amount of damage inflicted by dogs in the county. The damages so determined are to be paid out of the special county dog damage fund. Each board of county commissioners is authorized to settle and pay any claims presented for such sums as may be agreed upon by the claimant and the board of county commissioners, without appointing a board of appraisers. The statutes make it a misdemeanor to allow any dog to run at large, without the collar and tag required by this article, in any county having a dog warden. Using the 1959 statistics of the Durham County Health Department as an example, their 1909 Annual Report showed the following information concerning services rendered by the rabies control section: Type of Service Number Durham City and County Dogs immunized (by veterinarians) ll,lj.99 Dogs impounded, . 2,189 Injured, sick and stray dogs humanely destroyed . . . 1,718 Complaints investigated ..... 1,532 Biting incidents investigated 217 Dogs quarantined 211). SCHOOL HEALTH PROGRAM Although much of the school health program of the health departments is related to public health nursing, health education, and preventive medical service, it is a sufficiently important part of a department's program to warrant separate discussion. A school child is having difficulty with his school work due to dental defects. The defect is discovered at a clinic held in the school ' - 117 - at which the child receives a physical examination,, His parents are unable to pay to have the defect corrected. It is corrected at a health depart- ment's dental clinic. This is a typical example of how school health program funds are used. There are several State statutes relating to school health summarized below. G. S. 139-19 provides, in part, that the boards of education, super- intendents, principals and teachers in the public schools, and the local health director a?e to co-operate to the end that better health will be promoted among the school children of the area served by such local health director, G. S. Il5-lll3 provides, in part, that superintendents, supervisors, principals, teachers, and other employees in the public schools of the State must file in the office of the superintendent each year before assuming his or her duties, a certificate from the county physician, local health director, or other reputable physician, certifying that said person does not have tuberculosis in the communicable form, or any other disease, physical or mental, which would impair the ability of said person to perform effectively his or her duties. G. S. 115-20U provides: "There shall be organized and administered under the general super- vision of the State Superintendent of Public Instruction a compre- hensive program of physical education and of health education including scientific instruction in the subjects of alcoholism and narcotism. It shall be ths duty of teachers and principals in connection with this program to screen and observe all pupils in order to detect signs and symptoms of deviation from normal, and to record and report the results of their findings in accord- ance with the established policies and procedures and upon blanks furnished for this purpose. The State Superintendent of Public Instruction, with the State Board of Health cooperating, shall make rules and regulations regarding screening and observation by teachers and for medical and psychiatric examination of pupils - - ■ ' - • . • : ' . ' ■ • :• - 118 - attending the public schools. Correction of chronic remediable defects for underprivileged children may be paid out of school health funds appropriated by the General Assembly to the State Board of Education for allocation to school administrative units in accordance with policies agreed upon by the State Superintendent of Public Instruction and the State Board of Health, and as other- wise provided by law. The State Board of Health shall provide free- dental treatment for as many underprivileged school children as possible each year." Section 17 of the 19f>9 Appropriations Act provides » "That not less than ninety per cent (90$) of the expenditures out of the appropriations for each year made to the State Board of Education under the Nine Months School Fund for Child Health Program shall be expended for diagnosis and the correction of chronic remediable physical defects of public school children through the Child Health Program of the State Board of Education in the following manner: (1) Upon discovery of the defect, if it appears that the expenditure of school health funds will be required for correc- tion through providing spectacles, prostheses, or other correc- tion of chronic remediable defects, the appropriate school official shall forthwith notify the county superintendent of public welfare of the county in which the child resides. Thereupon, the super- intendent of public welfare shall make such investigation as neces- sary and only upon his certification of financial need shall funds be expended for this purpose: Provided, however, that in cases of minor dental defects involving expenditures not in excess of ten dollars ($10.00), school and health department personnel may deter- mine financial need. (2) Child Health Program funds as defined in this Section shall be expended in accordance with a uniform State-wide schedule of fees and costs, and only to provide spectacles, prostheses and others correction of chronic remediable defects for public school children: Provided, that an amount not in excess of ten per cent (10$) of the appropriation for each year may be expended for case finding, health education and intensive follow-up services." The budget recommendations submitted by the Governor in the Advisory Budget Commission to the 1959 General Assembly contained the following: "Schools and local health departments co-operatively carry on the health services in the schools. This item provides a share of cost borne by the schools. Local governments often provide supple- mental funds for this program and additional funds (largely for personnel) are provided in State appropriations to the Department of Health. At least 90 per cent of the funds provided here are used in paying cost of diagnosing and correcting defects in cases where medical indigency is found. Teachers screen out children ■ • ■ ■ ■ ' .. . - ■ . - 119 - who are observed to be handicapped by remediable physical defects or health conditions. Health departments personnel review these cases. Where treatment is deemed necessary, the school, the health department, and the welfare department co-operate in getting the parents or guardians to provide treatment} and the vast majority of cases are disposed of by such private resources. Tax funds are used to provide for cases where medical indigency is clearly estab- lished by investigations. Number of Children Receiving Services Actual Actual Actual Estimated 1955-56 1956-57 1957-58 1958-59 Diagnostic Services! Eye Examinations 1,876 1,180 1,7U0 1,800 Medical Examinations .... 81*, 660 79,90li 76,110 80,000 Chest X-rays 1,362 3itl 323 500 Hearing tests with audiometers 51,732 U7,236 UO,905 35,000 Cases receiving correction of defects by expenditures from this fund: Tonsils 3,1*77 2,983 3,17U 3,000 Teeth l6,I;27 13,699 15,686 17,000 Ears 175 180 196 200 Hernia Ill 127 138 150 Orthopedic 31 13 28 25 Intestinal parasites .... 5^6 711 52U 600 Eyes (glasses) . 2,620 1,862 2,695 2,700 Eyes (surgery) h& 32 16 20 All others 775 131 501 600" The General Assembly appropriated $Ui5,898 for each year of the 1959-61 biennium to the State Board of Education for the child health program. The State appropriation is made to the State Department of Public Instruction and is administered by a School Health Co-ordinating Committee composed of representatives from the State Department of Public Instruction and the State Board of Health. The statistics indicate that most of the school health funds are used for the correction of dental defects of medically indigent school children. Using Durham County as an example, the 1959 Report made by the Durham County Health Department to the State Board of Health indicated that during - . ■ ■ I ■ : '■ ■ - 120 - the year medical examinations by health department personnel were given to 1,817 children entering school, 2,383 elementary school children beyond the first grade, and l,58h high school children. The Report also showed that U,895 school children were screened for visual defects; that 5,781; school children were screened for oral defects; that 757 tuberculosis patch tests were applied; that 55 children were screened for pediculosis; that 29 were screened for ringworm; that 8l were screened for scabies; that 17 miscellaneous screenings were made; and, that 1,603 school children were referred to a public health nurse by a teacher. The Report further showed that 5,02U children were referred for medical or dental care, and that of this number, 1,1^0 referrals were for eye defects and 3,215 for mouth defects. An important aspect of the school health program is the giving of physical examinations to certain school children. In many counties, all children entering the first grade, who have not received a physical examination from their private physician, receive a physical examination at the school. In addition, many counties provide for subsequent physical examinations of school children in certain grades. The public health nurses normally plan, schedule, and assist .in the carrying out of the physicals which are held at the school. The nurse sees that all records are in order, and if the examining physician notes any defects the public health nurse will go into the home of such child to discuss the need for correcting such defects and any resources that might be available to assist in the rendering of such services. The physicians who co-operate with the health department by performing the medical services at these school health clinics are paid a small fee based upon ■ ■ ■ . . . ' - ■ ■ ■ ■ - - ■ - ■ . i - 121 - a fee scale prepared by the State Board of Health. Another important aspect of the school health program is the work of the public health nurses, public health educators, and other health department personnel with the school personnel on the planning and carry- ing out of health education programs. Public health nurses will often make talks to the classes or help the teachers plan the presentation of such matters as sex education, nutrition, alcoholism, etc.j help the teachers to prepare bulletin boards or materials for the teacher to use in health education programs ; act as a liaison between the teacher and the home of the child with respect to physical or mental health matters; and, encourage the teachers to be on the lookout for possible health defects as the teachers do most of the health screening. The public health nurse is often invited to the school to discuss the importance of physical examinations, correcting defects, obtaining iiranunizations, etc. POST-MORTEM MEDICOLEGAL EXAMINATIONS Although post-mortem medicolegal examinations are not a service of local health departments, they are sufficiently related to warrant summary discussion here. Article 21 of Ch. 130, relating to post-mortem medico- legal examinations, authorizes the board of county commissioners of any county desiring to come within the purvue of this article to adopt a resolution to that effect in which case the medical examiners system shall be in effect in that county. This article does not apply to any county until the board of county commissioners adopts such resolution. At the present time, only Guilford County is operating under this system. This article creates within the State Board of Health a committee ■ - - ■ ■ ■ ■ - - 122 - to be known as the Committee on Post-Mortem Medicolegal Examinations, which Committee consists of seven persons as follows: the State Health Director ; the Attorney General j the Director of the State Bureau of Investigation; the head of the department of pathology at the medical school of the University of North Carolina j the head of the department of pathology of the Bowman Gray School of Medicine j the head of the department of pathology of the School of Medicine of Duke University; and a layman appointed by the Governor, The State Health Director is the chairman of the Committee. The powers of the Committee include the promulgation of rules and regulations to carry out its duties, to further medical-legal education and training, and to establish and maintain a toxicological laboratory under the supervision of the State Board of Health (or, if the Committee deems it advisable, it may contract with other technical personnel or for the use of other technical facilities for the purpose of providing toxicologic service.) The Committee is authorized to divide the state into districts and the Committee is authorized to appoint district pathologists to serve at the pleasure of the Committee. It is made the duty of the district pathologist to perform a complete autopsy .in cases referred to him under the provisions of this article, and to make pathological studies of such anotomical materials as may be submitted to him by any medical examiner in his district, or by anyone empowered by the article to make such reference in the performance of their offical duties. The district pathologist is to make reports of his findings to the coroner, the solicitor of the superior court, and any other interested persons upon order of a court of record. For these duties, the district pathologist is to receive a fee to be fixed in each case by the board of county ■'-•'. . ■ ! ■ - 123 - commissioners and paid by the county of legal residence of the deceased, or by the county where the body of the deceased was first found, if the legal residence is unknown or is otherwise than in the State of North Carolina. These fees constitute full compensation of the district pathologist. This article further provides that the chairman of the Committee is to appoint, subject to the approval of the Committee and of the board of county commissioners of each county in the state that elects to come under the article, a qualified and practicing physician as medical examiner for the county to serve at the pleasure of the board of county commis- sioners. The medical examiner is authorized to appoint one or more assistants. The medical examiner is to be notified upon the death of any person apparently by the criminal act or default of another, or apparently by suicide, or suddenly when apparently in good health, or while an inmate of any penal or correctional institution, or under any suspicious, unususal or unnatural circumstances. He is to be notified by any person having knowledge of such death, and no person is to disturb the body at the scene of death until authorized by the county medical examiner. Upon receipt of such notice, the county medical examiner is to make a physical and medical examination of the body or parts of the body which may be found, making inquiries regarding the cause and manner of death, produce his findings in writing, and promptly make a full report thereof to the ooroner, the solicitor of the superior court, the chairman of the Medicolegal Committee, and upon request to the head of the law enforcement agency charged with the responsibility for investi- gation of the incident. Also, the report may be furnished to any other interested person upon order of the court. For each such investigation, - • ■ . ■ ' - ..■■..• . - - ■ - : . - 12U - the county medical examiner is to receive a fee to be determined by the board of county commissioners, If the medical examiner is of the opinion that it is advisable and in the public interest that an autopsy or other pathological study be made, or if an autopsy or other pathological study is requested by the superior court solioitor or the superior court judge, such autopsy or pathological study shall be made by the district pathologist or by a competent pathologist designated by the chairman of the Medico- legal Committee. ■■.■'■ - - 125 - CHAPTER V SANITARY DISTRICTS AND MOSQUITO CONTROL DISTRICTS Sanitary D i stricts Article 12 of Chapter 130 of the General Statutes of North Carolina sets out the procedure for incorporating a sanitary district as follows: 5l% or more of the resident freeholders within a proposed district may petition the board of county commissioners of the county in which all or a major portion of the petitioning freeholders are located setting forth the boundaries of the proposed district and the object it is proposed to accomplish. Upon receipt of such petition the board of county com- missioners, through its chairman, must notify the State Board of Health and the chairman of the board of county commissioners of any other county or counties in which a portion of the proposed district lies, of the receipt of the petition, and shall request that a representative of the State Board of Health hold a joint public hearing with the county com- missioners of all the counties in which a portion of the district lies concerning the creation of the proposed sanitary district. The State Health Director and the chairman of the board of county commissioners then name a time and place within the proposed district at which a pub- lic hearing is to be held. The chairman of the board of county commis- sioners gives notice of such hearing by posting a notice at the court- house door of the county and also by publication in a newspaper publish- ed in such county at least once a week for four successive weeks, and if the area involved is in more than one county a like notice is to be given in each of the counties involved. If, after such hearing the State Board of Health and the county commissioners concerned deem it ■ - - - . . ■ ,. - 126 - advisable to comply with the request of said petition, and determine that a district for the purpose or purposes therein stated should be created and established by them, the State Board of Health shall adopt a resolution to that effect defining the boundaries of the district and declaring the territory within such boundaries to be a sanitary district. Each district when so created shall be identified by a name and number assigned by the State Board of Health. Upon receiving notification from the State Board of Health of the creation of the district, the board or boards of county commissioners of the county or counties in which the district is located shall then hold a meeting or joint meeting for the purpose of electing a sanitary district board of three members, residents within the district, which shall thereafter be the governing body of the sanitary district. Such members of the sanitary district board are to serve until the next gen- eral election following their appointment at which time sanitary district board members are to be elected as are other county officers, except that the nomination and election shall be confined to the district. Those elected are to be elected for two-year terms. Prior to the appointment of a sanitary district board by the board or boards of county commissioners, or prior to the election of the mem- bers of the sanitary district board at any general election, the board or boards of county commissioners may by resolution determine that such a sanitary district board shall consist of five members (rather than three). At the primary at which nominees for membership on the sanitary district board are selected in such cases the 10 candidates receiving the highest number of votes are to be nominated as candidates for election in the next general election and the five candidates receiving the highest ■ •■ . ■ V. ■• If , ■ ' ■ ■ ' ■ " . ! ■'■''' ■ = _ - . - - fg - - ' - 127 - number of votes in the general election are to be elected as members of the sanitary district board; when 10 or less candidates qualify for the primary, then each shall be declared to be a candidate in the general election without his name being voted on in the primary. The primary and general election shall be non-partisan, and conducted by the board of elections in the county in which the greater portion of qualified voters of the sanitary district are located. County commissioners are authorized to fill vacancies in any sanitary district board until the next general election. If the district is located in more than one county, the vacancy is to be filled by the board of county commissioners of the county in which the vacancy occurred. Sanitary district boards have considerable authority, including the construction and maintenance of water and sewer systems and such other utilities as may be necessary for the protection and promotion of the public health and sanitary welfare of the district, and the issuance of bonds and levying of taxes for such purposes. When a sanitary district board adopts a bond resolution in accordance with the provisions of this article, the sanitary district board is to call upon the board or boards of county commissioners in the county or counties in which the district or any portion thereof is located to cause an election to be held on the proposition of issuing bonds as set forth in the bond resolution. The commissioners are to name election officers, set a date, name polling places and provide registration and polling books. The expenses of holding bond elections are to be paid from the funds of the sanitary dis- trict. Upon the creation of a sanitary district and after each assessment for taxes thereafter the board or boards of county commissioners of the . ■ ' ■ ; ■ ! .i 1 ■ ■ - 128 - county or counties in which the sanitary district is located shall file with the sanitary district board the valuation of assessable property within the district. The sanitary district board must then determine the amount of funds to be raised for the ensuing year to provide for the payment of interest and the proportionate part of the principal on all outstanding bonds, other indebtedness, and to pay all obligations incurred by the district in the performance of its lawful undertakings. The sanitary district board shall then determine the number of cents per $100 valuation necessary to raise the said amount and so certify to the board or boards of county commissioners. The board or boards of county commissioners in their next annual levy after receiving such certification shall include the number of cents per $100 valuation so certified by the sanitary district board in the levy against all taxable property within this district, which tax shall be collected as other county taxes are collected and every month the amount of tax so collected shall be remitted to the sanitary district board and deposited by the said board in a bank in the State of North Carolina separately from other funds of the dis- trict. The levy may include an amount for reimbursing the county for the expenses of levying and collecting said taxes, which amount shall be based upon such percentage of the collections of said taxes, not exceeding 5% thereof, as may be agreed upon by the sanitary district board and the board of county commissioners. Such agreed amount is to be deducted from the collections remitted to the sanitary district board. Such percentage shall remain the same until revised by agreement of the two boards. The sanitary district board may, in lieu of using the regular county assessing, levying, and collection machinery, provide for the listing of * : ' - : ■ 1 ! ■ - ■ - - 129 - all taxable property within the district with a person designated by the sanitary district board, and then after determining the amount of levy necessary, levy the same and appoint a tax collector to collect the same. This article further makes provision for an election on the removal of a member of the sanitary district board upon the presentation to the board or boards of county commissioners of the area in which the sanitary district is located a petition carrying the signature of 2%% or more of the legal voters within the sanitary district. The petition must state that the removal is requested because of the malfeasance or non-feasance in office of said sanitary district board member. This article establishes a procedure for the extension of a district upon petition by ]$% of resident freeholders within area to be included in the district, notice to board of county commissioners and State Board of Health, followed by notice and joint hearing by these two agencies, and a vote in area to be annexed. Fifteen percent of resident freeholders of the existing district may petition the board of county commissioners to hold an election within the district on the proposed annexation in which case the commissioners shall do so. If the vote rr votes are fai-crable, the district is to be automatically enlarged and the annexed territory becomes subject to the debts of the district. This article also makes provision for the filing of a petition with the board of county commissioners of a county in which a major portion of the district lies for the withdrawal of a portion of a sanitary dis- trict when the district has no outstanding indebtedness. The petition must be signed by <,\% or more of the resident freeholders of the portion desiring to withdraw, and if it is approved by the sanitary district board and the board of county commissioners, an election is to be held < ■ - - - ■ .. ■ ■ ■ - ■ - ■ - - 130 - on the question of whether or not such portion should be authorized to withdraw. If the vote favors the withdrawal, the county commissioners shall transmit this fact to the State Board of Health which shall exclude said portion from the district, dissolve said portion, and redefine the limits of the district accordingly. This article also makes provision for the dissolution of a sanitary district which has no outstanding indebtedness upon petition of $1% or more of the resident freeholders therein. Upon receipt of such petition the board of county commissioners through its chairman shall notify the State Board of Health and any other board or boards of county commissioners concerned. A public hearing is then held before the commissioners and a representative of the State Board of Health on the question of the dis- solution of the sanitary district. Such public hearing is to be held following notice by posting the same at the courthouse door and by publica- tion in a newspaper for four consecutive weeks. After such hearing, if the board or boards of county commissioners concerned and the representa- tive of the State Board of Health determine that the dissolution request should be complied with, the State Board of Health is to adopt a resolu- tion to that effect whereupon the district shall be deemed dissolved. Mosquito Control Districts Article 2U of Ch. 130 of the General Statutes, relating to the crea- tion and powers and duties of mosquito control districts, provides for the creation of a mosquito control district which lies wholly within a single county in somewhat f amilar fashion to the creation of a sanitary district. The statute provides that 10$ or more of the resident freeholders within the proposed district may petition the board of county commissioners - ■ .. - r - f ■ . - ■ ■ ' ■ • ■ ■ :. ■ • - . - 131 - of the county in which the proposed district lies, setting forth the boundaries of the district and a suggested name for the district. When the board of county commissioners receives the petition, they are to con- sider whether or not the creation of the district appears feasible and in the interest of the public health and, if so, they are to forward a copy of the petition to the State Board of Health which also considers the advisability of forming a district. If the State Board of Health deems that the formation of the district is advisable and in the interest of the public health, they notify the board of county commissioners where- upon the board gives notice of a public hearing upon the question of the formation of the district by advertising the time, place and purpose of the hearing once each week for four successive weeks in a newspaper published in the county or having a general circulation therein. If, after the public hearing and after consultation with the representative of the State Board of Health, the board of county commissioners deems it advisable that the district should be created and established, the board of county commissioners are then to submit to the qualified voters resid- ing in the proposed district at an election called for that purpose, the question of whether or not the district shall be created. Upon determin- ing that the district should be created, and prior to the submission of the question to the voters, the board of county commissioners may deter- mine the maximum special tax to be levied for mosquito control purposes should the formation of the district be approved by the voters, but in no event may the maximum authorized levy exceed 3$ cents on $100 assessed valua- tion. If the board of county commissioners determines that less than 3£ cents per $100 valuation is to be the maximum authorized upon approval of the district by the voters, the lesser maximum determined by the board - - ■ - ' : ■ - . ■' - - 132 - of county commissioners shall appear on the ballots to be used by the voters voting on the creation of the district. The board of county commissioners are to provide polling places, provide for registrar and judges at the polling places, provide for the registration of the voters, and prepare the necessary ballots. The cost of holding the election shall be paid from either the general or the health fund of the county or from both as may be determined by the board of county commissioners. Notice of the time and place of voting is to be published by the board of county com- missioners at least three times in a newspaper published or circulated in the county with the first of such notices to be published not less than 30 days preceding the election. If a majority of the qualified voters voting at the election vote in favor of the creation of the dis- trict and the levy of a special tax, the board of county commissioners shall declare that the district exists and shall adopt a resolution to that effect. If the proposed district lies in more than one county, the original determination aa to whether or not the formation of a district is feasible and in the interest of the public health is made by the State Board of Health. If the State Board of Health deems the formation of the district to be in the public interest and beneficial to public health, it shall direct the boards of county commissioners of the counties concerned to submit the question to an election. Again, the boards of county com- missioners are to provide one or more polling places, provide registrars and judges, and provide for registration of the voters. The State Board of Health is to provide for the printing and distribution of the ballots with the cost of printing and distribution and any other incidental costs being borne by and prorated among the several counties in which any • ■. ■ - ■■■■-■.■ ■ ■ ■ ■ ■ ■ ■ ■ ■ . - 133 - of the district lies in accordance with each county' s portion of the total number of acres within the district. Again, if a majority of the voters vote in favor of the creation of said district, the State Board of Health shall declare the district to exist and shall certify this fact to the board of county commissioners of each county where any part of said district lies. If the created mosquito control district lies wholly within a single county, the mosquito control district board is to be composed of five members, all of whom are residents of the district. Three of the members are to be appointed by the board of county commissioners for three-year staggered terms. One member is to be appointed by the State Health Director and one member by the Director of the Wildlife Resources Com- mission, with these two appointees serving at the pleasure of the appoint- ing authority. In the case of a district lying in two or more counties the board of commissioners of each county in which any part of the district lies shall appoint one member. The State Health Director shall appoint one member and the Director of the Wildlife Resources Commission shall appoint one member. In the event the district lies in only two counties, the board of commissioners of the county in which the majority of the district lies shall appoint two members and the other county shall appoint one member, each to serve three-year staggered terms. This is in addition to the members appointed by the State Health Director and the Director of the Wildlife Resources Commission. Mosquito control districts thus created have power to levy ad valorem taxes upon all the taxable property within the district at a rate not to exceed ^% upon the adjusted $100 assessed valuation (or such lesser r ■ - - - 13U - maximum rate as was determined at the time of the election on the creation of the district). If the district lies wholly within a single county, the valuation assessed by the county tax authorities shall be used by the mosquito control district as a basis for its tax assessment and the mosquito control district shall certify its tax rate to the county tax collector or supervisor in time to have such rate and the amount of tax due there- upon entered upon the official county tax receipts or stubs or duplicates, and it is then the duty of the county tax collector to collect said taxes at the same time that county taxes are collected. If the district lies in two or more counties, the mosquito control district board shall hori- zontally equalize the assessed valuation of the property of the several counties in which the district lies by adjusting the ratio of assessed valuation in the several counties to the true value of the taxable property in the several counties. From such adjusted and equalized valuation, an appeal may be had to the State Board of Assessments as in the case of appeal by property owners from the county board of equalization and review. Upon such equalized valuations, the mosquito control district board shall levy its tax and certify the amount of the levy against each taxpayer to the appropriate county tax collector or supervisor in time for the amount of such mosquito control district tax to be entered upon the county tax receipts stubs or duplicates, and it is the duty of the several county tax collectors to collect said tax and deposit same to the credit of the mosquito control district. The statutes give the mosquito control district board power to con- duct mosquito control programs. The mosquito control district board is authorized to adopt a resolution authorizing a bond issue stating the purpose for which the bonds are to be issued. Followl.ng the adoption i ■ : - &--'■'■ - ! - - 135 - of a bond resolution by the governing board of a district, the board shall call upon the board or boards of county commissioners in the county or counties in which the district or any of the portion thereof is located, to name elections officers, set the date, name the polling places, and cause to be held an election within the district on the proposition of the issuance of bonds as set forth in the bond resolution The expenses of holding bond elections are to be paid from the funds of the mosquito control district. If a majority of the voters vote in favor of the issuance of the bonds and the levy of a tax for payment thereof, a state- ment to that effect shall be signed by a majority of the members of the governing board of the district and deposited with the clerk of the court in the county in which the district lies, or, if parts of the district lie in two or more counties, with the clerk of the superior court in each of such counties. Provision is made for the dissolution of districts created under this article which have no outstanding indebtedness. The procedure calls for a petition by J>3$ or more of resident freeholders, notice and hearing before board or boards of county commissioners and representative of State Board of Health, and resolution by State Board of Health dissolving the district if that Board and the commissioners both deem it advisable. ■-...-. - ■ ■■■ ■ . . - • ■ • - - - - This book circulates for a 2-week period and is due on the last date stamped below. It must be brought to the library to be renewed RB 2 5 _198f OCT 7 m m frfa Form No. 771 fA 5^0 AN8 L726 I960 UNC-CH HEALTH SCIENCES LIBRARY H001 24003 A WA 5ko M8 LT26 I960 CI Ligon Public health in N. Carolina ISSUED TO 2|ll 3 ALJ US ra 3mb| ggR mm $ H IE I ■ S 7*/ Dffift&lE! I KU HI &s 1^1 I nHE mgsmggm ■Hi nana