Fubiic Health Administration in NortJi Carolina Pnyiikwi 01 HEALTH AFFAIRS UBRARY THE LIBRARY OF THE UNIVERSITY OF NORTH CAROLINA FROM THE BOOKS OF WILLIAM P. JACOCKS, M.D. CLASS OF 1904 FRIEND OF THE LIBRARY 54-0 ±94-o Muaama ERRATA ■ •• Page 21, Date in line 12 of paragraph, on General Administration should be 1937-38 instead of 1936-38. Page 48, The italic headings Pneumonia and Tuberculosis should be numbered thus: 1 ) Pneumonia 2) Tuberculosis Page 86, (b) should be omitted before heading "Provisions for Improvement of Obstetrical Practices." Page 97, The line just above table at bottom of page, beginning "Laboratory of Hygiene," should read, "Laboratory of Hygiene for the past four bienniums were : " S Page 137, Quotation marks should be at end of fifth paragraph, which ends with the word agencies. on Page 144, The heading, "Comment on A," should be "Comment on a." Page 146, The heading, "Comment on B," should be "Comment on b." Page 159, In lines 10 and 11 under "Comment," the phrase, "that is, in accordance with those of local health departments," should be omitted. Page 171, A heading reading "16. Recommendation Pertaining TO Group Research" should be just over paragraph beginning "16. That . . ." at bottom of page. Page 173, A heading reading "18. Recommendation Pertaining TO Operating Manual" should be just over the para- graph beginning "18. That . . ." at top of page. His Excellency, Clyde R. Hoey Governor of North Carolina Public Health Administration in North Carolina BY WILLIAM A. McINTOSH AND JOHN F. KENDRICK WITH A Foreword BY CARL V. REYNOLDS, M.D. State Health Officer and Executive-Secretary North Carolina State Board of Health 1940 DIVISION OF HEALTH AFFATP^ ? TPOlTB^ FOREWORD This report on Public Health Administration in North Carolina, compiled by Dr. William A. Mcintosh and Dr. John F. Kendrick, representatives of the International Health Division of The Rockefeller Foundation, sets forth the results of the most comprehensive study of its kind ever undertaken and successfully accomplished in North Carolina. Through months of painstaking study, which led the authors of this valu- able contribution through a veritable labyrinth of research, we have, in this publication, an accurate picture of the organization of and the services ren- dered by those who are engaged in carrying on our public health activities. The strength of this important document lies not only in the amount of intelligent effort expended in its preparation and its clear presentation of facts, but also in the constructive manner in which the authors have under- taken to make recommendations for a still greater public health structure in North Carolina. When I requested that this survey be made, I wanted to get an accurate, fair and impartial appraisal of just what is being done in our State. This desire has been realized, and I commend this report for study to those who believe in basing their objectives upon a desire for truth. No institution is so perfect that it cannot be improved; perfection can only be approximated by the finite mind, but the more accurately and impartially we appraise human effort, whether exercised by the individual or by society in the ag- gregate, the more nearly we will be drawn to a realization of the best. I not only commend the fine work of Dr. Mcintosh and Dr. Kendrick for the valuable contribution they have made to the annals of North Carolina, but I also thank The Rockefeller Foundation for the services of these two eminent authorities, and for its invaluable support of the cause of public health in general, both in America and throughout the world. Carl V. Reynolds, M.D., Secretary and State Health Officer. LETTER OF TRANSMITTAL December 8, 1939 Dear Doctor Reynolds: We take pleasure in transmitting herewith our report on the organization and administration of state and local health services in North Carolina. Its submission completes the task to which we were assigned. We wish to express our appreciation of the opportunity afforded us to make this study and of the invaluable assistance which was given by you and your staff. Respectfully submitted, W. A. McIxTOSH J. F. Kexdrick Vj' lUolX PUBLIC HEALTH ADMINISTRATION IN NORTH CAROLINA General Introduction To Parts I and II A fact-finding- investigation of the organization and services of State and local health departments in North Carolina, undertaken on October 28, 1937, by representatives of the International Health Division of The Rockefeller Foundation at the re^4uest of the State Health Officer, has recently been com- pleted. Request for this survey was made with two purposes in view: (1) the assemblage, by an agent disinterested politically, of information that would give a composite picture of the present status of State and local health ad- ministration in North Carolina in its relationship to government in general and to closely allied government agencies engaged in rendering health ser- vices; and (2) the formulation of such recommendations as may be appro- priate for the consideration of the State Health Officer in the planning of the future health program. On the completion of the study the following report was prepared, in which there is presented, first, an exposition of the North Carolina plan of State and local health services (Part I) and, second, recom- mendations and comments (Part II). PUBLIC HEALTH ADMINISTRATION IN NORTH CAROLINA CONTENTS Page Title Page 3 Foreword, State Health Officer 4 Letter of Transmittal from Consultants 5 General Introduction to Part I and Part II 7 Contents 11 Illustrations 13 PART I Organization and Services A. Introduction 15 B. The North Carolina Plan of State and Local Health Services 15 1. Boards of Health 15 2. Departments of Health 19 a. General Administration 21 1) State Health Officer 21 2 ) County and District Health Officers 23 3) Employment and Administration of Personnel 25 4) Financial Management 27 5 ) Filing Service 31 6) Public Health Library Service „ 34 7) Publicity Se)'vice 35 b. Epidemiological Service 36 1 ) Pneumonia „ 48 2) Tuberculosis ., 48 c. Vital Statistics Service 55 d. Sanitary Engineei-ing 59 e. Preventive Medicine 73 1 ) Public Health Education 74 2) School Health Supervision 78 3) Maternal and Child Hygiene 83 Birth Control 87 Eugenics Board 87 4) Crippled Children 89 f. Oral Hygiene 93 g. Public Health Laboratory Services 96 h. Industrial Hygiene 102 i. County Health Organization and Supervision 104 Page C. Miscellaneous Considerations 109 1. Introduction 109 2. General Description of State 109 3. Population 110 4. Government 112 a. State 112 b. Political Sub-divisions 118 c. County Government 118 5. The Educational System 120 6. Social Welfare Services 124 a. The State Organization 124 1) The State Board of Charities and Public Welfare 124 a) The Administrative Office 124 b) The Division of Child Welfare 126 c) The Division of Public Assistance 128 (1) Old Age Assistance 129 (2) Aid to Dependent Children 129 d) The Division of Casework Training and Family Rehabilitation 130 e) The Division of Mental Hygiene 130 f ) The Division of Institutions and Corrections 131 g) Service Units of the State Board 132 2) The Commission for the Blind and Schools for the Deaf and Blind 132 b. County Welfare Organizations 134 1) County Welfare Depai'tments 134 2) County Poor Relief 135 7. Agricultural Services 135 a. The Department of Agriculture 135 b. Agricultural Extension Work 136 8. Medical Dental and Public Health Associations 138 a. The Medical Society of the State of North Carolina 138 b. The North Carolina Dental Society 138 c. The North Carolina Health Officers' Association 139 9. Hospital Administration 139 10. References to Part I '....\ : 141 PART II Recommendations with Comments A. Introductiox 143 B. Recommendations 144 Appendix ;. :. 176 ILLUSTRATIONS Page His Excellency, Clyde R. Hoey — Governor of North Carolina Frontispiece Members of the State Board of Health 17 State Organization Chart 20 State Board of Health, Administration Building 20 North Carolina State Health Officers 22 State Health Officer and Directors of the Divisions of the State Health Department 24 Main Building, North Carolina Sanatorium 49 Dr. p. p. McCain — Superintendent, State Tuberculosis Sanatoria 49 Western North Carolina Sanatorium 50 Clarence A. Shore Memorial Building 98 State Biological Farm 98 Full-Time Health Services in North Carolina — Fiscal Year 1937-38 106 County Organization Chart 108 Map Showing Counties and Physiographical Areas of the State 117 Organization Chart of the North Carolina State Board of Charities AND Public Welfare 125 PUBLIC HEALTH ADMINISTRATION IN NORTH CAROLINA PART I ORGANIZATION AND SERVICES A. INTRODUCTION Part I of this study is divided into two main subdivisions, namely: (a) the North Carolina plan of State and local health services, and (b) miscellaneous considerations, including references to allied services. Of these main sub- divisions, the former is an exposition of the present organization and services of the State and local health organizations; whereas the latter furnishes cer- tain essential background information that helps to complete the picture of the conditions under which health work is done, and of other governmental or private agencies that contribute to the promotion of health. This study was made for the benefit of the State Health Officer and his staff. For purposes of exposition, the State health organization, as well as local health organization, is viewed as consisting of: (1) the control agency — the board of health — and (2) the operating or executive agency of this board — the department of health. In dealing with these branches of the health organization, and with such subdivisions of them as may exist, a brief historical introduction has been presented of each, and, in order to show the relationship of the State organization to its local counterparts, descriptions of these organizations have been presented, where practicable, in parallel columns. Considerable detail was included in order that the study may be utilized as a ready reference work and as an aid in the preparation of an operating manual, referred to hereafter. Part I served as an indespensible prerequisite to Part II, in which recommendations are enumerated. B. THE NORTH CAROLINA PLAN OF STATE AND LOCAL HEALTH SERVICES 1. Boards of Health On February 12, 1877, the General Assembly of North Carolina enacted legislation which provided that the State Medical Society act as a State Board of Health, and the Society established a Health Committee to discharge its public health responsibilities. In 1879 the Legislature created a State Board of Health consisting of nine members. The Governor was authorized to appoint six members and the State Medical Society three members. In 1893 the General Assembly decreased the Governor's appointments to five members and increased the State Medical Society's to four. No modification in the laws pertaining to the State Board of Health has been made since 1931. County boards of health were created by the State Legislatux-e in 1879. The membership of these boards was made up of all regular practicing phy- sicians in the county, the chairman of the board of county commissioners, the mayor of the county town and the county surveyor. In 1901 the General 16 Public Health Administration in North Carolina Assembly created county sanitary committees composed of the county commissioners and two physicians elected by the county commissioners. These committees were discontinued in 1911, when the Legislature pro- vided for county boards of health as they exist today, though it was not until 1931 that the membership of these boards was enlarged to include a dentist. Four special charters have been enacted by the General Assembly to provide for city and county boards of health and the manner in which these boards are set up varies for each charter. The transition in administering county health work from a part-time to a whole-time basis occurred in 1911. This change was favorably influenced by the campaign against hookworm disease which was begun in North Caro- lina in 1910. The first full-time county health officer to be appoined in North Carolina was Dr. G. M. Ross, who was made health officer of Guilford County on June 1, 1911. Attention should be called also to an enabling act passed by the General Assembly in 1935 for the purpose of authorizing the State Board of Health to use any available funds, not otherwise appropriated, for the establishment of local or district health departments for any town, city, and county or groups of such units in the state where the local governing powers desire the formation of such a department and are willing to support such enterprises financially in an amount at least equal to the state's financial participation. Present Organizations. — Nine members compose the State Board of Health, five of whom are appointed by the Governor and four are selected by the State Medical Society. Specific eligibility standards are not laid down by law, but custom limits the Governor's appointments to two physicians, an engineer, a dentist, and a pharmacist; whereas, the State Medical Society elects four physicians. Retiring members are eligible to succeed themselves. The term of office is four years, and groups of four and five members retire in rotation on successive odd years. The appointive power may remove members from office for cause and may fill vacancies which occur for the unexpired term. The election of officers of the State Board of Health is provided by law. The President is chosen from the membership of the Board, but the Secretary- Treasurer cannot be a Board member. Legal provision is made for an annual regular meeting to be held cojointly with the State Medical Society Meeting, and for holding special meetings on call. Minutes of meetings are kept. Members of the Board receive as compensation $4.00 a day and necessary travel expenses when on actual duty in the state. Only travel expenses for one delegate and the Secretary-Treasurer are allowed for attendance at im- portant meetings outside the State. The President signs requisitions for payment of legally authorized expenses of the Board members. Provision is made for an Executive Committee, composed of the President and two other members, and this Committee has such authority as may be assigned to it by the Board to act upon matters which arise between meetings, but actions taken by it are presented for confirmation at the succeeding Board meeting. Meetings of this Committee are called by the Secretary-Treasurer with the approval of the President. The Executive office of the State Board of Health is in Raleigh. Public Health Administration in North Carolina 17 Members of the State Board of Health G. G. Dixon, M.D., H. Lee Large, M.D., H. G. Baity, Sc.D., W. T. Rainey, M.D., S. D. Craig, M.D., President, J. N. Johnson, D.D.S., Vice-President, Hubert B. Haywood, M.D., John Labruce Ward, M.D., C. C. Fordham, Jr., Ph.G. 18 Public Health Administration in North Carolina Six members compose the county board of health, namely, the chairman of the board of county commissioners, the mayor of the county town (or the clerk of the superior court when the office of mayor does not exist) , the county superintendent of schools, two physicians, and a dentist. The ex officio mem- bers elect the other members (unless a special legislative enactment for a health district provides otherwise). Board members are eligible to succeed themselves. The term of office is two years for the elected members of the county boards of health and terminates on the first Monday of January of odd years. No specific provision is made in the law for removing members or for filling vacancies which may occur. The county commissioner is chairman of the county board of health, and it is customary for the county superin- tendent of schools to serve as secretary of the board. Meetings of the county boards of health are provided for by law. It is required that one of these shall occur annually in the county town. During the year, meetings may be called by the health officer or scheduled at monthly or quarterly intervals; and three members of the board are authorized to call meetings when, in their opinion, the public health of the county requires the board to convene. The presence of three members constitutes a quorum. Minutes of meetings held are kept in most instances. The seat of the executive office of county boards is not specified in the law, but it is customary to select the county town. There is no legal authorization for the compensation of county board mem- bers for the services they render, but these members receive a flat rate of $3.00 to $4.00 for attending meetings. An executive committee of county boards of health is not provided for by statute. Where there are wholetime district health departments, the boards of health of each local health juris- diction, which collectively compose the district unit, continue to function with- in their respective jurisdictions, but a district executive committee may be formed, consisting of a representative of each county health board and of the State Health Officer or his official representative, to eff'ect the cooperation of these persons in behalf of matters common to the district as a whole, or of an intercounty nature. Cities within the district may or may not be repre- sented on the committee. This committee, having no legal standing and there- fore no authority in itself, makes recommendations for the individual con- sideration and action of the several local health boards represented. Duties, Functions, and Responsibilities. — Numerous duties are assigned by law to the State Board of Health and county boards of health, the general character of which may be comprehended by the following considerations: The State Board of Health is: (a) to take cognizance of the health of the people; (b) to make investigations and inquiries pertaining to sanitary mat- ters, to causes of diseases dangerous to public health, to sources of morbidity, and to the eff'ect of locality, employment, and conditions upon the public health; (c) to gather and disseminate public health information; (d) to serve as sanitary advisors to the State with respect to location, sanitary construc- tion, and management of all State institutions, and with respect to directing the attention of the State to sanitary matters that affect the industries, prosperity, health, and lives of the people of the State; (e) to enact and en- force regulations deemed necessary for the protection of public health, to Public Health Administration in North Carolina 19 declare what diseases are preventable, and to adopt rules covering' require- ments for the control of such diseases; (f) to make certain appointments, such as that of the State Health Officer, with approval of the Governor, and of experts to carry out investigations; and (g) to have control and super- vision of divisions and services of the state health organization which have been set up under its authority or established directly by law and assigned to the State Board of Health for administration. The County Board of Health is: (a) to have immediate care and responsi- bility of the health interests of the county; (b) to make rules and regulations for the protection and advancement of public health and to adopt additional rules and regulations to those of the State Board of Health pertaining to the control of communicable diseases; (c) to elect either a county physician or a county health officer biennally (or in lieu of the latter, a county quarantine officer), subject to qualification standards established by the State Board of Health for county (or district) health officers of counties (or districts) receiving State aid; (d) to pay fees and salaries, except that such expendi- tures must be approved by the county commissioners; and (e) to exei'cise certain minor judicial functions. 2. Departments of Health In North Carolina the term "State Board of Health" from a strictly legal viewpoint embraces the Board proper and all operating agencies such as divisions and bureaus which have been organized as a part of the administra- tive unit of the State Board of Health. The county board of health would ap- pear also to consist of the members of the board and its operating staff. For purposes of exposition, however, it is convenient to conceive of the State and county health organizations as consisting of the Board of Health and a De- partment of Health. The Department of Health is the operating staff broken down, in the case of the State, into subdivisions such as divisions and bu- reaus, but undifferentiated in the case of county health departments. The standard whole-time county health department in North Carolina con- sists of a health officer, two public health nurses, a sanitary officer, and a secretary. There is also provision for an oral hygiene program, usually co- ordinated with the state division of oral hygiene. In a district health depart- ment, at least one nurse and also a clerk is engaged for each county, and there may be more than one sanitary officer employed. These employees serve under the direction of the district health officer. Except for the State Laboratory of Hygiene, the State Department of Health is housed in a large building situated on Caswell Square, Raleigh. The Laboratory, now located in another part of Raleigh, is soon to be re- placed by a new building which will be erected immediately adjacent to the Health Building. Locally, boards of county commissioners make available, rent free, suit- able space at the county seat, usually not less than three rooms, for use as headquarters of the staff of the county health department. The board of county commissioners for each of the counties comprising a health district make available, rent free, suitable office space and office equipment in each ORGANIZATION CHART NORTH CAROLINA STATE BOARD OF HEALTH STATE BO^RD••HEALTH STATE MEDICAL SOCIETY SECRETARY-TREASURER STATE MEALTM OFFCER " ASSISTANT STATE ^tALTH OFFICER CCr'TIUt. AO«USTRATON f;it:;":- Avi/f # 't -AVDvi^* MM-I^^ C*eMU.aiNC ■afer.t CB-i/^c/- eDu>m •Olthn C--, J*of oil*' DIViSOn LAaORATDACS h^oo^ f^<. ^i *j' n^ m^ rn.r, o/ooe/ DIVISON VITJkL ST«Ti3TlC» DiviSOn Of EPlDtMiOLOC* p^tliCBt-an af Cor^^l'afan i ' of fAr S*afm - - "V^ J cAi/if ^^a// /jtf. OlVlSON 1 ■— — A<*ie.'.f ■» «^»^ Jf^BB ^r^ , ^-T,0«. '>uof'f *-■»"- A-o,.^ y/**.* rf,r. ,. /Wf^ •f State Boakd of Health, Admixistration Building Public Health Administration in North Carolina 21 county-seat town for use as headquarters of the personnel of the district health department. a. General Administration With respect to the State Health Department, matters of general adminis- tration are handled by the Central Administrative Office. The scope of this Division's services pertain to the following matters: policies, programs, relations with other State departments and extra-State agencies, personnel, budgets, accounts, requisitions, library, printing, and publicity. The person- nel of the Central Administrative Office consists of nine employees, namely, (a) the State Health Officer and his secretary; (b) the principal accounting clerk and two assistants; (c) two filing clerks (librarians); (d) publicity specialists; and (e) a janitor-messenger. The total budget for the Central Administrative Office for the fiscal year 1937-38 was $39,355, of which the State appropriated $26,433 and the U. S. Public Health Service contributed $12,922. The entire budget of the State Board of Health for 1936-38 amount- ed to $1,242,999, of which $1,084,372 was expended. An itemized statement of these expenditures will be found in Table 1 of the accompanying Appendix. With respect to whole-time county and district health departments, mat- ters of general administration are discharged by the county or district health officer and his secretary, working in cooperation with the staff of the State Division of County Health Work. The budgets of these local health depart- ments are not itemized to show specific allocations for these general adminis- trative services. At present (June 30, 1938) there are forty county health officers and nine whole-time district health officers, having jurisdiction over sixty-seven counties in the State, serving a population of about 2,408,430. There are also five full-time assistant health officers employed in district and county health departments. 1) State Health Officer.'^ — The State Health Officer, who must be a regis- tered physician of North Carolina, is elected by the State Board of Health subject to the approval of the Governor and may be removed from office by the Board for cause. His term of office is four years, and he serves on a whole- time basis. His residence must be in Raleigh. The compensation of the State Health Officer consists of an annual salary, which is fixed within legal limits by the Board, and actual travel expenses. Provision is made by the Board for an Assistant State Health Officer, and when the State Health Officer and his assistant are absent from Raleigh, one of the directors of a division of the State Health Department is designated as acting head. The many responsibilities of the State Health Officer embrace those duties assigned specifically by law and those bestowed upon him by virtue of his 1 During the past sixty-one years that the State Board of Health has been in operation, there have been six state health officers, as follows : Dr. Thomas F. Wood (1879-1892) Dr. Richard H. Lewis (1892-1909) Dr. W. S. Rankin (1909-1925) Dr. Charles O'H Laughinghouse (1926-1930) Dr. James M. Parrott (1931-1934) Dr. Carl Vernon Reynolds (1934- ) Dr. G. M. Cooper ser\-ed as Acting State Health Officer in 1923-24, in 1925-26. and in 1934. This position was also held by Dr. H. A. Taylor in 1930-31. 22 Public Health Administration in North Carolina North Carolina State Health Officers 1879-1939 Dr. Thomas F. Wood (1879-1892), Dr. Richard H. Lewis (1892-1909), Dr. W. R. Rankin (1909-1925) , Dr. Charles O'H. Laughinghouse (1926-1930), Dr. James M. Parrott (1931-1934), Dr. Carl Vernon Reynolds (1934- ). Public Health Administration in North Carolina 23 position as Executive Officer of the State Board of Health. In general he is responsible for administrative leadership with respect to the formulation and execution of an effective health program, subject to the control of the State Board of Health. 2) County and District Health Officers. — The county health officer is elect- ed by the county board of health or appointed by the Secretary of the State Board of Health if the county board fails to act. Qualification standards are not specified in the law when these officers are elected by the county board, but when appointed by the State Health Officer, choice is limited to register- ed physicians in good standing in the county; when the State Board of Health contributes financially toward a whole-time county health department, the terms of the contract entered into specify qualification standards for the county health officer, namely: (1) that he be a reputable physician, holding a degree of Doctor of Medicine from a Grade A Medical School and having a license to practice medicine in North Carolina; (2) that he be a man of good moral character, without objectionable habits; and (3) that he be experienced or trained in public health administration as evidenced by at least two years of experience in public health administration satisfactory to the State Board of Health, or by holding a certificate from an approved training school for health officers. The term of office for the county health officer is two years, subject to the proviso that the tenure of his service is terminable at the pleasure of the county board of health. The county health officer works on a full-time basis. The county board of health is authorized to pay such salary as may be necessary to protect and advance the public health, and the State Health Officer, when the appointment is made by him, is empowered to fix the compensation of the county health officer, having in view the amount of taxes collected and the compensation paid by other counties for similar services. The manner in which a full-time district health officer is employed is not specifically provided for in the law which authorizes the establishment of district health departments; in practice, presumably, the appointment is made individually by the several local boards of health which operate within the district health jurisdiction concerned. Neither county nor district health officers serve locally as deputy State health officers, but local sanitary of- ficers may be made agents of the State Board of Health; furthermore, if the board of health of a city health jurisdiction, situated within a whole-time county or district does not appoint a health offcer. the county or district health officer automatically becomes the city health officer; the city board of health may elect the county or district health officer as city health officer, but this procedure is unnecessary. For the unorganized counties of the State, legal provision is made for the county Board of health to elect a county physician and a county quarantine officer, and to fill vacancies occurring in these offices. In the event local boards fail to act, the State Health Officer is empowered to assume such responsibil- ity. These officials serve on a part-time basis; the term of office for the county physician is two years and for the county quarantine officer, four years. In organized district health departments, the position of county physician is re- tained, whereas, that of county quarantine officer is abolished; the county 24 Public Health Administration in North Carolina STATE \ iOARD iIhealth STATE BOAliO Of b AL.I r» State Health Officer and Directors of the Divisions of the State Health Department physicians are not administratively responsible to the district health officer. In organized counties, both positions are abolished, but pi'ovision is made for the employment of a physician on terms approved by the board of county com- missioners to render the services of a county physician. Such a physician is usually engaged on a part-time basis but may be employed full-time when he is assigned additional responsibilities such as medical examination of school children. The presumption is that these full-time physicians are ad- ministratively responsible to the health officer. An insight into the administrative responsibilities of the county health officer may be obtained from the following incomplete listing of duties which are assigned to him by law: (1) To perform the duties of the county phy- sician and quarantine officer, i.e., (a) to make medico-legal postmortem ex- aminations for coroners' inquests; (b) to make examinations of the mentally ill for commitment; (c) upon the request of proper authorities, to render professional service to the sick inmates of convict camps, jails, and county homes or to employ a physician to render these services on terms approved by the board of county commissioners, except that the medical services for con- vict camps are now performed by the State prison system; and (d) to en- force all laws pertaining to inland quarantine and rules and regulations covering such matters. (2) To make sanitary inspections of public school buildings and grounds. (3) To examine school children who have been screen- ed by teachers of the school system for his consideration; to endeavor to examine feces of school children whom he suspects of having hookworm disease; and to carry out prescribed procedures designed to obtain correc- tions and treatments of school children through the cooperation of parents or guardians. (4) To cooperate with the school system to the end that school Public Health Administration in North Carolina 25 children may be better informed with regard to the importance of health and the methods of preventing disease. (5) To conduct an educational program through the agency of the press, public addresses, etc. for the purpose of ob- taining the cooperation of the public in the adoption of measures for the greater conservation of life. (6) To carry out procedures under the pro- visions of the law for the abatement of nuisances dangerous to public health; and (7) to serve in the capacity of a local registrar of vital statistics when designated to do so by the State Board of Health. The whole-time district health officer has the authority delegated to town, city, or county health officers and to town, city, or county quarantine officers in each of the several units comprising the district over which he has super- vision, except that his appointment does not affect in any way the election of a county physician in counties comprising the district health department. 3) Employment and Administration of Personnel. State Positions on the staff of the State Health Department are listed, to- gether with compensations approved, in the biennial budget of the State Board of Health. Within the scope of the budget the technical proced- ures relating to the employment of personnel is carried out by the State Health Officer, except that such ap- pointments must be passed upon by the Dii-ector of the State Budget Bureau before becoming affective. Key positions, such as directors of divisions, are filled by the State Health Officer, and subordinate po- sitions within the divisions are filled upon the recommendation of the di- rector concerned and the approval of the State Health Officer. Due dili- gence is given to finding the best qualified person for the position at the compensation available, and the recommendations of the Conference of State and Territorial Health Of- ficers, pertaining' to qualification standards, are followed as a guide. Qualification standards for staff po- sitions are not, however, set up in the law, nor are Civil Service regu- lations in effect in North Carolina. The appointive authority exercises the right to discharge employees when such action becomes necessary. At the beginning of each fiscal year a list of the employees of the State Health Department, together with the compensation each receives, is certified to the State Budget Bu- County or District Positions on the staff of the whole- time county or district health de- partments are listed, together with compensation approved, in the an- nual budget set up for these local districts. According to the contract entered into between the State Health Department and local boards of health, the county or district health officer has sole authority to employ, direct, and replace subordi- nate members of his staff, it being- understood that he is to engage only qualified field personnel who meet the requirements as outlined in the State Board of Health's policies for the allocation of State funds, i.e., at least two years' experience satis- factory to the State Board of Health in public health nursing or sanita- tion work, unless the public health nurse or sanitary officer has had adequate training in, or holds a cer- tificate from an approved training school. In the event that qualified personnel, more particularly the health officer, is not available, pro- visional arrangements may be made for engaging the services of other persons for a temporary period, but this arrangement is resorted to only infrequently and is limited to units in operation and is merely a measure to avoid interruption of service. The personnel of local health de- partments receiving State aid is em- ployed on a whole-time basis, except that physicians may be engaged on 1 B-880a, June 17, 18, 19, 1935. 26 Public Health Administration in North Carolina leau. Fui'thermore, when vacancies occur among employees during the year, this Bureau is notified when their services are discontinued. Record-keeping of time on duty of the staff of the State Health Depart- ment is attended to by directors of divisions and reported monthly to the State Health Officer. The fol- lowing provisions are made for time off duty annually with pay: (1) vacation period — 12 working days (non-accumulative) ; (2) sick leave ■ — 10 working days (accumulative) ; (3) petty leave — 2 working days (not to exceed 14 hours and non- accumulative) ; and (4) certain legal holidays as designated by the State. Directors of the divisions of the State Health Department are under the administrative supervision of the State Health Officer, and staff mem- bers within these divisions are re- sponsible to their respective chiefs. All members of the organization have the privilege of free access to the State Health Officer. The following administrative pro- cedures have been established by the State Health Officer pertaining to: (1) external )-elatiu}iships of per- sonnel, namely, (a) that the itiner- aries of directors of divisions and of their subordinate field staff must be left in each division's office and a copv furnished the secretary of the State Health Officer; (b) that all contacts pertaining to official busi- ness between directors of divisions of the State Board of Health and their subordinates, with persons of other state health departments or Federal agencies, must be approved beforehand by the State Health Of- ficer; (c) that all official communi- cations between any division of the State Health Department and any agency outside the state must be ap- proved by the State Health Officer as evidenced by his signature or by concluding the communication thus: "By direction of the State Health Officer"; and (d) that all applica- tions for employment with the State Health Department, except those pertaining to directorships of divi- sions, must be transmitted to the directors of the divisions concerned. (2) Internal relationships of staff, namely, (a) that a classified list of a part-time basis to perform thei-a- peutic duties assigned by law to local health officers, and all staff members must comply with the State Board of Health's policies pertaining to honesty, sobriety, and moral con- duct. Record-keeping of time on duty of the staff of the county or district health department is attended to by the county or district health officer through his clerk. The arrangement for vacation time, sick leave, and petty leave is the same as for the State Health Department. Provision is made for the notification of the State Health Officer whenever any such employee takes leave in excess of the amount allotted. The administrative relationships existing between the State and the whole-time county or district de- partments of health are effected through the State Division of County Health Work. In this connection, the State. Health Officer has estab- lished the following administrative procedures: (1) copies of all official communications of an administrative nature affecting local health depart- ments shall be furnished the division of the State Health Department in- volved; (2) copies of all official cor- respondence between any division of the State Health Department and any individual or agency in the local health officer's jurisdiction shall be sent to the local health officer; (3) all correspondence from a local health unit to any division of the State Health Department shall be conducted by the local health officer except that an emergency order for supplies may be placed by a sub- ordinate; (4) all correspondence from a local health officer request- ing advice or information from any division of the State Health Depart- ment shall be sent to such division, and a copy to the Division of County Health Work; (5) all correspond- ence pertaining to matters of poli- cies or finances by local health de- partments with agencies outside the State shall be referred to such agency by the State Division of County Health Work; (6) copies of reports on health conditions found in local health departments shall be supplied local health officers, the Public Health Administration in North Carolina 27 State and local health employees, in- director of the Division of County eluding addresses and telephone Health Work, the other divisions of numbers be compiled and a copy sup- the State Health Department af- plied to each division's director; (b) fected; (7) when consideration is that requests for the temporary being given to the removal of an services of an employee, outside the employee from a local health unit, division to which the employee be- the director of the State Division of longs, must be arranged by the di- County Health Work must be con- rectors concerned, or through the suited first, then the local health State Health Officer before contact- officer, and finally, the employee who ing the employee desired; and (c) is to be offered the position ; and (8) that official interdivisional communi- the local health officer shall be in- cations be made in duplicate, a copy formed beforehand of any official being sent to the director of the em- visit to his territory of any employee ployee addressed. of the State Board of Health, and As the need arises, staff confer- such employee shall use the local ences are called by the State Health health office as his headquarters dur- Officer but these meetings are not ing his stay. convened at regular scheduled in- Policies covering staff conferences tervals. have not been established for gen- eral application throughout local — health departments, the holding of such meetings being left to the dis- cretion of the local health officer. In Person-Orange-Chatham Health Department, for exaniple, about six staff conferences are held annually. 4) Financial Management. — The transactions of the Finance Office of the State Health Department are discharged by the Principal Accounting Clerk and her assistants, who operate under the supervision of the State Health Officer. This office works in close cooperation with the divisions of the State Health Department and with other State departments and agencies con- cerned, namely, the State Budget Bureau, the State Auditor's Department, the Treasury Department, and the Division of Purchases and Contracts. The Division of County Health Work of the State Health Department em- ploys an accountant who has charge, under this Division's Director, of co- operative budgets set up jointly by the State and local boards of health,i covering the State's subsidies and those of the U. S. Public Health Service. During the fiscal year. July 1, 1937, to June 30, 1938, these subsidies amount- ed to $307,080, of which the State contributed $92,600 and the U. S. Public Health Service $214,480.- This Division, however, is not a clearing agency for all the financial transactions which the State Health Department carries on in local whole-time health jurisdictions. The Division of Preventive Medi- cine assigns nurses of its staff to certain whole-time health units and ad- ministers, through the office of the Principal Accounting Clerk, funds re- ceived by the State from the Children's Bureau, a part of which are used to subsidize services which are carried on under the direction of local full-time health officers. Separate budgets for each local health unit are set up for these nurses, but the aid from the Children's Bureau, which finances the obstetrical and pediatric services of local health departments, is included as a part of the general administrative budget of the Division of Preventive Medicine. For the fiscal year 1937-38 the budgeted expenses of local public health nurses, exclusive of the consultant nurse, who was subsidized from ^ This accounting service was transferred to the central finance office on July 1, 1939. ' See section of this report on County Health Organization and Supervision. 28 Public Health Administration in North Carolina funds of the Children's Bureau, amounted to $3,370, and the budgeted ex- pense of the obstetrical and pediatric services was $20,000. The budgeted ex- penses of the eight nurses of the regular staff of the Division of Preventive Medicine amounted to $19,598, and that of the nursing consultant to $3,510, the former being appropriated by the State and the latter contributed by the Children's Bureau. Furthermore, certain other expenses for local health services, such as the subsidy by the Division of Epidemiology towards venereal disease control, does not appear in the budgets of local health departments; this item for venereal disease .amounted to $23,680 and was a State appro- priation. The $100,000 grant for syphilis made to the State Board of Health in 1937-38 by the Reynolds Foundation was increased to $160,000 for 1938-39 and is being used to promote syphilis control activities through local health departments. Furthermore, the State Board of Health's contribution to local oral hygiene services, administered through the Division of Oral Hygiene, was not shown in the budget of local health units. In this connection, it is in- teresting to note that the State's share of the local oral hygiene program's fund, as handled by the Division of County Health Work, is included in the funds matched by the State's funds administered by the Division of Oral Hygiene. Within local whole-time county and district health departments, the local health officer with the aid of his clerk transacts the financial procedures of the local health department. State The budget: In the fall of even years the directors of the sub- divisions of the State Board of Health prepare estimates of receipts, if any, and of expenditures for the ensuing biennial period. These esti- mates, itemized with respect to sal- aries, travel, and general expense, are presented to the Principal Ac- counting Clerk, who under the direc- tion of the State Health Officer, assembles them for the consideration of the State Budget Bureau. The items in the budget estimates are classified according to "Purpose" (subdivisions of the State Board of Health) and "Objects" (salaries, travel, expenses, etc.). Actual ex- penditures during recent years are shown for items listed, together with estimates for the current year, and the amounts requested for each of the years of the ensuing biennium. Under the heading "Less: Estimated Receipts" there appears an itemiza- tion of anticipated revenues for vital statistics, laboratory of hygiene, bedding fund, and oral hygiene. Fur- thermore, the average number of employees is listed according to the subdivisions of the estimates by "Purpose" and these estimates are County or District The budget: The State Board of Health subsidizes whole-time district and county health departments on the basis of contracts entered into between the State Board of Health and these local health units. In general, the allocations of the State to counties are apportioned as fol- lows (1) 25 per cent of the total official funds appropriated locally for five-piece units; (2) 20 per cent of the total for four-piece units; (3) 15 per cent of the total for three- piece units; and (4) 10 per cent of the total for two-piece units. An in- crease of 20 per cent of these per- centages is provided for when the local departments are directed by health officers who have had satis- factory specialized training, except that the State's allocation ordinarily cannot exceed $1,440 per annum. Locally, counties, cities, towns, boai'ds of education, trustees of spe- cial chartered school districts, etc. may appropriate funds towards the budgets of local health departments, including the amount contributed locally for oral hygiene, and the State Board of Health considers the total of such official funds in mak- ing its allocation. The basis of the Public Health Administration in North Carolina 29 classified according to the following headings: Average annual Salary or Wage, Summary of Purpose, and Summary of Object. After approval by the Executive Committee of the State Board of Health, the estimates are presented in December to the State Budget Bureau. The Director of the Budget adds a column in which appears his recommendations. These estimates are then printed as a section of the State budget for the consideration of the General Assembly, except that columns showing expenditui'es for recent years are limited to the cur- rent biennial period. The State Health Officer has an opportunity to appear before the Advisory Budget Commission and also the Appropria- tion Committee of the General As- sembly for hearings on his estimates before the Legislature enacts the State Budget. Each of the divisions of the State Health Department operates under itemized budgets. Provision is made whereby these intra-departmental budgets may be revised should the best interests of the work necessitate changes in the amount or character of the items. State's allocation may be varied, however, with the approval of the Executive Committee of the State Board of Health, when an unusual and outstanding type of health serv- ice is being rendei'ed by a county health department. Funds allocated to counties from other sources, such as Federal, and other non-local, are not included in the contract and are supplemental to official local and State appropriations. The State Board of Health allo- cates funds to district health depart- ments on such a basis as may be agreed upon by the State Board of Health and the contracting counties composing the official health district, except that the total allocation of the State Board of Health must be matched at least equally by the total allocation of the funds appropriated by these contracting parties. To facilitate the preparation of annual budgets locally, local health officers are informed during each spring by the Director of the Divi- sion of County Health Work as to the amount of the State and U. S. Public Health Service allocations that may be expected for the en- suing year. Annually, county and district health officers prepare budgets for their local health departments cover- ing expenditures and income for the fiscal year beginning July 1. A special triplicate form supplied by the Division of County Health Work is used. Estimated expenditures are itemized according to code numbers under the following headings: Personal Service, Supplies, Other Expenses, and Equip- ment. Actual expenditures for the previous year and the estimated expendi- tures for the ensuing year are summarized under these main headings, and provision in the budget form is made for entering the contributions covering the income of the local health department, itemized as to sources, for the current year. One copy of this budget is retained by the local health department, one copy is sent to the State Health Department, and the third copy is transmitted to the county auditor. Some local health officers present the annual budget to their local boards of health, while others do not; these budgets, however, must be submitted to the county commissioners and their approval obtained for the county's share of the appropriation. The contract entered into with the State Board of Health as a basis for the cooperative budget must be signed by the chairman of the board of county commissioners and the mayor or city manager in case a city or town con- tributes to the budget. Revision of cooperative budgets are handled through the Division of Countv Health Work. Accounting : Funds received for health purposes from the U. S. Pub- lic Health Service and the Children's Bureau are deposited with the State Treasurer and paid out in the same manner as State-appropriated funds. Accounting : The financial man- agement of local health departments is essentially a local government re- sponsibility, but in discharging this duty the county or district health officer works in close cooperation 30 Public Health Administration in North Carolina A special account is set up in a local bank for contributions received from philanthropic organizations, TVA, Office of Indian Affairs, etc. For the most part, budgets are es- tablished for the disbursement of these funds as in the case of those of the State, except that State funds and special funds are kept separate. Accounting of revenues and ex- penditures of the State Health De- partment is attended to in the cen- tral administrative office. In per- forming this function, the Princinal Accounting Clerk works in close co- operation with the State Auditor's office. Payrolls are made up and statements of general expenses pass through this office. Voucher war- rants for payment of these obliga- tions are issued in quadruplet, one going to the payee, one to the Audi- tor, one to the Treasurer, and one being retained. The voucher war- rant must be signed by the Auditor and the State Health Officer per the Principal Accounting Clerk before being payable by the State Treas- urer. Financial reports of expendi- tures of the State Health Depart- ment are made monthly to the Audi- tor, and the latter publishes an an- nual statement of such expenditures as a part of the financial report of the State government as a whole. All accounts of the State Health De- partment are subject to an annual audit by the Auditor's office. with the State Division of County- Health Work. The State's subsidy to the district or county health de- partment is paid monthly, the basis of such remittances being the receipt of satisfactory monthly statistical, narrative, and financial reports. All other agencies contributing to the budget make their remittances monthly also. In the majority of cases a special account for the local health department is established in a local bank and the remittances from the State and from local con- tributing agencies are deposited in this account by the county health officer. The obligations of the local health department are paid by checks issued on this special account by the local health officer and coun- tersigned by the County Auditor. The county health officer is not a bonded employee. In the case of a Federal subsidy to a local health de- partment, such funds are frequently budgeted in behalf of the salaries of persons employed, and periodic pay- ments are made by checks issued directly to the person concerned. In this event, the check is endorsed by the receiver, with few exceptions, and turned over to the local health officer, who deposits it to the account of the health department and issues another check on the local account to the employee. Another plan that is followed in a few local units pro- vides for the utilization of the finan- cial facilities of the county govern- ■ ment in handling the receipts and disbursements of the local health department. Whatever arrangement may be instituted with respect to such matters, the Director of the Division of County Health Work requires the local health officer to submit to the state monthly a detailed financial report. This report is made on a triplicate foi-m furnished by the State. Disburse- ments are analyzed as to payee, voucher numbei-, and code number of budget; and they are also itemized as to the main headings of the budget. Receipts and disbursements are summarized to show the status of the local account with respect to the provisions of the budget, and also with respect to cash balances on hand. The first copy of this report is retained by the local health department, the second is sent to the State Health Department and the third is transmitted to the county auditor. Apart from the trans- actions involved in making the above-mentioned financial reports of receipts and expenditures, no standard plan of local bookkeeping has been adopted for local health departments in general — such accounting being left to the discretion of local health officers. These officials may also set up petty cash accounts. No arrangements have been made for the official audit of local accounts of health departments. It may be added also that inventories of equipment owned by local units are not kept. The annual financial repoit of local full-time county and district health departments is compiled from the budget estimates and is published in the biennial report of the State Board of Health. Public Health Administration in North Carolina 31 luplet, one Bureau, one the Division Purchases: Purchases of the State Health Department are made through the State Division of Pur- chases and Contracts. Purchase or- ders are handled through the cen- tral administrative office by the Principal Accounting Clerk. Such order forms are made out in quad- going to the Budget to the Auditor, one to of Purchases and Con- tracts, and one being retained. The Laboratory of Hygiene, as an excep- tion to this rule, places orders direct with the commercial firms, and the Division of Oral Hygiene negotiates prices with commercial houses for dental supplies, but the orders are placed by the Division of Pui'chases and Contracts. Traveling Expenses: Automobiles are purchased and operated person- ally by the employees of the State Health Department. When used for official business, the employee is re- imbursed on the basis of 5 cents per mile. No insurance, insofar as the State Health Department is con- cerned, is required. A truck and trailer are operated by the Division of Industrial Hygiene, a truck by the Division of Epidemiology, and one by the Division of Oral Hygiene for the puppet show. A truck and passenger automobile are owned and operated by the Laboratory of Hy- giene. Actual expenses are allowed for travel by public conveyances. Within the State a subsistence al- lowance of an amount not to exceed $4.00 a day is provided for board and room, and without the State this amount is not to exceed $6. On forms supplied, the field staff is re- quired to keep an itemized record of these expenditures on the basis of which monthly reimbursements are made. Printing and Binding: Binding jobs and the printing of forms, tions, etc. — such as, for example, the biennial report, the monthly reports of the Bureau of Vital Statistics, health pamphlets and charts, etc. — are handled by the Division of Purchases and through the central administrative office. Budgeted funds for for the fiscal year 1937-38 were as follows: (1) Central Office, $8,500 appropriated by the State Legislature; Preventive Medicine, $4,000 contributed by the (3) Division of County Health Work, $500 Health Service. 5) Filing Service. — A central filing system with two filing clerks in charge has been established by the State Health Department as a section of the Cen- Pnrchases: Purchases of the local health depailment are transacted locally. The services of the State Division of Purchases and Contracts are not extended to local health de- partments subsidized by the State Board of Health. The Attorney General has ruled that the services of the Central Purchasing Agent of the State cannot legally be utilized by local health departments. Traveling Expenses: The travel allowance of field personnel of v/hole-time county and district health departments, as pi-ovided for by the contract between the State Board of Health and local boards of health, is as follows: (1) $25 per month for depreciation on cars owned by such employees; (2) 3 cents per mile for earned travel. All funds budgeted for travel of an employee can be used any time within the fiscal year, but the total amount of the reim- bursement cannot exceed the amount budgeted for any particular em- ployee. When two or more employees travel together, travel allowance is permitted for only one car. Monthly travel statements must be filed with county and district health officers by each employee drawing travel allowance on blanks supplied by the State Board of Health, showing- mileage per day and places visited. and Binding: Printed by local health depart- supplied by the State Printing forms used ments are Health Department when the State requii'es a form to be filled out. Printing jobs that are strictly local in character are transacted locally and paid for from the local unit's budget. publica- bulletin, circulars. Contracts this purpose Administrative (2) Division of Children's Bureau; and allocated bv the U. S. Public 32 Public Health Administration in North Carolina tral Administrative Office. The clerk of a county or district health depart- ment, operating under the health officer, is in charge of the files of the local health units. On the staff of the Division of County Health Work provision is made for a statistical consultant who cooperates with local health depart- ments relative to improving the efficiency of the local clerk, and one phase of the statistical consultant's work includes the further development of a local filing system. State The principal features of the State's filing system are as follows: (1) Cuuutij Organization File. Fil- ing space alphabetically arranged is provided for each county and district health department. Within each of the subdivisions of this file folders for each division of the State Health Department, distinguished from each other by colored guides, are placed when needed. The materials filed within these folders are arranged according to the date the document bears, i.e. those in January in order of the days of the month are placed at the back of the folder. Those for February occupy the position in front of January, etc. This file is set up on an annual basis and the materials for the preceding year, as well as the current year, are kept in the filing room, whereas the contents of earlier files are put in storage. (2) File Covering Special Topics. (Water, Sewage, Milk, etc.) Space is provided in this file for each county arranged in alphabetical or- der. These main sections are fur- ther subdivided according to the cities and towns situated in the county j'epresented. The folders placed within these subdivisions are distinguished from each other by the use of colored guides, i.e., the water folder guide is one color, the milk folder another, and so on. (3) File for Materials of a More Permanent Nature. Space in this file is provided for each adminis- trative division of the State Health Department, namely. Central Ad- ministrative Office, Division of Pre- ventive Medicine, and so on, the ar- rangement being alphabetical. The folders within these divisions of the file are assigned topical headings, the guides of such headings not being distinguished by color but ar- langed alphabetically. Materials ap- pearing in these files include such matters as certain expense accounts, County or District I. Genoal Files: For filing cor- lespondence, reports and other ma- terial of letter size, the following- guide for setting up a filing sched- ule in local health departments has been established. A. State Board of Health 1. 2 3. 4. 5. 6. 9. Executive Office Division of Countv Health Work a. Correspondence b. Statistical reports c. Narrative reports Division of Epidemiology Division of Vital Statistics Division of Oral Hygiene Division of Preventive Medi- cine a. Maternity and infancy b. School nursing c. Crippled children Division of Sanitary Engi- neering- Laboratory of Hygiene Division of Industrial Hygiene B. Admiitist)atiov- -Geywral Health Service Sanatorium 1. U. S. Public 2. Tuberculosis (N. C.) 3. Other State agencies and de- partments 4. Miscellaneous C. Administration — Local 1. County Board of Health a. Correspondence b. Reports 2. County Commissioners 3. Correspondence with other county agencies (County Tu- berculosis Sanatorium, Coun- ty Hospital, County Home, etc. If sufficient amount of correspondence is carried on, then a separate folder should be made for each, such as "a. County Tuberculosis San- atorium," "b. County Home," "c. County Hospital," and so on.) Public Health Administration in North Carolina 33 reports of field visits of central per- sonnel, important documents such as agreements, etc. Because of the dif- ficulty of classifying this matei'ial for ready reference, index cards are also made out and sometimes sev- eral such cards are executed for the same document so as to list it under several titles, thereby facilitating its location in the file when needed. (4) Vital Statistics File. A special file is set up for vital statistics. Where money matters are concerned, the letter of inquiry goes into the file under the name of the person whose birth or death certificate is concerned, and a cross reference sheet is used to give the naine of the person who wrote the letter. (5) Miscellaneous File. The letters of the alphabet are used to pro- vide the main subdivisions of this file. Within these subdivisions are placed folders for organizations, localities outside the State, etc. The labels of these folders are in five colors, each repi-esenting a group of letters, and the order of the colors in the main subdivisions of the file is based on the second letter of the filing title. The materials filed with- in folders are arranged in chrono- logical order. NiH'sing Program and Cooperative 1. Schools and school personnel 2. Parent-teacher associations 3. Midwives 4. Miscellaneous 4. Publicity and news releases 5. Education and health talks 6. Form letters 7. Miscellaneous D. Finances and Supplies 1. 2. 3. 5. Budgets Contracts Cancelled vouchers and state- ments by month Companies from which sup- plies aie ordered Miscellaneous E. Vital Statistics 1. Local registrars 2. Reports from local registrars (curi'ent year) 3. Correspondence with regard to birth and death certificates F. Sanitation 1. Cafe Sanitation a. Separate folder for each cafe under supervision b. Miscellaneous 2. Dairy Sanitation a. Separate folder for each dairy under supervision b. Miscellaneous 3. General Sanitation a. Water supplies b. Sewage disposal c. Schools d. Complaints e. Miscellaneous Agencies H. Miscellaneous 1. Correspondence with other health officers 2. Correspondence with physicians 3. Special reports, etc. The clerk is responsible for placing all materials in the files, including replacement of material taken out of the files by other staff members. In preparing materials for filing, each page should be marked, prefer- ably with red pencil, as to code number, such as, for example, A,l — the code number for the State Board of Health, Executive Office, and ar- ranged in pioper order for filing, namely, A,l A,2 etc. Letters sent and received should be filed together, the latest to the front, all correspond- ence being stapled or clipped in the upper righthand corner. Cardboard guides and folders of a good quality should be used. All correspondence, etc. should be filed behind the guide, and six to eight letters pertaining to a person justifies the use of a separate folder. In district health departments different colored labels may be used on the folders to facilitate the identification at a glance of the several local health juris- dictions which compose the district, but the material for all counties 34 Public Health Administration in North Carolina should be kept in one folder until sufficient material has accumulated to justify separate folders. The schedule as set up allows foi- a file to be carried over a number of years; if it becomes necessary to make a new folder for any item of the schedule, both the old and the new one should be dated, for ex- ample: "A,l Executive Office — 1937" for the old and "A,l Executive Office— 1938" for the new. The guide for setting up the filing schedule should be kept in the front of the file for ready reference, and additions to the file should be noted on the schedule itself. In the headquarters of district health depart- ments the suggested schedule here may need enlarging, and in branch offices a simplification may be in order. II. Family Folder File. — A manila folder of good quality is used, which when folded, fits into a 5 x 8 inch file. In the folder are placed all open records, except school and V-D, of the family. The folder itself carries space for family name, color, date and contact, family number, three successive addresses, three successive appraisals of economic status, three successive appraisals of excreta disposal status, three successive appraisals of water supply status, three successive appraisals of screen- ing status, household I'oster, and case histories entries. The family folder is carried into the field by the nurse and essential data are entered at the time of the first visit to the home or clinic. After the folder is returned to the office by the nurse, the secretary gives the family a serial number entei'ed under "Family Number" and also on the active record of each individual in the family. If there are two or more nurses in the local health department, one uses the letter "A" as identifying the geographical district in which she works, another the letter "B" and so on. The number placed on the family folder by the secretary runs serially, namely, 1-A, 2-B, etc., irrespective of the geo- graphical nursing districts. The family folder records ai-e filed alpha- betically as to geographical district in 5 x 8 inch box files, using alpha- betical guides. One such file is used for each district so that each nui'se has her active case load on her desk for daily use. Whenever there is no longer any need for a record of a given individual to be kept in the family folder, that record is withdrawn and filed alphabetically in a closed file. Before withdiawing such record, an entry is made on the family folder in the column "Date Closed" and, if the person is dead, cause of death is noted in this column. Individual tex-minated case records are filed alphabetically by service, that is, Maternity, Tuber- culosis, etc. Furthermore, if there is no longer a reason for carrying the family, then the whole record is completed and filed alphabetically. A cross-index card is marked "Terminated" and left in the active file in the event the family is re-opened. If a family moves to another county, the health officer may send his record to the other health de- partment, an entry being made on an index card to this effect. When the family folder is turned over to the secretary for serial numbering, an index card (3x8) is made also, carrying the family name, family folder number, address, and other essential data. If the patient has a name that is not the same as that of the household head, a second index caid is made out, carrying such cross-reference data as are needed. Index cards are filed alphabetically by the surname of the household head, and classification by geographical divisions is un- necessary; the same type of box file as used for filing family folders is used for cross-indexing, except that this file is smaller in size. 6) Public Health Library Service. — The library of the State Health De- partment is administered as a part of the Central Administrative Office. It is in the charge of the two clerks who operate the central filing system and who are also trained librarians. The reception room of the State Health De- Public Health Administration in North Carolina 35 partment for the most part is used to house the books, journals, and pamph- lets 01 the library, and also serves as a reading room. Additional bookcases are located in the corridors of the Health Building, and the engineering library is situated in the Drafting Room of the Division of Engineering. The State Health Department library includes the valuable collection of public health and medical literature of the late Dr. Charles O'H. Laughinghouse, long-time member of the State Board of Health and former State Health Officer. State Books: The usual reference books in public health and medical litera- ture are well represented, including several systems of medicine. There is also a complete set of bound vol- umes of the biennial reports of the State Board of Health and of the Public Health Bulletin published by the State Board of Health. These books are catalogued and lent on the basis of procedures carried on in public libraries in general. Provision is made for the placement of requi- sitions with the Principal Account- ing Clerk when staff members wish to order new books for the library. Jonrnuls: With respect to public health and medical periodicals, no subscriptions are made for them by the State Board of Health, but copies of the publications of the American Public Health Associa- tion, American Medical Association, Southern Medical Association, etc. are donated to the library by staff members. As numbers are received by the librarians, they are filed ac- cording to the name of the journal. Annually the numbers of the Jour- nal of the Ame)-ican Medical Asso- ciation are bound into two volumes and these are placed in the book- cases. County or District "With the encouragement of the State Health Department, progress is being made in the establishment of public health libraries at the heaflquarters of local health depart- ments, and the contingent fund from local cooperative budgets may be used for gradually building up these a special library local libraries or, item is set up in the local budget. The literature of these libraries consists of the standard textbooks on public health, medicine, and sani- tary engineering; the publications of such organizations as the State Board of Health, the U. S. Public Health Service, the American Pub- lic Health Association, the American Medical Association, and State Stat- utes, State Board of Health regula- tions, local ordinances, etc. As yet a loan plan for the distribution of literature of the library of the State Health Department to the personnel of local health departments has not been developed, nor has a plan for organizing the staff of local health departments into study groups been encouraged, the purpose of which would be to obtain group coopera- tion in keeping up with current public health literature. Pamphlets: Health pamphlets re- ceived by the State Health Department are filed according to subjects, i.e. a pamphlet on "measles" is filed under the heading "measles." An index card is made out for each pamphlet on which is listed the subject, author, publisher, place in the file, etc. If a pamphlet deals with more than one subject, a cross reference card is provided. These index cards are filed alphabetically. Another index card file is set up according to the headings into which this file for pamphlets is divided, and the topics of pamphlets in the file are listed under each classification. 7) Publicity Service. — Of approximately 200 newspapers published in North Carolina, about 35 are issued daily. The State Health Department does not subscribe for newspapers, but through the courtesy of the editors it re- ceives about 50 papers. The newspaper publicity service is operated as a part of the Central Ad- 36 Public Health Administration in North Carolina ministrative Office. A publicity specialist, who has had years of experience as a newspaper reporter, is in charge. His services are supplemented by the work of the Department of Health Education, Division of Preventive Medi- cine. The newspaper service of the latter department differs from that of the publicity specialist in that the copy prepared is more of an educational nature than it is a strictly news story. With reference to district and county health departments, the county health officer handles local publicity matters by cul- tivating the support of local newspaper reporters or the editors of local papers. State Releases of news items or stories pertaining to public health are being published constantly. The State Health Officer and the directors of the divisions of the State Health De- partment work through the publicity director who, when supplied with the basic information, prepares it in newspaper form and attends to the distiibution of such copy. Sometimes articles appearing in the Bulletin of the State Health Department may be rewritten for newspaper publica- tion by the publicity specialist as an interview with the author. In ob- taining newspaper releases, the pub- licity specialist utilizes the Raleigh office of the Associated Press, or distributes such materials direct to the editors of the newspapers pub- lished in the State. The publicity specialist looks over the papers received by the State Health Department for publications pertaining to health. When an edi- torial appears on a health topic, he calls it to the attention of the State Health Officer and frequently a let- ter of commendation is sent to the editor. Clippings of releases which have been used by the State Health Department are made by the publicity special- ist and filed in a scrap book. In this way a chronological record of many of the developments of the State Health Department is provided for. Fur- thermore, the State Health Department subscribes to the Carolina Clipping Service, and through this agency receives clippings of news print issued by the newspapers of North Carolina pertaining to public health. These clippings cover releases by the State Health Department, local health de- partments, and other agencies. The important items are placed in the central files of the State Health Department. b. Epidemiological Service The control of communicable diseases has constituted a major objective of the state and local boards of health in North Carolina since their creation. Administrative trends may be sketched as follows: 1). Constant vigilance tvith respect to epidemic diseases: The need for such watchfulness was demon- strated as early as 1888 when the State Board of Health was confronted with a serious situation occasioned by refugees to Western North Carolina County or District The i-eleases of the State publicity specialist are sent to the local health officers. These officials are urged to adapt this material for local publi- cation. Some of the local health officers have arranged with publishers for a health column under the name of the local health officer. Articles dealing with health topics, or with news items of public health inter- est, appear in these columns from time to time. A number of local health officers frequently make use of the local newspapers for the pub- lication of health stories or health educational items. These publica- tions may be clipped from the news- paper and filed in a scrapbook. In Hertford County, for example, health news items appear in all is- sues of the local weekly newspaper and in addition, once a year an edi- tion of this paper is devoted to pub- lic health work. Public Health Administration in North Carolina 37 from Florida where a yellow fever epidemic occurred. 2). The utilization of public health educational measures: Printed matter began to appear at least as early as 1893, when a pamphlet was issued by the State Board of Health on quarantine and disinfection. 3). The utilization of supplemental support: Of the numerous instances in the records, the following selections will suffice to illustrate the success of the State Health Department in the fulfillment of its ambitions in this direction. In 1910 the support of the Rockefeller Sani- tary Commission was obtained to combat hookworm disease, and for several years thereafter an active campaign was carried on. In 1912 a resolution passed by the conjoint meeting of the State Medical Society and the State Board of Health to the effect that pellagra was an interstate problem, was an important factor in provoking Congress to make an appropriation of $45,000 for a study of this disease. In 1918, following the passage by Congress of the Kahn-Chamberlain Bill, approximately $24,000 was made available to North Carolina for the control of venereal diseases, resulting in the establishment of a Bureau of Venereal Diseases. In 1920 a malaria control demonstration was organized in certain towns and cities in eastern North Carolina with the cooperation of the U. S. Public Health Service and the International Health Board; and in 1923 a Division of Malaria was established in Pamlico through local and International Health Board support. To supplement the State's resources, support from the Federal Government has been received continually in such fields as malaria and venereal disease control. Advan- tage has also been taken of funds made available by outside agencies for the training of staff members engaged in venereal disease activities. The Rosenwald Fund and the TVA have been generous, directly or indirectly, in the support of epidemiological projects, and the Zachary Smith Reynolds Foundation, founded in 1936, has recently made the munificient gift of $100,- 000 annually for a period of 15 years to the State Board of Health for the further development of a militant campaign against syphilis within the State. 4). The utilization of campaigns and demonstrations to initiate control mea- sures: Diseases of public health interest in North Carolina have been singled out for special attack from time to time, namely: hookworm disease, cam- paign beginning in 1910; typhoid fever immunization, campaign, 1914; ven- ereal diseases, special emphasis received in 1918 and renewed interest in re- cent years; malaria, the demonstration for control beginning in 1920, etc. 5). Facilitating the use of scientifically approved biological products: Pro- visions were made for Pasteur treatments in 1907. The free distribution by counties of diphtheria antitoxin was made possible by legislation enacted in 1909, and in 1911 the Legislature appropriated approximately $1,000 to facili- tate the making of contracts with the manufacturers of diphtheria antitoxin. Free distribution of typhoid vaccine was introduced about 1914. Later, agents for active immunization against diphtheria, the distribution of drugs for the treatment of venereal diseases, etc. have followed. 6). Sponsoring legislation and promulgating rules and regulations for the reporting and con- trol of communicable diseases: The records are filled with legislative enact- ments pertaining to public health. In 1917 the General Assembly passed "An Act to prevent and control the occurrence of certain diseases in North Caro- lina", which deserves special mention because it provides for the State Epi- 38 Public Health Administration in North Carolina demiologist and Bureau of Epidemiology. 7) . The development over the years of an organization for rendering epidemiological services: From the time the Bureau of Epidemiology was established in 1917, under the direction of Dr. A. McR. Crouch, until 1932, when it was reorganized by Dr. D. F. Milam, the administration of the Bureau has undergone many vicissitudes. Twice it was consolidated with the Bureau of Vital Statistics and once with the Bureau of County Health Work. During this period the Bureau of Venereal Diseases, which had been established in 1918 under the direction of Dr. J. A. Keiger with the aid of Federal funds, was joined (1921) with the Bureau of Epidemiology. The directorship of this Bureau changed hands frequently, and it would appear that major emphasis at one time was given to venereal diseases and, at another, to malaria control. Following its reorganization in 1932, a more balanced program has been maintained, and the Bureau has been able to continue to function as a separate unit of the State Health De- partment. 1 State 0)ganization Legislative provision is made for a State Epidemiologist and a Divi- sion of Epidemiology- operated un- der the control of the State Board of Health. The scope of the Divi- sion's activities embraces communi- cable diseases in general, except tuberculosis. The staff of the Divi- sion consists of 11 employees, name- ly: (1) Director or State Epidemi- ologist; (2) assistant director of venereal disease control; (3) a sani- tary engineer, an entomologist and two laboratory technicians engaged in malaria control, and (4) a secre- tarial staff consisting of 2 stenog- laphers and 3 clerks. Mandatory qualification standards have not been established by law for the di- i-ector and other key employees, but by custom a physician receives the appointment of state epidemiologist. The present Director has had spe- cialized training to fit him for his responsibilities, and the venereal di- sease officer has had special train- ing. The Division's budget of 1937- 38 totaled $56,645, of which the State appropriated $35,445, and the U. S. Public Health Service contributed county and mu- a population of for counties sup- health services. Local Organizatio)i Local Qnararitine Officers: Except for incorporated municipalities of 10,000 population or over, for coun- ties with a joint board of health presiding over the nicipalities having 10,000 or more, or porting organized provision is made for a county quar- antine officer elected by the county board of health. Such local board of health is required to notify the Secretary-Treasurer of the State Board of Health of such elections. Vacancies occurring in this office are filled by the local board, or, if the Boaid fails to act, then by the Secretary-Treasurer of the State Board of Health. The county quar- antine officer is required to take be- fore the clerk of the superior court, an oath of affirmation to faithful performance of duty and to notify the State that such oath has been taken, but on failure to do so, the Secretary-Treasurer of the State Board of Health is empowered to re- move such an officer and to appoint a quarantine officer. Quaiantine of- ficers also take oaths of allegiance 1 The directors of this Bureau have been as follows : Dr. A. McR. Crouch 1917-10 Dr. F. M. Register 1919-20: 1923-30 Dr. J. S. Mitchener 1920-28 Dr. H. A. Taylor 1930-31 Dr. John H. Hamilton 1932-33 Dr. D. F. Milam (Acting) 1933-34 Dr. J. C. Knox 1934- - The name was changed by action of the State Board of Health in 1931, from the Bureau of Epidemiology to the Division of Epidemiology. Public Health Administration in North Carolina 39 $21,200. The allocate share for venereal disease control appropri- ated by the State was S28,780, ex- cept for $3,780 contributed bv the U. S. Public Health Service. Of this fund, $23,680 was available to sub- sidize venereal disease clinics op- erated throughout the state — $10,- 000 being used for antisyphilitic drugs and the remainder being held for matching purposes, purchase of equipment, etc. Furthermore, $15,- 000, all contributed by the U. S. Public Health Service, was allocated for malaria control. This analysis of the financial assets of the Divi- sion does not include $100,000 re- cently donated by the Reynolds Foundation towards venereal di- sease control activities within the State. In addition, legal provision is made for an annual appropria- tion of $3,000 to be used in the con- trol of ophthalmia neonatorum and for an emergency fund of S5,000 to be used at the discretion of the Gov- ernor in case of visitation of a pes- tilential disease. to the United States in order to re- ceive the Federal appointment of assistant collaborating epidemiol- ogist, a position which carries with it the privilege of using franked mail. Compensation for quarantine officers is paid monthly by the county treasurer or corresponding local of- ficer on certification by the Secre- tary-Treasurer of the State Board of Health of the satisfactory per- formance of duties in accordance with a system of fees established by the State Board of Health for each item of work involved, except that the annual contribution shall not exceed a maximum sum specified on the basis of the population of the county. As a basis for cei'tification, the quarantine officer files with the State Epidemiologist a monthly re- port of the services rendered on a form presci-ibed for the purpose; this report is checked against the morbidity records of the Division and coriections are made, if need be, accordingly. The quarantine of- ficer is entitled to reimbursement for incidental expenses incurred, includ- ing postage and disinfectants up to $100 annually. Furthermore, legal provision is made for county commissioners to pay expenditures incurred in the examination, isolation, and treatment of venereal disease patients. Similarly, municipal quarantine officers are elected for municipal health jurisdictions. Whole-tiuie county and district health officets act as county quarantine of- ficers in organized counties or district health jurisdictions, replacing the county quarantine officers, i.e. the position of county quarantine officer is abolished when organized health services are established in counties or dis- tricts. Oaths of affirmation and allegiance are also required of these officers. Duties Regulatoty Functions: The State Board of Health has power to de- clare what diseases are preventable and to adopt rules and regulations covering minimum requirements for their control. Provision is made for publication of regulatory measures, and copies of these ai'e furnished free to those concerned, such as health officers, quarantine officers, etc.i In general, the basic laws of the State establish the broad frame- work upon which the more detailed regulations of the State Board of Duties Re g ulat o rij F unct ions: Local boards of health are empowered to promulgate regulatory measures ner- taining to the control of communi- This authority is ex- direction of supple- powers granted by by regulations adopt- ed by the State Board of Health, and may be shared, at least to some degree, with the general legislative i'uthoiity or police powers of county and town governments. Local boards of health may require school chil- cable diseases, ercised in the menting the State laws and ' Regulations governing the control of communicable disease in North Carolina, adopted by the State Board of Health in May. 1936. Subject matter covered includes: definition of terms, the list of notifiable diseases, reporting, methods of isolation of cases and of certain carriers, concurrent and tei-minal disinfection, restrictions of food handlers, transportation of cases, and funerals. 40 Public Health Administration in North Carolina Health are based. Provision is made for the imposition of penalties for violation and also for making re- visions of such regulations. Special reference in the law is made to the powers of the State Board of Health with respect to certain diseases such as venereal diseases and oph- thalmia neonatorum. dren to present a certificate of im- munity against smallpox and local governments may enact regulations covering the vaccination of inhabi- tants (exceptions may be made for certain persons by a jury, owing to a peculiar state of health). Manda- tory immunization against diph- theria has been required of school children in a few instances by local regulatory agents for sometime past, but in 1939, the General Assembly enacted mandatory legislation for the whole State, requiring the immuniza- tion of all children between the ages of six months and one year; exceptions being made for conscientious objectors. Schick and tuberculin tests may also be made compulsory by local boards of health for school children, and each J ear blood tests for syphilis may be required of public school teachers. Local board of health ordinances may also cover such matters as exclusion of chil- dren from public schools when shown by examination to have a communicable disease, such children being readmitted by permission slips issued by the health officer. Furthermore, schools may be closed by municipal or county governments on recommendation of the local board of health as a precaution- ary measure against the transmission of communicable disease. Local health boards may add to the State's list of notifiable diseases, as, for example, pneu- monia has been made a reportable disease for Wilmington City-New Hanover County Health Department by enactment of a local ordinance. Then too, the State law may delegate specific regulatory powers to local boards of health, as for example, the right to govern the travel locally of persons from infect- ed places in other states. The system of quarantine in force in incorporated municipalities having a population of 10,000 or more, and in counties with a joint board of health presiding over the county and municipality, must be approved by the State Board of Health. This applies particularly to isolation and quarantine regu- lations. General Fnnctiovs: The staff of the Division of Epidemiology is to see that the rules and regulations of the State Board of Health are ex- ecuted. In practice, the State Epi- demiologist, through official chan- nels, is responsible for rendering the services of a consultant to local health officers, particularly to those who operate on a full-time basis, and for exercising leadership among them in the formulation, execution, and evaluation of the routine epi- demiological program carried out in local health jurisdictions. In gen- eral, the specialized facilities of the Division of Epidemiology supple- ment the generalized facilities of local health organizations in the joint development and execution of an integrated communicable disease program. With respect to unorgan- ized parts of the State, the State Epidemiologist visits only on request of local quarantine officers who may General Functions: The county quaiantine officer or corresponding official enforces all laws within his jurisdiction pertaining to inland quarantine and disinfection as well as the rules and regulations cover- ing these matters as prescribed by State and local boards of health. The county board of health arranges with the local quarantine official to accept and discharge the duties as- signed to him by law, and such other duties pertaining to the control of infectious diseases as may be as- signed to him by the local board of health. Provision is made in the State law that a local quarantine officer cannot be interferred with in the performance of his duties. The regulatory powers of boards and the executive functions of health officers are restricted in certain particulars by State laws, as for example, a child or other person may remain in the custody of his parents or family. Public Health Administration in North Carolina 41 seek his help or guidance in solving problems which arise. The application of isolation and quarantine measures pertaining to the control of the various reportable ■ diseases of the State is carried out by the staff of local health depart- ments in organized parts of the State and by the quarantine officer in un- organized health jurisdictions. In practice, local public health nurses fre- quently have the j'esponsibility of quarantining or isolating cases of com- municable diseases or collecting epidemiological data pertaining to them. For the major diseases, the first visit may be made by the health officer (or his medical assistant, if any), and these officials may impose isolation restric- tions on such cases, whereas, the nurse makes subsequent follow-up visits. The detailed procedure to be followed up in exercising these functions are incorporated mto the rules and regulations promulgated by State and local boards of health. Special Services. — Some of the more specialized services of the Division may be enumerated as follows: (a) Morbidity Registration. — The morbidity registration area is the county, and the technical aspects of collecting and analyzing the morbid- ity data is a function of this Divi- sion, cooperating with local health officials. Morbidity reporting goes back to 1893, and the systematic analysis of data collected, to 1918. The annual number of cases re- ported is about 54,000. Weekly and monthly compilations of morbidity reports for the State are sent to the U. S. Public Health Service; the weekly reports are telegraphed. Weekly reports of communicable di- seases are also compiled according to counties and municipalities and mailed to local health and quaran- tine officers. The completeness of morbidity re- turns is checked by the Division as follows: (1) annually the official roster of physicians is reviewed to determine the percentage of them who have reported communicable diseases; this figure is about 70 per cent for all doctors (including specialists, those on the inactive list, etc.) ; (2) returns made by counties are checked; (3) laboratory reports are checked against morbidity re- turns for the typhoid group, undu- lant fever, tularemia, and Rocky Mountain spotted fever (venereal diseases and tuberculosis are not in- cluded) ; (4) the ratio of deaths to morbidity is determined for certain communicable diseases. For exam- ple, during 1936 the following ratio obtained: diphtheria, 12 cases per (a) Morbidity Registration. — Phy- sicians (or if no physician is in at- tendance, the responsible person con- cerned) notify the local quarantine officer within 24 hours of the occur- rence of a reportable disease. Re- ports are made on forms furnished by the State. Formerly these were of four types, but in November, 1938, a form was devised which could be converted, upon receipt, to a punched card, and all diseases ex- cept syphilis are now reported on this form. There is a place on the form to indicate when a new supply of forms is needed and both the local health officer and the State Epidemiologist are jointly respon- sible for replenishing supplies to physicians and others concerned. Physicians are permitted to tele- phone reports, especially those of a more serious nature, to local or state health authorities. Cases of venereal disease may be reported by name (78 per cent) or by number; if reported by number, the physician is required to keep his records so that he will be in a posi- tion to make specific identification. (Inactive laws provide that drug- gists report to the State weekly on forms supplied them the proprietary remedies sold for use in venereal diseases, etc., and that druggists keep prescriptions for venereal di- seases, etc., in a separate file sub- ject to inspection by an officer of the State Board of Health). Since September 1935 morbidity returns of tuberculosis are being made 42 Public Health Administration in North Carolina death, typhoid group, 7 cases per death, pellagra, 2 cases per death. An annual bulletin on morbidity statistics is published (mimeo- graphed) and includes the following analyses: (1) reported cases for the State as a whole of 33 report- able diseases, by months; (2) re- ported cases for each of 11 cities of 12 major repoilable diseases; (3) leported cases by county, by month, for 27 reportable diseases; (4) re- ported cases of 33 communicable di- seases by age; and (5) leported cases of 33 communicable diseases by race and sex. (b) Health Ediicdfioii of the Pub- lic. — This field of activity includes the pi-eparation and distribution of printed materials, talks to groups (may be illustrated by motion pic- tures, slides, etc.), newspaper pub- licity, radio addresses, preparation and display of exhibit materials, etc. Facts about certain communicable diseases have been presented in pam- phlet form for publication, and, in addition, publications which treat of communicable diseases from the viewpoint of the health officer and physician have been issued. Fur- thermore, the laws of the State may specify particular education respon- sibilities pertaining to communicable diseases, and such functions may be shared with other divisions of the State Board of Health, as for ex- ample, the law specifies that the State Beard of Health is to inform the public regarding the danger of opthal- mia neonatorum and the importance of prompt treatment of this condition, but this service is handled by the Division of Preventive Medicine as a part of its maternity and infant welfare program. (c) Diagnostic Service. — Occasion- (c) Diagnostic Service. — In or- ally the State Enidemiologist is ganized health districts, physicians. through the local and State author- ities in conformity with the general pi-ocedures for reporting communi- cable diseases. Within 24 hours of receipt, the local quarantine officer transmits re- turns received to the State Epidemi- ologist on forms supplied by the State. Local quarantine officers (not whole-time health officers) receive a fee of 50 cents for cei'tain diseases reported to the state and 25 cents for others (except that the fee for sec- ondary cases occurring in a family is less in amount, and in some coun- ties the county commissioners have reduced the State's fee schedule). (b) Health Education of the Pub- lic. — Popular education pertaining to communicable diseases is one of the. piincipal features of the general health educational program carried on locally by health units. The staff" is dependent upon the Division of Epidemiology for supplies of litera- ture distributed locally. Personal in- terviews (especially when isolation procedui-es are being applied), talks to groups, newspaper releases, etc. are the educational agencies which are utilized. Educational measures may include motion picture reels pertaining to social hygiene, etc. mimeograph charts illustrating the manner in which communicable di- seases are transmitted, etc. called upon to go into the field to establish the diagnosis of communi- cable disease. Furtheimore, the State Laboratory of Hvgiene is an invaluable adjunct to the epidemio- logical staff", to county health of- ficers, and to local physicians in making diagnoses. (d) Emergency Measu)es: During the occurrence of an unusual preva- lence of serious communicable dis- ease the staff" of the Division of teachers, parents, etc. are encour- aged to share their responsibilities with local health officers for report- ing communicable diseases when an illness occurs regarding which there may be a leasonable doubt as to the correct diagnosis. The local health officer may call in the State Epi- demiologist if he is unable to reach a decision. (d) Emogency Measures, Epidem- iological Studies, etc.: The health officer of organized local health de- partments applies epidemiological Public Health Administration in North Carolina 43 Epidemiology may supplement the facilities of local health departments in carrying out control measures. Legal provision is made for an emer- gency fund of $5,000, previously re- ferred to. (e) Epidemiological Services. — The Division of Epidemiology coop- erates with other agencies such as the U. S. Public Health Service in planning and executing special stud- ies of important communicable di- seases. At present, attention is given to a malaria project in 7 counties in the eastern part of the State (Beaufort, Pitt, Greene, Edgecombe, Robeson, Halifax, and Wayne). All of these counties are organized on a full-time basis, and the health of- ficers in charge have manifested a special interest and aptitude for work of this character. The plan contemplated is to integrate a ma- laria service into the generalized program of the local health depart- ments with the aid of specialists (medical malariologist, entomologist, engineer, and two laboratory tech- nicians) employed by the Division of Epidemiology. ' The U. S. Public Health Service contributed $15,000. A thick blood smear survey of school children is under way to de- fine the localities in which the ma- laria problem is appreciable. Within these recognized areas clinical his- tories of malaria will be taken ; the index of anophelines will be ascer- tained by the use of traps; and the breeding areas will be studied by making larva surveys, determining the reaction of the water involved, etc. Through the Legislature, au- thority has been granted to regulate the impounding of water, a permit being required before such impound- ings are permitted, providing the area impounded is as great as one acre. procedures that are required to com- bat the usual outbreaks of epidemic diseases that occur in his health jurisdiction. In handling the more serious diseases, the facilities of local units may be supplemented by those of the Division of Epidemiol- ogy and other State departments, should the outbreak be unusually severe. (e) Epidemiological Service. — ■ Data collected in investigating re- portable diseases are used to estab- lish the epidemiological characteris- tics of these diseases in the several whole-time health jurisdictions, es- pecially for those diseases which constitute important public health problems. Public health nurses are relied upon quite largely to do plac- arding of communicable diseases. In addition to special forms provided by the Division of Epidemiology there is a general foim used for re- cording information obtained by making medical and nursing visits to patients with communicable di- seases, other than tubei^culosis and venereal diseases. This record is carried in the family folder until terminated, when it is placed in the terminal file for communicable di- seases. If the service of the nurse is merely a quarantine matter it may not be necessary to open a family folder, providing the family has not been so carried before the case in question occurred. In addi- tion to this general form special case record forms for epidemiologi- cal investigation of communicable diseases have been prepared by the Division of Epidemiology for the convenience of local health officers, namely: diphtheria, scarlet fever, smallpox, typhoid fever, paratyphoid B., tularemia, endemic typhus fever, rabies, and Rocky Mountain spotted fever. The form for typhoid fever, when folded, fits into the family folder used by local health units, but in practice a separate file is used; this form is made out in duplicate — the original being retained and a yellow copy being transmitted to the Division of Epidemiology. Special flies are set up in the local health office for diphtheria, scarlet fever, small- pox, etc. A binder record sheet is used for minor diseases such as mumps, chickenpox, etc. A number of local health departments prepare tabulations, 44 Public Health Administration in North Carolina tables, graphs, etc. from the epidemiological data collected, to show geogra- phical distribution of diseases, incidence by months and years, incidence by age-groups, by sex, etc. Malaria. — The formulation and execution of malaria programs locally may require the supplemental assistance of the Division of Epidemiology, the State Laboratory of Hygiene, the Division of Sanitary Engineering, and Federal agencies. In Edgecombe county, for example, such a cooperative pi'ogram is being carried out. Thick blood smears are taken of school children in a num- ber of areas in this county. These smears are examined in the State Labora- tory of Hygiene. On the basis of information gained from these smears, the status of malaria in various sections in the county is determined. Where smears indicate the existence of a serious malaria problem, a detailed map of the region is prepared to show individual houses, roads, courses of streams, and the relationship of cases to breeding places of anopheline mosquitoes. Each house is numbered and a history of malaria taken of the families who occupy them. Symbols are used to indicate on the map whether the family has had malaria or not. With respect to control measures, extensive demon- stration projects are being carried out under WPA funds. Such demonstra- tion districts are provided for by law, and an agreement is entered into with Federal authorities which provides for the maintenance of ditches by land- owners in these demonstration areas. The services of local personnel are sup- plemented by staff members of the Division of Epidemiology. Furthermore, the town of Tarboro has an ordinance' for the control of mosquitoes, and an inspector is employed to enforce its provisions; he makes house-to-house in- spections at frequent intervals during the mosquito breeding season, and carries out rather an extensive oiling program in the town and its vicinity. Malaria control work in Wilmington and vicinity is administered by a commission consisting of two members, one of whom is the health officer. The budget for this program amounts to $2,500 annually, the city and New Hanover county sharing the expense equally. In recent years arrangements have been made to provide prison labor in addition to a crew of three oilers. Measures which have been put into effect include an extensive drainage pro- ject and the use of oil for spraying mos^juito breeding areas. Interest was stimulated in malaria control by Federal authorities at the end of the World War and the Federal Government took the initiative in establishing the main drainage channels around the city. Although malaria has been greatly re- duced in Wilmington, mosquitoes remain somewhat a pest owing to the fact that no effort is made to control salt water mosquitoes. Control measures in- clude drainage, screening of homes, oiling and dusting of bodies of water in- volved, and in some instances the removing of the residents to a more health- ful locality. (f) Vene)eal Disease Se)vice: A Vene)'eal Disease Service. — Local section of the Division of Epidemi- cooperative venereal disease pro- ology is devoted to the control of grams are operated on the basis of venereal diseases. The director, who an agreement entered into between has specialized in public health in the State Board of Health and local general and venereal disease in par- boards of health. The princinal ticular, functions as an expert ad- administrative features of the plan viser to local health officers with are: (1) Support and cooperation reference to the formulation, execu- must be pledged by local agencies tion, and evaluation of locally op- concerned (health authorities, the erated pi-ograms. Emphasis is placed county medical society, and county on syphilis. The scope of service in- and municipal governments, includ- cludes: (1) operation of clinics ing police authorities and welfare ^ Ordinances for the prevention of mosquito breeding in the town of Tarboro, North Caro- lina were adopted February. 1937. Provisions of this enactment cover: screening: standing or flowing watt r and methods of treatment, including emptying containers at seven-day inter- vals, using larvacides, freeing from vegetable growth and other obstructions, stocking with fish, filling or draining, etc. Public Health Administration in North Carolina 45 which are held in centers of popula- tion throughout the state. For the most part (about 80 per cent) these clinics are in the charge of local health officers. Drugs are supplied free by the State. The aim is to give each syphilitic patient a minimum of 40 treatments — 20 arsenic and 20 heavy metals. The average attend- ance at venereal disease clinics has been about 40 patients; (2) exami- nation and treatment of prisoners is piovided for in the law and faith- fully carried out in some localities. A high percentage (about 65 per cent in some samples taken) of pris- oners is found infected with syph- ilis; (3) serological surveys of State institutions, and in some instances of industries, constitute a part of the program. The results of one such survey conducted in an industry em- ploying 800 men were: White employees — 12 per cent positive Colored employees — 20 per cent positive; (4) the examination of domestic servants for venereal diseases is pro- vided for by State law and the re- sults of blood tests run about 30 per cent positive; (5) Legislation covers venereal disease examinations for those applying for a marriage li- cense; (6) the field investigations of venereal diseases are largely lim- ited to the return of delinquent pa- tients for treatment at clinics, little being done at present to investigate sources of infection or to obtain a complete epidemiological picture; (7) legislative provisions fashioned to secure the cooperation of drug- gists in uncovering persons with venereal diseases are inactive; (8) provision is made for the control of ophthalmia neonatorum, and to this end prophylactic silver nitrate solu- tion for instillation into the eyes of the new-born is distributed by the Division of Preventive Medicine to those engaged in midwifery. Owing to the beneficence of the Reynolds Foundation, the venereal disease program of the State Board of Health is being markedly expand- ed at present. The staff of the Sec- tion of Venereal Diseases is being enlarged by the employment of full- agencies). (2) Executive responsi- bility is vested in the local health officer, but the selection of local pro- fessional personnel for treatment centers by the health officer is sub- ject to the appi-oval of the State Board of Health. (3) Clinic facil- ities must meet minimum require- ments prescribed with reference to space, equipment, accessibility (a number of centers may be operated in a local health district), accommo- dation of races (mostly colored pa- tients attend), etc; and clinics must operate in conformity to scheduled clinic hours: clinics may be adver- tised through the newspapers and also by those who attend. (4) Local funds for venereal disease activities, which conform to requirements specified by the State Board of Health, are matched by available funds handled by the State Board of Health on a 50-50 basis, unless special circumstances necessitate an adjustment of such a matching basis. (In the laws of the State pro- vision is made for county commis- sioners to pay expenditures incurred in the examination, isolation, and treatment of venereal disease pa- tients). (5) Minimum requirements pertaining to clinic management are prescribed, including: (a) an ade- quate physical examination of new patients to determine their physical status; (b) the collection of epidemi- ological data as to source of infec- tion, persons exposed to infection by the patients, etc., and patients are interviewed to this end when they enter the clinic; and (c) the official reporting of new cases of venereal diseases by the clinic. (6) Provision is made for adequately trained per- sonnel to administer treatments, it being understood that venereal di- sease clinicians must meet the re- quirements specified by the U. S. Public Health Service or the Con- ference of State and Territorial Health Officers, and, also, that clin- ics be operated in compliance with instructions furnished by the State Board of Health, for example, urin- alysis and blood counts are to be made when indicated, patients must be queried relative to untoward re- actions following their last treat- 46 Public Health Administration in North Carolina time syphilologists, i)art-time clini- ment, etc. (7) The staffs of local ciaris, full-time public health nurses, health departments are utilized so clerks and laboratory technicians. far as practicable in performing the The program projected provides for services that are required in putting a community basis of work. Cer- into effect the venereal disease pro- tain demonstration areas scattered gram. Many health officers are en- throughout the state are being se- listed as clinic physicians. Public lected on the basis of local financial health nurses work in clinics and participation, the existence of a make follow-up visits in the field, definite need, and the assurance of The sanitary inspector is used to adequate cooperation. Through finan- contact certain cases calling for the cial support from this source, drugs, services of a male worker. Special .supplies, and equipment will be made clinic nurses may be employed in available also. large clinics but the responsibilities of these nurses are confined essen- tially to their clinic duties. The pro- cedure recommended for following- lapsed cases calls, first, for a mail notice, second, for a nursing visit, and ul- timately, as a last resort for legal procedures resulting in the arrest of the patient. Case-finding visits and epidemiological investigations are included i.s a part of the field program, and the health authorities may resort to legal procedures to obtain ti-eatment of infectious patients who refuse to cooperate. Provision is made for inter-jurisdictional notification, on forms prescribed by the State, when patients move from one health jurisdiction to another. (8) Types of patients to be admitted include: (a) syphilitic patients, (expectant mothers, persons with primary or secondary lesions, children born of syphili- tic parents, infectious relapsed patients whose duration of infection is under five years, patients with gummata, iritis, early nervous system manifesta- tions, etc.) and (b) patients with gonorrhea, chancroid, and granuloma in- guinale. First consideration is given to infectious patients, but in practice the patients who attend clinics have the disease most frequently in chronic form, especially in the case of the newer clinics. (9) On forms supplied, monthly clinic reports based upon individual clinic records, and financial re- ports (including an accounting for supplies furnished) mu.st be made to the State Board of Health. Inventories of all equipment are also made annually to the State Board of Health. (10) Drugs are furnished free by the State Board of Health to local clinics, and provision is made for the distribution of drugs by local health officers to practicing physicians for the treatment of indigent or semi-indigent private patients. (11) The follow-up services of local health departments are available on request to practicing physicians, and a mode of procedure is suggested as a basis for the transfer of patients from private physicians to clinic and vice versa. Doctors may be requested, also, to refer to public clinics private patients who are unable to complete the prescribed course of treatment because of inability to continue payments. Case-finding efforts may consist of (1) routine blood-tesi-ine of public food handlers, domestic servants, and expectant mothers; (2) the seeking out and the examination of sources and contacts of known cases; and (3) solicit- ing cooperation of physicians in better reporting. Apart from case-finding activities and provisions for treatment facilities, the local antisyphilis pro- gram may include the development of an informed and active public opinion through educational channels, and the development of cooperation by the private physician in administering adequate treatment to their private "cases and in locating contacts. As a prerequisite to selecting new clinic cities, made possible by the Rey- nolds Fund, local health departments and county medical societies must agree to cooperate with the State Board of Health in making a survey to deter- mine: (1) the percentage of persons infected in the area; (2) the classifica- tion of cases as to the stage of illness; and (3) the adequacy of treatment. With such information before it, the State Division of Epidemiology is in a Public Health Administration in North Carolina 47 position to select clinic centers on the basis of relative needs, and to appraise the effectiveness of control measures applied by comparing the status of these diseases from time to time with their status at the time the clinic was or- ganized. All expenditures of funds available for venereal disease control pro- vided by the Reynolds Foundation are made directly by the State Board of Health, and equipment purchased with Foundation funds remains the property of the State Board of Health. Prophylactic Measures. — From the Prophylactic Measures. — The ad- State's standpoint this service is limited largely to the distribution of biologicals. Free drugs for the treat- ment of venereal diseases are dis- tributed by the Division of Epidemi- ology. The Division of Preventive Medicine distributes silver nitrate solution free on request to physi- cians, midwives, and hospitals, for the prevention of ophthalmia neo- natorum among the new-born, and it may purchase diphtheria toxoid for free distribution locally. Dur- ing the biennium ending June 30, 1938, this Division supplied free tox- oid to local health officers and phy- sicians sufficient in amount to im- munize nearly a third of the babies born during the period, and silver nitrate prophylactic diops were sup- plied in an amount sufficient to pro- vide for 83 per cent of the children born during the biennium. The State Laboratory of Hygiene distributes a number of biological products, in- cluding: (\) diphtheria antitoxin (a 25 cent charge is made for the con- tainer), toxoid, and toxin for Schick testing (free) ; (2) rabies vaccine; (3) antityphoid vaccine (free) ; (4) smallpox vaccine (free) ; (5) per- tussis vaccine (free) ; (6) scarlet fever immune serum (sold); (7) tetanus antitoxin (75 cents per out- fit); (8) measles prophylactic, etc. ministration of immunization meas- ures in the control of certain com- municable diseases is essentially a function of local health departments. Particular attention is being given to vaccination against smallpox, antityphoid inoculation, and diph- theria immunization. Approval of the local medical society may or may not be sought by the health depart- ment for immunization procedures carried out by the health staff. The health officer may circularize parents by letter when an infant reaches six months of age, urging immunization against diphtheria, preferably by the family doctor (the 1939 law makes immunization man- datory). Campaigns for inoculation against typhoid fever are carried out duiing the summer season on a scheduled basis. During the summer round-up of preschool children and during the health examinations sub- sequently made of school children, emphasis is placed upon vaccination against smallpox. In this connec- tion, parents may be circularized to the effect that their school children will be vaccinated by health author- ities unless a request to the contrary is received from parents. Those practicing midwifery are responsible for the use of prophy- lactic drops in the eyes of the new- born. When smallpox occurs in any community, jnovision is made for fi-ee vaccination, by county and municipal physicians and by health officers, of persons not able to pay.* Legal provision is also made for free vaccination against smallpox, by the county physician and county health officer, of persons admitted to public institu- tions (jails, county homes, etc.), but the execution of this law would appear to be neglected. Apart from carrying out mass immunization campaigns against typhoid, diphtheria, and smallpox, special attention is given to the protection of contacts of patients ill with these diseases when local health of- ficers institute isolation and quarantine procedures. Immunization records for diphtheria, typhoid fever, and smallpox may be !:ept on forms provided for the purpose by the health department. Ques- tionnaires may be sent to local practicing physicians to obtain a record of children immunized by them. Biologicals used in immunological procedures may be distributed to practicing physicians through the local health officer. 48 Public Health Administration in North Carolina / Pneumonia. — Pneumonia is not officially a notifiable disease in North Caro- lina, and apart from some effort in the field of public education, little is being done directly by the Division of Epidemiology to combat lobar pneumonia. Attention should be called, however, to the Pneumonia Commission which the State Board of Health, with the aid of the State Medical Society and the Medical School faculty of Duke University has established for the study and control of the disease in North Carolina. The Commission consists of 12 physicians, namely: members of the State Board of Health, including the State Health Officer, 5; representatives of the State Medical Society, in- cluding the president and secretary, 3; and faculty members of the medical schools within the state, 4. Under the auspices of this Commission steps have been taken to train laboratory technicians who will be available in every section of the State for the typing of pneumococcus organisms and to familiarize the physicians of the State with the efficacy of serum therapy in proper types of pneumonia cases (I, II, V, VII, VIII). Early in 1938 a short laboratory course of instruction in pneumonia typing and other scientific procedures concerned with the treatment of pneumonia was given for technicians and physicians at Duke University School of Medicine, and a symposium and clinic on pneumonia was held for the benefit of practicing physicians which covered the pathology of the disease; its bac- teriology and laboratory diagnosis; its character in infants, children, and adults; empyema and surgical complications; and X-ray diagnosis. Selec- tion of technicians for training at Duke University was limited to candi- dates holding or eligible to hold a certificate of the American Board of Cli- nical Pathologists. Sixty-eight typing stations in 49 communities have been established in the State, and provision has been made with commercial firms to place supplies of serum at strategical points in the State, particularly population centers, so as to make serum readily available to all physicians. Technicians are re- quired to report to the State Board of Health the cases diagnosed by them, type of organism involved, and the main particulars pertaining to the serum therapy administered. With the support of this Commission, it is perhaps not too much to expect that the time is approaching when a section of respiratory diseases may be established within the Division of Epidemiology. Tuberculosis. — From 1913 to 1923 the State Board of Health was respon- sible for the State's tuberculosis program, including the institutional care of patients. Except for this period, State leadership has been vested essential- ly in the Board of Directors of the State Sanatoria. Local government au- thorities, however, share with the State the responsibility of instituting con- trol measures. Organizations State Sanatoria. — The North County or District Sanatoria. — Carolina Sanatorium for the Treat- Counties are empowered to estab- ment of Tuberculosis, situated at lish and maintain tuberculosis hos- Sanatorium, was founded in 1907, pitals. One procedure for taking this and the Western North Carolina step is as follows: The board of Sanatorium for the Treatment of county commissioners by majority Tuberculosis, located at Black Moun- vote or upon petition of ^4 of the "£ '4- d^Sf'J Main Building, North Carolina Sanatorium Dr. p. p. McCain — Superintendent, State Tuberculosis Sanatoria 50 Public Health Administration in North Carolina Western North Carolina Sanatorium tain, was dedicated in 1939. The common Board of Directors of these two institutions consists of twelve members, appointed by the Governor and approved by the Senate. The Secretary-Treasurer of the State Board of Health is an ex officio mem- ber and the State Treasurer is the Board's ex-officio treasurer. These directors constitute a body politic and corporate and provision is made for its organization including the creation of an executive committee of three members. The directors are empowered to enact by-laws and i-egulations, to issue bonds (within certain I'estrictions), to accept gifts for the Sanatorium, etc. The tenure of office of directors is six years, and the membership of the Boai'd is arranged on a rotary basis; vacan- cies ai-e filled by the appointive au- thorities. Members are entitled to receive $5 per day for services ren- dered and necessary travel expenses, including hotel accommodations. With respect to the operating staff, the directors elect a superin- tendent — selection being limited to those who satisfy certain specified qualifications. His term of office is two years, but he is subject to dis- missal for cause. The duties of the superintendent are prescribed by the freeholders orders an election to determine the will of the people with respect to bonding the county (not to exceed $250,000) for the es- tablishment of the sanatorium. For the maintenance of this institution the county commissioners are au- thoi'ized to levy a special annual tax (not to exceed 5 cents on $100 prop- erty valuation and 15 cents on the poll) but the question of this levy is to be submitted to the voters. The manner of holding elections referred to is specified in the law. Furthei- more, provision is made for a board of managers. The county health officer is a member ex officio, and in addition there are five other mem- bers elected by the county commis- sioners. Only one county commis- sioner can be a member of the board of managers and this member is chairman. Women are eligible for service on the board. The elected managers hold office for four years on a rotary basis, except that the commissioner-member serves for two years (or for the unexpired term of his office). Vacancies are filled by the board of county commissioners. The county commissioners may ap- point the managers following the favorable results of a popular elec- tion oi- may defer such appointments ■^- Public Health Administration' in North Carolina 51 directors, and he is placed in charge of both State sanatoria. Subordinate employees are employed by him, sub- ject to the approval of the directors, and he is empowered to discharge subordinates for cause, reporting such acts to the directors. The aver- age number of employees of the North Carolina Sanatorium is ap- proximately 169, namely: adminis- tration, 4; professional care and treatment, 61; custodial care, 68; operation of plant, 8; maintenance of plant, 6; agriculture, 22. The North Carolina Sanatoiium has 485 beds, and its average census is 471. An associate superintendent and medical director is in charge of the Western North Carolina Sanato- rium. This institution has 140 bed.^, and an additional wing is being con- .' i^y^ — B«fs^ ■-?>r- — ^r 3 '^ y j^^ K"3' ' ' * -■.••:-"•' "V < ^yi%. ^•" :--,V^ JS^ K/fi^ L (o*"tSf* S-A-^*w^^ VS*. iiSJKftir = = cc to •^^MB^^iHt^^^B^S ^,^. c- ^^■F^iWi /i ^^ 1— 1 fil Ik. ■;^Vf^M^ Ki B < 1 (fi^BK^Hi^^^ . (A / ^ 1 ' ^^^^^ ^ ^Bl^V-^^^^^^^^K^H ,< \ J L^ .^^^^ rr ^^^^^^^^^ '. ^^^^^^ » ^i^^^^^^^^^^^^^^^^^^ m 1 l:^H^^^Hi ^H ^ ^HH^^^^B. \ CO ■*^^^^^^^^Bi^^^H J ^^^B^^^^^^^^^ »/ e 1 1^ w^w^^ ^■■*^^^^^^B 6B^^^^ z ^ ^i^^^^ hJ i ^^^..AL .i^r *" * (^ u ^S^^^^^^^^^Hr^^HI^^^^^^ X n 33 1 WTiH I ^ • V:r^ ilHn V t— 1 kJ^^Mll 1 « ^^v:~~"J= 'A^i^^R^ o ^Bvoli ^W^H'\ ! 1 to I ^^^BB -""-^^^ ^^fc^ " l^^^flH^ \ \ s to S 'L^S^mX \ g ~fc ; ,- .-i^'&'/i •„ '/-^-^fl^BIW ii; Oh E x^;i,~^^:^<%^ ij^BI £ g 1 \^-^^o^^^ » pPi 1 o :^ - t /E^VoM ^wi 1 t^ ^l^iBm 1 . J ^ .J^^p^ >^ 1-1 ^P^ ^ t; a n X \ = B 11 1 — I Vi ^ - s e - " Public Health Administration in North Carolina 107 the auspices of the Public Health Administration. This course proved to be so successful that plans were made to enlarge its scope by the establishment of a public health department at the University for the training of health officers and sanitarians (See section on Preventive Medicine, pages 90 and 91). Also in 1935, an enabling act was passed by the General Assembly authorizing the State Boai-d of Health to use any available funds at its dis- posal, not otherwise appropriated, to establish full-time local or district health service for any town, city, and county, or group of such units, where the local governing powers desire the establishment of such service and are willing to support the enterprise to an amount at least equal to the amount of the State financial assistance. Under this additional authority and with Federal funds provided through the United States Public Health Service and the Children's Bureau, plans were worked out for marked expansion and intensification of full-time health services. During the year ending June 30, 1938, funds contributed by the State and other agencies, principally Federal, were allocated by the State Boai'd of Health to 48 full-time county and district health departments that were rendering service in 66 counties. To another health department, serving a single county, the Board made an allotment of State funds but no allotment of funds derived from other sources. Rendering these services, therefore, were 49 full-time health departments, each having jurisdiction in a single county or in a group of from two to five counties. The former are known as county health departments; the latter as district health departments. The number of counties being served by each of these 49 health departments as of June 30, 1938, was as follows: Number of Health Departments Serving : Total Total One Two Three Four Five Counties Departments County Counties Counties Counties Counties 67 49 40 3 4 1 1 Over and above the supplementary health funds allocated through the State Board of Health to county and district health departments, are alloca- tions made to five city health departments. These funds, amounting in 1937-38 to $12,737, were derived entirely from sources other than the State of North Carolina. These county, district, and city health departments served a total population (based on the 1930 census) of 2,408,430 during the year ending June 30, 1938. The health officers and nurses employed by these de- partments were as follows: Health Officers Total County health officers 40 District health officers _ 9 Assistant health officers 5 54 City health officers 5 Total health officers 59 Public Health Nnrsen County and district nui-ses 146 Nurse supervisors 7 City nurses 42 Nurse supervisors (city) 3 Total public health nurses 198 DIAGRAM OF OF?GANIZATION AND OF FULL-TIME LOCAL HEALTH DER IN NORTH CAROLINA ACTI VITIES ENTS GOVERNOR STATE BOARD OF HCALTH I 1 STATE ^CnCAL SOCCTY j COUNTY BOARD OF HEALTH Mayo' of COo—i-y /o--" '^f^t'fl Ca^nff S^panntrnda'^* cf Schaois a->* foco/ denf.3' U. o^f.co 1 1 . 1 _ ____ 1 1 1 j SANITARY OFFICER OFFICE CLERK PUBLIC HEALTH NURSE PUBLIC HEALTH DENTIST 1 1 AOMimaTiuTiyc nmu 0>roa<-orr, ^afn.tp ana COt»f.on HandieappaJ lnd\,ttr.al hfgiwn» So^"^-'2cc,dmnf i-lmo/fh (ma.ale^.on Off, cm aJn^"-'- 9*re',on C^di»f» F-rtana^» C^nfmrtne* a incrmta dapoamf 3»t^»rofa Wotm' A^piH fo off.f D>*ti-'buhon af /,/mi-af<^ru •nclvd'ni Motam.U f^.dr^./a i^aar^a.^r^ Inton' and Pra- £aucat D.doet.c •ma'th on *» CXTTCS Co'"'Ti«-»,f »*/• a- aaaia can*'ai tf^'nwn.tat.on* T^pna^a ra*ar Oip^tfwr.a tp.da-^ alaf.cal O'agno-thc jartca Tuharc-jloa-* iuph.lit-Gonai'haa '<>*arn-t tt: to U. M u. CC PC W o 1-1 o X J to ^ 5 ^ ss 1-1 o H O £-, 1-1 E- g — to > 1-1 ^ £^ W i ^ < CO a o ^ o Ct. CO CJ o to to ct: z u o ^ S < o 1-1 < w O 1-1 to Dl. £-1 1-1 ffl CO ■^ 1-1 O S !J CO 5 g£ >H 1-. 3 O 2 O M W z o O O — .^ :S ^ ;« fr^ K a 5x f? < < o ^ fe tv3 g CO O E f-i CO i. a CO o < o pc o o s 1-1 o o -_ a H 1-1 — S X' o S P fr' 1-1 ti & c^ CO M to S w o 1-1 E-1 O :0 s Cc^ • o M 2 o CC CiI c_, ^, -_ 1—1 P h-1 O w 2 fc .-; w CO H o g ■^ ."0 CO o m — --: Sa W EC ^ o w a; -1 5 w 1—1 u^ o li p g^ ■ * t— 1 o ^g CQ K CJ o ti: H CJ jj 1-1 o ^ ^ ;s 1—1 1-1 >^ 1-1 a. hJ y _<: O 3 f-i J "£ >- o CO n w CO W g £ - '-0 CO CO o 3 B P K 1-1 O ^ E^ c. < O ^ < W Ct. "^ ^ i-t HE-' CO j^ J to M CJ o "^ 1-1 O ffi IH CO m o B ES? :2 3 o u: p ■»; O 1-1 t- 1-1 i- CO Cj 5: w U CO o CL, i— * CO tJ CJ w X CO CO o s — .3 < 3 O CJ M >- 1-1 Z J 6-1 fc. H H <; s ^ ^_ °S5^ B £1 i. -) :^ ISIO RK AND HABI o >^ < ag g 1-1 Q 3 O O o ;= O CQ 1-1 CO ^ =J £-1 J to |3 CO 6h t-i o § o CQ W £-1 <; e-i < z Q 33 K o z o s o < z ■< 126 Public Health Administration in North Carolina matters, maintains a library, operates an information service, performs sta- tistical services, and attends to administrative matters in general. Classi- fied as a part of the administrative office also, and directly responsible to the Assistant Commissioner, are the ten field social work representatives who serve as the principal link between the various divisions of the State Depart- ment (to be described later) and the County Welfare Departments. That the several functions of the State Department may be properly co- ordinated, directed, and supervised, there have been created five divisions; namely. Child Welfare, Public Assistance, Case Work Training and Family Rehabilitation, Mental Hygiene, and Institutions and Corrections. There are in the State Department, also, four service units, concerned especially with: (a) county organization, (b) surplus commodity distribution, (c) work among Negroes, and (d) selection and certification of applicants for Civilian Conservation Corps. These departmental divisions and service units are shown diagramatically in the accompanying chart. b). The Division of Child Welfare. — Through legislation enacted by the General Assembly of 1917, the State Board of Charities and Public Welfare was directed "to study and promote the welfare of the dependent and delin- quent child and to provide, either directly or through a bureau of the board, for the placing and supervision of dependent, delinquent, and defective chil- dren. In 1920, when the Division of Child Welfare was created, the Board was able to expand the scope of its program to include the care of children outside of their own homes and in institutions or foster homes. Subsequent- ly, additional responsibilities were undertaken such as, for example, the ad- ministration and supervision of the State Mothers' Aid Fund as provided by the General Assembly of 1923. With State acceptance and adoption of the provisions of the Federal Social Security Act, and with establishment of other divisions within the Depart- ment, there has been some change in the responsibilities of the Division of Child Welfare. The duties of this Division are now as follows: (1) care of children outside their homes or in substitute or foster homes; (2) special casework service to children who, though living with their families, pi-esent personality and behavior problems; (3) improvement and enlargement of facilities for foster care; and (4) joining forces with all agencies in the children's field in a sincere, cooperative effort to determine what groups of children in the State are most neglected by both the public and the private children's agencies and how the child welfare program can be adapted to care for their needs." Correspondence and casework with families and adults was transferred to the Division of Casework Training and Family Rehabili- tation, and the administration of the funds for care of children in their own homes was made a responsibility of the Division of Public Assistance. The State and county public welfare agencies are mutually responsible by law for the administration of certain specific measures for the protection of children. The relationship between these or between either of these and a private agency, which must be licensed and supervised by the State, "is rooted in a common concern for proper care of the underprivileged children of the State needing service, and a mutual desire and effort to utilize all re- Public Health Administration in North Carolina 127 sources both public and private to provide the service. The approach to the common task is through the recognition of minimum standards, and the development of a broad, flexible program adapted to the needs of all handi- capped children. Such relationship and approach protect both the child and the standard agency from exploitation by persons and agencies whose mo- tives are self-service rather than service to children." The present trend is that of preserving the home or of placing children in foster homes rather than in institutions. In 1938 there were twenty-seven approved orphanages in the State which cared for 4,441 children. Of these institutions, 18 were supported by religious organizations, 5 by fraternal orders, 3 by communities, and one by a county. Only three of the institutions are licensed as temporary care homes for chil- dren. In connection with the handling of approximately 2,650 cases each year by the 108 juvenile courts in the State, seven counties maintain deten- tion quarters, some use a boarding home-probation-system for juveniles, but many continue to confine children to jail, illegally. As of June 30, 1938, there were 911 juveniles confined in training schools, 73 in detention quarters, and 106 in county jails. As previously stated, the administration of the funds for the care of chil- dren in their own homes, in accordance with the Act for Aid to Dependent Children, is now a responsibility of the Division of Public Assistance. The placing of children in foster homes, however, is undertaken by juvenile courts and private agencies, the Board's responsibility in behalf of these children being executed by the Division of Child Welfare. The probation of- ficers for the juvenile courts, who are usually members of the staffs of County Welfare Departments and render casework service in behalf of fos- ter children, must be approved by the State Board. During the year 1937 two private children's agencies rendered services to a total of 704 children. Apart from participating in Social Security pi'ovisions for Aid to Dependent children, the State has appropriated annually since 1931 about $5,000, which is known as the State Boarding Home Fund. Counties share this fund on a 50-50 basis. Foster homes are inspected and licensed by the Division of Child Welfare and definite standards must be adhered to. In 1937-38 65 children from thirty-eight counties were cared for through State and county boarding home funds at a cost of $11,212. The number of boarding months totaled 629, and the average cost for board per child per month was $17.82. Licensed boarding homes in the State increased from 28 in 13 counties in 1936, to 57 in 29 counties in 1938. There are four maternity homes in North Carolina, located at Charlotte, Asheville, Greensboro, and Durham. These institutions are for the care of unmarried expectant mothers, and they provide accommodation for 100 pa- tients. The chief function of the home is to provide proper prenatal, natal, and postnatal care for these mothers and their children. An additional ser- vice is to retrain young women to enable them to make a satisfactory emo- tional and social adjustment when they are discharged. These homes are not permitted to do any child placing. General supervision of them, includ- ing licensing, is exercised by the Division of Child Welfare. 128 Public Health Administration in North Carolina In April, 1936, the State became eligible to participate in the following provisions of the Social Security Act, Title V, Section 3: "(a) for develop- ing State services for the encouragement and assistance of adequate methods of community child welfare organization in areas predominantly rural and other areas of special need; and (b) for payment of part of the cost of dis- trict, county, or other local child-welfare services in areas predominantly rural." Under this plan, the fundamental activity involves the placement, maintenance, and supervision of adequately trained child welfare assistants on the staffs of county departments of public welfare. Special projects un- der the plan include the development of a demonstration and training area, consisting of the counties of Durham, Chatham, and Orange, in cooperation with these county governments and the University of North Carolina ; a pro- ject in connection with the State training school for delinquent children; psychological services for children; research in intelligence rating of public school children; participation in the study of the population of child-caring institutions; consultant service on children's problems which had no special children's workers; and provision for educational leave for employees of child welfare services. Child welfare assistants are placed in counties only upon a formal re^juest signed by the judge of the juvenile court, the chairman of the county welfare board, the chairman of the board of county commissioners, and the superin- tendent of welfare. The work of the child welfare assistants is supervised by the three case consultants on the staff of the State Division of Child Wel- fare, one of these being a psychiatric social worker. It is noteworthy that several of the counties have voluntarily agreed to assume part of the salary and traveling expenses, sometimes including out-of-county mileage, of their child welfare workers, as well as to furnish office space and stenographic ser- vices. Progress in obtaining county participation in the cost of this work is shown by the fact that as of June 30, 1938, fifteen child welfare assistants had been placed in fourteen counties, and arrangements had been completed for placements in three others. c). The Division of Public Assistance. — The 1937 session of the General Assembly enacted legislation (Chapter 288, laws of 1937) to provide old age assistance and aid to dependent children in accordance with provisions of the Federal Social Security Act. In the same statute the State legislature pro- vided for the establishment of a Division of Public Assistance and a State Board of Allotments and Appeal within the State Board of Charities and Public Welfare. The Division of Public Assistance was established and began to function officially on July 1, 1937. The Division "is responsible for all fiscal matters relative to old age assistance and aid to dependent children, including: keep- ing the Social Security Board informed as to both the needs of the State and the laws, policies, and procedures of administration; working out, with each county, allotments and quotas consistent with the need and the funds avail- able; and writing all assistance checks, sending them to the local welfare de- partments for distribution to recipients." Furthermore, the Division "is i-esponsible for receiving and checking all applications for old age assistance Public Health Administration in North Carolina 129 and aid to dependent children and all forms pertaining to those applications, in order to help the counties maintain the validity of their case loads, by keeping within the laws and policies of the State and Federal oflSces." Through the State Board of Allotments — consisting of the Chairman of the State Board of Charities and Public Welfare, the State Commissioner, and the Director of the Division of Public Assistance — the Division endeavors to strengthen the relationship between the county welfare departments and the client by vouchsafing to the latter an unbiased hearing and by explaining policies and procedures as they relate to him. Every effort is made, also, to coordinate the services of this Division with those of the other divisions of the department and to function in close cooperation with county welfare de- partments. (1). Old Age Assistance. — Assistance under this category is granted on a budget deficiency basis, that is, the amount of income which an applicant may have is deducted from the amount he needs, and the diff"erence between the two is the amount of assistance that is to be given. In determining the actual needs of an individual the existing conditions in each case are to be considered, and the amount of assistance in supplementation to any other in- come is to be suflJicient to provide subsistence compatible with decency and health. In no case, however, is the amount of assistance to exceed thirty dollars per month or $360 a year. Funds to meet these payments are de- rived in the proportion of one-half from Federal funds, one-fourth from State funds, and one-fourth from county funds. The provisions of the law are mandatory on the State and every county, and full authority is given the boards of county commissioners to levy, impose, and collect the required taxes. The law provides the usual eligibility requirements as to age, citizen- ship, residency, and economic dependency, and safeguards the State against illegal claims and fraudulent practices. Total old age assistance grants for the fiscal year ending June 30, 1938, amounted to $2,209,869.29, of which the Federal Government contributed $1,104,934.63, the State $604,266.37, and the counties $500,668.29. A total of 33,060 persons had been accepted for the old age assistance and were re- ceiving average monthly grants of $8.97, or about half the national average. (2). Aid to Dependent Children. — The Mother's Aid Fund provided the principal means of public support to the dependent child from July 1, 1923, to July 1, 1937. For this purpose the State appropriated annually about $50,090, which was to be matched by an equal amount from the counties; and administration of the joint funds was supervised by the State Division of Child Welfare. Participation on the part of the counties was entirely volun- tai-y, which accounted for the fact that less than half of them engaged in this type of assistance. On July 1, 1937, the law providing for mother's aid having been repealed, responsibility for aid to dependent children was trans- ferred to the Division of Public Assistance. Whereas, under the Mothers' Aid Law the recipient of assistance could be none other than the child's own mother, and then only if she met certain qualifications, the new law enumerates several other relatives in addition to the mother. Moreover, the only qualifications required of such relatives is 130 Public Health Administration in North Carolina that a "safe and proper home," shall be maintained for the child. The maxi- mum age limit for eligibility, which was fourteen years under the Mothers' Assistance Law, was increased to sixteen years under the Aid to Dependent Children Act. The provisions of the latter law are mandatory on the State and every county, and assistance funds are derived equally from the Federal Government, the State, and the County. The maximum amount of assistance is not to exceed $18 per month for one child and $12 for each additional child in the home. As of June 30, 1938, there were 22,196 children in 7,959 North Carolina families who had been paid a total of $816,284.93 in the form of assistance payments during the preceding twelve months. d). The Division of Casework Training and Family Rehabilitation. — Prior to July 1, 1937, this service was designated the Division of Field Social Work, and was responsible for the supervision of ten field representatives. The field work of the new Division, except the conduct of the one-day institutes given by the director, still is performed by the field representatives of the State Department. The present functions of the Division which, basically, are intended to ad- vance the knowledge and to improve the efficiency of both State and local staffs include: (1) the training of welfare workers thi-ough institutes conducted by the director and through in-service training under supervision ; (2) special casework training in the technique and philosophy of the management of cases involving family rehabilitation; (3) supervisory responsibility in the referral service of county welfare departments to the W. P. A., N. Y. A,, and authorities for surplus commodity distribution; (4) the handling of out-of- state inquiries concerning families, and correspondence concerning general relief; and (5) responsibility for the preparation of plans for the annual public welfare institute sponsored by the State Board and the Division of Public Welfare and Social Work, University of North Carolina. Social workers are constantly urged to take full advantage of opportuni- ties which include a leave of absence on half pay for further training in pro- fessional schools of social work. Many members of the State and county staffs have secured training at the State University. e) The Diinsioyi of Mental Hygiene. — For a period of about 17 years Harry W. Crane, Ph.D., professor of abnormal psychology at the University of North Carolina, served as a director of this Division, devoting one-third of his time to the work. Since his resignation in 1937 two psychologists, who were his assistants, have carried on the following activities: (1) clinical ser- vices, (2) educational services, (3) the acquiring and filing of data, and (4) the inspection of State and private institutions for the mentally diseased and mentally deficient. During the biennium ending June 30, 1938, 1,740 individual cases were ex- amined. For the satisfactory completion of these examinations it was neces- sary for the clinicians to interview many people familiar with the patient, to investigate the patient's home, school, or institutional environment, and to prepare written reports on each case. The intelligence quotients of those in this group varied from less than 20 for 28 children, to 140 for one child. The largest group, 1,319, or 75.8 per cent, had quotients lower than 80, and 1,527, Public Health Administration in North Carolina 131 or 87.7 per cent, had quotients of 90 or less, indicating varying degrees of feeblemindedness. The examinations made disclosed cases of epilepsy, psy- choses, sexual disturbances, and behavior problems. It is of interest to note that the demands for clinical services in this field were far greater than the limited staif of this division was able to render, and that referrals during the period 1936-38 in the order of frequency, were made by the following agencies : 1. Child welfare assistance 489 2. State departments and institutions 409 3. School superintendents 315 4. County superintendents of welfare 275 5. Orphanages 148 6. Miscellaneous 48 7. City welfare departments 42 8. Probation officers 8 9. County health officers 6 f ) The Division of Institutions and Corrections. — The staff of this division consists of a director, a field agent, a consultant on intake and discharge to and from the four state correctional institutions, three institutional case workers, and one statistical clerk and secretary. The State Board, through this Division, discharges its legal responsibility of inspecting and supervising the whole system of charitable and penal in- stitutions of the State. Each of the State institutions has its own board of trustees or directors, and the supervision exercised by the State Board involves making inspec- tions and recommendations, investigations of complaints, and assistance in planning programs and establishing policies. On June 30, 1938, these State and county supported charitable, correc- tional, and penal institutions had a total population of 23,805 inmates — a population larger than that of any one of fifty counties of the State. Of these, 12,258, or more than 50 per cent, were confined in State and county penal and correctional institutions. In the three State mental hospitals and the school for the feebleminded there were 7,347 inmates ; in the 82 county homes, 2,- 788; in State and county tuberculosis sanatoria, 1,211; in the State Ortho- pedic Hospital, 158; and in the State Homes for the Confederate Aged, 43 inmates. (See Appendix, Table No. 7). Other duties of the Division are: "to assist in the coordination of commun- ity and institutional efforts in the care and treatment of delinquent children by encouraging the development and use of local provisions for such chil- dren — reserving institutional care only for those children who cannot be handled successfully otherwise — and by promoting better supervision of delin- quent children conditionally released from State institutions; to cooperate with the Federal Bureau of Prisons and the prison organization of the various states in securing social data in regard to prisoners whose residence or whose families are in North Carolina; to conduct pertinent research and act as a clearing house for State and county institutional statistics and in- formation; to publish and distribute State institutional biennial reports in cooperation with State institutions; and other services which the Division may be called upon to render." ]32 Public Health Administration in North Carolina The services of the staff members of the State mental hospitals have been confined almost entirely within the institutions. None of these hospitals is rendering mental hygiene services or has established an outpatient service providing diagnostic and treatment clinics to serve their respective communi- ties. Aside from the clinical activities of the Division of Mental Hygiene, previously mentioned, services to the public in the field of mental health ap- pear to have been limited to those undertaken by the psychiatric service at Duke Hospital, by the psychologist at the Caswell Training School, and by a few private psychiatrists. g) Service Units of the State Board. — The four service units of the State Board do not have the status of divisions, but work in close cooperation with State divisions and county welfare departments. The two units dealing with the selection and certification of applicants for Civilian Conservation Corps and with surplus commodity distribution, respectively, have been organized and are now operating on a statewide basis. With reference to the county organization unit, welfare departments have now been established in each of the hundred counties, and the Director of County Organization is con- cerned with raising the standards to be met by the county superintendents and other members of the county welfare staffs; with improving State and county relationships; with securing the active interest of the county wel- fare boards; with the establishment of working relationships with county commissioners; and with enlisting the cooperation and support of social and civic groups in the interpretation and promotion of the welfare program. The consultant and field agent for work among Negroes serves all agencies that touch the life of the Negro. His duties are: (1) consultation on matters pertaining to welfare work among Negroes; (2) placement of Negro social workers; and (3) planning and conducting annual welfare institutes for Negro social workers. 2. The Commission for the Blind and Schools for the Deaf and Blind. — Through enactment of Chapter 53 of the public laws of 1935, there was created the North Carolina Commission for the Blind. This Commission was composed of three unpaid members appointed by the Governor for a term of five years, and two ex-officio members — the Superintendent of the State School for the Blind and State Supervisor of Vocational Rehabilitation. The duties of the Commission v/ere: 1. To maintain a complete register of the blind in North Carolina, in- cluding a description of the condition, cause of blindness, capacity for education, and industrial training, and other pertinent infor- mation. 2. To maintain bureaus of information and industrial aid to assist the blind in finding employment and to teach them trades and occupa- tions to be followed in their own homes and to assist in disposing of products of their home industry. 3. To provide training schools and workshops for the employment of suitable blind persons; to pay fair wages to blind woi'kers; to de- vise means for the sale and distribution of products; and to provide lodging, tuition, support, and all necessary expenses for blind per- sons during their training or instruction in any suitable occupation, either within or without the State, as deemed advisable. 4. To make inquiries concerning the cause of blindness, to determine Public Health Administration in North Carolina 133 what proportion of cases is preventable; and to provide free exam- inations and medical or surgical treatment for the blind whenever a qualified ophthalmologist considers that such person can be benefited thereby. In 1937 the above-mentioned law was amended to enable the State to parti- cipate in the Federal Social Security Plan for aid to the blind. This amend- ment increased the membership of the Commission for the Blind to eleven; six members to be appointed by the Governor for terms of five years; and five ex-officio members, consisting, in addition to the two named above of the Secretary of the State Board of Health, the Director of the State Employ- ment Service, and the State Commissioner of Public Welfare. All members of the Commission serve without pay, but a paid executive secretary is pro- vided for. This amendment (Chapter 124, laws of 1937) charged the Com- mission for the Blind with responsibility for the supervision of the adminis- tration of assistance to the needy blind in addition to those duties imposed in Chapter 53 of 1935, as enumerated above. The law prescribes the specific conditions under which State residents shall be eligible for relief to the needy blind; limits the amount of relief to a maxi- mum of $30 per month for each individual; and directs the Commission to make all rules and regulations necessary for carrying out the provisions of the Act. The program, including all social case work, is administered locally by the county welfare departments, which serve as the local agents of the boards of county commissioners and the State Commission for the Blind. Funds for the administration of sections of the 1935 law are provided en- tirely by the State, while funds for aid to the needy blind (Chapter 124 of 1937) are derived in the proportion of half from Federal funds, one-fourth from State funds, and one-fourth from county funds. During the fiscal year 1937-38, the State spent $43,370 under the provisions of the 1935 law, and, under the social security program of aid to the needy blind, there was a total expenditure of $287,084.15. Of the latter amount, $17,317.85 was expended for administration. In the promotion of its training and rehabilitation work, the Commission has cooperated closely with official and private agencies, both of which are rendering most praiseworthy assistance. During the biennium ending June 30, 1938, a total of 6,505 indigent persons were examined by ophthalmologists. Of these, 2,180 were not amenable to treatment, 919 were recommended for operation, and 222 for treatment. Through treatment, 344 persons were eli- minated from the classification of blindness. The State law i-equires that every blind and deaf child of sound mind in North Carolina shall attend a school for the blind or deaf for a tei'm of nine months each year between the ages of seven and eighteen years. Responsibil- ity for placing such children in schools for the blind or deaf is placed upon parents, guardians, or custodians of these children. To provide adequate and proper training for white and colored blind and deaf children the State maintains a school for white deaf children at Mor- ganton, and the State School for the Blind and Deaf at Raleigh. The latter has a department for white blind children in west Raleigh, and a department for colored blind and deaf children in east Raleigh. These institutions are 134 Public Health Administration in North Carolina under their own boards of directors and operate standard schools through the high school courses. In addition, pupils are given special training in such types of work as they are capable of undertaking. During the year 1937-38 the School at Raleigh enrolled 208 pupils in the white department, and in the colored departments, 88 blind and 100 deaf pupils. b. County Welfare Organizations 1) Connty Welfare Departments. — A state law was passed in 1919, re- quiring the State Board of Charities and Public Welfare to appoint in each county three persons to be known as the county board of charities and public welfare. One board member was appointed each year for a term of three years, and members served without pay. County superintendents of welfare were elected in every county for a term of two years by the county board of education and the county board of commissioners. The superintendent's sal- ary was fixed by these two boards. In any county with less than 32,000 pop- ulation, where the county commissioners did not care to take part in the election of the county superintendent, the county superintendent of public instruction became, ex officio, county superintendent of public welfare, but without additional remuneration. The provisions of the 1919 Act continued in force until 1937, when the General Assembly amended the law. Under the provisions of the revised law, the county boards of charities and public welfare consist of three unpaid members, one appointed by the board of county commissioners, one by the State Board of Charities and Public Welfare, and one selected by such two appointed members. Each member is appointed for a term of three years and the term of service of one member expires annually. No one is eligible to succeed himself after two successive terms as a board member. Each county board is required to meet at least once a month with the county superintend- ent of welfare and to advise him in regard to problems pertaining to his office. The 1937 law makes it mandatory that each county, regardless of size or population, shall have a county superintendent of welfare. The superintend- ent, who must be approved by the State Board of Charities and Public Wel- fare, is appointed by the county board of welfare and the board of county commissioners in joint session, and serves on a full-time basis. After appoint- ment, and approval by the State Board of Charities and Public Welfai'e, the superintendent becomes the executive officer and secretary of the county board. Although not retroactive for superintendents in service prior to April, 1936, minimum qualifications for these officials have been established by the State Board of Charities and Public Welfare. Under the law, the superintendent "shall be qualified by character, fitness, and experience to discharge the duties thereof." Provision is made whereby the governing bodies of cities may arrange with the county commissioners for joint city and county welfare work with such division of expenses as may be mutually agreed upon. The duties of the county board of welfare and of the county superintendent, as defined by law, are many and varied. No legal provision is made as to the number of assistants a county superintendent of welfare is to have. As a Public Health Administration in North Carolina 135 rule, each superintendent has a clerical assistant, many have one caseworker or more, and in several counties there is a child welfare worker. 2) County Poor Relief. — The board of commissioners of each county is au- thorized by law to provide by taxation for the maintenance of the poor, and to do everything expedient for their comfort and well ordering. The commis- sioners may employ biennially a competent person as superintendent of the county home for the aged and infirm and, "all persons who become charge- able to any county shall be maintained at the county home for the aged and infirm, or at such place or places as the board of commissioners select or agree upon. The commissioners of each county are authorized also to con- tract for a period not to exceed thirty years with public or private hospitals or institutions located within or without the county for the treatment and hos- pitalization of the sick and afflicted poor of the county upon such terms and conditions as may be agreed; provided the annual payments required under such contract shall not exceed $10,000. Such a contract is valid and binding without the approval of a majority of the qualified voters of the county. Within recent years the State Board of Charities and Public Welfare has endeavored to promote the establishment of district hospital homes to replace ordinary county homes, and legal authority has been given for the establish- ment of such homes by any two or more adjacent counties. During the bi- ennium ending June 30, 1938, four county homes were closed, leaving eighty- two such homes still in operation. In February, 1938, there were 2,911 in- mates in the 82 county homes of the State. Of these, 3.2 per cent were chil- dren under 16 years of age; 53 per cent were persons between 16 and 65 years of age; and 43.8 per cent were over 65 years of age. A survey of these in- stitutions indicates that 1,860, or 64 per cent, of the 2911 inmates, are likely eligible for some form of assistance through the Federal social security pro- gram for old age assistance, aid to dependent children, or aid to the blind. The remaining 1,051, or 36 per cent, are so incapacitated physically or men- tally as to require institutional care. It is one of the legal duties of the State Board of Chai'ities and Public Wel- fare to have plans for district hospital homes prepared and to furnish these at cost on request to any board of trustees of a district hospital home. More- over, all such homes must be built in accordance with plans furnished or ap- proved by the State Board. 7. Agricultural Services In a State like North Carolina, where about 75 per cent of the population is rural, and over 50 per cent actually live on farms, agriculture looms large in the lives of the people. The importance of efficient production and distribu- tion to the welfare of those engaged in agriculture, and indeed to the entire population, has long been recognized by the State. In furtherance of the benefits of education in agriculture, the Constitution provides for a Commis- sioner of Agriculture, and requires that the General Assembly "establish and maintain, in connection with the University, a Department of Agri- culture, ..." a. The Department of Agriculture. — The North Carolina Depai'tment of Agriculture is under the control of the Commissioner of Agriculture, "with 136 Public Health Administration in North Carolina the consent and advice of the Board of Agricultui'e." The Commissioner is elected by popular vote for a term of four years. The Board of Agriculture consists of the Commissioner, who is, ex officio, member and chairman there- of, and ten members from the state at large. The latter are appointed by the Governor, by and with the consent of the Senate, for terms of six years. Ap- pointments are so arranged that at the end of two-year periods the terms of either three or four members expire. The functions of the Board of Agricul- ture (Chapter 174 of 1925) are strictly legislative and advisory, while all executive power in the Department is vested in the Commissioner. Within the Department there are fifteen divisions, each rendering important ser- vices to the farmers of the State. These services include: inspections, quaran- tines, and other regulatory and law enforcement work in connection with plant pests, insects aff"ecting man and animals, and bee diseases; cooperative marketing; financial loans; the dissemination of information; the control of animal diseases; the analysis of feeds and fertilizers; the accurate labeling of seeds; the administration of the pure food laws and the sanitary inspec- tion of bottling plants, creameries, ice cream plants, cheese factories, and bakeries; the testing of the cream content of milk, and the testing of scales and balancers used in weighing milk; and the maintenance of test farms. The Department of Agriculture operates on its own receipts from a tax on fertilizers, the sale of serum, proceeds from test farms, inspection services, etc. The receipts for 1937-38 amounted to $453,286 which, with a balance of $318,865 from the previous year, gave a total of $772,151 available. The ex- penditures for 1937-38 amounted to $459,849. While the activities of this Department are principally concerned with the promotional aspects of agriculture, several phases of the work have a definite relation to public health. These relate to such matters as the control of animal diseases, including bovine tuberculosis, Bang's Disease, rabies, etc., and the administration of the pure food laws and sanitary inspections. Work to promote the produc^^ion and use of adequate supplies of the foods essen- tial to the health of human beings is left largely to the extension service of the State College of Agriculture. The Department, however, has succeeded in practically eliminating bovine tuberculosis from the State. In 1934 work for the control of Bang's Disease was inaugurated in cooperation with the Federal Government. After introducing the work throughout the counties of the State during the course of about three years, more intensive operations, on the area plan, were commenced in 1937. Whereas, originally the Federal Government financed most of the cost of this work, including indemnities, out- lays for the latter purpose are now being shared by the State on a 50-50 basis. b. Agricultural Exteusion Work. — The following excerpt from the 1937 report of the extension division of the State College succinctly describes this service: "The State College Agricultural Service, supported by Federal, State, and county appropriations, is an organization dedicated to the up- building of rural North Carolina. It is a part of the State College, and is the North Carolina branch of the nation-wide Extension Service of the United States Department of Agriculture. In addition to the regular extension personnel, a number of specialists Public Health Administration in North Carolina 137 and county farm agents are employed cooperatively by the Extension Service, the Tennessee Valley Authority, and the Soil Conservation Service to promote work which the Extension Service is doing in cooperation with these agencies. There are 36 white men and 9 white women specialists who have been given intensive ti-aining in their respective fields of work, which incluue farm management, agricultural engineering, agronomy, dairying, beef cattle, swine, sheep, cotton, tobacco, insect and disease control, 4-H clubs, foods and nutrition, marketing, clothing, home management, and the like. A district faim agent and a district home agent supervise extension work with white people in each of the five extension districts. There is also a white home agent-at-large. Extension work with Negroes is super- vised by a State agent, a district farm agent and a district home agent, a subject matter specialist, and a 4-H club leader. Many of the white extension workers give part of their time to the program for Negroes. The Extension Service was selected by the Federal Government to ad- minister the Agricultural Adjustment Administration programs in ci'op control and in agricultural conservation. State AAA headquarters are maintained at the College whei'e the officials in charge work closely with the extension leaders. The program is administered locally through the white farm agents and county committees elected by the fai"mers. The publication department distributes news stories, pictures, and other information designed to acquaint the public with what the Extension Service is doing to convey definite information of value to rural people. It also edits, publishes, and distributes agricultural and home demonstra- tion bulletins prepared by staff members of the Extension Service and Experiment Station. The Extension Service cooperates with the North Carolina Agricultural Experiment Station, the Tennessee Valley Authoiity, the Soil Conserva- tion Service, the Farm Security Administration, the Rural Electrification Administration, the National Youth Administration, the State Depart- ment of Agriculture, vocational agricultural teachers, and other agricul- tural agencies." The projects conducted by the Extension Service in 1938 were carried out locally by 100 white county farm agents and 82 assistant agents serv- ing in the 100 counties of the State; by 82 white home agents and two assistants in 82 counties; and by 28 Negro farm agents serving 30 coun- ties and 15 Negro home agents in 15 counties. In addition to the economic improvement that results from this work among the farm population, the demonstrations and training in foods and nutrition, home management, dairying, clothing, etc., among members of adult and 4-H clubs are bound to exert a powerful influence upon the health of these farming communi- ties. The growing recognition by these groups of the importance of health in these rural communities is reflected by the increase in the number of counties carrying foods and nutrition as their major project, and by the highly competitive county, district, and state health contests conducted annually by the 4-H clubs. The former program aims to have an ade- 138 Public Health Administration in North Carolina quate supply and variety of food for the family produced on every farm; to have every member of the family practicing good food selection habits and free from ailments indicating faulty diet; and to have meals well prepared and planned to meet body needs. 8. Medical, Dental, and Public Health Associations a. The Medical Society of the State of North Carolina. — This Society was organized on April 16, 1800. The Society is governed by a constitu- tion and by-laws, and by the principles of medical ethics established by the American Medical Association. Those district and county medical societies which hold charters from the State organization are component societies, and the combined membership of these component societies con- stitutes the membership of the State Society. The total number of mem- bers as recorded in the transactions of the Society was 1,585, for 1938. Legal responsibility for granting licenses to practice in the State is vested in the State Board of Medical Examiners. This Board consists of seven members, elected by the State Society for a period of six years. The Medical Licensure and Practice Law defines the term practicing, and sets forth the conditions under which the examining board may grant or re- fuse to grant license to practice in the State. The total number of physicians in North Carolina, as listed in the American Medical Directory for 1938, was 2,663. On the basis of the 1930 population (3,170,276) this would represent an average of one physi- cian to 1,190 persons. The concentration of physicians in urban areas, however, has resulted in a marked variation in the proportion of physicians to population in urban and rural areas. In some communities the average is one physician to about 500 population, while in others there is one physician to 1,200 to 3,000, or more of population. As to the relationships between the medical profession and the State and local health authorities in North Carolina, it may be recalled here that it was through the initiative of prominent physicians of the State that the original State Board of Health was organized. For several years the State Medical Society was the State Board of Health, and even now, the Society is legally authorized to appoint from its membership four of the Board members. Moreover, the State Board of Health is required by law (C.S. 7055) to hold its regular annual meeting at the same time and place as the State Medical Society, at which time the Secretary shall submit his annual report. Undoubtedly, these relationships have served to insure a clear understanding between the profession and the health executives, and to preserve a tradition of mutual co-operation in matters of common concern. b. The North Carolina Dental Society. — This Society was organized on October 16, 1856, its membership being limited to the alumni of dental colleges practicing in the State. Annual meetings of the Society were held until the outbreak of the Civil War in 1861, and the Society was not reorganized until 1875. The Society is governed by a constitution and by- laws adopted in 1935, and a code of ethics adopted in 1928. It is a constituent society of the American Dental Association, and, at present. Public Health Administration in North Carolina 139 has 585 active members on its roll. As to the total number of dentists in North Carolina, the report of the Secretary of the State Dental Exam- ining Board gave 831 as having paid renewal license up to February 1st for the year 1938. The North Carolina Board of Dental Examiners is the legal agency of the state for the regulation of the practice of dentistry. The Board con- sists of six members of the North Carolina Dental Society, elected by the Society and commissioned by the Governor for a period of three years. No person may engage in the practice of dentistry in the State without first having obtained a license for the purpose from the Board of Dental Exam- iners, or without first having obtained from the Board a certificate of re- newal of license for each calendar year. In their effort to introduce pre- ventive dentistry into the public schools and certain other State institu- tions, the State Board of Health has had the enthusiastic support of the Sate Dental Society, and at present there is scarcely a practicing dentist in the State who opposes the program now being carried out by the State Division of Oral Hygiene. c. The North Carolina Health Officers Association. — This Association was organized on June 20, 1911, the stated purpose being: ". . . to bring into one organization the public health officers of the State of North Caro- lina so that by regular meetings and interchange of ideas they may secure more efficient cooperation, and uniform enforcement of sanitary laws and regulations, and for the better dissemination of such knowledge as will make more efficient the opinions of the profession in all scientific, legisla- tive, public health, material and social aff"airs." Eligible for membership are any public health officers in the State who ai'e in good moral and pro- fessional standing, and all members and employees of Boards of Health, either State, county, or municipal. About ten years ago the name of the Association was changed to: The North Carolina Public Health Associa- tion, and minor changes were made in the constitution and by-laws. An- nual meetings are held at the same time and place as those of the State Medical Society. 9. Hospital Administration Legal provision is made for a county, township, or town to establish a public hospital. A petition signed by 200 resident freeholders is presented to the governing body, asking that an annual tax be levied for the estab- lishment and maintenance of a public hospital and specifying the maxi- mum amount of money proposed to be expended in purchasing or building the hospital. The governing body submits the question to the qualified electors at the next general election or at a special election. The tax to be levied under such election shall not exceed 1/15 of one cent on the dollar for a period not to exceed 30 years and shall be for the issuance of bonds to provide funds for the purchase of a site and the erection of hospital buildings. The governing body submits to the electors at a regular or special election the question whether a tax of 1/15 of one cent on the dollar shall be levied upon the assessed property for the purchase of real estate for hospital purposes, for the construction of hospital buildings, and for 140 Public Health Administration in North Carolina their maintenance, or for either or all of such purposes. If the majority of the voters favor such a tax, the governing body levies the tax, collects it as other taxes are collected, credits the revenue received to the "hospi- tal fund" which shall be paid out on the order of the hospital trustees. If the majority of voters are in favor of the establishment of a hospital, the governing body appoints a hospital board of trustees consisting of 7 members — three of whom may be women — chosen from local citizens at lai'ge, who hold office until the next general election. Trustees then are selected by popular vote, provision being made whereby the terms of two members expire every two years. Practicing physicians are not eligible to become members of the board. Trustees are entitled to reimbursement only for cash expenditures made for personal expenses incurred as trustees. They are authorized to make and adopt by-laws and rules and regulations for their own guidance, and for the government of the hospital. They control all expenditures and are authorized to appoint, fix the compensa- tion of, and remove, the hospital employees. Meetings are held at least once a month and records arc kept of proceedings. Four members con- stitute a quorum. One trustee must visit and examine the hospital at least twice a month. Annual reports are to be made to the governing- body. Trustees are denied pecuniary interests in purchase of supplies unless there is competitive bidding. Vacancies are filled by the governing- body. All money received is deposited in the official treasury to the credit of the hospital fund and paid out upon warrants of the auditor when authenticated by vouchers of the board. Provision is made for the issu- ance of bonds. Plans and specifications for hospitals must be adopted by trustees and bids advertised according to law. Provision is made for the govei-ning body to appropriate each year additional funds for the im- provement and maintenance of the hospital. The trustees have power to accept donations. The benefits of the hospital are for the inhabitants and those stricken sick and injured in the hospital jurisdiction, but all except paupers shall pay for services and conduct themselves in accordance with regulations prescribed by the trustees; these benefits may be extended to non-residents by the board. All persons (physicians, nurses, attendants, patients, etc.) and all articles used or brought to the hospital are subject to the regulations prescribed by the board. A municipal hospital juris- diction is specified. The conditions and privileges of physicians and nurses to practice in public hospitals are determined by the board. A training school for nurses may be established and maintained. For hospitals at the county seat, a room for the examination of the insane is to be pro- vided. The board passes upon charity patients and fixes the compensa- tion to be paid by other patients. Plans must be approved by the State Board of Health before a county or town sanatorium or a tuberculosis in- stitution can be established. The local governing body may contract with the board of trustees for the hospitalization in the sanatorium department of indigent tuberculous residents. The hospital number of the Journal of the American Medical Associa- tion (March 11, 1939) states that in 1938 North Carolina had a total of Public Health Administration in North Carolina 141 157 hospitals with 17,647 beds. There were 113 general hospitals with 6,842 beds. The percentage of beds occupied in these during 1938 was 63.3, and eight hospitals were approved by the Council on Medical Educa- tion and Hospitals for general internship. The following tables classify the hospitals in the state by ownership and by service: O WNERSHIP CLA SSIFICA TION Government Hospitals Number Beds Total Number Total Beds Federal 4 1,010 State 9 8,451 County 12 785 City 3 380 City-County 6 239 34 10,865 Non-profit Hospitals Number Beds Total Number Total Beds Church 15 1.056 Fraternal 1 20 Non-profit corporations 71 4,348 87 5,424 ProprietaiT 36 1,358 36 1,358 GRAND TOTAL 157 17,647 SERVICE CLASSIFICATIONS Description Number Beds General hospitals 113 6,842 Nervous and mental diseases 9 7,814 Tuberculosis 20 2,409 Maternity 1 45 Industrial 1 50 Eve, nose, and throat 3 62 Children's 4 155 Orthopedic 1 160 Hospital Departments of Institutions 3 75 Convalescent and rest 2 35 Total 157 17,647 10. References 1. Annual Report of Agricultural Extension Work in N. C, 1937 2. Biennial Reports of the State Board of Health. 3. Biennial Reports of the State Department of Agriculture. 4. Biennial Reports of the State Board of Charities and Public Welfare. 5. Connor, R. D. W. 6. Hobbs, S. H., Jr. -I. O. Schaub, Director, State Col- lege Station, Raleigh, North Caro- lina. -Race Elements in the white popu- lation of North Carolina. N. C. State Noi-mal and Industrial Col- lege. Historical Publications, Nos. 1-3. -North Carolina Economic and So- cial, Chapel Hill: U. N. C. press. 142 Public Health Administration in North Carolina 7. Hubbard, E. C. 8. North Carolina Manual 9. N. C. Today and Tomorrow 10. Report on a Survey of the Or- ganization and Administration of the State of N. C. 11. The Budget 12. Wager, Paul Woodford, Ph.D. -"Scoring Shellfish Shucking Houses" — paper read at Southern Medical Association Meeting at Oklahoma City, November, 1938. -1929-1937. -N. C. Department of Conservation and Development. R. Bruce Ether- idge. Director. -The Institute for Government Re- search of the Brookings Institu- tion, Washington, D. C. 1930. -State of North Carolina, for the Biennium 1939-1941. -County Government and Adminis- tration in N. C: Chapel Hill: U. N. C. press, 1928. PART 11 RECOMMENDATIONS WITH COMMENTS A. INTRODUCTION Part I of this study embodies an exposition of the present State and local health organizations of North Carolina. For purposes of orientation there have been included also: (1) a description of the State; (2) an analysis of population and fiscal data; and (3) a brief exposition of State and local governments, of closely interrelated government departments, of the plan for local government hospitals, and of the medical and dental associations. Part I is prerequisite to Part II which treats with recom- mendations. In raising questions affecting the present State and county health organizations of North Carolina, the view is taken that modifications, which may be projected as a result, should not be introduced with such haste as to disrupt the advantages of continuity of program but should be effected as appropriate mutations in the normal evolutionary growth of the health organization, due consideration being given to expediency. A clear understanding of this viewpoint makes possible the inclusion of recommendations that would be controversial in character if revolutionary changes were contemplated without regard to contraindications presented by existing circumstances. Furthermore, the fundamental principles, a number of which are in conformity with existing practices and trends in North Carolina, are enumerated for the purpose of establishing basic reasons for certain recommendations presented hereafter and of setting forth guide posts which the State Health Officer may care to consider in the future development, in general, of his public health program: 1. That the employment of trained, whole-time personnel under conditions which permit the optimum utilization of their talents is indispensable to the efficient functioning of an organization; 2. That the full success of a public health organization is dependent upon the functional integration of its component parts — subdivisions of the State Health Department and the several local health units — as well as upon integration with allied govern- ment departments, such as education, welfare, and agriculture, so as to effect team work or co-ordinated effort in the attainment of objectives directly and indirectly concerned with the realization of the aims of the health department. 3. That primary emphasis, in the preparation of public health programs, be given to the solution of problems which are vulner- able to proved methods of attack. 4. That all non-government agencies, including physicians, dentists, and voluntary health organizations, which can partici- pate advantageously in the attainment of health objectives be given the opportunity to render their several services in order that duplication of effort may be minimized, extra departmental facilities fully utilized, and harmonious relationships promoted. 5. That the professional staffs of governmentj institutions which are in a position to contribute to the cause of public health, cooperate with public health field workers in conducting preventive 144 Public Health Administration in North Carolina programs in order that the need of institutionalization of such patients may be reduced to a minimum as speedily as possible. 6. That the consolidation of related functions within the State Health Department should be provided for under a limited number of bureaus or divisions in order to reduce overhead administrative cost, to effect a greater degree of coherence, and to utilize funds saved thereby for the buildling up of the technical staffs of these divisions. 7. That the specialization of sei'vices within the State Depart- ment of Health be organized on an inter-divisional rather than an intra-divisional basis. 8. That primary responsibilities of the State Health Depart- ment and of the rural health departments are the development of specialized and generalized services, respectively, and that the policy of administrative interrelationship should be such that the generalized facilities of the rural health unit are complemented by the specialized services of the State in the execution of well- rounded local programs. 9. That legislative provisions relating to the duties of health administrators be expressed in broad terms, and that amplifi- cation be left to boards of health acting under regulatory powers delegated to them, due consideration being given by both legisla- tive agencies to the need for latitude in the exercise of initiative, training, and experience on the part of trained health workers in the accomplishment of desirable health objectives. B. RECOMMENDATIONS 1. Recommendations Pertaining to Boards of Health a. That the laws governing local health jurisdiction be amended to provide for: 1) County boards of health consisting of the three ex-officio members as now provided for, and, in addition, of four elective members, comprising one physician, one dentist, and two pub- lic-spirited county residents, each elected for a term of four years. 2) Reasonable compensation for county board members when on actual duty. 3) The filling of vacancies occurring among the elected mem- bers of county boards. 4) The designation of the county health officer as the executive officer of the board, and 5) The creation of district boards of health, and the abolition of the several county boards of health of all counties that con- solidate to establish a health district. b. That a section be included in the Public Health Operating Manual devoted to administrative policies and procedures of State, county, and district boards of health. Comments on A The present law provides for a board of health in each county con- sisting of six members. The three ex-officio members — the chairman of the board of county commissioners, the mayor of the county seat or the clerk of the superior court, and the county superintendent of schools — elect the three other members (two physicians and a dentist) for a term of two yeai-s. If the provisions of the recommendations were put into effect, the elective members on the board would be in the majority, and the possibility of tie votes would be eliminated. Moreover, should the elective members Public Health Administration in North Carolina 145 be chosen on a rotating basis for a term of four years, as suggested, these members of the board would not be subject to a turn-over every two years and their services should be of greater value to the health department because of the additional experience each member would acquire. Further- more, the term of office of the elective members of county boards of health would then conform to the tenure of office of members of the State Board of Health. The current legal requirement that the elected members of each county board of health shall comprise two physicians and one dentist seems to have been predicated upon the assumption that specific qualifications are desirable, with particular emphasis being placed on medicine and dentistry. At the time this law was passed (1911), the state department of health had not reached its present stage of development nor had any of the counties employed full-time trained health officers. County boards of health, with the assistance of county physicians and quarantine officers, were responsible for such local public health activities as were undertaken. Under these circumstances board members with a professional back- ground were desirable in order to enable the Board to exercise com- petent judgment in technical matters. With the guidance in specialized fields now provided by the State Board of Health through the employ- ment of specialists on the staffs of its divisions, and with the employ- ment of full-time trained and experienced local health officers, the need for professional representation on county boards of health has been reduced. The board, possessing legal powers for controlling its operating- staff with respect to the establishment of policies and public health admin- istrative matters in general, should now function essentially as a proxy for the people, to the end that the public may place responsibility on a small group of representative, public-spirited citizens for looking after the public interests in the field of health, for providing adequate public funds and employing competent personnel, for assisting and facilitating the efforts of the operating staff in the formulation and execution of a suitable health program, and for evaluating the performance of the paid personnel of the local health department. To provide a board to fulfill these requirements, and to avoid the loss of services of some of the leading citizens on the local board of health, the legal qualifications for member- ship on the board might well be broadened to include, in addition to one physician and one dentist, two public-spirited local residents who have real interest in, and knowledge of, public affairs. No legal authorization for the compensation of board members for the services they render now exists, nor is there any specific provision for filling vacancies occurring among elected members. When the law is amended, therefore, these items should be included. The relationship of the county health officer to the county board of health in the existing law is not specified. The recommendation made in this respect is designed to clarify the law and to provide that the i-esponsi- bility of the county health officer to the local board of health be placed 146 Public Health Administration in North Carolina more in alignment with that of the State Health Officer to the State Board of Health. Under the present law, each county constituting a part of a health district has a board of health to which the local health officer is responsible and with which he has to work. No single official board legally responsible for health matters throughout the district is provided for, hence in order to eliminate this divided responsibility, to conserve the health officer's time, and to unify operations and provide uniform legislation for the district, it is recommended that all boards of health of counties forming a district be abolished and replaced by a single district board of health. The jurisdiction of the district board would be over all counties and political subdivisions that unite to comprise the health district. It would exercise over the district the powers and duties that are now delegated, or may be delegated in the future, by State laws and State Board of Health regulations to county boards of health. We suggest that the mem- bership of the board would consist of three ex-officio and four elected members. The ex-officio members could be a county commissioner, a super- intendent of schools, and a mayor of one of the county towns, and might be chosen in one of two ways: (1) the county commissioners would meet jointly to select any county commissioner in the district as their repre- sentative on the board; the mayors of the county towns would meet jointly to select a member from among their number to represent them on the board; and the county superintendents of schools would convene to select a board representative from among them; or (2) should any or all of these groups fail to meet and appoint their representatives as indi- cated, the State Health Officer would be empowered to make the appoint- ments. With respect to the elected members of the boai'd, the following pro- visions might be made: 1. Four members would be elected by the ex-officio members. 2. Any public-spirited resident of the district would be eligible for membership, except that one member would be a physician and one a dentist, and due consideration would be given to geo- graphical representation within the district. Furthermore, this proposed legislation should specify the term of office of elected members, the manner in which the board is to be organized, the frequency and method of calling meetings, the constitution of a quorum, how vacancies are to be filled, how and in what amount, members are to be remunerated for services rendered, and all other matters germaine to the effective functioning of the district board. Comments on B In North Carolina legal provision is made for 100 county boards of health in addition to the State Board of Health, comprising a total mem- bership of 609 persons, of whom 206 are physicians, 200 are prominent government executives, 100 are county superintendents of schools, 101 are dentists, one is an engineer, and one a pharmacist. To bring into full Public Health Administration in North Carolina 147 realization the vital services these citizens are in a strategic position to contribute to the cause of public health is a major administrative problem. Hence, for the purpose of taking an advanced step in this direction the recommendation is made that a section be included in the proposed public health operating manual (See Recommendation 18), devoted to an expo- sition of the role these boards should play. The subject matter presented should include directions for planning and conducting local board meetings and for carrying on a continuous health educational program in behalf of board members so as to facilitate their efforts to be informed regarding health developments in the State. The dii-ections should specify that there be an executive session and an open session at which the presence of the staff as well as interested citizens are welcome, and they should include an enumeration of the responsibilities and duties of these boards. With reference to county, and proposed district, boards, agenda should be mailed to members in advance of meetings to give them an opportunity to famil- iarize themselves with the subject matter to be dealt with, and it is believed advisable also that delegates of each local board should be encour- aged to attend the annual conference of State and local health officers. Apart from the stimulating effect the latter provision should have, this intermingling should bring out the fact that local departments of health are component parts of a large organization which should work closely together under the leadership of the State Board of Health in the attain- ment of common objectives. Furthermore, for suggestive value to those who may be called upon to prepare this section of the manual, the following views are being listed covering our conception of what the responsibilities and functions of boards of health should be: (1) that the official health organization of North Carolina is composed of State and local subdivisions of government, integrated functionally, and that the State and county counterparts are subdivided into (a) a board of conti'ol with certain regulatory powers, and (b) a department with executive functions; (2) that the boards in their respective spheres of influence represent the general public in matters pertaining to official public health administration, thererby (a) reflecting the attitudes of the general public towards health administrative procedures for the guidance of health executives in the discharge of responsibilities centered in them as trained health admin- istrators for the formulation and execution of effective programs; (b) accepting public responsibility for lending support to health executives in building up and maintaining adequate State and local health depart- ments; (c) accepting public responsibility for protecting State and local health departments in the efficient performance of their duties in the interests of the public as a whole from interference on the part of special interest groups; (d) passing upon the administrative policies and practices of the State and local health departments; (3) that the boards consider and pass upon, at least biennially, health programs projected by health executives and take such steps as may be necessary to evaluate the progress being made in the accomplishment of health objectives; (4) that 148 Public Health Administration in North Carolina the boards review and pass upon budget estimates; (5) that the boards keep written records of their proceedings and of action taken at meetings held; (6) that the boards exercise regulatory powers through the enact- ment of rules and regulations; and (7) that the boards approve eligibility standards for the employment of health personnel, adopt policies per- taining to the conditions of employment and the administration of health personnel, and vouchsafe continuous tenure of office of employees during efficient performance of duty. 2. Recommendations Pertaining to State and Local Health Departments a. That the operating staffs of boards of health be termed: 1. The State Health Department 2. The County Health Department 3. The District Health Department b. That the State Health Department be reorganized into the following subdivisions: 1) Office of Administration a) The Division of Central Administration (1) The Section of Business Management (a) Employment and administration of personnel (b) Financial management (c) Filing seivice (d) Legal Services (2) The Section of Public Health Education (3) The Section of Public Health Nursing b) The Division of Local Administration 2) Divisions of Technical Services a) Statistical Methods b) Epidemiology c) Laboratories d) Sanitary Engineering e) Preventive Medicine f) Industrial Hygiene g) Oral Hygiene 3) Cooperating Agencies a) School Health Service b) Nutrition Service c) Mental Hygiene Service d) Group Research Service Comment With reference to terminology, the suggestion here implies that the term "Health Department" be used to mean the operating staff of a board of health. In North Carolina the term is not used in the law, except in the case of district health departments. The staffs of county and district health departments are not differen- tiated into subdivisions because of their small size and the generalized nature of their work. The plan of organization presented for consideration here shows the State Health Department as divided into (1) Office of Administration, (2) Divisions of Technical Services, and (3) Cooperating Agencies. The Office of Administration is subdivided into two major Public Health Administration in North Carolina 149 divisions: (a) the Division of Central Administration and (b) the Division of Local Administration — the latter being a transfer and change of desig- nation of the present Division of County Health Work. In comparison with present arrangements, this plan, if adopted, would add to the Division of Central Administration a section of public health education and a section of public health nursing, and, to the Section of Business Manage- ment there would be added a subdivision of legal services. Seven divisions of technical services are listed and some of these, as shall be observed later, are broken down into subdivisions to provide a greater degree of specialization. Thus it may be seen that an attempt has been made to group the more generalized services, and those more intimately related administratively to the State Health Officer, under the Office of Admin- istration. The cooperating agencies consist of four services. One of these, school health service, is in the process of formation, and the other three are non-existent at present. Because the health department shares the responsi- bility for the development of these service agencies with other government departments, it is incorrect to consider them as wholly organized within the State Health Department. Since these services are, or are to be, organized in cooperation with other departments of the State Government, the facilities of the several depaitments participating can, it is believed, be more effectively integrated if such services are established and admin- istered as cooperating agencies. It is of the utmost importance that county and district health execu- tives, as well as the directors of the subdivisions of the State Health Department, and of cooperating service agencies, fully realize that the services they administer are integral parts of a large, coherent organization and that the welfare of the whole, as well as of its parts, necessitates horizontal administration, as distinguished fiom vertical administration, through official channels under the direction of the State Health Officer. 3. Recommendations Pertaining to State, County, and District Health Officers a. That the tenure of office of county and district health officers be established by law for at least a four-year term and that a mandatory retirement age be established. b. That county and district health officers, who fulfill qualifica- tion standards established by the State Board of Health and whose performance in the field merit the distinction, be appointed deputy state health officers. c. That county health officers be relieved of responsibilities in the field of therapeutic medicine, or that a whole-time medical assistant be employed on the stafl!" of the county health department to assume these responsibilities and other duties in the field of preventive medicine assigned to him by the health officer; and that the position of county physician be abolished in counties composing a district health jurisdiction and in lieu thereof one whole-time medical assistant, or more than one if necessary, be employed on the staff of the district health department to assume therapeutic responsibilities and other duties in the field of pre- ventive medicine assigned by the health officer. 150 Public Health Administration in North Carolina d. That the appointment of part-time county health officers be disallowed by law and in lieu thereof it be made mandatory for all counties to establish whole-time health departments, or to unite with neighboring counties to become a part of whole-time district health departments (see also Rec. 5, a). e. That the present duties and functions of the State and local health officers be modified, if need be, to enable them to perform the following services: 1) To select and dismiss subordinate personnel in accordance with provisions suggested in recommendation 4, d. 2) To exercise leadership in all matters pertaining to public health and to prepare, at least biennially, a projected health program (in case of the local health officer, with the counsel of the director of the Division of Local Administration) for the approval of their respective boards. 3) To direct the subordinate personnel of their respective de- partments in the execution of the approved program. 4) To execute with the aid of subordinate personnel, all laws and regulations applying to their respective jurisdictions. 5) To evaluate biennially, on the basis of accomplishments, the progress being made by the health department in the attain- ment of health objectives enumerated in the previously approved program for the biennium in question. Comments a. Tenure of Office and Retirement Age. The present tenure of office, as established by law is for a two-year term. It is recom- mended that the law be changed, to specify a term of at least four years. This provision would bring the tenure of local health officers in alignment with the term prescribed for the State Health Officer. As an alternative, the period of appointment might be made indefinite, at the pleasure of the appointive power. The basis of tenure should be competency, and provisions to protect the competent in office and to weed out the unfit with dispatch should be worked out. This view is in alignment with the belief that these should be career positions in order that able persons may be attracted to them. Sixty-five years is suggested as the age for retirement. A pro- viso might be made authorizing boards of health to extend the age of retirement to 70 in order that the public may not be denied the services of the exceptional health officer who retains full vigor of his faculties at the age of 65 years. The potential danger of such a pi"oviso is that it will be abused in practice through mis- placed human sympathy for a health officer who has passed his prime, whereas, the primary consideration should be what is best for the public. b. Deputy State Health Officer. Such an arrangement is suggested as a means to promote further integration between the state and local health executives. By virtue of his position the local health officer is vested now only with the legal authority delegated by law and regulations to such executives. Were he to be appointed a deputy state health officer, he would also be vested with the authority to carry out the instructions of the State Health Officer, or his official representatives, in a restricted district of the State. Any question as to the wisdom of enti'usting this additional authority to a local representative is largely obviated by the limiting provisions included as a part of the recommenda- Public Health Administration in North Carolina 151 tion. Experience has shown that the arrangement works success- fully in Maryland, where it is practiced. c. Therapeutic Medicine. The role of health officer is in the field of preventive medicine, not therapeutic medicine. Probably the motive underlying the placement of therapeutic responsibilities on county health officers is to eliminate the expense of the employment of county physicians. Economic considerations, however, would not appear to justify the provision, from the viewpoint of the com- munity, for a competent health officer should be able to invest the time that he is required to give in the discharge of therapeutic re- sponsibilities, to better advantage in the field of preventive medi- cine. He has only so much time at his disposal, and the time it takes to care for the sick or perform autopsies at a coroner's inquest ob- viously cannot be avoided. These are emergency duties for which time must be taken, and more time is needed in keeping informed in the therapeutic field if he is to keep up to date, as he should, in practicing the profession. Hence, his public health responsibilities unavoidably suffer from sei'ious neglect. It is believed that the suggestions included m the recommendation would bring about a correction and would further the primary interests of the county and district health departments. d. Part-time Position. Since approximately 75 per cent of the counties of North Carolina are now organized on the full-time basis, since ample time has been devoted to proving the advantages of the full-time plan over the part-time, and since economic considerations have been obviated owing to provisions for poor counties to unite with neighboring counties to form health districts and to receive substantial state subsidies, the time would seem at hand for the law to be made mandatory for all counties of the State to be organized on a whole-time basis. The precedent set by the General Assembly in the organization of welfare services throughout the State on a whole-time basis should give promise to the hope that the Legislature would approve a similar author- ization in behalf of the cause of public health. e. Duties of Health Officers. In studying legal provisions enumerating the duties of health executives in North Carolina one is left with the impression that they are amply inclusive. Rather than looking upon his work as that of executing legal provisions that are specifically stated in the law, the health officer should appreciate fully that public health is a cooperative enterprise and that his primary responsibility is to exercise leadership in the formulation and execution of a program which meets the needs of the State and locality. He is employed by the community as an expert in the field of public health administra- tion, and it is his responsibility to mobilize the assets of the community in carrying out a program which will protect the people from disease and which will also promote positive health. This attitude is in keeping with administration trends in North Carolina. The suggestions made in the recommendation submitted do not necessarily call for an amendment of the State laws, but are made primarily for such suggestive value as they may have. 4. Recommendations Pertaining to the Employment and Administration of Personnel a. That the tenure of office and a retirement age of health executives and subordinate personnel be established by law. b. That eligibility standards for key positions in the State Health Department be established by regulations of the State 152 Public Health Administration in North Carolina Boaid of Health, and that the standards now in effect for the personnel of local health departments be amplified to include clerks. c. That annual health examinations of all staff members of the State Health Department and of local health departments be made mandatory. d. That the authority of local health officers to employ local personnel be made subject to qualifications established by the State Board of Health, and the authority to discharge local personnel be made subject to the approval of the State Health Officer. Comments a. Tenure of Office aud Retirement Age of Health Personnel. What has been said previously in comment on the tenure of office and retirement age of health officers (Recommendation 3, a) applies equally to all other employees of health departments. Efficiency in disease prevention and health promotion depends upon the proper functioning of an alert, energetic organization, and in health work, as in other important fields of endeavor, efficiency is not compatible with either insecurity of employment or superannuation. b. Eligibility Standards. Although North Carolina has no State civil service regulations, the people of the State have been for- tunate in the selections of State health officers that have been made for them by the State Board of Health. They have also been fortunate in the selections that these health officers have made of persons to serve as directors of the various subdivisions of the State Department of Health. All of these appointments have been made without any special statutory requirements per- taining thereto, except that the Executive Secretary of the State Beard of Health, or the State Health Officer, must be a registered physician of North Carolina. Selection of personnel for other key- positions, such as directors of divisions of the State Department of Health are made by the State Health Officer. In matters of this kind, however, past experience cannot always serve as a sure criteiion for the future, and in order that neithei' the State Board of Health nor the State Health Officer may find themselves sub- jected to pressure from political or other sources that may prove prejudicial to the best interests of the public health, it is recom- mended that the State Board of Health establish definite minimum qualifications for persons to be appointed to key-positions in the State Health Department. These health executives should be quali- fied as to training and experience in public health administration and should possess personal traits which will insure their being leaders in their respective fields. These safeguards should lead to the selection of such candidates for all future appointments. c. Annual Health E.caminations. An outstanding health pro- tective measure that has been advocated by nearly all public health departments for a number of years has been a complete, annual medical examination for every individual. This, undoubt- edly, is sound advice. When health officials advocate for the public a measure which they themselves, and members of their staff, fail to observe, however, the average individual begins to ques- tion either the sincerity of the proponent or the validity of the advice. If the adoption of this practice by the public is considered a w'orthy objective of a public health department, it would seem rational for the latter to insist that the members of its staff con- Public Health Administration in North Carolina 153 form to what they aie attempting to teach. Apart from the resulting benefit that the individual might derive, this should be of assistance to the State Health Officer in maintaining an efficient working organization, as well as serving as an excellent example to the public. d. E)nployme}it and Discharge of Personnel. At the present time every full-time county or district health department in the State receives supplemental financial assistance from the State Board of Health. Under the contract providing for these subsidies, the local health officer has sole authority to employ, direct, and replace all other members of the staff of his department, it being understood that he is to employ only qualified individuals who meet the requirements outlined in the State Board's policies for the allocation of funds for health work. These requirements would seem to amply safeguard the public in those health jurisdictions that receive state subsidies, but, for jurisdictions receiving no such subsidies, qualification requirements for health personnel are wantin?-. It has been recommended elsewhere (See Recom- mendations 3 and 5) that the employment of part-time personnel be disallowed by law and that each county be required to provide sufficient funds to meet its equitable share of the cost of main- taining adequate whole-time county or district health depart- ments. Such legislation might well include minimum aualifications established by the State Board of Health for all persons on the staffs of county or district health departments. In order to maintain discipline and to insure efficiency, it is essential, of coui-se, that each local health officer shall be in position to discharge subordinate members of his staff for justified cause. But by way of preventing the occasional exercise of auto- cratic or unreasonable action against an employee, and of safe- guarding the health officer in this fundamental right from local interfei'ence, it is suggested that the dismissal of staff members by a local health officer be subject to the approval of the State Health Officer. 5. Recommendations Pertaining to Financial Management a. That the General Assembly enact mandatory legislation . requiring every county in the State to levy, impose, and collect a tax (as other taxes are collected) sufficient together with State and other available supplementary funds, to meet its equitable share of the costs required to establish and maintain adequate whole-time county or district health organizations. b. That the management of financial matters for which the State Board of Health is responsible be consolidated as a unit directed by the Principal Accounting Secretary, operating imme- diately under the State Health Officer. c. That the State's subsidy to county and district health depart- ments be paid quarterly instead of monthly as now practiced. d. That a standard method of bookkeeping be adopted for local health departments. e. That arrangements be made for the official audit of accounts of local health departments periodically. f. That inventories be made periodically of equipment in the custody of local health departments. g. That the advantages of group o)' centralized purchasing- be made available to local health departments. h. That the possibility of the establishment of a retirement 154 Public Health Administration in North Carolina fund for employees of the State and county health departments be investigated and, if found practical, that such steps be taken, as may be necessary, to bring into realization a suitably devised annuity plan. Comments a. Mandatory Legislation for FuU-Time Local Health Depart- ments. The first whole-time county health department in North Carolina dates back to 1911, when such an organization was established in Guilford County. The operation of this, and similar services that followed in its wake, have convinced State and local authorities that such a plan offers the most promising method of safeguarding the public health of the State as a whole, and of the locality in particular, of any that has yet been devised. State and Federal recognition of the importance of such work has been reflected in the ever increasing financial support that has been forthcoming, and local recognition by the gradual increase in the number of whole-time county and district health departments. At the present time (.June .30, 19.38) there are forty-nine whole- time local health departments — forty single county units and nine units representing two to five counties — serving a total of sixty- seven counties. From experience in this State as well as in numer- ous others, the conclusion may fairly be drawn that local health work undertaken along the lines now being pursued in North Carolina has proved to be a highly satisfactory health protective procedure and is worthy of emulation by all counties in which no such developments are now in progress. Realizing that county lines offer no barriers against the spread of disease, that unsatisfactory health conditions are a menace to adjacent counties, and that disease prevention and health pro- motion is as important as any service a government can render its citizens, the General Assemblies of 1917 and 1935 set aside appropriations to assist counties in their efforts to provide better local health services. Furthermore, the latter act authorized the State Board of Health to use any available funds at its command, not otherwise appropriated, to establish full-time local and district health department service for any town, city, and county or group of such units in the State where local authorities are willing to pay at least as much of the cost as is borne by the State. Thus in the case of counties where the taxable wealth is low and public funds somewhat scarce, the way was opened not only for receiving State subsidies for local health work, but also for such counties to pool their resources with those of one or more adjacent counties to establish a health district. Even with this stimulus, however, there are still thirty-three counties inter- spersed throughout the State that provide only part-time health service. In other words, the evident expectation that the above- mentioned legislation would lead to the provision of full-time • health service in every county has not materialized. Moreover, it does not appear that an appreciable number of counties without such service is likely to provide it voluntarily in the very near future. Without any invidious attempt to provoke a discussion with regard to the relative importance of such public services as health, welfare, and education, all of which are closely interre- lated, we may state that we aie in full accord with the belief that every element of the State's population, both old and young, is entitled to adequate health protection. If, unfortunately, the local governing authorities of a few counties fail to appreciate Public Health Administration in North Carolina 155 and to provide this service, then, as in the case of education and welfare, it should be made mandatory by the General Assembly. b. Consolidation of Financial Management, etc. Prior to July 1, 1939, responsibility for cooperative budgets set up jointly by the State and local boards of health was lodged with an accountant who functioned directly under the Director of the Division of County Health Work. With the consolidation of this service, on the above mentioned date, under the Principal Accounting Secre- tary of the State Board of Health, this subsection of Recom- mendation 5 was placed in effect. If, therefore, satisfactory changes pertaining to subsections c, d, e, f, and g, which are self-explanatory, can be worked out, the accounting system of the department should be greatly simplified. h. Retirement Fund. A discussion of the desirability of the establishment of a retirement fund is superfluous here except that it may be well to point to the following considerations: (1) Health employees, by-and-large, do not now enjoy the economic security necessary to attract young men and women with superior ability to public health as a career; and (2) the salaries received by health employees in general are not sufficient to enable them to set aside ample savings to allow them to retire before their period of usefulness has broken down. The adoption of a plan for the retirement of health employees should eliminate or lessen these adverse circumstances and therefore should work to the advantage of the State health officer in his effort to develop an efficient public health organization. 6. Recommendations Pertaining to Legal Services a. That the duties of the legally trained employee responsible for the administration of the Bedding Law be expanded so as to include assisting (1) in the administration of such other legal services as may be required by State and local health depart- ments, (2) fhe drafting of health bills, (3) the enforcement of health laws and regulations, and (4) the codification and clari- fication of health statutes. b. That such legal health service be established as a section of the Division of Central Administration. Comment The General Assembly of 1923 enacted a law (Reference — Chapter 2 and subsequent amendments) to improve the sanitary conditions of the manufacture of bedding and to prevent fraudu- lent descriptions of the materials used therein. Responsibility for the enforcement of this law was placed upon the State Board of Health, and the actual execution of its provisions has been carried out by two inspectors employed by the Division of Sanitary En- gineering. One of these inspectors has had legal training, has passed the North Carolina Bar examination, and is eligible to membership in the North Carolina Bar Association. The salaries and expenses of the inspectors are paid from funds derived from the sale of stamps and labels which are required to be affixed to mattresses, comforters, pads, pillows, etc., offered for sale. The services rendered by these two inspectors are limited almost entirely to the prevention of fraudulent practices in the bedding industry. Their entire time is given to this work and they receive little or no assistance from State or local inspectors whose duty it is to prevent practices in other matters that may adversely affect the public health. 156 Public Health Administration in North Carolina The administration of a large organization sucli as a State health department calls for the development of a number of spe- cialties, such as laboratory service, sanitary engineering, and statistical service, as well as a high degree of integration of these services among themselves and with those of local health depart- ments. In line with the establishment of these specialties, is the need for legal services in the field of public health law. Just as the Division of Sanitary Engineering calls upon the Division of Lab- oratories for laboratory service, so also should the divisions of the State Health Department and local health departments have available the services of a legally trained specialist who is par- ticularly well versed in public health law. In considering the furthei- development of a specialized legal service within the State Health Department, our thought is not to lay undue stress upon law enforcement nor to minimize the desirability of utilizing edu- cational and persuasive measures to secure voluntary cooperation in complying with public health laws. The view taken is that health laws and regulations may demand the exercise of police powers under exceptional circumstances, and, since the North Carolina State Health Department already employs a person with legal training whose time is devoted to the administration of the Bedding Law, but whose experience with the Department should qualify him for additional legal services to State and local organ- izations, it would seem advisable that a section of legal seivices, in the office of Central Administration, be established under his direction. In assuming charge of this section, the director would not be expected to take over the functions of the Attorney-General or local district attorneys in prosecuting violators of public health laws in the courts of the State, but it would be his duty to under- take preliminary procedures when prosecutions appear to offer the only means of securing compliance with public health laws. Health officers in general, and local health officers in particular, are usually not very familiar with legal procedure, and they are at a disadvantage in interpreting and putting into effect some of the legal procedures incumbent upon them in the discharge of their responsibilities. The institution of suits against persons or corporations who contravene provisions of the law reacts un- favorably against local health officers, and the principle of having such officers do more than testify seems unwarranted. If local prosecutions could be handled by a competent State employee rather than by county or district health officers, the usefulness of the latter would be far less likely to be impaired. As previously mentioned, the bedding inspection service throughout the State is conducted by two inspectors, without any assistance from local sanitary officers. This entails very consider- able traveling expense, and, with such a large territory to be covered, there may be some question as to whether inspections are frequent enough to be entirely effective. Should i-esponsibility for these routine inspections be handed over to sanitarians em- ployed by local health departments, the State bedding staff would be in a position to function more in an advisory capacity in this field and to assume the duties enumerated in this recommendation. Thus, in consideration of the inspectional service rendered by local health personnel, the Section of Legal Services would share with local units the responsibilities arising from failure or refusal of persons to comply with health laws. If the training of local inspectors is such that they are not qualified to undertake the inspection of bedding, this woi'k could be shifted to them gradually, Public Health Administration in North Carolina 157 as they acquire knowledge of it under the supervision of the director of legal services. Moreover, the director could conduct a short course at the University where training- of local sanitarians in this specialized field could be carried out. 7. Recommendations Pertaining to Public Health Education a. That the public health education services of the State Department of Health, now including: (1) those being carried out by the Division of Preventive Medicine and the Division of Oral Hygiene, and (2) the Publicity Service, be centralized into a section of public health education, Office of Central Administra- tion; and, that the personnel of this section consist of a director, preferably a physician, who has specialized in public health educa- tion methods and or has rendered distinguished services in this field, together with such subordinate personnel as may be neces- sary for the fulfillment of the functions of this Section. b. That the director of this section be given the active support and cooperation of the directors of the several divisions of the State Depai'tment of Health and of local departments of health in the formulation, execution, and appraisal, through official channels, of a coordinated State and local health educational pro- gram, and that in addition to being responsible for exercising leadership in carrying out such a program, his duties, together with those of his subordinates, include that of (1) editor of publications, (2) custodian and distributor of printed matter, motion pictui'e material, exhibits, etc., (3) educational secre- tary in charge of arrangements for public addresses, radio talks, programs of meetings, etc., (4) supervisor of library services, (5) assistant to the coordinator of school health services, and (6) advisor to county health officers, with respect to educational programs promoted within these local health jurisdictions. Comment Public health education activities in North Carolina are being- carried out by the divisions of the State Department of Health as a part of their specialized intradivisional programs and by local health departments as a subsection of their generalized services. To further develop central leadership and to provide more adequately for a unified, balanced health educational pro- gram on a state-wide basis, which will coordinate more completely the facilities of each of the divisions of th^ State Department of Health and also those of local health departments, there would appear to be a need for the establishment of a section of public health education within the Division of Central Administration. At present the responsibility for central leadership in the devel- opment of a unified health educational program rests, in particu- lar, upon the Director of the Division of Preventive Medicine. Because, in an organization that has reached the magnitude of the Noi'th Carolina State Department of Health, responsibilities in the fields of preventive medicine and public health education fully justify the employment of full-time directors for each of these services, the wisdom of continuing the double responsibilities of the Director of the Division of Preventive Medicine longer than is necessary to overcome such economic difficulties as now stand in the way of placing each service under a separate director, would appear to be open to serious question. In the beginning the personnel of the section of public health education need not consist of more employees than the director. 158 Public Health Administration in North Carolina the publicity director, and a secretary. As a basis for the formu- lation of a state-wide coordinated educational program the director should be given ample time to appraise the State's needs in the field of public health education and to familiarize himself thor- oughly with all phases of the educational program now being car- ried out by the various divisions of the State Department of Health and of the several local health units. After this prelim- inary step has been carefully taken, the realization of the pro- gram so conceived might well be initiated during a suitable transition period through the continuation of the services of the existing educational facilities, the function of the director of the section being limited to leadership as a coordinator and to render- ing, through official channels, supplemental technical supervision. Later, as the educational program gets under way and as cir- cumstances arise which may make administrative modifications opportune, any suboidinate employees of divisions of the State Department of Health who serve essentially as specialists in the educational field should be transferred to the staff of the section of public health education. When these transfers have been made or an adequate technical staff provided, the educational services of the Health Department should be carried out, insofar as prac- ticable, by the section of public health education as an interde- partmental service rather than by the divisions of the State De- partment of Health as specialized intradivisional services. In the field of public health education this section would then serve the other divisions of the State Department of Health and local health departments as, in the field of laboratory work, the State Laboratory of Hygiene serves these component parts of the whole health organization. The directors of the various services would, of course, continue to share with the director of this section the responsibility for the development of adequate and effective edu- cational pi'ograms as concerns their several fields of interest. Each of these specialized educational services, however, would constitute integral parts of the state health program, conceived as a whole, and these directors would be lelieved of the duty of building up technical staffs and of providing equipment within their several divisions, for such subordinate employees would constitute the staff of the section of public health education and the equipment needed for carrying on the State's educational program would be centralized in this Division. 8. Recommendations Pertaining to Public Health Nursing a That the public health nursing services of the State Depart- ment of Health, now including (1) those being directed by the Division of County Health Work, and (2) those supported by the Division of Preventive Medicine, be centralized into a section of public health nursing. Office of Central Administration; and that the personnel of this section consist of a director, respon- sible to the State Health Officer, and such subordinate personnel as may be necessary for the fulfillment of the functions of the section. b. That the director of this section advise or assist, through official channels, the directoi's of divisions and agencies of the State Health Department, employing nurses and operating spe- cial nursing services, and directors of local health departments in (a) the selection of nurses, (b) in the formulation, execution, and appraisal of coordinated state and local health nursing pro- grams in their respective spheres of influence, and (c) in super- Public Health Administration in North Carolina 159 vising the technical services of nurses employed by these subdi- visions of the State and local health departments. Comment The establishment of a separate section of public health nurs- ing is recommended because the organizational relationship of pub- lic health nursing to other services which make up the whole health organization is looked upon as interdepartmental in character. Owing to the fact that the effective realization of specialized programs of a number of the divisions of the State Department of Health is dependent upon nursing sei'vices and that the execu- tion of these programs is being accomplished more and more through the integration of state facilities with those of local de- partments — that is, in accordance with those of local health departments — that is, in accordance with the policy of horizontal as distinguished from a vertical plan of administration — the recommendation further provides that this section be set up within the Division of Central Administration. The director of this section, with the assitance of subordinate staff members, would work with the directors of the other divisions of the State De- partment of Health and with directors of the local departments of health through the Division of County Health Work to the end that the special nursing interests of these State divisions and the generalized nursing interests of local health units would be harmonized through the formation of a unified, balanced, State- wide public health nursing program. The nurses employed by local health departments would, of course, operate under the immediate administrative supervision of their local medical direc- tors, who, in turn, would be responsible administratively, insofar as State supervision may be applied to local units, to the Direc- tor of the Division of County Health Work. Apart from exer- cising central leadership in the formulation of a State-wide nurs- ing program, the director of this section, with the assistance of her subordinate staff, would participate through official chan- nels in the realization of it. The services rendered would also include: (1) aid in the selection of nursing personnel; (2) aid in the supervision of nursing techniques of local nurses and in the standardization of the content of each type of nursing visit; (3) assistance in the formulation of a plan which would provide for the continuous education of local field nurses; and (4) aid in the periodic appraisal of local nursing programs. The staff of the section of public health nursing need not be large, but in addition to the director it would appear advisable to employ at least two additional supervisors. One of these would be stationed in, and have charge of, the coastal region of the State, and the other the western section of the State. The dii-ector would take charge of the central section of the State as well as supervise and direct the other two nurses on her staff. The plan of administration suggested precludes the employment of nurses as staff members of other divisions of the State Depart- ment of Health, it being understood that the needs of these divisions would be discharged through the staff of the section of public health nursing. The nurses on the staff of the section of public health nursing should, of course, possess superior quali- fications with respect to general educational background, ade- quate specialized training in all phases of public health nursing, and suitable experience in performing the service each is called upon to supervise. IGO Public Health Administration in North Carolina The trend in North Carolina pertaining to the administi-ation of public health nursing service is in the general direction of the provisions of these recommendations, except that the central nurs- ing service is set up as an intradivisional service of the Division of County Health Work. If the suggestions set forth here were to be put into effect, it would carry this trend a step beyond the stage of organization now reached. It would centralize responsi- bility for leadership in the formulation of a coordinated State and local public health nursing program in the hands of a direc- tor and subordinate assistants who are specialists in the field of public health nursing. The nursing service is coordinate from an organizational viewpiont with the other divisions composing the State Department of Health with respect to the magnitude of the staff involved and the importance of the program being developed. Hence, this change would be in keeping with the prac- tice adhered to in providing direction to other specialists which have been organized as divisions of the State Department of Health. Precedent has also been established in the Division of Sanitary Engineering, for example, for the utilization of the services of a non-medical director of such specialized services. 9. Recommendations pertaining to administrative relationships be- tween State and local health departments in the promotion of local health programs in general and between the health department and other agencies concerned in the promotion of their services cooperatively within a demon- stration district of the state: a. That the Division of County Health Work be transferred to and made a part of the Office of Administration; that its name be changed to the division of local administration; that its per- sonnel be increased by the employment of two medical adminis- trative assistants; and that the Director, with the assistance of his subordinates, function as: 1) A coordinator between the divisional directors of the State Department of Health and the directors of local health departments in the further development of gen- eral programs now being carried out in the local whole- time health jurisdictions of the State, and 2) A coordinator between the divisional directors of the State Department of Health and the health director of a local health department set up as a special demonstration or experimental area for the purpose of providing a prov- ing ground for trying out new administrative and tech- nical procedures prior to their introduction on a State- wide basis. b. That the State Department of Health participate with other State departments, such as Education, Welfare, and Agri- culture, and with other agencies concerned in the organization and promotion of an experimental district in the State for the purpose of projecting methods for the cooperative functioning of such services locally and testing out experimentally in the field the merit of such cooperation to the end : 1) That joint administrative cooperative projects such as a school health service (see Recommendation 2, b., 3) may be tried out in a proving ground prior to an introduction on a State-wide basis, 2) That joint basic research projects as, for example, epi- demiological field investigations of syphilis and field nutri- Public Health Administration in North Carolina 161 tion studies, may be conducted under the most advanta- geous circumstances possible, and 3) That a special administrative project may be undertaken to determine if it is practical to re-district the counties of the State into larger administrative jurisdictions to effect economy and efficiency of local administration. Comment In recent years rapid progress has been made in North Caro- lina in the extension of local health departments, and it is be- lieved that this movement will continue until all the people of the State enjoy the services of whole-time local health depart- ments. The State Division of County Health Work has been cre- ated to promote the extension of such units into the remaining unorganized areas of the State and to simplify the administration of the units now in operation. The trend of the State's adminis- trative policy being followed is to integrate the specialized facili- ties provided by the technical divisions of the State Department of Health with the generalized facilities of full-time local health departments, the one supplementing the other in the develop- ment of well-rounded local health programs. On the one hand, the several local health departments are tied together by the Division of County Health Work, each constituting an integral part of a coordinated service. On the other hand, the directors of the technical divisions of the State Department of Health work through the Director of the Division of County Health Work in integrating special phases of public health as parts of the generalized programs of local health units. Hence, the Director of County Health Work provides an administrative channel through which the interrelated functions of the Divisions of the State Department of Health and of the several local health departments are discharged to the mutual advantage of the State and the locality. Because the Division of County Health Work coordinates administratively State and local complements of the whole health organization, its logical position in the plan of organization would appear to be that of a division of local administration in the Office of Administration. With reference to the personnel of this Division, these recom- mendation suggest the employment of two assistant divisional directors. One of these would be stationed in, and have charge of, the coastal region of the State and the other, the western section of the State. The Director would have immediate charge of the central section of the State and would supervise the other two assistant directors on his staff. Furthermore, with respect to the technical employees on the staff of this Division who render intradivisional specialized services, it is suggested in addition that consideration be given to transferring these employees to the staffs of the divisions of the State Department of Health which are responsible for the development of these specialized services. The view is taken that such specialized services should be provided on the basis of an interdepartmental as distinguished from an intradivisional plan of organization. It follows, without the need of undue emphasis, that administrative changes of this character need not be looked upon as urgent for the immediate future but rather that such personnel transfers be made when circumstances arise which make the transition opportune. •The Tri-County Health Department, consisting of Orange, 162 Public Health Administration in North Carolina Person, and Chatham Counties, fulfills now some of the func- tions of the demonstration district suggested in these recom- mendations, and this district could be developed further to advantage, it is believed, in the fulfillment of all of the objectives ennumerated. It may be pointed out that, with headquarters at Chapel Hill, this full-time district health department is im- mediately accessible to the University of North Carolina, with which it is affiliated, and is also conveniently near Duke Uni- versity, and Raleigh where the departments of State government concerned are located. To fulfill an immediate need, the demon- stration district would be utilized as an experimental area in which a program for local health service within the State would be perfected. Under the leadership of the Director of the Division of County Health Work the directors of the technical divisions of the State Department of Health would work with the director of the demonstration area in the development of their special services as integral parts of the local health program, and to this end there would be assigned technical employees of the several State divisions concerned to supplement the basic staff of the district health unit. After the program in the exper- imental area has been formulated and put into successful opera- tion, provision would be made for the in-training of the staffs of local health districts operating throughout the State and for the temporary assignment of members of the supplemental staff of the demonstration district to local health departments. By in-training in the experimental area and by supplementing local health staffs with technical assistants from the demonstration district, it is believed that marked progress would be made in strengthening many, or all, of the services rendered by local health districts throughout the State — that is, the demonstration district would play the role of a pacesetter in elevating standards of these local health departments. Concurrently, or as circum- stances may make opportune, the other roles projected for the demonstration district, enumerated in these recommendations, would also be developed. 10. Recommendations Pertaining to Statistical Services a. That the scope of the services of the Division of Vital Statistics be extended gradually to include the technical super- vision of the collection and analysis of public health statistical data in general, and thereby function eventually as a division of statistical methods. b. That the director of this Division cooperate, through official channels, with (1) the other directors of divisions and agencies of the State Health Department (See Epidemiology) for guidance in the set-up of statistical procedures and for rendering technical services in the analysis and interpretation of data collected, and with (2) the directors of local whole-time departments of health, through the technical supervision of the statistical secretary of the division of local administration, for: (a) rendering guidance in the further development of meth- ods covering the registration, collection and analysis of mortality and morbidity statistics; of data pertaining to the health status of the several age groups of the population; and of statistics concerning the sanitary status of domestic water, milk, food establishments, sew- age disposal, etc., and, for Public Health Administration in North Carolina 163 (b) rendering technical services in the analysis and inter- pretation of the data collected — to the end that this service fulfill the function of evaluating the progress which is being made in the attainment of public health objectives of the whole health organization. Comment The collection and compilation of statistics are required by each of the divisions of the State Department of Health and also by local health departments within the State. In order to provide an integrated statistical service which meets the needs of the health organization as a whole as well as its component parts, these recommendations suggest that the Division of Vital Sta- tistics be expanded into a division of statistical methods. The principal advantage of such a plan would be to provide responsi- bility for central leadership in the visualization and realization of a unified statistical service in the person of the Director of the Division of Vital Statistics who has been trained as a spe- cialist in this field of activity. Furthermore, such a plan would be in keeping with the policy of administration recommended for coordinating other divisions of the State Department of Health in rendering basic interdepartmental services. 11. Recommendations Pertaining to Epidemiological Services a. That the technical aspects of collection and analysis of morbidity reports be undertaken by the Division of Vital Sta- tistics for the Division of Epidemiology as an interrelated de- partment service. b. That a section of tuberculosis be established in, and made a part of, the Division of Epidemiologv under the direction of a physician who has specialized adequately in the epidemioloo-ical aspects of tuberculosis, and preferably has had basic training and experience in public health administration, together with such subordinate personnel as may be necessary for the section to fulfill its functions; and that the director of this section be responsible to the director of the division of epidemiology for the development, through official channels, of an effective cooperative program in the counties of the State which inte- grates the facilities of State and local sanatorium services, in- eluding, the extension Bureau of Tuberculosis of the State Sana- torium, local health departments, and other agencies concerned. c. That a section of respiratory diseases be established in, and made a part of the Division of Epidemiology, under the direction of a physician who has specialized adequately in the clinical, laboratory, and epidemiological aspects of respiratory diseases (especially pneumonia and influenza) and preferably has had basic training and experience in public health admin- istration, together with such subordinate personnel as may be necessary for the section to fulfill its functions; and that an advisory commission to the director of this section be created — consisting of representatives of the medical profession and scientists of the staff's of medical schools in the State who are specialists in the fields of pneumonia and filterable viruses; and that the director of this section and his advisory committee be responsible to the Division of Epidemiology for the development of an eff"ective cooperative progi-am in the" counties of the State which integrates the facilities pf the State Laboratory of Hy- 164 Public Health Administration in North Carolina giene, other laboratories (typing stations), health departments, medical societies, and others concerned. d. That pneumonia be made a reportable disease. e. That a section of cancer control be established in, and made a part of the Division of Epidemiology, under the direc- tion of a physician who is a cancer specialist, together with such subordinate personnel as may be necessary to fulfill its function; and that an advisoi'y commission to this section be created, con- sisting of cancer specialists on the staffs of medical schools in the State or on the staffs of institutions or hospitals in which cancer is given special emphasis, and of representatives appointed by the State Medical Society; and that the director of this section, and his advisory committee, be responsible to the direc- tor of the Division of Epidemiology for the development, through official channels, of a cancer program for local health depart- ments that would incorporate the facilities of local health de- partments, medical societies, hospital organizations, and other institutions and agencies concerned. Comment To bring about more effective organizational integration, these recommendations provide that the morbidity statistics be compiled by the Division of Vital Statistics as an interdepart- mental function rather than by the Division of Epidemiology as an intradivisional activity. The statistical clerks of the Division of Epidemiology would be transferred to the staff of the Division of Vital Statistics. The time required of the Director of the Division of Epidemiology in supervising these employees would be conserved for his other responsibilities, and the compilation of these data would be facilitated through the availability of modern equipment in the Division of Vital Statistics. Tuberculosis is a major public health problem in North Caro- lina. To provide for central leadership in combating this disease, a section of tuberculosis within the Division of Epidemiology is considered essential in order to effect proper integration of the facilities of the health and sanatoria authorities. The solution of administrative questions pertaining to the administrative relation- ship which should exist betv.'een this section and the extension Bu- reau of the State Sanatorium might best be deferred, it is believed, until the director of this section has been appointed and has had an opportunity to study thoroughly the problem involved. In this connection, it is to be pointed out that commendable progress is being made by the authorities of the State Sanatorium in the extension of their influence beyond the walls of State sana- toria to the tuberculosis problem in the field. It would appear obvious that the guiding policy for bringing about the cooper- ation of all parties concerned in the development of the State's tuberculosis program should be such as to further promote this trend. Apart from serving as a coordinator of all interests now operating in the tuberculosis field, the director of the section of tuberculosis would complement these facilities by contributing the services of an epidemiologist trained specifically with refer- ence to tuberculosis. The establishment of a section of respiratory diseases within the Division of Epidemiology is recommended because the prog- ress of the research on these diseases has now advanced to the stage where it would appear to be opportune for the establish- Public Health Administration in North Carolina 165 ment of public health machinery for the development of more effective programs. In the beginning, this section would be in a position to stress a pneumonia program designed to reduce ex- isting death rates by bringing about better nursing care of these patients and the better utilization of biological products and new specific drugs which have been introduced in recent years and found effective in the treatment of pneumonia. Furthermore, in view of the advanced development of laboratory facilities in North Carolina, this section would be in an opportune position to cooperate with the State Laboratory of Hygiene in carrying out joint epidemiological and laboratory studies pertaining to influ- enza. With the building up of the facilities of the State De- partment of Health for efficient work in influenza, it may be possible for the director of the section of respiratory diseases to mature a control program so as to be in a position to ward off devastating effects when a pandemic of the disease again returns to sweep the state. The establishment of a section of cancer control is advocated because the view is taken that health administrators should not be inactive when confronted with a health problem of such mag- nitude. To start with, the program of such a section might in- clude the following activities: (a) The carrying out of educa- tional measures designed to secure the cooperation of the public with practicing physicians in an effort to uncover cancer before metastasis occurs; (b) the operation of field diagnostic clinics following a plan similar to that in vogue for the early detection of tuberculosis patients; (c) the fuller development and utiliza- tion of facilities within the state for the diagnosis and treat- ment of cancer, such as that of radium. X-ray, etc.; and (d) through the agency of local health departments, efforts could be made to develop programs that would concentrate attention on special phases of the cancer problem, such as, for example, control of cancer of the breast. Cancer should also be made a reportable disease. These measures are suggested to indicate in what directions the program of the section of cancer control might be matured. If full use should be made of the control measures now at the disposal of health administrators, it is possible that many lives would be saved and that improvements in or perfec- tion of the cancer control progi'am would be realized much more quickly. 12. Recommendations Pertaining to Public Health Laboratory Services a. That private laboi-atories in the State which undertake the examination of specimens or samples for public health pur- poses be licensed, subject to inspection and approval, by the State Board of Health, and that suitable legislation to this end be enacted. b. That the Director of the State Laboratory of Hygiene make such investigations as may be necessary to familiarize himself with the status of local laboratory work, how well local needs are being met, and in what way local laboratory service may be improved, to the end that local and central laboratory services may be better integi-ated in the development of a unified laboratory service for the State as a whole. c. That adequate laboratory facilities be established for work with filterable viruses of public health interest, attention being directed in the beginning to influenza. 166 Public Health Administration in North Carolina d. That budgetary provisions be made to enable the State Laboratory of Hygiene to expand its facilities for initiating research or cooperating with other divisions in scientific investi- gations — particularly, studies of the fundamental nature of dis- eases of public health importance occurring in North Carolina — for the purpose of obtaining knowledge which will lead to the development of more effective and more practical methods of control. Comment The construction and equipment of the new laboratory build- ing, as well as the development of the Biological Farm recently acquired will continue to occupy fully the attention of the Director of the State Laboratory of Hygiene for the immediate future. When these major projects have been completed or advanced sufficiently, attention can then be given to the realiza- tion of the plans projected in these recommendations. The principal aims embodied in them are as follows: (1) To estab- lish adequate local public health laboratory services; and (2) to develop public health laboratory research further. From the initiation of the public health laboratory service in North Carolina down to the present, attention has been almost exclusively devoted to the development of the central laboratory facilities of the State Department of Health. In the near future progress in the realization of the objectives of the State Labora- tory of Hygiene will have been advanced sufficiently to permit the State laboratory director to turn his attention to the solu- tion of the local laboratory problem. These local laboratories should be established at strategic communication centers and the technical staff employed should be well qualified and carefully selected. Whether or not these laboratories should be organized as field branches of the State Laboratory of Hygiene or as sub- divisions of local health departments would not appear to be a matter of great administrative moment, providing, of course, that these local laboratories are functionally integrated with the State Laboratory of Hygiene. Such functional interrelationship is of primary importance in order that the facilities of the State laboratory may complement those of the local laboratories to mutual advantage in rendering a well-rounded laboratory service. The establishment of regional laboratories is essential because the local needs for public health laboratory services are far from be- ing fully realized and the burden of routine work placed upon the State Laboratory of Hygiene has now reached such propor- tions as to demand relief. It may be well to point out also that local private laboratories performing public health services should be licensed in order that the reliability of their work may be assured. Furthermore, the State Laboratory of Hygiene should strengthen its relationship with other government laboratories and with university labora- tories situated within the State to the end that their "auxiliary facilities, insofar as applicable, may be mobilized to the fullest extent possible in meeting the public health needs of North Carolina. Attention thus far has primarily been given to the develop- ment of those phases of the laboratory program which deal with routine technical tests and with the manufacture and distribu- tion of biological products. These phases of the program should, Public Health Administration in North Carolina 167 of course, continue to receive major emphasis, but at the same time the role of the government laboratory as a research institu- tion should also receive due consideration. The laboratory direc- tor occupies a strategic position within the health organization to exercise leadership in the promotion of joint laboratory and field investigations, the objectives of which are the acquisition of knowledge needed to open doors now closed to the health adminis- trator. Furthermore, though the leadership of the Director of the State Laboratory of Hygiene, undertakings in the research field might be shared to mutual advantage with university labora- tories. Attention in these recommendations is specifically directed toward virus dieases of public health interest. 13. Recommendations Pertaining to Sanitary Engineering Service a. That the present trend toward the integration of the sani- tary services of the Division of Sanitary Engineering with those of whole-time health departments be further developed as rapidly as the local employment of trained sanitary officers permits, to the end that inspectional services of the State be transferred to local sanitary officers. b. That the State Department of Health in cooperation with the State Department of Agriculture review existing legislation pertaining to the supervision of dairy and other food products for the purpose of formulating amendments or new legislation that would empower the State Board of Health to supervise the strictly public health aspects of such industries, thereby obvi- ating any unnecessary duplication of authority and inspection service. c. That the State Department of Health in cooperation with the North Carolina Fisheries Commission review existing legisla- tion pertaining to the shellfish industry for the purpose of formulating amendments or new legislation that would em- power the State Board of Health to supervise the strictly public health aspects of this industry. d. That enabling acts be provided authorizing the State Board of Health to pass rules and regulations covering the sani- tary control of swimming pools, and of recreational resorts and tourist camps. e. That State laws delegating authority to the State Board of Health with reference to the sanitation of public institutions be amended, or new legislation enacted, to provide for approval by the State Board of Health for the construction of new school buildings, or the remodeling of old, in so far as said plans pertain to sanitation. f. That a survey of the State be made to determine the status of stream pollution by trade wastes and sewage, and that, if the need exists, legislative authority be sought for coping with the problems presented. Comment These recommendations embrace two main considerations, namely, (1) a question of administrative policy governing the interrelationships of the Division of Sanitary Engineering and whole-time local health departments, and (2) provisions for strengthening and extending the activities of the Division of Sanitary Engineering. 168 Public Health Administration in North Carolina A large part of North Carolina now enjoys the services of whole-time local health departments, and for the most part the staffs of these units include trained sanitary officers. Because of these circumstances the time would seem to be opportune for the further integration of whole-time local and state sanitary services. Operating through the administrative channels of the Division of County Health Work, the Division of Sanitary Engineering is in a favorable position to exercise leadership and share responsibility in the formulation and execution of local sanitary programs to the end that the State and local facilities may complement each other. The Division of Sanitary Engineering is in an awkward posi- tion at present to develop sanitary programs pertaining to swim- ming pools, the dairy industry, and the shellfish industry because legal responsibilities are either obscure or delegated indirectly to the health authorities through some other government agency. To correct this condition, it is recommended that legislative enact- ments be obtained so as to define clearly the responsibilities of the State Board of Health and to provide bases upon which control programs may be developed. It is further recommended that the facilities of the Division of Sanitary Engineering be made available to educational authorities for the purpose of establish- ing proper sanitary and hygienic facilities at the time new school buildings are erected or old buildings remodeled. To this end, it is suggested that the Division of Sanitary Engineering be re- quired to aprove architectural plans for new or remodeled school buildings prior to the time that structural work is undertaken. Precedent for such service on the part of the State Board of Health has been established with reference to the approval of plans for public water supplies and sewage disposal systems. An additional recommendation pertains to the problem of stream pollution and provides for a survey to determine the status of existing conditions as a basis upon which future control pro- grams may be formulated. Little has been done in this field of sanitation in North Carolina, but it is probable that a survey will indicate a real need and that this need will become more acute as the State becomes more industrialized. 14. Recommendations Pert-mning to Preventive Medicine Services a. That the Director of the Division of Preventive Medicine through official channels, be 1) Responsible for exercising leadership among directors of local health departments in the formulation, execution, and appraisal of programs in the further development, or establishment, of the following services : a) Maternal hygiene, including midwifery supervision. b) Infant and preschool care. c) Health supervision of dependent children and children gainfully employed. d) Health supervision of adult groups. e) The care of crippled children — and, to facilitate these developments, that there be employed specialists in obstetrics, pediatrics, etc., to supplement the staffs of local health units in raising local professional stand- ards in the field of maternal, infant, and pre-school care; and, 2) Responsible, coordinately with directors of other State Public Health Administration in North Carolina 169 agencies concerned, for exercising leadership among direc- tors of local health departments in the formulation, exe- cution, and appraisal of programs in the further develop- ment (or establishment) of the following services: a) School health. b) Nutrition. c) Mental hygiene. d) Eugenics. in so far as these services may pertain to preventive medicine, and the facilities of the division can assist in furthering the objectives sought. b. That the excessive responsibilities with which the Director of this Division is now burdened be lessened by the transfer of duties pertaining to general health education, and the technical supervision of the Division's nursing services to other sections or agencies of the State Health Department (see Recommendations Nos. 7 and 8). Comment According to the provisions of these recommendations, the services of the Division of Preventive Medicine are grouped under two main headings, namely, (1) those for which the Director is immediately responsible and (2) those for which the Director shares coordinate responsibility. The administration of the serv- ices listed in the first subdivision is viewed as a responsibility which lies essentially within the health organization, whereas the administration of the services listed in the second subdivision is looked upon as being shared by the State Board of Health with other government agencies. In recognition of common responsibilities which can best be shared by more than one government agency, for example, the health and educational authorities have established a coordinating agency as a means of integi'ating the facilities of each organiza- tion in the establishment and maintenance of a school health service. The State Health Department is given representation in the coordinating agency through the affiliation with it of the Director of the Division of Preventive Medicine, and by virtue of this tie-in shares a major responsibility in the development of the school health service. Similarly, in the fields of nutrition, mental hygiene, and eugenics, other state agencies, in addition to the State Health Department, have responsibilities in common in the development of these services, and it is anticipated that coordinating agencies will be established for them also to imple- ment the teamwork needed. The responsibility of the Director of the Division of Preventive Medicine should not be looked upon, however, as being completely delegated to these coordinat- ing agencies, but he, as well as the executive officers of other government services concerned, should clearly appreciate that the agency is to be utilized by each of the participants in putting into eff'ect an integrated service, thereby eliminating the nec- essity of setting up independent programs — i.e. the coordinating agency serves as a common arm for all participants. With reference to health supervision of adult groups, we would suggest that this sei'vice be developed in close cooperation with public hospital administrators and officials of local medical societies. The facilities of hospitals are needed in order to carry out periodic health examinations of adults with the degree of 170 Public Health Administration in North Carolina completeness desirable and to provide advantageously for the correction of defects or abnormalities which may be disclosed. In North Carolina there exist excellent laws covering the con- struction and maintenance of public hospitals, and owing to the interest and assistance of the Duke Foundation considerable progress has been made in the establishment of hospital services. Furthermore, the interest of the local medical profession should be solicited to the end that the periodic health examination may serve as a means for further developing the preventive medical practice of physicians. Because deviations from the normal in presumably healthy people may be diflficult to disclose, it is be- lieved that group practice is indicated. Such groups would con- sist of a general practitioner with whom would be associated specialists in the various fields of medicine. The general practi- tioner would be in direct charge of the patient, but in supervising the health of the patient he would have the guidance and assist- ance of these specialists. It is suggested further that the plan be matured first in one health jurisdiction before any effort is made to introduce the service on a state-wide basis. In this way, imperfections in the administrative procedures can be eliminated without the complication of multiplicity of eff'ort or the crippling influence of mistakes which might be of considerable moment if they were made on a state-wide basis. The economic problem involved would require the careful consideration of the adminis- trative officers of health departments, hospitals, and the medical societies. Should it be possible, however, to mature periodic health examinations so as to merit the confidence of the public, it is anticipated that in time this service will develop into the periodic examinations of family groups. In this event, the public health provisions for the examination of school children, as well as infant welfare conferences, etc.^ may be incorporated into a well-rounded professional service in the field of preventive medicine. With reference to a eugenics program, it may be well to point out that considerable progress has been made in the development of birth control projects through the auspices of the official health organization. Attention should be given, we believe, to broaden- ing the birth control program into a project which is basically concerned with the objectives of the eugenicist. Since the state laws regarding the sterilization of the unfit have been quite well developed for North Carolina, it would also appear to be advisable for the health authorities to explore the feasibility of joining forces with the Eugenics Board in order to determine in what manner, if any, each can complement the other in develooing further a program of common concern. The eugenics problem has many complexities, so, the guidance of a specialist should be secured who has ample scientific training to fit him to assume the responsibility. 15. Recommendations Pertaining to Oral Hygiene Services a. That the districts of the State to which dentists on the staff of the Division of Oral Hygiene are assigned, consist of one county or more and that these dentists, while working in counties which support whole-time health departments, function as spe- cialists supplementing the staffs of these local units to the end that oral hygiene services of the Division be integrated, through Public Health Administration in North Carolina 171 official channels, as an integi-al part of the program of whole- time local health departments. b. That the Director of Oral Hygiene serve as adviser to the coordinator of school health work with reference to matters pertaining to oral hygiene, and cooperate with the director of the section of Public Health Education in the coordination of the educational program of this division as an integral part of the general educational program of the health department. Comment The recommendation set forth here advocates the horizontal plan of administration for the Division of Oral Hygiene rather than the vertical plan now in effect. This change, however, should be brought about gradually during an adequate transitional period. At first the dental field staff would continue as a part of the personnel of the Division of Oral Hygiene, but the Director of this Division would make it clear to them that they are to identify themselves closely with the local health staff when operating in areas served by whole-time health units. At the close of the transitional period these field dentists should become bona fide employees of local health departments and would therefore be directly responsible adminis- tratively to the local health officer. Operating through official channels, the Director of the Division of Oral Hygiene, however, would continue to exercise technical supervision over these field dentists. Financial provision for local dentists would be provided preferably in accordance with the plan now in effect for financing local health depa)tments in general, — i.e. the state would sup- plement local funds, providing that (1) qualification standards for the employment of dentists are adhered to, and (2) technical super- vision by the Director of the Division of Oral Hygiene is accepted. When the section of public health education, as proposed heretofore, has been organized, the oral hygiene educational serv- ices should become a part of the services of this section. The Director of Oral Hygiene would cooperate with the director of the section of public health education in the formulation of the educational program for oral hygiene, but the responsibility for integrating it as a component part of the whole educational pro- gram would be placed upon the director of the section of public health education. In carrying out the oral hygiene phase of the educational program, the educational director would depend upon the services of the local staff of dentists, teachers in the public schools, public health nurses, etc. The purpose of the recom- mendation is to relate the part to the whole and to make avail- able to the Director of the Division of Oral Hygiene the services of a public health education specialist. When the time becomes opportune, the employees of the Division of Oral Hygiene who are specifically engaged in promoting public health educational measures would be transferred to the staff of the section of public health education. The field of public health dentistry in North Carolina is limited to the public schools of the State. Because of this cir- cumstance, it is essential that the coordinating agency for ren- dering school health services utilize the facilities of the Division of Oral Hygiene. The School Health Coordinator and the Direc- tor of this Division would therefore be called upon to work in very close cooperation. 16. That group research be made a basic function of the State and local health departments and that a steering commit- 172 Public Health Administration in North Carolina tee consisting of the directors of the various specialized services of the State Department of Health be organized to formulate and promote the execution of coordinated programs through the integrated facilities of this large health oi'ganization with its ramifications throughout the state. Comment The view is entertained here that the government health organization should function as a research institution in addition to serving as an operating agency. The problem of the health administrator is to interrelate these major subdivisions of the public health program so that the one complements the other to the mutual benefit of both. Because research may lead to further control of disease and to advances in the promotion of health, the administrator of the government health organization should feel obligated, it is believed, to take full advantage of the unique opportunities presented for productive investigational work. The steering committee's function is to coordinate the serv- ices of the whole health organization to the end that group judg- ment and leadership may be exercised in formulating research programs, and that the facilities of the whole organization may be integrated, so far as may be feasible, in carrying out these projects. Through the leadership of this steering committee the facilities of universities and other agencies should also be en- couraged to participate. In this way. the organized facilities of services within and without the official health organization can be utilized cooperatively in advancing basic research projects in North Carolina. 17. Recommendations Pertaining to Industrial Hygiene Services a. That the industrial hygiene service be classified as one of the cooperative agencies of the State Health Department. b. That the facilities of this agency be integrated, insofar as practicable, with those of local health departments to the end that the specialized services which are carried out by it in whole- time health jurisdictions be reported to the local health officers in order that they may be kept fully informed of the status of industrial hygiene in their health jurisdictions and may be in a position, through their sanitary staffs, to supplement these soe- cialized services by cooperating and rendering follow-up services or in any other way mutually agreed upon. Comment Since the objectives of the Division of Industrial Hygiene are a joint responsibility of the State Board of Health and the State Industrial Commission, it would appear logical for this service to be organized as a cooperating agency rather than as a tech- nical service of the State Board of Health as at present. If such a change in the organizational relationship of this service were made, it is suggested that consideration be given to the setting up of a Committee on Industrial Hygiene to assist the executive officers of both the State Board of Health and the State Indus- trial Commission in the Division's administration. The purpose of such a coordinating committee is to simplify the interdepart- mental relationships without in any way divorcing this service from the State Board of Health. The second objective of these recommendations is to effect Public Health Administration in North Carolina 173 the integration of the facilities of the Division of Industrial Hygiene with those of whole-time local health departments to the extent that such cooperation may be mutually beneficial. 18. That a public health operating manual embodying the principles, policies, and procedures of the entire health organiza- tion be prepared for the guidance and orientation of the staffs of the state and local health departments in the fulfillment of their several interrelated functions. Comment An operating manual is an instrument which gives a clear exposition of the several services of the State Health Depart- ment and of the services of local health organizations. It pro- vides a pattern of administrative procedures for the guidance of the staff of the central and local health organization to the end that the personnel of the whole health organization may function as a team in carrying out a unified program. Because public health administrative problems are complex and the rou- tine demands upon the time of health officers interfere with con- structive thinking and planning disorientation is apt to result, and trivial matters may be permitted to consume the valuable time of public health personnel. Furthermore, health officials who operate on the basis of a topical program are apt to expe- rience difficulty in its realization, and because of the obstacles presented they may become content to do routine matters which arise every day rather than to exercise administrative ingenuity in working objectively toward the attainment of definite public health goals. Owing to these circumstances, the recommendation set forth here is considered of major importance. The preparation of an operating manual should be the re- sponsibility of a joint committee consisting of state and local representatives. Its membership might well be the directors of the various divisions of the State Health Department and out- standing local health officers, public health nurses, sanitarians, and clerks. The scope of the operating manual should cover the organization and services of the various divisions of the State Health Department and also of whole-time local health depart- ments. Thus, through the utilization of group judgment in the establishment of standards of practice, the promise of integration of personnel and assets of central and local health departments in the execution of a unified health program would appear to be most effectively provided for. Part I of this report is, in a limited sense, an abridged operat- ing manual. Much of the material presented should be of value to the proposed committee in the accomplishment of its objectives. APPENDIX APPENDIX Table Xe. Expenditures of the State Board ol Health, 1037-1938 1 Counties of North Carolina, Area, Population, (1930 Census), and Assessed Valuation 2 General Fund Receipts, 1937-1938 3 General Fund Expenditures, 1937-1938 4 Highway Fund Receipts, 1937-1938 5 Agriculture Fund Receipts, 1937-1938 6 State Charitable, Correctional, and Penal Institutions, and County Institutions in North Carolina 7 Institutions of Higher Learning in North Carolina, Standard Four-Year Colleges (White) 8 Institutions of Higher Learning in North Carolina, Standard Four-Year Colleges (Colored) 9 County Tuberculosis Sanatoria in North Carolina 10 Racial Distribution of Population in North Carolina 11 Public Health Administration in North Carolina 179 TABLE NO. 1 EXPENDITURES OF THE STATE BOARD OF HEALTH 1937-1938 Total E.\penditures Sources of Funds Division State General Fund Federal Funds* Special Funds Administration $ 22,215.56 379,639.06 49.064.33 71,743.45 144,391.22 121.411.11 123,256.66 28,813.14 11,080.03 17,450.90 105,212.64 10,093.92 $ 13,317.10 95.513.04 32,223.82 58,378.39 70,494.34 31,747.02 117,678.65 24,166.92 11,080.03 $ 8,898.46 281,126.02 5.582.39 4.538.47 31,420.80 89,664.09 5,578.01 4,646.22 17,450.90 105,212.64 10,093.92 $ 11,258.12* County Health Work _. 8.S26.59t Epidemiology' 42,476.041 Sanitary Engineering Oral Hygiene _. Preventive Medicine _. Laboratorv of Hygiene _ -- \'ital Statistics .. .. .. Printing .. _ .- Industrial Hygiene Crippled Children Alalaria Control Total $1,084,372.02 $ 457,599.31 $ 564,211.96 $ 62,560.75 * — Reynolds Foundation Fund t — Bedding Fund. ■*■ — Special Dental Fund. FEDERAL FUNDS U. S. Public Health Service Funds $ .337,914.39 Children's Bureau: M. C.H $ 121,084.91 Crippled Children 105,212.64 226, 297.. 57 S 564,211.96 180 Public Health Administration in North Carolina TABLE NO. 2 COUNTIES OF NORTH CAROLINA AREA, POPULATION, (1930 CENSUS), AND ASSESSED VALUATION Counties Land Area in Square Miles Total Population Total .\ss ss d Valuation 1937 NORTH CAROLINA 48,740 3,170.276 2,348,030 143 Alamance 492 289 234 556 427 23S 840 703 976 790 082 534 390 471 220 573 402 40S 696 4.54 Kio 220 496 933 660 670 292 377 569 258 790 312 509 388 46S ■■m 359 298 503 252 6;il 676 588 .546 35S 341 417 iil7 588 494 42,140 12,922 7,186 29,349 21,019 11,803 35,026 25,844 22,389 15,818 97,937 29,410 44,331 28,016 5,461 16,900 18,214 43.991 24.177 16,151 11,282 5 434 51.914 37,720 30,665 45.219 6.710 5.202 47,865 14,386 35,103 67,196 47,894 111,681 29,456 78,093 10.. 551 5.841 28.723 18,656 1.33.010 53,246 37,911 28.273 23.404 17,542 14.244 8,550 46,693 17.519 35,611,200 Alexander. .. 7 675 746 Aleghany 4,0.S3 125 Anson . . 14,441,545 Ashe .- _ 3.8.58.812 A verT 4.377,990 Beaufort . 21,681 701 Bertie 9.744,808 Bladen. 11.019.971 Brunswick Buncombe.. 7.008.435 89.762.336 Burke 2.5.041.399 Cabarrus. ... 45.1.50.284 Caldwell . 21,816,092 Camden 3,153.112 Carteret 10.225.427 Caswell 7. 9S 1.646 Catawba . . 43.s63,049 Chatham.- 15.. 59 1.969 Cherokee .. 7,415,254 7.085.807 Clay 1.597.777 Cleveland . . . . 29,45S,030 Columbus 19.0S3.301 Craven.. 13.404,862 Cumberland.. 23.423,769 4.. 307. 986 Dare 2. 6^1,568 Davidson . 32, S2 1,890 Davie 10.S60.030 15,839,617 Durham. _ .. 111,S61,381 24,493,976 Forsyth 161,1.5S,015 12.033,357 Gaston . ... .. 82,394,457 5,530,445 Graham 6.. 560. 030 16.976.757 Greene . 6,731.857 Guilford-. 171,328,569 Halifax 30.S14,405 Harnett 21.S05.,507 Havwood. . 24,210,933 Henderson 21. .521, 597 Hertford 9,891,942 Hoke 7,312,601 Hyde 3.846,853 Iredell 34.419.281 Jackson 8,018.776 Public Health Administration in North Carolina 181 TABLE NO. 2— Continued COUNTIES OF NORTH CAROLINA AREA, POPULATION, (1930 CENSUS), AND ASSESSED VALUATION Counties Johnston Jones Lee Lenoir Lincoln McDowell... Macon Madison Martin Mecklenburg - Mitchell Montgomery. Moore Nash New Hanover Northampton. Onslow Orange Pamlico Pasquotank.. Pender Perquimans.. Person Pitt Polk Randolph R ehmond. . . Robeson Rockingham.. Rowan Rutherford- . Sampson Scoltand Stanly Stokes Surry Swain Transylvania _ Tyrrell Union Vance Wake Warren Washington... Watauga Wayne Wilkes Wilson Yadkin Yancey Land Area in Souare Miles S07 417 2t]l 3&0 2f'9 400 513 43 t-- oc ■ 30 UiO 10 24 34 12 12 24 IG 9 25 is IS 30 4 4 S 23 20 40 514 311 825 Buncombe Columbus Cumberland Durham (Infirmary) Edgecombe Forsyth Guilford Halifax V'ance (Scott Parker Sanatorium) Johnson Mecklenburg Nash Wake Wilkes New Hanover Martin Wilson Asheville Whiteville Fayettevill>___ Durham Tarboro Winston-Salem Jamestown Halifax Henderson Smithfield Huntersville, . Nashville Raleigh Wilkesboro Wilmington Williamston Wilson 190 Public Health Administration in North Carolina o z I— I < 1^ O < o X H O o H < 1-9 h O o o H P tt H 14 8 O O cr. o O O ^ '(f O t'- CC W5 O «5 O lO O O »ft ^ O lO Oi ic ^ -^ r- tn i^ I- IC — " ^ » *o r^ oo ■«*• M M cc o c o TT O ""»• CSI CJ CC >— ' o d o o o* « r^ zs ca CO cc c^ o S o o o o o to OC' t^ 1— I O r^ -^ -^ cc •-> c^ o: iiD o d -<»• 00 :c t-- CO — ^ ^- c^ c: r^ :c >— p CO ?5 i t' t-- C; X lO ■p .2 c s 'c. "2 = o ^ Ph CO fl. o aa a o M ^ '-5 ££S.^^ This book circulates for a 2-week period and is due on the last date stamped below. It must be brought to the Ubrary to be renewed. Form No. 771 ] UNC-CH HEALTH SCIENCES LIBRARY H00115416 h WA 540 AN8 M152 1940 c. 2 Mcintosh, WiMiam Alexander, 1890- Public Health Administration in North Carolina