Report or International Health Education Conference of the World Conference on Education under the auspices of the National Education Association June 28-July 6, 1923 San Francisco, California TABLE OF CONTENTS Page GROUPS CO-OPERATING TO PREPARE THE PROGRAM. . . . 5 PROGRAM 7 COMMITTEES 11 FOREWORD 13 Part I THE HOPES AND AIMS OF THE CONFERENCE 15 Introductory Remarks, by Dr. Augustus Thomas, Dr. Thomas D. Wood-16; Address of Welcome, by Mr. Courtenay Dinwiddie- 17; The Interest of the National Education Association in a Health Education Program, by Mr. William B. Owen-21; The Needs and Possible Scope of Health Education in the World Today, by Dr. William Palmer Lucas-26; The Spirit of Health Education, by Miss Sally Lucas Jean-33. Part II SOME FUNCTIONING HEALTH PROGRAMS 37 Health Education of Very Young Children, by Miss Edna White- 37; Discussion, by Miss Helen Reynolds-42; Dr. Keating-44; A Successful Elementary School Program, by Mrs. Mary M. Fitz- Gerald-44; Discussion, by Mrs. Rebekah K. Earle-50; Mr. Walter W. Davis-51; The Virginia Plan for Health Education, by Dr. Mary Evelyn Brydon-54; Discussion, by Mrs. Josephine Corliss Preston-61; Belgian Work With Undernourished Children, by Mlle. Madeleine Kaiser-64; Round Table on Schoolroom Prob- lems in Health Education, by Miss Hannah L. Lezinsky, Dr. Clara Greenough-68; Mrs. Gertrude Whitton Barrett, Mrs. John Collier, Miss Maud Steinbach-69; Miss Lezinsky, Mrs. Barrett, Miss Leila Wilson-70. Part III SOME FACTORS IN A HEALTH EDUCATION PROGRAM... 71 Objectives in. Health Education, by Miss Mary E. Murphy-71; Discussion, by Miss Emma Dollinger-77; Educational Principles that Should Underlie Effective Methods, by Prof. H. B. Wilson-78; Discussion, by M. Leon de Paeuw-80; Dr. Thomas D. Wood- 81; The Use and Abuse of Physical Indices in a Program, of Health Education, by Dr. Bird T. Baldwin-82; Discussion, by Miss Maud A. Brown-89; Dr. Fred Burger-90; Dr. Henry Koch, Dr. Baldwin-92; The Importance of Health Education in a Public Health Program, by Prof. C. E. Turner-92; Round Table on Ad- ministrative Problems in Health Education: Prof. Turner-98; Dr. Walter McNab Miller, Dr. Katherine Wolfe-99; Miss Edith S. Countryman, Dr. Clara M. Greenough, Miss L. E. Perritt, Dr. Bird T. Baldwin-100; Dr. Clark Hetherington-101. Page NUTRITION IN RELATION TO HEALTH EDUCATION 103 The Food Needs of the Nation in Relation to Economic Resources, by Dr. A. E. Taylor-103; Discussion, by Dr. Herbert M. Coulter -114; Dr. Henry Koch-115; The Essentials in the Training of Nutrition Workers in Public Schools, by Dr. E. V. McCollum-115; Discussion, by Dr. Agnes Fay Morgan-121; Dr. John N. Force, Dr. Adelaide Brown-122; Dr. Montague Cleeves, Miss Maud Brown, Miss Mary Murphy, Miss Sally Lucas Jean-123; Nutri- trition Work in Public Schools, by Miss Mary G. McCormick-124; Nutrition Work of Non-School Agencies, by Miss Margery M. Smith, -131; Discussion, by Miss Jessie M. Hoover-136; The Place of Home Economics in the Health Education Program, by Miss Mar- garet Sawyer-138; Discussion, by Miss Louise Stanley-144. Part IV Part V THE RELATION OF PHYSICIANS AND DENTISTS TO HEALTH EDUCATION 146 The Contribution Physicians Have to Offer to Health Education, by Dr. Harold K. Faber-146; Dr. Haven Emerson-149; Discussion, by Dr. John Foote-155; Dr. E. V. McCollum-156; Dr. William Palmer Lucas-157; The Contribution of the Dentist to the Health Education Program, by Dr. Guy Millberry-157; Discussion, by Dr. W. M. Cameron-161; Dr. Nobbs, Dr. John E. Gurley, Dr. Haven Emerson-162; How the School Can Best Use Professional Health Workers, by Dr. John M. Dodson-163; Discussion, by Dr. John Sundwall-173; Dr. E. A. Layton-174; The Building of a School Health Program, by Dr. Antonia Ursua-175; Health Education in Mexico, by Dr. Alphonso R. Ochoa-177; Discussion, by Dr. Herbert F. True-180; Dr. Katherine Wolfe, Dr. Alvin Powell-181; Public Care of Health in Germany, by Dr. Wilhelm Hagen-182. Part VI THE NURSE AND HEALTH EDUCATION 185 Courses of Study in Schools of Nursing, by Miss Carolyn Gray- 185; Discussion, by Miss Maude Landis-193; Injecting Health Education into the Curriculum of Schools of Nursing, by Miss Mary May Pickering-194; Discussion, by Miss Anna G. Jamm£-201; Dr. Walter McNab Miller-203; Health Education as a Subject for Graduate Schools, by Miss Edith S. Bryan-203; Discussion, by Dr. Estelle Warner-206; Miss Elnora Thomson, Miss Mary L. Cole-207; Miss Marion Crowe-208; The Nurse's Oppor- tunity in Health Education, by Miss Sally Lucas Jean-211; Round Table on the Nurse in Health Education, by Miss Thomson, Dr. Miller, Miss Perritt, Miss Grace Anderson, Miss Friend, Mrs. G. M. Blakely, Miss Evelyn Wood, Miss Cole-217; Mrs. Isabelle W. Baker, Miss Jean-218; Miss Anderson, Miss Davis, Miss Pickering-219. Page PHYSICAL EDUCATION IN RELATION TO HEALTH EDU- CATION 220 Behavioristic Psychology and Physical Education, by Dr. Herbert R. Stolz-221; Discussion, by Mr. George Hjelte-225; Athletics for Girls, by Miss Alta Sims-227; A New Program in Physical Education, by Miss Florence D. Alden-230; Discussion, by Dr. R. Tait McKensie-240; Dr. William Burdick-242; Coordination of Health Teaching and the Play Activity Program, by Miss Mar- guerite M. Hussey-242; Discussion, by Mr. J. B. Nash, Miss Christina Stael von Holstein-246; The Washington Conference on Athletics for Girls, by Miss Helen Bunting-248; Discussion, by Miss Helen McKinstry-253. Part VII Part VIII THE TRAINING OF TEACHERS AND LEADERS FOR HEALTH EDUCATION 255 Announcement of Scholarships, by Miss Jean-255; Putting the Practice of Health into the Teacher-Training Program, by Miss Mary I. Preston-156; Discussion, by Dr. Clara M. Greenough- 262; Miss Alice Wilmarth-264; Prof. Clark Hetherington-266; Scientific Foundation of the Health Teacher's Professional Training, by Dr. Edna W. Bailey-266; Discussion, by Dr. John Sundwall -274; Miss Dolfinger-280; Plans for Health Education in Bel- gium, by M. L6on de Paeuw-281; The Growth of Health Teaching in Japan, by Miss T. Ueda-283; The Health Needs of Ecuador, by Miss Hortensia Balarezo-285; The New Conception of Physical Education in China, by Mr. Thomas Yuan-287; Health Education in Nicaragua, by Miss Juanita Molina-289; Discussion, by Miss Edythe Hershey-290; Training Teachers and Supervisors for Carrying Out a Health Program, by Dr. Thomas D. Wood-291; Education's Obligation to Parenthood, by Miss Alma Binzel-294. Part IX THE CONTRIBUTION OF NON-SCHOOL AGENCIES TO A HEALTH EDUCATION PROGRAM 301 The Belgian Red Cross, by M. Edmond Dronsart-301; The League of Red Cross Societies, by Miss Theodora George-305; The Amer- ican Red Cross, by Mr. William Carl Hunt-307; Boy Scouts of America, by Dr. G. H. Richardson-310; The Girl Scouts of America, by Mrs. Herbert Hoover-313; Dr. Elizabeth Kemper Adams-315; Miss Mary Hicks-320; The Girl Guides of Eng- land, by Miss Marjorie Wise-321; The Camp Fire Girls, by Miss Celia Davis-322; The Young Women's Christian Association, by Dr. Anna L. Brown-323; The Modern Health Crusade of the National Tuberculosis Association, by Dr. Linsly Williams (read by Miss Edith Countryman)-328; The Playground and Recreation Association of America, by Mr. J. B. Nash-332; The Woman's Christian Temperance Union, by Miss Cora Frances Stoddard- 334; The Narcotic Education Association, by Mr. H. R. Bonner- 336; American Social Hygiene Association and National Health Council, by Dr. William F. Snow-337; American Public Health Association, by Prof. C. E. Turner-338; Health Centers, by Mrs. Gertrude Whitton Barrett-339; Expressions of Appreciation, by Mr. Thomas Yuan, Dr. Thomas D. Wood-341. RESOLUTIONS PRESENTED BY THE HEALTH EDUCATION CONFERENCE TO THE PLENARY SESSION OF THE WORLD CONFERENCE ON EDUCATION 342 MEMBERS OF COMMITTEE ON RESOLUTIONS 345 GROUPS CO-OPERATING TO PREPARE THE PROGRAM Joint Committee on Health Problems in Education of the National Education Association and the American Medical Association THIS committee was established in 1911 with the pur- pose of promoting the health interests in the schools of the country by proposing and recommending standards of health for the schools and by preparing health reports and health charts dealing with various phases of health problems in public education. The Joint Committee has now in preparation a program of Health Education for Public Schools and Teacher Training Institutions and an- other report on Standards of Health Norms and Health De- fects of School Children. Previous publications have had a combined circulation of approximately two million. Chair- man, Dr. Thomas D. Wood, Columbia University, New York City. American School Hygiene Association This association endeavors to unite in a professional or- ganization the American administrators and field workers, including superintendents, directors, principals, super- visors, teachers, physicians, dentists and nurses in all the various subdivisions of the field of health in education in order that methods may be perfected; experiences and records exchanged; standards established; suggestions evaluated; proposals studied; research encouraged and service extended. It aims thus to aid in promoting nation- wide provision for and improvement in the work of health building, health supervision, and health teaching in all grades of all schools. Dr. Harry B. Bums, Secretary Treasurer, Board of Public Education, Pittsburgh, Pa. Child Hygiene Department of the National Education Association This department aims to secure for every child in the public schools modern fireproof buildings, so planned and cared for as to conserve and upbuild health; a properly organized health supervision, including annual health ex- aminations, services of school nurses, clinics and special classes for the physically handicapped; a physical education which shall create both desire and opportunity for proper daily physical activity for all; and a graded course in hygiene teaching including health habit formation, in- formation as to the necessity of these habits, ideals of health and physical efficiency, and proper individual and community attitudes toward health. Chairman, Dr. Wil- liam A. Howe, State Department of Education, Albany, N. Y. Physical Education Department of the National Education Association It is the aim of this program to bring up for discussion three phases of Physical Education, and to determine the place and importance of each. (1) The development of social qualities and their bearing on successful living. (2) The opportunity of the teacher of Physical Education to teach healthy living. (3) The right type of athletic activity for girls. Chairman, Ethel Perrin, Board of Education, Detroit, Mich. American CHILD HEALTH Association The association believes that all health education for children must concentrate on gaining their active interest in health, and that physical well-being must be lifted up before them as a glorious positive ideal in terms of beauty, strength and joy. It believes that parents, doctors, teachers, nurses-all health workers, everywhere-who share this ideal and work together to realize it, will profoundly affect the world for lasting good. Courtenay Dinwiddie, General Executive, Administrative Office, 370 Seventh Avenue, New York City; Headquarters, 532 Seventeenth Street, N.W., Washington, D. C. PROGRAM Chairman of Sessions Dr. Thomas D. Wood Teachers College, Columbia University, New York City The Hopes and Aims of the Conference Papers presented by Courtenay Dinwiddie, General Executive, American Child Health Association, New York City. William B. Owen, President, National Education Association, 1923, and Chicago Normal College, Chicago, III. Dr. William Palmer Lucas, Professor of Pediatrics, University of California Medical School, San Francisco, Calif. Sally Lucas Jean, Director, Health Education Division, Ameri- can Child Health Association, New York City. Some Functioning Health Programs Papers presented by Edna N. White, Director, Merrill-Palmer School, Detroit, Mich. Mary M. Fitz-Gerald, Principal, John Swett School, San Fran- cisco, Calif. Dr. Mary Evelyn Brydon, Director, Bureau Child Welfare, State Board of Health, Richmond, Va. Mlle. Madeleine Kaiser, Director of the Colony for Debilitated Children, Brussels, Belgium. Discussions led by Helen M. Reynolds, Head of Department of Primary Method, Seattle Public Schools, Seattle, Wash. Mrs. Rebekah K. Earle, Assistant Nutrition Director, City Schools, Los Angeles, Calif. Walter W. Davis, Ph.D., Supervisor Physical Education and Hygiene, Seattle Public Schools, Seattle, Wash. Mrs. Josephine Corliss Preston, Superintendent of Public In- struction, State Department of Education, Olympia, Wash. 8 Factors in a Health Education Program Papers presented by Mary E. Murphy, Assistant Director, Elizabeth McCormick Memorial Fund, Chicago, III. H. B. Wilson, Superintendent of Schools, Berkeley, and Pro- fessor of Education Administration, University of California. Dr. Bird T. Baldwin, Director, Iowa Child Welfare Research Station, University of Iowa, Iowa City, Iowa. C. E. Turner, Assistant Professor, Department of Biology and Public Health, Massachusetts Institute of Technology, Boston, Mass. Discussions led by Emma Dolfinger, Associate Director, American Child Health Association, New York City. Leon de Paeuw, Director General of Normal Schools, Ministry of Science and Arts, Brussels, Belgium. Maud A. Brown, Elizabeth McCormick Memorial Fund (Director Elect of Health Education for the Fargo, N. D., Child Health Demonstration). Nutrition and Health Education Papers presented by A. E. Taylor, Director, Food Research Institute, Stanford Uni- versity, Calif. E. V. McCollum, Professor, Department of Chemical Hygiene, Johns Hopkins University, Baltimore, Md. Mary G. McCormick, Supervisor of Nutrition, State Department of Education, Albany, N. Y. Margery M. Smith, Assistant in Nutrition, Extension Service, Oregon State Agricultural College, Corvallis, Ore. Margaret Sawyer, Director of Nutrition Service, American Red Cross, Washington, D. C. Discussions led) by Agnes Fay Morgan, Ph.D., Department of Home Economics, University of California, Berkeley, Calif. Jessie M. Hoover, Milk Utilization Specialist, U. S. Department of Agriculture, Washington, D. C. Louise Stanley, Chief, Bureau of Home Economics, U. S. Department of Agriculture, Washington, D. C. 9 The Relation of School Physicians and Dentists to Health Education Papers presented by Dr. Harold K. Faber, Professor of Pediatrics, Stanford Uni- versity Medical School, Calif. Dr. Haven Emerson, Professor of Public Health Administration, Columbia University, New York City. Dr. Guy Millberry, Dean, Dental Department, University of California, San Francisco, Calif. Dr. John M. Dodson, Dean, Rush Medical College, University of Chicago, Chicago, III. Dr. Antonia Ursua, Representative of Secretary of Education, Mexico. Dr. Alfonso R. Ochoa, Representative of Secretary of the Bureau of Health Education and Propaganda of the Depart- ment of Public Health, Mexico. Dr. Wilhelm Hagen, City Physician, Hbchst am Main, Germany. (Paper read.) Discussions led by Dr. John Foote, Washington, D. C. Dr. W. M. Cameron, University of California, College of Dentistry, San Francisco, Calif. Dr. E. A. Layton, Director of Health, Tacoma Public Schools. Dr. Alvin Powell, Director, Public Health Center of Alameda County, Oakland, Calif. The Nurse and Health Education Papers presented by Carolyn E. Gray, Department of Nursing Education, Western Reserve University, Cleveland, O. Mary May Pickering., Director, School of Nursing, University of California Hospital, San Francisco. Edith S. Bryan, Assistant Professor Public Health Nursing, University of California, Berkeley. Mary L. Cole, Director of Nursing Service, Pacific Division, American Red Cross. Marion G. Crowe, Superintendent Visiting Nurse Association, Portland, Ore. Sally Lucas Jean, Director, Health Education Division, Ameri- can Child Health Association, New York City. Discussions led by Maude Landis, Superintendent, Stanford University Hospital, San Francisco. Anna G. Jamme, Director, Bureau of Registration of Nurses, California State Board of Health, San Francisco. Dr. Estelle Warner, Director, Department of Child Hygiene, Oregon State Board of Health, Portland. 10 Physical Training in Relation to Health Education Papers presented by Dr. Herbert R. Stolz, Supervisor of Physical Education, State Board of Education, Sacramento, Calif. Alta Sims, Director of Physical Education in Public Schools, Oakland, Calif. Florence D. Alden, Director, School of Physical Education, Department for Women, University of Oregon, Eugene, Ore. Marguerite M. Hussey, Head, Department of Physical Education for Women, State Teachers College, Fresno, Calif. Mrs. Herbert Hoover, Vice-President National Amateur Athletic Federation. Helen Bunting, Assistant Professor and Director of Physical Education for Women, Stanford University, Calif. Discussions led by Mr. George Hjelte, Assistant State Director of Physical Educa- tion, Sacramento, Calif. Dr. R. Tait McKensie, University of Pennsylvania, Philadelphia. J. B. Nash, Director of Physical Education and of Play Activities, and Superintendent of Playgrounds, Oakland, Calif. Dr. William Burdick, Director, Playground Athletic League, Baltimore, Md. Christina Stael von Holstein, Normal School, Stockholm, Sweden. Helen M. McKinstry, Director, Central School of Hygiene and Physical Education, New York City. The Training of Teachers and Leaders for Health Education Papers presented by Mary I. Preston, San Francisco State Teachers College, Calif. Edna W. Bailey, Ph.D., Supervisor of the Teaching of Science, University High School, Oakland, Calif. Leon de Paeuw, Director General of Normal Schools, Ministry of Science and Arts, Brussels, Belgium. Miss T. Ueda, Department of Justice, Japan. Hortensia Balarezo, Representative from Ecuador. Thomas Yuan, Peking Teachers College, Peking, China. Juanita Molina, Representative from Nicaragua. Dr. Thomas D. Wood., Adviser in Health Education, Teachers College, and Professor of Physical Education, Columbia Uni- versity; Chairman, Joint Committee on Health Problems in Education of the National Education Association and the American Medical Association. Alma Binzel, Assistant Professor of Child Training, Home Economics Department, University of Minnesota, Minneapolis. 11 Discussions led by Dr. Clara M. Greenough, Health Education Department, State Normal School, Cheney, Washington. John Sundwall, Ph.D., M.D., Director, Division of Hygiene and Public Health, University of Michigan, Ann Arbor, Mich. The Contribution of Non-School Agencies to a Health Education Program Papers presented by Edmond Dronsart, Director General, Belgian Red Cross, Brus- sels, Belgium. League of Red Cross Societies-Theodora George, Junior Red Cross Division, Paris, France. American Red Cross-William Carl Hunt, Assistant to Vice- Chairman, Washington, D. C. Boy Scouts of America-Raymond 0. Hanson, Scout Executive, San Francisco, Calif. Girl Scouts of America-Mrs. Herbert Hoover, President; Dr. Elizabeth K. Adams, Educational Secretary, New York City, and Mary Hicks, Educational Director, Public Health Feder- ation, Cincinnati, Ohio. British Girl Guides-Marjorie Wise, England. Camp Fire Girls-Celia Davis, San Francisco, Calif. National Y. W. C. A.-Dr. Anna L. Brown, Education and Re- search Division, New York City. National Tuberculosis Association-Dr. Linsly R. Williams, Managing Director, New York City. American Playground and Recreation Association-Jay B. Nash, Superintendent of Recreation and Director of Physical Education, Oakland Public Schools, Oakland, Calif. National W. C. T. U.-Cora Frances Stoddard, Director, Washington, D. C. The Narcotic Education Association-H. C. Bonner, Secretary, Los Angeles, Calif. American Social Hygiene Association and National Health Council-Dr. William F. Snow, General Director, Amer- ican Social Hygiene Association, New York City. American Public Health Association-Professor C. E. Turner, Massachusetts Institute of Technology, Boston. Health Centers as Institutions for Health Education- Mrs. Gertrude Whitton Barrett, Secretary Health Education, ■ Public Health Center, Oakland, Calif. COMMITTEE ON ARRANGEMENTS Dr. Thomas D. Wood, Chairman Sally Lucas Jean, Secretary 12 LOCAL COMMITTEE ON ARRANGEMENTS Dr. Alvin Powell, Chairman, Oakland Mrs. Lucy Wood Collier, California Representative Ameri- can Child Health Association, San Francisco Dr. Edna W. Bailey, Berkeley Edith S. Bryan, Berkeley Mrs. Alfred I. Esberg, San Francisco Mrs. Wm. A. Fitz-Gerald, San Francisco Mrs. C. Hetherington, San Francisco Dr. William Palmer Lucas, San Francisco Mrs. E. J. Mott, San Francisco Jay B. Nash, Oakland Mary Preston, San Francisco Elisabeth Sherman, Oakland Mrs. F. C. Turner, Oakland Emma Dolfinger, Chairman Dr. Richard A. Bolt Dr. William Burdick Dr. Harry B. Burns Dr. William A. Howe Dr. Charles H. Keene Ethel Perrin Elnora Thomson COMMITTEE ON PROGRAM FOREWORD The Lamp and the Servant of the Lamp A BOY called Aladdin, after many adventures, found a wonderful lamp. Every boy and girl who has ad- ventured in the country of knowledge, since the world began, has found a lamp no less miraculous: the clear shining of a trained mind. All of us must live within a little plot of life fenced in with years. But by rubbing up the lamp of the mind we may break through into the past and take possession of broad acres bounded by centuries. Therein lies the fascina- tion of learning. With the mind we may take possession of the past, but to fulfil its dreams for the future, the mind must call upon its servant, the body. Knowledge develops aptitudes, and aptitudes to children open up tremendous vistas of glory. John is good at mathematics and in his dreams he builds bridges over the seven seas. William loves to read of far countries in his geography book and the scent of spices and the breath of the hot south wind blow about him as his ship beats up the Indian Ocean. The educational process to be successful must fit a steady hand to the bridge-builder's mind, a strong supple body to the trader's instinct. The servant must be trained to do the bidding of the lamp. The International Health Education Conference, held in San Francisco, June 28 to July 6, 1923, marks the beginning of a new epoch in education, for it indicates that this co- education of mind and body has begun. Health teaching has taken its place in the school curriculum, not as a fad, not as a one-sided fanatical program, but as one important branch of education. At that Conference, which was held as a section of the World Conference on Education, phy- sicians, research workers and educators met on the same platform and discussed sane practical plans for the cultiva- tion of the whole child, mind and body. 13 14 The enthusiasm and the unselfish labor of the classroom teacher and the health worker have brought the Health Education movement to the point of its acceptance as an integral part of the school curriculum. It is to these teachers and health workers, and to the institutions that trained them and will train those who follow after them, that this report of the International Health Education Con- ference is dedicated. Within it are stored the expert knowledge and the practical experience of leaders in the fields of education, medicine, nursing and nutrition, who gave the addresses and took part in the discussions. It contains the final reso- lutions of the Conference on Health Education which were presented to and unanimously passed by the World Con- ference. These resolutions are instinct with a world-wide significance, for they represent the earnest deliberations of delegates from all over the United States and from thirty- two foreign countries. This report is offered as one landmark in that country of knowledge where the lamp and the servant of the lamp, the trained mind and the trained body, are the rewards of all adventurers. Part 1 THE HOPES AND AIMS OF THE CONFERENCE A WORD of explanation is perhaps necessary to a com- plete understanding of the following program and proceedings. The world's store of knowledge, rela- tively scant though it be, is far in excess of its application of that knowledge. Nowhere is this truer than in the fields of science that pertain to healthy living. In the United States we have striven during recent years, to make familiar to the man in the street, some of the facts of physiology, nutrition and sanitation established in our scientific labora- tories. While there is still much controversy, we are on the whole agreed on certain personal and public health essentials. One of our great needs is to teach these facts so they will function in people's lives. We believe that the most effective place to begin is in the schools with the children. Therefore, to develop effective methods of Health Edu- cation for children and for their teachers, is with us, in the United States today, one of our vital tasks. This Conference was called to further our Health Education program. That is why the discussions in the report deal with educational aims and methods, with choice of subject-matter from dif- ferent fields, with problems of administration. That is why there is no mention of public health measures, nor of the contribution to hygiene, to the conquest of disease, to the better understanding of physiology, as these have come from our laboratories. We have chosen but one of the many problems, that of interpreting our present knowledge for the use of teachers, to be incorporated as simply and hap- pily as possible into the lives of children. It is hard to transfer to paper the eager spirit of service to childhood that animated the Conference. In preparing the report we have summarized the thought of each session, and have presented in full those messages which would have lost their effectiveness if condensed. With this explanation, the following report of the Conference is offered. 15 16 MOST fittingly, the Chairman of Sessions, Dr. Thomas D. Wood, opened the Conference by introducing Dr. Augustus O. Thomas, State Superintendent of the Schools of Maine, Chairman of the Foreign Relations Committee of the National Education Association, under whose leader- ship the World Conference on Education was brought to realization. After welcoming the foreign delegates to the Interna- tional Conference on Education and expressing his appreci- ation of the support and sympathy of President Owen of the National Education Association and the agencies coop- erating to produce the International Health Conference, Dr. Thomas concluded his brief remarks thus: "There is not any greater or more important thing- before the educational world-than to bring up the children so that they can render their greatest service to humanity. And in these conferences we hope to develop those ideals, programs and directions which will help 'the five million teachers of the world to carry to the two hundred million children in the schools of the world the messages which will make them be useful men and women. And I hope that this group meeting on the health aspect of the world's children may mark the beginning of new things for the children of the world." Dr. Wood then began the real business of the Conference by outlining its plan of organization to those present as follows: Dr. Wood: The International Education Conference officially is composed of delegates sent by organized education groups from thirty-two countries. These delegates have come pre- pared to discuss agenda on eight points of vital importance to education. Delegates will attend the separate meetings where each of the subjects of the agenda will be discussed preliminary to the drawing up of resolutions which will embody those significant points developed by the discussion, which the delegates in a special group think should be pre- sented to the World Conference as a whole. When such resolutions are adopted by the World Conference they will be broadcast to every country represented and will become a basis for discussion and perhaps a goal for action. 17 To carry out this plan we must appoint for every dis- tinct section of the Conference a qualified committee to draw up resolutions based upon the meeting in question. These resolutions when adopted by the Health Conference (section E of the World Conference) will then be presented by your chairman to the World Conference in its final plenary session. A Delegate: Mr. Chairman, I move that the Chairman of the meeting be authorized to appoint such a committee for each session each day, as seems desirable. This motion was seconded and no discussion being of- fered, it was submitted to viva voce vote. There being no dissenting vote, the Chairman announced the motion as carried and stated that the first committee would be ap- pointed in time to prepare resolutions on sessions one and two. The mechanics of the Conference being thus disposed of, the chairman prefaced his introduction of the first speaker with an evaluation of Health Education, saying in part: Dr. Wood: Health Education could be defined as the sum of the ex- periences in the school and elsewhere which favorably influence habits, attitudes and knowledge related to indi- vidual and community health. Health Education, through its program, should prepare the young in any community, in any nation,-the children and the youth of the world,- for all of the opportunities and the obligations of life. I am sure that it is the purpose of this group, in all of its deliberations and plans, to make this program contribute in the most helpful way to a world program of education which shall further the highest interests of mankind. The address of welcome at the beginning of this session will be given by Mr. Courtenay Dinwiddie, General Execu- tive of the American Child Health Association, New York, whom I am very glad to introduce. Mr. Courtenay Dinwiddie: IDO not know when I have felt more pleasure in greet- ing a group of thinkers and doers in as important a field as this, because I believe that there are millions, and 18 perhaps tens of millions of children, whose lives may be materially affected and helped by the deliberations and the work of this company and of those who are represented here today. Those who are engaged in Health Education are busy with a pioneer task. There is much that we have learned, and are learning every day as to new and better ways of meeting the needs of the young child and of stimulating his development along the lines that Dr. Wood has suggested to you. But already there has been enough of real, genuine achievement, both to furnish an inspiration to us, and to make us sure that we are going further yet in building up the resourcefulness and the strength of our coming generations. The thing that appeals most of all about this gathering today is its international character; the breadth of repre- sentation of different nations. The fact that we are gather- ing here, to discuss in common terms a most vital problem, represents one step, and a most important step, in thinking and acting internationally, and I do not know of anything that this world needs more today than that one thing. We have, in these modern days, adopted formulas for some of our problems and have found new methods of meeting the conditions of modern life; but it is distressing to see how slightly we have brought the information that some of us possess to the average mass of the people. In the rural districts in this country you will find too often taught in our schools in the name of health simply the old blood and bones physiology, or perhaps something a little bit better, and possibly you will also find some system of physical drill. At the same time you will see the immedi- ately surrounding area about those same schools literally drained of butter fats and of green vegetables, of those things that are a vital necessity to the physical development of the children there. You will be oppressed by a lack of sanitation that is appalling. Instruction concerning these subjects is perhaps touched upon in the schools, but in a way that does not grip or stir anyone to action. In our cities, hospitals and clinics have been developed for the care of those who are ill and in need of attention. But in going about among the children in our city schools, how often you will find conditions of undernourishment, or lack of devel- opment, or defects that make us ashamed to raise our 19 heads! On the part of those who are responsible for teach- ing our children, and even on the part of those whose duty it is to attend to their health, in cities as well as in country districts, there is too much lack of real knowledge of the basic principles, of methods of teaching, and in general of the whole of modern thinking on the subject of Health Education. I love that old English expression, "And he was made whole." What a picture it brings up of re-invigoration of the body and of the mental attitude! What a stimulus there is to the spiritual strength of the individual who is made whole! If we could begin now to have a vision of health of that sort, how little would our differences be! How easy it would be for the details of our program to fit in with one another! Our physicians, our nurses, our nutrition workers, and all of the rest of us who are contributing to this program would find our places in the picture in which nothing was out of drawing, in which we could just see the thing as a whole. Health should be one of the objectives of the whole educational system, and when we realize that, our task will be much easier. I want to make a plea to the educators who are in this group for the outsiders, the non-school agencies as they are called in this program. Let me say this: most of the people who have approached the school system to demand some development in the way of Health Education, or to try to assist in it, have done so because they have seen conditions in the raw, not only in the school, but in the home, on the street,-conditions of suffering, dirt, disease and degen- eracy; because they have seen the opposite side of the picture, the great possibilities of health, of strength, of happiness, that come from the full development of the in- dividual. That is why these people have wanted to make a contribution to the educational process from the standpoint of health. We are all here for the purpose of sitting down, and patiently and wisely trying to see where the objectives of those who are thinking primarily in terms of health can be fitted into the school system; how they can be carried out in ways that are pedagogically sound; how we can see the whole problem eye to eye, and join in a united plan of action. All of us are apt to forget sometimes that life is the greatest educator of all. Everywhere educators are using 20 the natural processes of the child's development to further his education. I should like to make a plea that we go a step further and use to the fullest all of those groups which are actually affecting conditions that surround the child every day, not only in the school but in the home, in the Sunday School, in the church, on the street. The educators know how to teach; many others who have a great contri- bution to make, do not know. Many parents, who are en- trusted with the most delicate task that exists in the world, do not know the most elementary principles of the education of a child. Think of the educational opportunities that exist for physicians, a group whose leaders are developing such wonderful things in preventive medicine! It is impressive to consider what could be done if the parents, physicians, nurses and nutrition workers had all of the pedagogical wisdom that the teacher has to give them; and if the phy- sician, the nurse, the nutrition expert, the physical director, could give to the teacher what she needs of the specific pro- fessional knowledge each such expert has to contribute! Let us all think of these various groups as part of one large educational system in which all are becoming teachers, and each is getting the benefit of what the other has to contribute. In uniting and making effective the forces of the com- munity for Health Education as well as other health measures we have only touched the service. Particularly in relation to the schools, we have not begun to realize in any adequate way the possibilities of Parent-Teachers Asso- ciations and neighborhood associations generally as great educational forces and as able allies to those who are in charge of the school. The great appeal about this whole Conference is its in- ternational character. If it can contribute even a little to the better understanding of one another's problems,-to mutual service between nations in the common cause of humanity,-it will have done a notable thing. I appeal especially to those from countries other than the United States, to participate in the discussions, to tell of their ex- perience and to offer their suggestions; to make this genu- inely the conference of everyone present. I welcome you most heartily. We have a wonderful opportunity here before us, and I am confident that we are going to use it to the fullest. 21 The Chairman: The successful promotion of Health Education in the national program of public education involves primarily the co-operation of two groups,-first, those whose business it is to promote professional interest in this field; but second, and of less importance, the educational supervisors, administrators, those who are responsible for and who deal with the educational program and its policy and practice as a whole. I have, then, very peculiar pleasure in announc- ing the next speaker, who is one of the leading educational administrators and statesmen of the United States, and one of the most intelligent, helpful supporters and promoters in the entire field of health education in this country. Mr. William B. Owen, President of the National Education Association, will talk to us on The Interest of the National Education Association in a Health Education Program Mr. Owen: MR. CHAIRMAN, Ladies and Gentlemen: It is a privi- lege to be here to address this unusual gathering, and to see realized here, what some months ago in the present condition of the world seemed a rather daring thing to undertake,-this great movement in this particular Con- ference, which seems to me especially important from the standpoint of international cooperation. You cannot annex or monopolize health. There is enough health to go around if we only know how to get it. There is no temptation to put up the tariff on it, or to exercise any unusual controls. It happens to be one of those things that we can give out, and still keep all that we have intelligence to retain. I want to talk this morning rather practically and definitely on this subject, from the standpoint of one who is practically concerned with education. I am going to say a good many things that I will not have time to defend, though I am ready to defend them. The school, of course, we know from the inside. I do not want to repeat a great many platitudes about schools. But the schools have a big task. The world changes so rapidly that it keeps the schools busy keeping up with it. If 22 we could only get the world stabilized long enough so that it knew what it was doing, our job would be a mighty simple one; but for a long time to come, we shall have to deal with a very rapidly changing world. And here is really, seri- ously, the difficulty that we have in dealing with Health Education in the schools. There is no objection on the part of teachers to taking on new things, but the difficulty lies in the large number of new things that we are asked to take on, and which we ought to take on. We cannot afford to go too rapidly in our selection and adoption of new things, be- cause if we take things in prematurely, we sometimes have to devote a good deal of time to getting them out. I speak, of course, from the standpoint of the American schools. There is a great deal of experimentation going on in Ameri- can schools all of the time, some of it deliberate and some of it unconscious. If we define "experiment" in an exact and true sense, and do not look upon it as something occa- sional, but as a studied method of life, then, all school life is experimental. That is as it ought to be. More and more we are coming to recognize the fact that we cannot, as school people, for a moment accept the point of view that what we teach in the school is all we need re- gard if we are going to control our education. Rather, there is a total life, a total experience that the child brings into the school. When it comes to school it already has had six years of education,-perhaps a good part of the possi- bility of education having been determined before we ever got the child in the school. While the child is coming to school it is all of the time under educative if not educational influences and experiences. The chief contribution the teacher can make to this child is to help him organize that experience, both extra-school and intra-school into some kind of a personal unity and efficiency. It is, therefore, virtually true that our whole course of study and curriculum in the more progressive schools is now being formed on the above basis. And this is the answer to the suggestion that the schools are likely to be troubled by a health program. Health as a part of the program is like any other thing that we take into the school. School is nothing but a co- operative enterprise on the part of the community to do in a way more economical of time and of energy what the community cannot do individually. Whenever it became more economical in time and in energy to teach people to 23 read in a school, they began to teach them in school. After we got that pretty well worked out, people seemed to settle down to the idea, that that was all the school ought to teach. This is how the curriculum is enlarged. When the com- munity cannot do as well in any other way, what the community senses as necessary for the children who are growing up; when knowledge necessary for the develop- ment and growth of children is not commonly available, or not found in the life of the family and of the community,- in other words, when you need something of an expert character, then that something gets into the schools. So it will be with Health Education. Just as soon as people get beyond the level where they try to control their health by reading the suggestive labels on patent medicine bottles, or by the family traditions, and have the teachers begin to set up for them some plausible relation between practice and result,-then, the average family recognizes that it is un- able to function in this field, seeks professional guidance,- and the school has to take it over. We are trying in a health program to do that type of thing. Of course, one of the difficulties that we are having in our health program right now is the shifting in technical and professional opinion as to what is really necessary in order to control health. First, how shall we get our material, our subject-matter, which is to be the scientific and intellectual basis for a health program? We must get that by some sort of co- operation between the medical societies and the students of health,-scientists of all sorts who have to do with the body,-biologists, chemists and food specialists. We shall have to lay a foundation of solid, proved and accepted ma- terial. I do not mean material to have the children learn, but we teachers must have it, no matter how we get it over to the child. What is necessary? How ought people to eat? How ought they to clothe themselves? How ought they to exercise, to take care of their teeth? We shall have to challenge the experts to give us material that we can count on. We are trying to get that now. The next thing is the technical program of adaptation and organization of this material so as to make it play a part in the life of the child. We recognize that problem very clearly. And here, I think, the school teachers are supreme. Not because they are wiser, but because they 24 have had more experience in teaching things to children. They have reached a certain kind of humility that is help- ful in a program like this, and they know pretty well what they can do and what they cannot do. The best schools are paying very little attention these days to committing to memory, except as a sort of clean-up process. They are organizing the life of the school so that the child finds the need of the knowledge that you want him to get, and is given an opportunity to make use of it. And so our practice in Health Education will be like this. The life of the child in its health relations will come up in the school, and we will get a view of it, outside and inside the school. These relations will be discussed and problems will come out. The children will report what is done at home. They will take back home what they get in the school. They will bring to the school their report on what the effect is at home. There you have the home and the school joined, not artificially joined, but in a very prac- tical manner. You cannot educate parents, except through the children. The child will go home and educate a whole family, and make them conform. You know it is true, don't you, what Mr. Hoover and his people found out during the war,-that when you wanted those food regulations lived up to you got the children interested in them, and then they went home and saw that the parents didn't break them. So this health program, when we know what we want to call attention to, will be given a test of practical application in the life of the child. And the children will submit to the test whatever we work out. There will be no trouble to find an army of school teachers who will put this program into effect. But we have got to begin with the teachers them- selves, in the normal schools and colleges and so on, not teaching them how to teach health, but teaching them how to control their own health. (Applause.) When they have had two and three and four years of an enthusiastic par- ticipation in a health regimen in their own school and individual life, they will at least go to the school learned and intelligent as to health, and will know variations from the health program when they meet them. I want to outline specifically and definitely at the close the plan of the National Education Association. Beginning some years ago, a joint committee on health problems was set up by the American Medical Association and the Na- 25 tional Education Association to see what could be done in the way of cooperation between these two associations, one having expert knowledge in the field of health and the other expert knowledge in the field of education. They naturally began first to deal with those conditions surrounding or in the school, such as lighting, ventilation, heating, and those things. And they found certain obstacles to health in the material surroundings, the environment of the school, that intelligence could readily remedy. Now, that committee had a wonderful experience. It helped to make the schools of America realize that here was a problem they must recog- nize, and every school administrator and every school teacher now acknowledges that it is part of his or her busi- ness, to be alert with regard to those matters. About a year or so ago as a result of these ten or twelve years of experience, and of the general health movement, we decided to take the next steps. First, we are getting a body of the best experts to dig out a fundamental body of knowledge and procedure and habits, so that we can confidently make the foundation of our school health program. And then we are going to work out a hypothetical course and ask the schools to try that. We simply say, "Let's try this, and you report what happens in your fifth grade in this city, and you report what happens in your fifth grade in another city." When teachers participate in these activities, and feel that they have something to do that counts, we get a cooperative effort here that is irresistible. Now this program is not yet definite, but it is moving along. We shall soon get the first statement of a health teaching program out in a definite form as a starting point for experimentation and for procedure in the schools of the country. We are definitely launched on this program, and I have the greatest confidence that it is going to mark a great difference in our whole school life. Children and parents, homes and schools and teachers, all of the agencies, public and private, will be looking at this thing from a common point of view. I sincerely hope that this Conference will help us, that it will strengthen our confidence to go ahead in building this great program. The Chairman: Nothing in the general program for health and Health Education in this country is more significant or more prom- 26 ising than the developing appreciation and understanding of the relationship borne to this program by the contribu- tion which the physicians of the country can make. The physicians are rapidly coming to understand education better, and to appreciate what cooperation of the physicians and teachers may mean. It is, then, particularly appropri- ate that a representative of the advanced group of phy- sicians in this country, appreciative of education, exercising leadership in this program of health work for children, co- operating with the schools in the program of Health Education, should speak to us next. I am therefore glad to introduce Dr. William Palmer Lucas, Professor of Pedi- atrics, University of California Medical School, of San Francisco, who will speak on The Needs and Possible Scope of Health Education in the World Today Dr. Lucas: THE World War closed many eyes-we do not like to dwell upon the millions of lives stamped out by war and its accompanying starvation and disease. We have seen how much of human life is just the outcome of some blind tragic impulse. We have begun to realize how much human disaster is due to lack of intelligence. We thought we were educated men and women. We were impressed with the wise philosophies and psychologies of modern civilization. We believed that the world was being guided by the wisdom of thoughtful men, that the time was far past "when quarrels were put into the hearts of the poor and treaties signed in peasants' blood." Ruskin's claim that "there is no wealth but life" we had come to feel was really the ac- cepted code, and that "that country is the richest which nourishes the greatest number of noble and happy human beings." Then suddenly we were confronted with the great fact of war, and the code we had so complacently accepted as ours became a tattered remnant of an ideal, and the old axiom of childhood, "Actions speak louder than words," rang unpleasantly in our ears. The whole world participated and the whole world bears the impress for better or for worse of its own behaviour. The vast army of the dead 27 with its closed eyes has passed on. We are concerned today with that far greater army of living men whose eyes the World War opened. To see ourselves in action has been perhaps the greatest educational force our generation will meet. We know now that we failed to meet the test of a good education from the social point of view. Our minds were not trained to think out the problems. We did not take the initiative in observing accurately the facts of the situation, and we apparently failed to act with any in- telligent object in view. We plunged and grappled fiercely with life and death at close quarters, but when the bloody smoke cleared away a little we saw certain realities in all their compelling vividness of contact. We saw what figures and statistics, what science and research, what education had failed to make clear to us, that the true poverty line of any nation is not made by the amount of power of that nation but by the amount of intelligence. This great Inter- national Meeting on Education on this far western coast is but humble acknowledgment of the fact that education knows no national boundaries, that united world action means a united world mind. Most of us here are no longer in the "plastic state" physically, and many of us are skirting the non-plastic period intellectually. Harvey, you remember, suggested that no man over forty would accept his view on the circula- tion of the blood because their minds were too full of ac- cepted views, but perhaps he would have been more lenient with us as to age if he met us with most of our accepted views blown away by a world catastrophe. Twenty-four years ago Lecky told us that "to raise the level of national health is one of the surest ways of raising the level of na- tional happiness; ... no branch of legislation is more really valuable than that which is occupied with the health of the people, nor is any form of individual education more really valuable than that which teaches the main conditions of a healthy life." But still we clung to the three R's- Health was nobody's business, Disease was the doctor's, Education was the teacher's, and yet long before the three R's Gratian, the philosopher, had declared that "Perfection consisted of three H's, Health, Holiness and a Head-piece." It seems to me that this wise statement is a splendid defini- tion of the modern education we are beginning to make real. Health, the things of the spirit, and a useable brain, if the 28 shade of the philosopher of long ago will forgive my in- terpretation-and it is just as sound a description of Health Education, as health must always include the spirit and brain of men. John Graham Brooks said that a crank was once defined as "a man who sees one fact so vividly that he is blind to all the other facts which alone can explain the one he sees." Medical men have sometimes been accused of being "disease cranks," and we certainly have no desire to be thought of as "health cranks" because we see vividly the needs of health; but it is the testing time, we know, of our sanity in this matter by the broader field of education, and we are anxious to acquit ourselves like men of sense. Osler de- clared in his last year of life that the future of medical practice lay in the preservation of health, the prevention of disease. The War has taught us that the future of world civilization lies in the preservation of the child life of the world. "Scientific biology," Sir Leslie Mackenzie claims, "has transfigured the study of the child. He is now under- stood to be the growing point of society and to neglect him is to neglect an essential of social efficiency." Any standard of life or education that wastes child life is too extravagant for any nation to indulge in. We know that now from actual contact with the mass picture of the war's sacrifice of the children. The starving children of the world have become a national nightmare from which no nation can free itself until it stretches out its hands and touches the weak, neglected bodies of its children, and from that contact de- velops a comprehensive program of prevention of disease and construction of health. It is of deep significance that the American who saved the lives of millions of European children, who fought starvation at close range for the sake of the future of civilization, has brought his great vision of community service and his almost miraculous powers of or- ganization to the work of prevention of disease and of pro- gressive health for the children of his own country. What Herbert Hoover will do as President of the American Child Health Association, what he will inspire others to do, will, we are confident, be epoch-making not only for the children of America but for the children of all the world. Health Education has an economic aim. We know how quickly the "health line" of a nation affects its economic soundness. We used for a time to stress only the converse 29 of that theorem that the economic prosperity of a country affects directly its health. We know that is not the whole truth. Economic prosperity we know can lessen disease and prolong life if intelligence accompanies the prosperity, but if there is a lack of intelligence in health matters, prosperity may not affect the health line. Every member of a com- munity-man, woman and child-should be able to work, at whatever task in industry, home or schoolroom, to the full extent of his powers, and those powers should be as great as possible. Anything that defeats these ends is economically short-sighted and wasteful. Health Education must teach a standard of fitness. The War taught us to grade men for the army life and service according to their physical and mental fitness for such service, which of course included home as well as field work. All this imperative need for men who were fit revealed to us how lax we had been in our study and preservation of the normal healthy individual. Disabilities and defects ap- peared that should never appear in communities properly educated in health ideals. These revelations were startling; they are familiar now to all educators and have become the great incentive for Health Education of children at a time when defects can be remedied and subnormal and abnormal conditions made to approximate the normal. I remember one set of figures that were most convincingly used by Mac- kenzie, that out of every nine men of military age examined in Great Britain for military service, three only were per- fectly fit and healthy, two were on a definitely lower than normal plane of health and strength either from some disability or lack of development, three were incapable of undergoing anything but most moderate physical exercise and the remaining one was an invalid with a precarious hold on life. Our own figures for this country on defects in children of school age are not of an assuring nature. Nineteen million out of our twenty-two million school children are defective physically, and of these fifteen million are defective for pre- ventable reasons; state the problem roughly and force us to consider more carefully the standards of fitness and how we can make such standards available to every child. Pre- ventive medicine has for a long time stressed the import- ance of healthy environment, the importance of the control of infections, and we have learned that healthy environ- 30 ments and freedom from infection do not necessarily pro- duce a higher standard of individual fitness. We know now that we must undertake directly the Health Education of each individual child and that community health is depend- ent upon the reaction of each individual in that community to the environment provided. All sickly looking children are not merely poorly fed; all well-fed looking children are not necessarily free from defects, many lazy children are not so from moral reasons but sometimes from insufficient food. Professor Nitti, Italy's brilliant economist and one-time premier, said as long ago as 1896 in discussing the food and labor powers of nations that "an Englishman eats more and better than a German, he works more and better than a German. An American eats more and better than a German or a Frenchman or an Englishman and works more and better than any of them."' Food is of course a vital subject in all Health Education. The child cannot function without it, but it is not the only factor. The importance of it to the child rests upon his own understanding of the effect of food upon him. We do know that the best education in any subject lies in actual participation in it. What a child does has far more influence upon him and far more lasting in- fluence upon him than what he hears. Sir Leslie Mackenzie, that wise Scotch physician, in defining physical education as a mental process explains that it is always the living person we have to educate. "If he would meet the inimitably various demands of life, he has to be sound in all his organs; to be sensitive yet enduring; to be adaptive yet reactive; to be supple yet strong; to be alert in action; to be capable of acting without hesitation on a given emergency; to be capable in a crisis of mobilizing his whole strength without conflict of motive or failure of control. So conceived, physical education becomes a training in the dynamics of character." I think these words might be easily applied to the Health Education aims for children. Education in its big sense as a system is simply the guidance and stimula- tion and supervision of growth, and Health Education is the definite relation of this system to the problem of physical well being. Health Education for the school child, is of course, rapidly building up a routine, but it must be remembered that routine is but the framework and that the important 31 fact is what the framework contains. The best health teaching will probably not be that which we have thought of as professedly educational but it will come to the child in three main ways. First, it will come from the interests naturally involved in the child's own life and home, and these interests are inextricably bound up with his daily habits of living. The child's power of acquiring interests is itself largely a question of early training, and a child's mind that has acquired the habit of being intelligent about health standards will be secured against habits which would tend to lower those standards. We all realize that James was quite right when in dis- cussing habit he said, "The hell to be endured hereafter of which theology tells, is no worse than the hell we make for ourselves in this world by habitually fashioning our characters in the wrong way. Could the young but realize how soon they will become mere walking bundles of habits, they would give more heed to their conduct while in the plastic state." But alas, the young are not interested in their conduct from the point of view of the psychologist, nor are they conscious of being in a plastic state. They have minds, however, that are capable of being interested in health, and we must fish for their interest with any bait that will catch them. Wise health teachers whether behind desks in schoolrooms or at home in the nursery have found that inhibition is a better method of education than pro- hibition, for inhibition substitutes interests which dismiss the undesirable action from the mind instead of making it more interesting by attaching a penalty. The second way in which Health Education will come to the child will be from the lives of those he imitates, his teachers and parents and those near enough to him for him to understand. The child is not only more interested in what he does, but he is much more interested in what other people do than in what they say. Text-books and charts may interest him, sometimes they even deserve to! But an act appeals more strongly to the mind than a fact. The first ardent belief that a health teacher must have is that such an appeal to the mind of a child can never fail; her task is to study how from first to last to make that appeal. Our modern health ideals are not mere negations but are positive and progressive. We have spent years in "beating up the rear" so to speak, in picking up those who had fallen behind 32 and helping them to go forward and we still have much of that to do, but we are determined to push our preventive standards still higher. The attitudes of teachers and parents in co-operation will chiefly determine to what extent the child will profit by them. The third way in which Health Education will come to a child is perhaps in the best form of all. It will come to him from the claims which the community makes upon him. There is little chance that our future citizens will be in- terested in national health and international health if their own neighborhoods fail to stimulate in them a pride in the health of their district. To be a city district with the lowest death rate and the fewest cases of sickness in a year appeals to the most fundamental emotion in humans, a group pride, to belong to the healthiest school neighborhood, to have the strongest scout troop in the city, to be appealed to by the community, to be the type of individual that brings credit to the community in its striving for better end results for its citizens. The community can do many things, it can secure the proper food, the proper housing, the proper drainage, protection against fire, prevention of disease and to some extent cure of disease, but only if the community can secure the active co-operation of individuals. The community can- not secure health or Health Education without the effort of every man, woman and child in that community. No com- munity can give, gratis, without asking for any exertion in the undertaking, good health or even partial good health to its members. The health officer is the necessary pace setter, but the real health of the community is bound up with the conscious efforts of the smallest child. Someone has said that a man's circumstances depend upon what he is himself. How true this is of that circumstance we call health. Health Education will not be accomplished by scare publicity. Few children or adults are frightened into good health habits. Headlines catch our eyes but they do not hold our interest. They sell the papers but they do not educate the public. In our health publicity we are aiming at educating the public-we cannot do this without the help of the true pedagogue who knows how to make interesting to the child everyday happiness, the common welfare and his own behaviour. Health is not a dull subject, it is full of just as many dramatic possibilities of development as disease, and with much happier endings. Health is the 33 background against which all educational achievements must rest. What a child does with his books depends very largely upon what he does with his body. We must play fair, and teach him early how to care for his body; he can learn to spell health just as early as he can learn to spell cat, and it can be made just as real to him from the angle of his own experiences. The child has a right to a knowledge of health, and he has a right to that knowledge while there is time for his own actions to affect the results for himself and for others. Such knowledge cannot be put off until adult years have re- vealed the tragic loss of time. Benjamin Franklin gave educators a thrilling slogan when he said, "You value life- then do not squander time, for time is the stuff of life." The Chairman: Nothing is needed more in this period of Health Educa- tion than the person who has an unselfish devotion to the welfare and happiness of the child, the individual who has, with keen imagination, vivid vision of the ideals and the possibilities of Health Education in the entire program. I know of nobody who embodies this better, and in a manner to help and inspire us more, than the next speaker, Miss Sally Lucas Jean, Director of the Health Education Di- vision, American Child Health Association, who will talk on The Spirit of Health Education. Miss Jean: THIS is a great event, one we have been looking forward to for many days. Four years ago, when the first con- ference on Health Education was called in New York City, it seemed scarcely possible to gather together a body of fifty people who would for three days consider whether or not teachers could teach health in the schools of this country. Two years later a conference was called of one hundred people carefully selected from all the groups who might have a contribution to make to the subject. They gathered for a week at Lake Mohonk for the consideration of "How to Teach Health" in the classrooms of the country. It was no longer, "Can the teacher teach health," but "How shall the teacher teach health?" Out of that conference came the call for an international conference, whereby the peoples of 34 the world could sit together, shoulder to shoulder, and con- sider this great problem of how to build strong men and women from our girls and boys in the classrooms of the world today. Then, when the announcement was made that the National Education Association had called a World's Educational Conference, it seemed a splendid opportunity for the two groups to get together. Hence, at the invitation of the National Education Association, the American Child Health Association joined forces with the other groups who had been interested, and had worked upon various phases of Health Education in connection with the National Edu- cation Association, really to pool the best that each had to offer. Therefore, today we are here to consider how we can best build strong boys and girls to carry the problems of the world. The organized movement to train teachers to teach health is definitely under way. We all agree that instructing children in the formation and functioning of their bodies has not had the slightest effect upon their daily living, nor do we believe that medical inspection and school nursing alone have brought health to our children, though adenoids, enlarged tonsils, eye strain and other defects have been corrected. The work of school doctors and nurses, without question, has succeeded in re- moving defects, but we do not, in our blindest moments, consider that this work more than comprises one section of a health program. Nutrition teaching has been limited largely to home economics classes for girls above the sixth grade, while physical education has too often meant only exercises and competitive games. The result of such narrow specialization is apparent in the conversation of the usual adult group today discussing health matters. The grossest ignorance exists in the minds of even the so-called intelligent. These people, our friends, get their misinformation from the newspapers and maga- zine advertisements. It is only necessary to spend a few hundred thousand dollars to succeed in selling any patent food to the people, even though it may be of little value and very expensive. All human beings crave health as a road towards well-being and happiness. These same instincts exist in our children, and it is possible to benefit by the same psychology in dealing with these boys and girls as the ad- 35 vertiser so cleverly uses in selling his product. The doctor and the educator are inclined to scorn this group, but we cannot afford to misunderstand and misinterpret the value of the psychological appeal which is so ably demonstrated by our advertisers. There is no one method of teaching health to children. It is, however, essential to interest the child himself, and to this end, the imaginative method has been found most successful. I want also to stress the importance of beauty in the lives of children. All children want to be beautiful, naturally, but we have not encouraged this desire. "Behave as well as you look" is a remark with which we are all fa- miliar, while we seldom call attention to the beauty of bodily development in the young woman or the young man to whom the child so gladly looks for inspiration. Create a desire in the minds and hearts of our children for beautiful, well-developed bodies and expect them to reach out toward that goal. I am inclined to believe that the most important step in improving our methods of health teaching has come from the adoption of a gauge whereby the layman as well as the specialist can judge of the child's physical development. Through the use of the height and weight table, with a scale in the classroom, we have placed in the minds of the chil- dren themselves and of the teacher a standard whereby they are guided. Much misuse of this simple device has brought about criticism as to whether or not any one height and weight standard is acceptable, but all agree it is one means whereby the classroom teacher can stimulate interest and establish a goal of achievement in the minds of the children. All school health programs must include the best which the doctor, the nurse, the nutritional expert and the phy- sical educator, as well as the pedagogue, can offer, while the subject-matter of the whole curriculum must be correlated if we are to succeed in arousing and holding the child's en- thusiastic practice of health habits in the building of a healthy child. This can only be accomplished by the class- room teacher who has been trained to teach health. The classroom teachers cannot be specialists in any of these branches, but we can give them an understanding of the importance of each of these subjects and of its contribution toward the well-being of the child. 36 Educators are anxiously seeking a syllabus for the teach- ing of health. Such guides must of course be prepared, but let us be careful not to hand out such a course of study as will stifle the timid attempts of the classroom teacher to develop her own methods for the teaching of health. Most of the effective health teaching today has come from the stimulation of classroom teachers who have been made to feel that it was worth while for them to develop methods for the teaching of health. If we are to continue to vitalize methods for the teaching of health, the classroom teacher must be encouraged to use her initiative. No method is effective, however, which does not take into consideration the spirit in which the teaching is done. Teacher-training centres and extension courses must keep this constantly before our teachers. We must fill them with the thought that they are to be leaders, that they are to carry the news, that they are to pass the torch along. The details of how to go about this we must leave to the leaders in the normal schools and teachers' colleges. But all the training is of no value unless we have in- spired these young students to be real teachers of health to the children whom they are destined to lead. The Chairman in closing the first session expressed for the Committee on Arrangements, its keen appreciation of the audience's expression of interest, and of the large at- tendance, both of foreign representatives, and of people from our own cities and states. Part 11 SOME FUNCTIONING HEALTH PROGRAMS ONE of the great purposes of this Conference was to enable groups of special workers in the various fields of Health Education to present their contribution and their problems to the other groups, in a series of meetings devoted to the special fields. But it was believed that these special meetings would have greater significance if pro- jected against a background of actual school practice. Therefore, this first session after the introductory one, is an effort to picture a few successful working programs. There are very many such successful programs. These are not offered as unique, but as typical of some of the kinds of program which are both practicable and pedagogically sound. DR. WOOD, in accordance with instructions of the first session, appointed a committee to draw up for the plenary session, in the form of resolutions, the fundamental contributions to a Health Education program, made by this session. The Chairman then introduced Miss Edna White, Di- rector of the Merrill-Palmer School, Detroit, Michigan. Miss White drew the first picture of a health program in action in a discussion of Health Education of Very Young Children Miss White: IN the light of what modern psychology has taught us of the importance of habit formation in early childhood, the discussion of the educational problems involved in Health Education of very young children by such a body as this, is most significant and encouraging. The Health Education of school children has been re- ceiving the special attention of wide-awake educators for some time. Infant Welfare Centers have developed and 37 38 multiplied all over the world and much has been accom- plished by both physicians and nurses in teaching the average mother the necessity of close supervision of the child's health during the period of infancy. The child is weighed and measured at frequent intervals and any de- viation from the normal behavior attracts attention. In most instances this supervision and care is relaxed as the child passes the second summer and he is left for the most part to fight his own battles with the feeling that nature is quite capable of taking care of his normal development until he reaches school age, when the physician and nurse again resume their supervision. Just why we should have been so complacent regarding the ability of the pre-school child to develop normally, and recognize so definitely our obligations in the case of the in- fant and school child, is a puzzle. It may be due in part to the fact that we have had little opportunity to examine pre- school children in groups, and have, therefore, failed to recognize their needs, but probably the greatest factor has been the lack of standards by which to measure their progress. Fairly definite standards have been set up for the infant, and the intelligent mother can follow them, but she has no such definite picture in her mind of the development of the child after the period of infancy. She fails to note devi- ations from the normal in her child, in color and texture of skin, firmness of flesh, steadiness of legs, straightness of back, expansion of chest, texture and condition of hair, de- velopment of teeth, muscular co-ordination and similar significant points because she has no standard by which to compare. Weight has been used as a measure of growth both because it is convenient and because, in the case of laboratory animals, it has been found to be a delicate index of the state of nutrition. In the case of the child, we have not yet secured as reliable standards as for the white rat, but though we do not know yet the ideal height and weight for a given child, the fact remains that progressive changes in height and weight are indices of normal growth. The weighing and measuring campaigns in schools have brought many a rude awakening to complacent parents regarding the physical condition of their children but, unfortunately, the damage is often difficult to repair because the founda- tion was laid in earlier years. 39 In England the Education Act of 1918, known as the Fisher Act, authorized local education authorities to furnish nursery schools for children from two to five when neces- sary or desirable to provide for their healthy physical and mental development. This is an attempt to extend the health teaching and supervision from the period covered by infant welfare centers to the school period, because in the neglected pre-school age many defects develop due to bad health habits and neglect. In America the health of pre-school children has of ne- cessity been a matter of concern in children's clinics, but an attempt to deal with the problem from a preventive and educational angle comparable to that begun in England with the nursery school, is a very recent experiment. Since these schools offer almost the only definite attempts in Health Education for the pre-school child, I shall base my discus- sion on the information we have gained in our study of a group of pre-school children in the past year and a half. Our children, numbering thirty-six at any one time, come to us from many types of homes, but in the majority of cases the homes would be recognized as superior. We insist on a complete physical examination, including labora- tory tests. The results have been rather astonishing. We have found all sorts of defects, including diseased tonsils, low hemoglobin in eighteen cases, abnormal urinary find- ings in nine cases, unstable nervous systems, constipation in almost every child, and defects of many other types. In most cases these difficulties had either not been recognized at all or had been dismissed as of no importance. Tests of vision and hearing are very difficult to give satisfactorily to children of these ages, but we hope to get better results through psychological methods. Every morning the children are examined by a nurse sent from the Board of Health. The greatest problem with these children is, of course, that of infection and we do our utmost to guard against contagion. Monthly studies are made of the height, weight and general physical develop- ment, and careful records are kept. The weight is obtained without clothing. The length of the child is taken both in the recumbent and standing positions for the purpose of comparison. This is done on specially devised instruments. The instrument for taking recumbent measurements is a modification of the one used by the Iowa Child Welfare Re- 40 search Station, while the instrument for taking standing heights was devised at the school. Stem length, circum- ference of head and chest are also studied. The growth and development of the children have been compared with pub- lished standards and averages. In general, the children have equalled the expected gain in weight and averaged one and one-half times the expected growth in height. As a standard for normal weight, the weight for height measure- ment as given by the Children's Bureau is used. Graphic studies have been made of a few individual children showing the relationship of the chronological, the mental and the physiological age, the latter being based on height. (Eight out of twelve show a closer relation between physiological and mental, than between chronological and mental age; only one shows closer relation between chron- ological and mental.) Graphic studies of seasonal growth of a small group of children do not show a special tendency to gain weight during the summer months, as was shown by the children studied by Camerer and Porter. These studies were made on school children and there is need of further study of pre-school children. The purpose of our nursery school is to provide an en- vironment that will train the children in health habits, physical, mental and social. Group psychology is of great assistance in many problems, notably in the formation of better dietary habits. There is little difficulty in teaching children in groups to eat the right amounts and kinds of food. Many mothers can testify as to the difficulties in teaching individual children good food habits. In the school regime, the nap and eating times are definitely set and regular habits formed. Each Friday copies of the menus for the coming week are sent home so that the mother may know the school plan; a card is also sent for a daily bowel report. From time to time, suggestions for the foods best suited to the other meals for the day are sent and twice each term the mother is asked to keep an accurate record of all the food given the child at home for a week. They are taught in school to wash hands and face, care of teeth, toilet habits and any other habits necessary to health- ful living as well as encouraged in types of exercise that develop muscular co-ordination and control. Every day the children choose some individual occupation which they are encouraged to carry out as intelligently as possible and an 41 effort is made to see that they carry this bit of work to completion. Sometimes they prefer to work out some little project in a group and their grocery store or their zoo or their dramatization of "Little Black Sambo" or "Fair Rosy" have shown that children of this age enjoy group activities just as much as older children. They have as much outdoor play as the weather will permit and they use and enjoy much of the same apparatus as older children when it is regulated to their size. One activity which has proven most interesting is the instruc- tion in rhythm and music. No child is required to partici- pate but nearly all do so with apparent pleasure. The nap period, following the main meal at midday, also illustrates the value of the group psychology. All the chil- dren rest for about two hours and practically all sleep. There is no protest because all do it; it is the accepted order. In general, the results of the nursery school health regime may be summarized as follows: 1. An improvement in the dietary habits of the children; the general dislike of vegetables is soon overcome and within a short time the children are eating all food served them. 2. The correction of constipation in practically all of the children. 3. An improvement in the blood count of all the children with a marked improvement in over thirty cases. 4. Correction of abnormal urinary findings (as albumen, small amounts of sugar, or increased indican in ten cases). 5. A marked improvement in the general physical condition of ten children who were impaired physically at the time of admission. From the standpoint of the formation of the right mental and social habits, the advantages of group associa- tion have been almost startling. These young children have responded so quickly in attitude and adjusted themselves so readily in their social relationships that we have a strik- ing illustration of the oft-quoted advantage of a large family under the supervision of a wise mother. The lack of friction and the tranquil atmosphere of the school react most favorably on these small children. The influence of a child's attitude of mind and social reactions on his general physical well-being, can scarcely be overestimated and car- ries through life. We are not interested in taking children whose parents do not co-operate. This offers an opportunity for individual education of mothers. Our testimony, as well as that of 42 the English group, is that the nursery school has in no way lessened the feeling of responsibility on the part of the par- ents but on the contrary, by pointing out the particular needs of the child, very definitely tends to increase the sense of obligation. Conferences with parents are held whenever necessary, to discuss problems of behavior and physical or mental status, and have proved a very definite assistance to both school and parents. Our nursery school has been organized because we are interested in training for motherhood and we have had as students this last quarter, eighteen seniors representing seven of the best known colleges and universities in the country. If, through such agencies as nursery schools, pre- school clinics and similar institutions, standards for the measurement of child growth and development, as well as the principles underlying training, can be developed, the coming generation may enjoy what President Thwing has listed as the fourth right of childhood-"the right to learn from parents by example and precept, the principles of truth, honor, purity and right living." Discussion Miss Helen Reynolds, Head of Department of Primary Method, Seattle Public Schools, said, in comment on Miss White's address: Miss Reynolds: We have probably all been feeling, as we listened to Miss White's description of the school in Detroit, that we are very fortunate to be living and working in a day when little children are being studied from a point of view both scientific and human. Now, I don't know that we have any right to call scientific investigations inhuman, but sometimes they seem to get very far away from the child. This school is very near to the children. Those of us who deal with many, many children entering school, in the kindergartens and first grades, have a great desire that schools like this one in Detroit, schools like the one carried on by the Bureau of Educational Experi- ments in New York, modifications of the nursery schools of England, adaptations of our own kindergartens, may be found some day in every corner of our own country. When we realize that many little children come to us from conditions that have made a sane and rational development impossible, we know the need of just such schools. We are looking, in some parts of the west, towards the mothers, who are being organized into pre-school circles by the great parent- 43 teacher associations of the country. Seattle is fortunate in this particular. We were one of the first cities in the country to begin this type of organization, and the mothers who have joined these circles have been particularly responsive to the idea that in this period of which Miss White speaks, between the time of the child-welfare clinics and the entrance into school life, many of the good things that have been done for the little child during babyhood have been lost. One of the most interesting statements of this situation you will find in "The Pre-School Child," the book which Dr. Gesell of Yale has just published. His statement of that situation ought to arouse everyone who has anything to do with schools anywhere in the world. He says that we are losing our great opportunity. Seattle has made a very small beginning in trying to bring into our kindergartens for physical examination every child who the next year will enter kinder- garten or the first grade. This will mean a great step towards keeping watch over the children. Miss White spoke of the need for standards as to what the child ought to attain in the way of physical good health during this pre- school period. I have read with great interest within the last week the book by Dr. Lucas, of California, "The Runabout Child." The standards that he sets forth are tentative and must be confirmed by many experiments such as those at Detroit; but they will help the people who cannot take their children to such institutions at this time. You are probably, most of you, familiar with the English books on the nursery school movement-the book by Grace Owen, and one by Margaret MacMillan. Both of them have contributed to the American teacher's and the American mother's point of view in a large degree. We have also been working on helping the mothers in formulating a curriculum of home habits. We have called this "A Curriculum of Home and School Habits," that we may emphasize more strongly the cooperative element, not placing the responsibility upon either one, but upon both. Very careful studies in this direction have been made by two people. One by Agnes Rogers, Professor of Psychology at Goucher College, is in print, and is a selected list of habits which the teacher in the kindergarten or entering classes may make use of to help her establish standards. The other is by Miss Madeline Veverka of Los Angeles, and was worked out through the cooperation of mothers and teachers. That is not yet in print, but may be obtained by writing to Miss Veverka, in charge of the kindergartens of Los Angeles. They are now working there on a habit curriculum for mothers, a statement in terms of the mother of the habits she should establish for herself in her home in order to make conditions right for the child, right for establishing in even very little children these ideals and knowledges and habits of health. The great thing that we all have a possibility of doing, is that of opening our eyes. We all can open our eyes and learn from these care- fully worked-out experiments. Then we can arouse all of our energy and make up our minds that no child is going to escape from the child welfare clinics and be let to run wild until he is brought into school with many troublesome things to be mended, at a period too late to 44 meet some of his needs. One of our kindergarten teachers has started a little campaign of her own. Through the older children in the school, and through the mothers in the parent-teacher association, she gathers in, quite early in the spring, all of the mothers and all of the children who are coming to kindergarten next year. The children have a party that pleases them, and of course if the children are pleased the mothers are pleased and interested, and the mothers have a talk with the teacher in regard to what they may do for the children during the summer that will make them better ready for kindergarten in the fall. Those of us who are in the public schools find our responsibility lies in learning from these experiments and adapting to our needs all that we may learn. Dr. Keating, of Chicago, said of the nursery school: It is humiliating to a physician to hear that the work that should be done by the physician for the various families of his community must be done by the public or through public channels. But there is no doubt that the experiment that Miss White is making is along lines that are perfectly right. He then made the point that a physician in his effort to give his child patients the best health mileage possible, after an acute illness is cured, often finds it difficult to get pa- rental co-operation for the long continued constructive health measures he prescribes. He stated that it was the teacher's duty to aid the physician in getting this co- operation from parents. A picture of a successful Health Education program in the elementary schools, in primary, intermediate, and gram- mar grades was next described by Mrs. Mary M. Fitz-Ger- ald, Principal of the John Swett School, San Francisco, Cal. A Successful Elementary School Program Mrs. Fitz-Gerald: I AM asked to describe a school program based upon the experiences I have had in the past year in developing health work-experiences which have been given in the re- port I made to Mrs. John Collier a year ago. First of all, the John Swett School is a typical large city elementary school with mixed racial groups and a migra- tory population that causes an almost complete turnover in every year's enrollment. Ordinarily there are more than nine hundred pupils present with an annual state enroll- ment of at least eleven hundred from the kindergarten 45 through the eighth grade. The constantly changing city enrollment causes more variation. Then, in so large a school every term there are many changes of teachers due to leaves of absence and resignation. This makes more difficult the task of the principal, whose chief duty it is to develop a health consciousness that shall pervade the whole school and bring more quickly under its influence every new pupil and every new teacher. Some of the ways and means employed to accomplish this result follow: I. Monthly weighing and measuring of all pupils in the school. To make this official and effective we stamp upon report cards given in grades three to eight inclusive, two addi- tional items, (1) Does weigh (2) Should weigh Underweight is recorded in red ink the same as any de- ficiency in school work. When the child is not up to weight a note is written to the parent, urging the drinking of more milk or a personal visit to the school to discuss the needs of the underweight child. Such notes are signed, "Yours for Health, The John Swett School." The parents respond most promptly. The intensive health work has made them feel more than ever that the school is a most valuable neighborhood agent. The weighing, the measuring, and the recording, as well as the working out of percentages, are all done by reliable boys and girls from the upper grades, the class to be weighed being at all times in charge of its own teacher, who thus is able to keep in intimate touch with the situation. The seventh and the eighth grade arithmetic classes as part of their regular work make a graph for each class weighed. The class fortunate enough to have no underweights is given a large gold star which is displayed most conspicu- ously. Finally, a graph is made for the whole school and placed in the principal's office for public inspection and comment. We had eight of those monthly graphs for both terms on exhibition before June 1, 1923. The school graph is similar to the class graph except in size, and shows in patriotic colors: 46 (1) Normal group 5% below to 15% above (2) Borderline group 5% below to 10% above (3) Danger group 10% below normal II. Bread and Milk Class We have developed a procedure to suit our own needs. Each morning before school time, eighth grade girls under the direction of a class teacher butter bread, which is cov- ered and screened until used. At twenty minutes past ten, seventh and eighth grade boys arrange the milk service and put straws into the patent capped milk bottles. When the first bell for recess rings, pupils for the milk class leave their rooms, enter the auditorium, help themselves as they pass in line, take seats, eat and drink comfortably, and when finished pass out doors for the other half of the morn- ing recess. The charge per pupil is five cents a day. By economical buying we create a surplus which permits free service to all underweights whose parents cannot afford to pay. III. The Fairy Health House This device is used in the four primary grades. The teacher draws a large house on a three by four sheet of heavy paper and marks off bricks and shingles. The house is then finished as a class project calling for health habits respecting cleanliness. Clean ears, clean eyes, clean nose, clean teeth, clean neck, clean hands, clean nails, clean shoes, clean clothes are obvious. When the morning inspection discloses a row perfect in any one of these virtues, that row is permitted to color a brick or a shingle. Each row has its own color, so there is great endeavor to make a good show- ing. Lack of cleanliness is a matter of discipline that is taken up immediately with the home. IV. The Rules of the Game Every day one rule is discussed and made the basis of the oral and the written language work of the day. When the spelling or the grammar lesson demands the making of sentences, we require that such sentences shall embody health facts whenever possible. We have made most re- markable collections of pictures and educational posters which, upon request, have been most generously sent to us by lithographers, by producers of fresh and canned foods, and by handlers of materials concerned in hygiene and sani- 47 tation. The children vie with one another in getting from the butcher, the baker, or the grocer a fine picture to help the health work. Every chance we get we use the Rules of the Game to enliven and to motivate the work of the course of study. Of all the Rules of the Game the one most stressed is "A bowel movement every day." In the upper grades, the principal broached the subject and thereafter the pupils and teachers discussed the rule most naturally. The dreaded castor oil was replaced by roughage, the virtues of cabbage, sauerkraut, spinach and other leaf vegetables were explained, oatmeal mush and whole wheat bread lauded, care of the teeth and much water d>inking demanded, and exercise and fresh air given the first place in keeping the bowels in good working condition. The reading lessons in the first grade contributed to the general scheme as well as the remarkable physiology lesson in the seventh grade on the topic of digestion. V. The Bztsy Work Health Book Every child delighted in making this book and it so ab- sorbed his interest that it took every spare second in school and gave employment at home for many hitherto idle mo- ments. The first page of the inside cover is given to a tiny poster of Cho Cho's Rules of the Game. The second page shows the owner's monthly record in weight and height, which in the lowest grades must be transcribed by the teacher. Thereafter the pictures selected have to do with the work of the day. In the kindergarten, milk bottles, milk men, milk cans, milk trains and other things talked about are cut out, colored and pasted in their books. In the first grades the daily talks lead to the supplementary read- ing lesson which is printed upon the blackboard, read by the child, reproduced orally, struck off on the teacher's printing press as leaflets to be pasted in the health book, and followed by illustrations drawn by the little artists or cut out from can labels, discarded books and old magazines. As the children progress, their work centers on things good to eat and why, so we have pictures of above ground and below ground vegetables, groups of food to show iron, lime, acid, fat or flesh content, and the making of menus for breakfast, luncheon and dinner. When they are able to write a word and later a sentence from the writing lesson they are proud to have the book show their skill. Uncon- 48 scious tuition wends its way most serenely; words the child uses as part of his regular vocabulary, and facts and fancies he acquires are not supposed to come until a much later stage of his development. But they do arrive and the child feels the urge and expresses himself most intelligently. The second grades go further. The health talks, par- ticularly on sleep, milk, and leaf vegetables, correlate with the language work the first term as sentences and the second term as topic paragraphs. When a suitable sentence is given by the pupil it is written on the blackboard by the teacher and copied in the busy work book by the pupil. Finally, the teacher writes these sentences on cards and uses them for blackboard writing material to be used for one section of the class at a time, thus affording opportunity to do individual work with backward pupils. The sentences are soon learned off by heart, reproduced orally and in writ- ing and finally taken home to Mother and Father, who are delighted with the common sense work of the school. Now also begin to appear in the busy work books correlations with arithmetic. Little problems are illustrated by pint and quart milk bottles, fruits, vegetables, etc., and number stories afford a good vehicle for further health work. The third grade augments the work by gathering ma- terials when there is a special drive on raisins, prunes or eggs, or when a fruit or vegetable makes its first appear- ance in the market. Talks resulting in blackboard composi- tion give a little story as to origin, the food value, and a good way to serve, all of which material later finds its way to the busy work book. In the fourth grade, Miss Jenkins' Sketch Book, Milk, the Master Builder, Happy's Calendar, and the Land of Health Map further develop the child's initiative and fur- nish many incentives for original projects and dramatiza- tions. This work continues in the grammar grades; some books are unique, beautiful and most illuminating projects. The higher the grade, the more closely is this work cor- related with the course of study. The seventh grade charts, menu and calorie books and the eighth grade charts and books on vitamines in various foods are worthy of more than a passing glance. The wisdom acquired and the habits formed tend not only to the health uplift of the school, but also help the general morale. 49 VI. Correlations Groups of teachers work on separate subjects to cor- relate Health Education with the course of study. It is absolutely necessary to take advantage of the time and the suggestions given so that we may carry on the health work in such manner as not to destroy its spontaneity, so also that we make the subjects now in the curriculum serve our purpose and lend themselves to proper motivation by health topics, health programs and health projects. This we do intensively and extensively. VII. Play Activities The play chart is a part of the equipment of each room. It is a monthly record of daily play kept by the pupil him- self. The child is urged to play at least one vigorous out- door game each day. When the weather permits the classes go out doors to take the Decathlon test or engage in the yard games suggested by Bancroft. We have a regular yard schedule to prevent interference of classes and are assisted by the fine co-operation and close supervision of the Phy- sical Education Department. Then, too, as part of our play, we have toothbrush drills, motion songs, indoor games, dra- matizations, and folk dancing. VIII. Posture Every room is furnished with a posture chart-the state law so requires. Whenever the occasion demands, instruc- tion is given. As the lines pass out of the building to the yard or to the street and during the daily visits to the class- room, the principal gives close and active attention to each child so that with the constant co-operation of the teachers, our school has in this respect attained the highest ranking in the department. IX. Campaign Against Coffee Drinking There has never been a time in the history of our school when the drinking of tea and coffee has not been fought. For the past two years the game of the milk bottles chasing the tea pot and the coffee pot out of the classroom has been played to such good purpose that there is but little fault to be found with the kindergarten and primary grades. We award a blue star, the same size as the gold weight star, to each class with a clear daily record. From March 1st to 50 June 1st of this year we conducted an intensive campaign by using debates and compositions in the seventh and eighth grades and by discussions and oral reproduction thereof in the fifth and sixth grades, by talks and games in the pri- mary grades, notes to parents, etc., with the result that in the given time we have reduced coffee drinking sixty-six and two-thirds per cent. X. Professional Visitations While under Mrs. Collier's supervision we gave several demonstrations of our work to school directors, deputy su- perintendents, out-of-town teachers, nurses, supervisors, and physicians. The visits of these educators were most stimulating and helped very largely to keep alive the in- terest of pupils and teachers. The principal's visits to the classroom, her daily talks on health, and generous recogni- tion of good health work made everyone anxious to present something original or distinctive. To persevere, one needs unlimited good will and every day there was manifestation of such a spirit by the teachers and such an ardent response by the pupils that there resulted a very splendid "Health First" program. Discussion The discussion of this paper was introduced by Mrs. Rebekah K. Earle, Assistant Nutrition Director, Los An- geles, California, who said: Mrs. Earle: I believe the most valuable thing in the paper just read is demonstration of the principal's importance to visualize any program, and her power to stimulate or crush the spontaneity of the teachers. One feels the health consciousness introduced into schools and homes by the vivid interest and intelligent co-ordination of the principal and the teachers. We of Los Angeles have many departments in our schools, and they are all interested in child health. One of our assets is that very delightful combination, a man in the medical department who is a teacher. The Parent-Teachers Association is another valuable asset in the co-ordination, as is also the home economics department. We ap- proach the child through the height-weight competition. Our health and development department began some of the earliest efforts at self- teaching. Our children are taught how to cure such things as speech and postural defects. We have our annual posture parade, and we use it throughout the year to promote attention to good posture. We have 51 incorporated in our general school curriculum a course of study which co-ordinates health with every subject in the curriculum, and it is our great desire to make it vivid and powerful in the lives of our people. A contribution to the discussion of this paper was made by Walter W. Davis, Ph.D., Supervisor of Physical Educa- tion and Hygiene, Seattle Public Schools, Seattle, Wash. Mr. Davis: I was pleased to note that the weighing and measuring was kept under the charge of the grade teacher. Such participation by the teacher is necessary to keep her in close touch with the health condi- tions of her group. The morning inspection for cleanliness is perhaps the best means of actually forming health habits among children that we can use in the schools, for by it children get real practice in habit training day by day throughout their school life. Habits cannot be formed by reading about them or by hearing the teacher talk about them. Acts must be done over and over to grow into habits. A fine feature of the inspection for cleanliness, I think, is the fact that we do not ask the child to report what he has done; he is not tempted to claim an unearned virtue, but is actually examined to determine a condition. To develop an action into habit there must be favorable opportuni- ties for performance. A Seattle boy answered the question, "Do you wash your hands before each meal?" in this way: "I do every morn- ing and at supper, but not before noon because there is no soap at school." I submit for your opinion whether the inspection for cleanliness should not be accompanied by an inspection for communicable diseases, made by the teacher with the occasional help of the nurse. Such an inspection each morning would weed out the serious colds and avoid much spreading of disease. Posters and other health projects, I am convinced, should have a definite health aim in view. To emphasize this point let me quote a fourth-grade teacher who last September took charge of a room in one of the Seattle poorer districts. She says: "I began to study the children for they were entirely different from any other children I had ever worked with. The majority were poorly nourished, and cleanliness was not a part of their daily life habits. I wanted to teach them something about these things that could not be forgotten. I was impressed with the idea of teaching health habits in correlation with language work and book-making." This teacher had a definite aim in view and a definite plan and means at hand. Another teacher sets out her project aim as, "Health: a requisite for good scholarship." All teachers may not have exactly the same aim in teaching health habits. They sometimes need to emphasize quite different phases of hygiene, because groups of pupils differ so greatly in their health needs. I shall try to make this plain by the use of some statistics we collected about Seattle school children. In one school 100 per cent 52 of the seventh grade lived in homes that had bath tubs; in another school the percentage for the seventh grade was only 28. The average for the city was 86 per cent. One school averaged only 9 per cent of pupils who confessed to frequent headaches; another school scored 39 per cent. The average for the city was 17 per cent. In one school 79 per cent of the seventh grade stated that they drank coffee. In another school none of the children of the sixth grade drank coffee. The average for the city was 35 per cent. In one school where nine-tenths of the pupils are Orientals the percentage of the tea drinkers was 54 per cent, for the city 19 per cent, and for one other school 11 per cent. Due to differences in nationality or variations in economic condi- tions separate groups live quite different lives and need instruction in quite different phases of hygiene. I am sure that any teacher will do well to find out all she can about the health conditions of her neighborhood either by a formal questionnaire to her pupils or by conferences with the individual pupils. By such means she will learn what special help each needs and thus be able to make out a practical course in hygiene for her group. Correlation seems to be the outstanding feature of health work in the John Swett School, and correlation, I believe, will prove to be the best means at hand for teaching health in the grade schools. This must be so for one reason if for no other, because the curriculum is already crowded and additional time cannot be taken from the regular program especially for health teaching. Twenty to thirty minutes per week is not enough for hygiene instruction unless supplemented with correlation with other branches. Another reason for such correlation lies in the fact that since the child is not directly interested in health, it is best to make the approach through other channels as through language, reading or manual arts. It seems that an appreciation of verse can be developed very nicely in connection with health teaching. To show how one first-grade teacher has done this, I want to read her own narration of the story of one of them. "The boy who wrote the 'Stand Straight Rhyme' said at first: 'Eat soup, eat soup, all day long. Eat soup, eat soup, then you will grow strong.' The children in the class shouted with laughter and I said, 'What will happen to him?' 'He'll burst,' they said. 'What can he do all day long and still grow strong?' I asked, and they recited the verse in its present form." Here is the revised version: Sit straight, stand straight, All day long. Sit straight, stand straight Then you will grow strong. It seems to me much better to spend time in this way rather than in making parodies on the classics, Mother Goose included. Children commit to memory Stevenson's Good and Bad Children. Any child will be benefited in a lasting way by this little poem. Correlation between Health Education and manual arts may be made by the health poster. The poster must have a punch for health and at least a suggestion of art-the better drawn and more beautiful 53 it is the better health poster it is. There must be enough pleasurable work about it to soak something into the health consciousness of the child but not so much detail work about it that the drudgery wearies and disgusts him. Instruction in hygiene and art may well be com- bined for a short period each year. Mr. Davis then described briefly the Seattle plan for improving posture, as follows: In Seattle we are trying the plan of grading posture four times a year and entering the grades on the quarterly report card. This grade is made up of two factors, a mark on formal posture, using a modification of the Bancroft test, and a mark on general posture, keeping in mind the child's position in study, work and play. The greater emphasis is laid on natural posture. It is good to hear of the excellent results from using the game of the milk bottles against the tea pot and the coffee pot. The prin- ciple of the game rests in sound psychology. Will you pardon me if I give you a few more statistics at this point. In our investigation of the health habits of Seattle school children we found that there was a striking connection between milk drinking and coffee drinking. We found that the drinking of milk decreases gradually from the fourth grade to the eighth grade, while the drinking of coffee increases during the same period and the decrease in one is offset almost exactly by the increase in the other. Coffee displaces milk in the diet of the growing child. That one habit may be directly affected by the other seemed indicated by the records of several schools. One school in particular made a fine improvement in coffee drinking during the very period when a milk campaign had increased milk consumption from 100 to 330 bottles per day. These facts point to a vigorous milk campaign as the best means of fighting coffee drinking among school children. To complete the outlines of the functioning health edu- cation picture we are attempting to sketch, the Committee desired to present the state programs in effect in New York and in Virginia,-these two being chosen since they repre- sented two quite different types of organization to achieve the same end. Owing to the unavoidable absence of Dr. George Wiley, Assistant Commissioner of Elementary Edu- cation, State Department of Education, New York, the New York program is not here given. In a later section the work of the State Supervisor of Nutrition, functioning in this department, is, however, described. Dr. Mary Evelyn Brydon, Director, Bureau of Child Welfare, State Board of Health, Richmond, Virginia, then outlined the Virginia plan for Health Education as follows: 54 The Virginia Plan for Health Education Dr. Brydon: THAT portion of Virginia's health program which I shall discuss today relates to the annual physical inspection of school children. For this work we are utilizing teachers; and the advantages or disadvantages of our plan are all creditable or chargeable to that determination. Being a physician, it was only natural that my original bias was toward inspections to be undertaken by phy- sicians; but the results of our three years' experience justi- fies me in believing, certainly so far as Virginia is con- cerned, that the physical inspection of children in all the public schools, elementary or high, is properly the work of the teacher. The inspection consists of weighing, measuring, looking at the teeth, and testing the vision and hearing. After in- specting the children, the teacher makes a record of this inspection for her file and sends to the parents a notice of the obvious defects which she finds, advising consultation with the family physician or dentist, as the case may re- quire. The teacher is instructed not to make diagnoses or to prescribe treatment, but merely to report obvious de- partures from the normal. One must carefully differentiate between the physical inspection by the teacher and the medical examination by the doctor. The ideal plan would be for each child to have annually a complete medical examination, given by his family phy- sician or the medical health officer; but we appreciate the present impossibility of realizing this object. So we utilize the teacher for the discovery of defects so apparent that they may easily be recognized and advise that she personally or through the nurse urge parents to have the defects remedied. During the past year about 80 per cent of the children in the rural public schools of Virginia were inspected. The teachers weighed and measured approximately 375,000 children, looked at their teeth and inspected their vision and hearing. Without the teachers' contribution to this work, it would have been impossible to inspect this large number of children. This means that a great many of these children who are leaving our schools would never have had 55 their defects discovered and corrected, and many more would have been handicapped for years. This plan makes more children physically fit and secures results more quickly than any other that can be worked under existing conditions. This very real advantage alone justifies our program. The teacher who has had specific training for this par- ticular phase of work can prepare the child for the annual inspection so that it will be done in a normal, natural way without attracting undue attention to the body and its functions. She can make it a natural part of the school pro- cedure. It is difficult to test the vision and hearing of a child who has been made nervous by the sudden appearance of strangers. The inspection is a personal introduction of the physical side of the child to the teacher. Teachers testify that they get a very much better understanding of the physical con- dition of their pupils by inspecting them themselves than they can by looking over cards recording some one else's inspection. This knowledge gained by doing makes the teacher more alert to the physical well-being of her pupils, and is the first step in carrying forward a more compre- hensive health program in the schools. This first-hand knowledge stimulates constant watchful- ness for symptoms of disease, and has prevented epidemics and frequent sickness in many places. In this way it has increased school attendance. Knowledge of the child's handicaps has enabled the teacher to deal more intelligently with the problem of seating, regulation of light, home study and the daily program. The teacher is with the children all the time they are in the schoolroom, and has them under daily observation. This provides innumerable opportunities to encourage the correctional work. It may be interesting here also to note that this active participation in the health program and knowledge of phy- sical conditions gained by the inspection of the children, reacts favorably on the teacher in caring for her own health. There are two admitted difficulties in the way of phy- sical inspection by the teachers. One is the suspicious atti- tude of the parents; the other is the unwillingness of the teacher to undertake the work. Both of these difficulties are due to misapprehension of the facts. 56 It is natural that parents, like other people, will not be- lieve that a layman can do the work of a professional; but the answer to that objection is: we do not ask a layman to do professional work. Our physical inspection is so simple that anyone intelligent enough to be a teacher will be suf- ficiently intelligent to make the required inspections. The other objection also vanishes with a comprehension of the work and its relation to the ordinary duties of the teacher. Many teachers have been distinctly unwilling to undertake this new work; but few, if any, have remained unwilling after they have been made to understand how they can aid in the physical well-being of their pupils, and the extent to which health and strength contribute to mental progress. We do not claim that our teachers are inerrable. It may be that some of them regard this health work as an auxiliary of education and not as a part of it, and that others are too scrupulous in making inspections. It may be that an occasional teacher will suggest remedies for de- fects, although they are cautioned against doing so. It may be that sometimes a teacher may make the mistake of send- ing a child to the doctor for treatment when treatment is unnecessary. But these exceptional instances do not weigh against the mass of favorable experiences. We are now working towards an end that will, if reached, reduce still further the demands upon the teacher. We are striving to have all children made physically fit be- fore they enter school; and we hope for the day when the majority of the patrons of our public schools will have their children receive medical examinations regularly. In some of the counties in Virginia plans are already being worked out by the health authorities to provide for the inspection of children of pre-school age and the correc- tion of defects during the summer previous to the opening of school. Our fundamental proposition is that all authority over the classroom should be vested in the teacher, and that to introduce a doctor or nurse as a temporary authority is subversive of that proposition and fundamentally unwise. We have chosen to consider the child as a unit, neglect- ing no element of his personality. We attempt to provide for his normal development, physically, mentally, morally and spiritually. We try to keep constantly in mind the rela- tions of these factors in development; and we believe that 57 the child's guidance, other than that given at home or by the church, should be left, so far as possible, with one per- son. If that be a proper conclusion, the obvious director must be the teacher. We may take for granted the teacher's ability to aid in the mental, moral and spiritual instruction of children; and, in order to supply the demand for well trained teachers who are prepared to direct the child's growth along all health lines, the State Board of Health of Virginia and the State Board of Education are co-operating in supervising courses in health and physical education in all schools in the state actively engaged in preparing teachers. They also co- operate in conducting a correspondence course in health work for teachers. According to a law passed by the Gen- eral Assembly in 1920, the State Board of Education, with the approval of the State Board of Health, has established "regulations whereby on or after September, 1925, no ap- plicant may receive a certificate to teach in the schools of this state who does not present first, satisfactory evidence of having covered creditably an approved course in general physical education in a training school or course for teachers recognized by the State Board of Education as a school or course in good standing." I have said that our records for last year showed that 80 per cent of the children had been inspected. In con- formity with the law just noted, every teacher will have been prepared, prior to 1925, for the intelligent inspection of the children; and we deem it safe to anticipate in that year and afterwards virtually 100 per cent inspection. About 6,000 teachers' certificates are issued annually; each one of these must show credit for this health course before the certificate is endorsed by the State Board of Education. The course as outlined has a minimum credit of one college session hour and consists of four main divisions: 1. Physical Defects and their Control 2. Communicable Diseases and their Control 3. Health Education, which includes (a) First Aid and Prevention of Accidents (b) Care of School Plant (c) Personal Hygiene (d) Physical Training (e) Mental Hygiene 4. Methods of Teaching, which include emphasis on the formation of health habits. 58 It may be well, just here, to mention briefly our summer schools for teachers at which the entire health course is given. These are the four State normals, the University of Virginia, two colleges, William and Mary, and Emory and Henry, and three colored normal schools. We have an un- usually high proportion of teachers attending these schools: the Virginia percentage runs between fifty and sixty, while the percentage for the country as a whole is about twenty- five. One of the most powerful forces that we can have mov- ing us is an enthusiastic, trained teaching body with a thoroughly awakened health consciousness. Co-operating with them, we hope to have a corps of doctors, nurses, specialists, and an appreciative, understanding public. So far as the nurse is concerned, we encounter few ob- jections to our proposition, but we cannot overlook some medical opposition. Doctors are not always in sympathy with our work and are sometimes inclined to magnify any mistake made by the teacher. The medical profession should understand that our plan is really favorable to the doctors. Physical inspection should not be made a part of the business of the doctor. He has not sufficient time to make a thorough examination of every child in the average county, and so he must overlook many or shun his work. Our program is, however, not primarily in the interest of the medical profession. We believe that it is helpful to the doctors, but that is incidental. Our first concern is for the child; and we know that the teacher will not assume her full responsibility towards her pupils so long as a doctor or a nurse is taking part of the responsibility. In the cities where there is a school doctor, these things must be remembered: If he is a full-time health officer, he has duties other than school duties or he has several schools under his jurisdiction; if he is a part-time official, his in- terests are divided between public duties and private practice. The public health official does not make a diagnosis. He recommends that the child who has a defect should be taken to a physician or a dentist. If the public official makes a diagnosis, he is apt to come into disagreeable conflict with the private practitioner to whom the child is referred. Now it must be obvious, with these facts in mind, that the 59 school doctor is in a particularly ticklish position, on the one hand with the public; on the other with his fellow phy- sicians. Our plan saves him much worry. The family physician has a definite place in our plan. No child should be permitted to engage in strenuous exer- cise or games if he is underweight or until he has been ex- amined for hernia, and has had his heart and lungs tested. These medical examinations are not a part of classroom routine, and they should not be made in the classroom. Children to be examined should be sent to the doctor's office. Lung or heart examinations should not be made through clothing. The family physician should make these examinations and issue a certificate based on his findings. The nurse also has a specific place in our program. She follows up the work of the teacher after she has assured herself of the teacher's ability to do her part. She sees that parents are impressed with the necessity for having the corrective work undertaken. This is the main work of the school nurse, and it is enough to require virtually all of her time. Unfortunately, many of our counties have public health nurses who can give only part of their time to the schools; but the nursing service is being rapidly extended in order to correct this weakness in our system. In Virginia, we have made no comparative study of the results of the inspection made by teachers, and of the in- spection made by nurses and doctors, but in Detroit, where a thorough study is being made, they report that "the opinion of the teachers coincides very closely with the medical opinion of the physicians. In fact, the physician having the most extreme opinion showed far greater devia- tion from the median of all four physicians than the teacher" (inspecting the same children). The results of this investigation in Detroit led to the conclusion that: "The teachers are quite capable of grading thyroid, vision, hearing, mouth breathing, tonsils, skin, anemia, teeth, palate, cervical glands, and orthopedic defects, though they cannot examine for lung and heart affections." (Page 727, Public Health Bulletin, September, 1922. Michigan De- partment of Health, Lansing, Michigan.) We do not, how- ever, ask our teachers to undertake all the inspections which seem to have been included in the Detroit experiment. 60 The value of any work is best gauged by its results. The most enthusiastic opinion will not weigh in the balance against a conflicting record. Therefore, while I cannot give you complete figures covering the state as a whole, I should like to present a few statistical observations. During the fall of 1922, Accomac county, with a school enrollment of less than 9,000 reported more than 1,000 corrections of defects discovered in the classroom. In Greensville county, with an enrollment of 3,042, there were 900 corrections. In Prince Edward county, 595 corrections were made in the school population of 3,471. The pro- portion of defects is, of course, much larger to school population. The health program that is functioning in Virginia to- day has evolved naturally. Our whole plan is an evolution. We visioned a goal and then devised pathways toward that point of ultimate endeavor. We began as pioneers and are still pioneering, profiting, we hope, by our mistakes, and utilizing, when we may, the experience of others. Of course, we have not reached our goal, and it would be a confession of weakness to suggest that we ever shall reach it; for, as the work progresses, new opportunities are pre- sented; and our final objective will have to be placed at a point far above and beyond our original vision. After carefully reviewing the arguments for and against our plan for the physical inspection of school children from every point of view, and surveying the whole field of public health, our conclusion is that its far-reaching benefits to the children of the present generation cannot be measured. We realize that it is not perfect, but we believe results jus- tify our claim for it that it is the most effective plan in con- ducting a well-rounded program that has for its purpose- to enable the greatest number of children to reach their highest development. The Chairman then introduced for discussion of this topic Mrs. Josephine Corliss Preston, Superintendent of Public Instruction, Olympia, Washington, who contributed the following sum- mary of state health programs in the Northwest: 61 Discussion Mrs. Preston: Leaders in education as well as all public welfare workers from the Atlantic to the Pacific seem suddenly to have awakened to the fact that our greatest human asset, good health, is being destroyed in countless thoughtless ways. From coast to coast now comes this national urge for conservation and development of our national health and vitality. In the year 1920 the U. S. Commissioner of Education reported that twenty states had laws providing for physical education, all but one of them making it compulsory. He also stated that the most significant feature of this legislation was the broad and compre- hensive interpretation of physical education given either in the statutes themselves, or in the administrative programs adopted by the State Departments of Education. The most notable weakness was the failure to provide adequate financial support for administration and supervision and the failure to provide administrative means for making the laws locally effective. The education of children in hygiene demands the active co-opera- tion of parents. Children cannot be made healthy through the mere training and instruction in hygiene given in the grades. The sanitary and hygienic conditions necessary for health must be supplied at home as well as at school. Hygienic habits must not be merely school, but also home habits. Parents need to be enlightened as well as the chil- dren. The Parent-Teacher Association movement which has now become so popular is an excellent way of bringing parents and teachers of the state together to co-operate for the health of the child. Laws may be written, but only health-educated legislatures will pass them or make them sound and effective. Only health-educated "constituents," citizens at home who have had some health education and physical training, will support health legislation or live up to it when it is passed. In California the state law requires physical training in every school in the state. Strict adherence to all the state requirements for proper lighting, heating and ventilation are observed. An exten- sive hygiene course is taught in practically all the grades in all the schools. Practically all the counties of California report that although all the work along health and sanitation lines is new, a great deal of progress is being made. The great need apparently is for state-wide progress so that the entire state may benefit by a health program. The Idaho Bureau of Child Hygiene is doing much for child health. Mother and child health conferences are to be held in each county in the state during the year, at which any mother may have a thorough physical examination by a competent physician; and also her child may be examined. The members of this staff do not do corrective work in these conferences. If there is need of such the patient is referred to her family physician. The Modern Health Crusade is included in the state course of study, and the teachers are given one credit towards the standardiza- tion of their school for carrying on the Health Crusade program. The public health nurses of Idaho Anti-Tuberculosis Association 62 have inspected 29,734 children in the public and parochial schools of the state. Songs, plays, stories, posters and moving pictures are employed to present health. This past year a nutrition program, added to the Health Crusade program in the schools as a follow-up of the nurses' inspections, under the direction of a nurse specially trained in nutrition work, has produced most encouraging results. Dental clinics are being advocated, and through co-operation of the State Dental Association a program will be worked out for the coming year. Co-operation with the various state agencies is established and especially good work accomplished through the Bureau of Animal Industry in the promotion of a clean milk supply. For a number of years Nevada has, under the direction of the State Board of Health, conducted examinations of the physical condi- tion of school children and while, in the hands of the teachers, expert examinations could not be given, the detection of adenoids, bad tonsils and teeth, defective hearing and kindred ailments was made possible and the parents were given information concerning conditions of which they were not aware. The law does not provide sufficiently for this kind of work. The law requiring physical training in the four-year high schools has been a step in the right direction, but has not been thorough-going enough in this respect. The general plan for health and physical training work in the ele- mentary and junior high schools of Utah includes: Provision for the physical examination and medical inspection of all school children at least once a year; a system of "follow-up" for the purpose of cor- recting the defects discovered by the medical inspection; the inspection of school buildings and grounds and the maintenance of satisfactory sanitary and hygienic conditions; the protection of the school popula- tion from contagious diseases by daily inspection and exclusion of incipient cases; careful instruction in personal, household and public hygiene; systematic physical training as a means of promoting normal physical growth. Mrs. Preston then described the way in which the State Health Department of New Mexico had been stimulating the creation of county health departments, under the direction of trained and experienced health officers, thirty-five per cent of the state's population being served by such units. She said that an important part of the work of these organi- zations was school hygiene. The school authorities find their attendance markedly improved by the prompt control of communicable diseases; in one such county, no school hav- ing been closed because of an outbreak of contagious dis- ease in more than a year, while previously, it had been necessary to close many of the rural schools for brief periods, due to this cause. Of her own state, Mrs. Preston said: In the state of Washington we are giving more attention each year to the health of school children. A certificate of health must be 63 presented by each teacher to a board of directors before a contract may be legally signed and the teacher regularly employed in a school district. A large percentage of schools furnish hot lunches in rural districts, as well as in the larger cities. We feel that a school lunch service should be part of every rural school. Children who have a warm lunch at noon are better nourished and do their school work in the afternoon with better results. For malnourished children, of whom there are often 20 per cent in our schools, we find the warm lunch essential. First-class school districts in Washington provide milk for children. Many rural schools have scales for the regular weighing and measuring of children as part of organized community service work. Special care is given to heating, lighting and venti- lating details in school buildings. Requirements for standard schools in addition to the recognized ones in buildings, equipment, grounds, and other features which are upheld, include those of thrift education as related to the saving of the four essentials-health primarily, time, talent and money. Many of the schools are active in Health Crusade work and Junior Red Cross; promotion of health work in its various forms; health credit work, and medical inspection. Co-operative child health service is an activity of the Department of Home Economics in both the University of Wash- ington and the State College. There are practically a dozen visiting nurses traveling through the state in addition to the county nurses that are employed by a majority of the respective counties. Washington had a physical training law which provided for the installation of physical training courses in all the schools of the state, making the requirement of twenty minutes daily supervision. Physical education work was compulsory in every public school until the 1923 session, when it was made permissive. A large number of orthopedic cases are found by nurses each year and are sent to the Children's Hospital in Seattle and Spokane. Defects in children of pre-school age that public nurses find in homes they visit in performance of their regular work are frequently remedied by these organizations. A nurse frequently co-operates with the county superintendent of schools. The American people are beginning to appreciate the fundamental importance of health for happy and successful living. This has been a very brief outline of the efforts initiated in a few of the western states towards improving the health of children. Health within certain limits is to be gained only by the proper expenditure of money and by education. The Chairman: We look forward with very keen anticipation to the con- tributions from our friends from other countries, and the first offering is the next number on the program, by Mlle. Madeleine Kaiser, Directress of the Colony for Debilitated Children, Brussels, Belgium. 64 Belgian Work With Undernourished Children Mlle. Kaiser: AS a prelude to the address I am about to deliver I should like to declare how happy and proud I feel to be here amongst you. Happy, because of the pleasant memories associated in my mind with my previous stay in your country, when I was enabled to perceive the active and generous sympathy which a great nation like yours is always ready to extend to every- thing and everybody connected with the work of social im- provement and the welfare of humanity. Proud, because I represent here: A country, Belgium, small, indeed, in area and population, but great because of the place it occupies in the history of Europe since the memorable year 1914. No words of mine are needed to remind you, our allies of the war years and our friends of today, what a mighty effort our little country made to defend its national honor and preserve the integrity of its soil, but it is with feelings of joy and pride that I shall endeavor now to show you an- other aspect of my country's effort, the fight it waged dur- ing the war and continued tenaciously since the armistice to protect the lives and health of its children. This is the subject on which I am about to address you. The National Children's Welfare Organization I. Before the War The welfare of children of the poorer class was en- trusted at the same time to public bodies and to private charities. The measures taken for their assistance were more remedial than preventive, and were consequently com- pletely insufficient from the double point of view of racial improvement and social progress. II. During the Occupation It became necessary to set to work at once to counteract the harmful consequences of the war,-disorganization of the political and economic life of the country, trade diffi- culties and lack of food which affected people in general and more especially children. 65 In the endeavor to remedy the evils of the occupation the National Relief Committee was created and later on in January, 1915, a Children's Aid and Protection Section was added, the program of which was as follows: 1. The granting of subsidies to the different charitable organiza- tions already existing, such as creches, nursing consultations, etc., which had been self-supporting hitherto. 2. Financial aid to orphanages, patronage committees and societies for the protection of children. 3. Creation of a National War Orphans' Organization. 4. Creation of an organization for providing meals for school chil- dren. 5. Placing consumptive children in the country. All the work was carried out under strict medical super- vision. III. The Situation at the Armistice Organizations Affording aid to Nursing consultations 90,130 children Maternal canteens 7,769 future mothers Canteens for delicate children 112,040 children Soup for school children 1,174,163 children Besides these, since 1917, fifty homes for delicate chil- dren with accommodation for 7,000 children, have been founded. Establishments for the reception of delicate children during the day for sun and air cure have resulted in a con- siderable lowering of the average in infant mortality in the case of children under twelve months old. Dr. Lucas, Professor of Pediatrics in the University of California, writes of this work: "I am glad to be able to state that the consequence of the great devotion of the workers in the different organizations in Belgium conse- crated to child welfare has been to bring the children's con- dition above the normal." It will thus be seen that the effort made in Belgium on behalf of the children's organizations during the war years was very successful. To the question: Should the beneficial results already acquired be allowed to die of inanition after the armistice, the legislature was not slow to respond by passing on the 5th of September, 1919, "The National Chil- dren's Welfare Act." 66 The National Children's Welfare Act is intended to en- courage and develop organizations for the protection of children, and more especially to favor the diffusion and application of rules and methods based on scientific prin- ciples bearing on the health of children, whether at home in their families or in public or private educational estab- lishments; to encourage and sustain by means of grants or otherwise the different organizations interested in chil- dren's health; and to exercise an administrative and medi- cal control over all such recognized organizations. The peculiar character of Belgian organization for child welfare is that a law, voted unanimously by our Parliament, renders the creation of nursing consultations obligatory in all communities of the country. Consequently, the bene- ficial action of the early medical examination for children of the open air institution, as well as of the other health in- stitutions, forcibly reaches the total of our children. Strong measures are taken by the government against those com- munities which do not obey this law. The National Children's Welfare Organization possesses legal status. It is a public autonomous organization, con- stituted by act of Parliament and under government con- trol, but otherwise independent. It is managed and admin- istered by "Le Conseil Superieur des Oeuvres de 1'Enfance," composed of forty members nominated by the King. The duties of this council or board are as follows: First, to take such steps as it may deem necessary in the children's in- terest and, second, to give its opinion on all questions relat- ing to child protection that may be submitted by the government. In order to insure unity and cohesion in the working of the different services in different parts of the country and to facilitate the carrying out of such measures as the Gen- eral Council may direct, provincial councils were founded. The latter councils are in close relation with the local or- ganizations and understand their working better than the General Council. Lastly, in order to superintend local work there exists in every district a local committee consisting of the directors of the children's organizations of the town- ship and a nominated delegate. The National Children's Welfare Organization has under its charge the following useful charitable and phil- anthropic organizations: 67 1. Nursing Consultations. This useful work is now carried on in every township in Belgium. Its purpose is the medical control of children under three years of age; and it has been the means of sav- ing the lives of thousands of little ones. 2. "The Drop of Milk," now amalgamated with the preceding organization, is intended to supply infants of the poorer classes with a sufficient quantity of milk and milk diet foods. 3. Les Creches or Day Nurseries. The service which the work of the creches has rendered to children is too well known to go into at any length. 4. Maternal Canteens provide to pregnant mothers or mothers with babies at the breast a substantial daily meal. 5. Meals for School Children. Through the instrumentality of this organization an extra quantity of food is provided for school children, and the more delicate amongst them are entitled to partake of a substantial dinner at the Canteen for Delicate Children. 6. Convalescent Homes for Delicate Children are established at the seaside and in the country, where little ones threatened with tuberculosis or unusually delicate from any cause whatever, are especially cared for and enabled to derive the greatest benefit from the fresh air cure combined with suitable diet and the acquirement of proper health habits. The organizations are only recognized if, on being in- spected by one of the inspectors of the National Organiza- tion, the latter submits a satisfactory report on their work- ing and efficiency. The utility of the work approved of by the National Children's Welfare Organization is shown by the fact that each succeeding year the results become more and more satisfactory. In concluding this rapid survey of the work done on the children's behalf I am comforted by the feeling of satisfac- tion I experience in the knowledge that I have spoken to friends about a work which, if it is dear to me, has also your sympathy, because I know that you are interested in all welfare work, and more especially in anything calculated to improve the children's condition. What Belgium has done to improve the public health and ameliorate the race may be gathered from two figures which speak for them- selves and need no comment. In 1914, the budget of the interior contained provision for the payment of the sum of 300,000 francs for all that concerned public health and child welfare; this year the princely sum of twenty-five million francs is placed at the disposal of the National Organiza- tion for Children's Welfare to enable it to carry on its bene- ficial and salutary work. 68 In our country we are suffering much from the evil con- sequences of the war, but the moral energy of our people is calculated to overcome all obstacles to our economic prog- ress. In the midst of the ruins and devastations of the war which still bear witness to the sufferings we underwent, the National Children's Welfare Organization blooms like a flower and its presence will appeal to the traditional quali- ties of our race, to urge us on to increased effort to win a complete victory in the noble work of social amelioration, as in the past we triumphed on the battlefield. Through the initiative of the Commission for the Relief of Belgium Educational Foundation and the American Child Health Association, I have visited wonderful organi- zations in this country and penetrated the beautiful spirit of its directors. These visions I take back with me to make my countrymen benefit from them. I thank you for that! Thank you for your kind attention! Mlle. Kaiser showed some moving pictures of the Bel- gian work she had just described, illustrating the regime for healthful living in force in one of the colonies. Miss White then showed charming pictures of the Nursery School, illustrating some of the children's activi- ties which had Health Education values. This closed the second session. The resolutions presented by the Committee to the Plenary Session and based upon the first two sessions, will be found on page 342. Interest in this program led to a desire for further discussion. Mrs. John Collier, Western Representative, American Child Health Association, conducted a round table on Schoolroom Problems in Health Education. The following is a summary of the chief points developed: Miss Hannah L. Lezinsky, Physical Education Department, Fresno, Calif., said she had been doing health work for 13 years-recently with teachers themselves. She said that in spite of a fairly good school outline in health and hygiene, teachers were not teaching this course, and that the cause was a need for interesting, training and starting these teachers to work, all because no training in Health Education had been provided for them in their normal schools. Dr. Clara Greenough, State Normal School, Cheney, Wash., said that a teacher must know something of the sciences underlying health 69 rules; hence the training course must include not only methods but also sound subject-matter. Mrs. Gertrude Whitton Barrett, Secretary, Public Health Educa- tion, Oakland-Alameda County Health Center, Oakland, Calif., described the most helpful contributions of the Center, to teachers during the past year: (1) Gathering materials together in one place convenient to the teacher, in the public health center, where she can study and have her references and her visual education material; (2) getting together a teacher's library of Health Education material, with periodicals and standard reference books on file; (3) collecting colored models of foods which can be grouped together, making bal- anced meals for children. The Center now makes original slides in its laboratories. The schools need things of this sort as an inspiration, and the teachers also need them as tools. The demand is slight for them at first, but later the demand exceeds the supply. The Health Center also secured a 16-weeks course, gathering together specialists, teachers and workers, week after week, for talks and discussion, bringing in things the children had done at one time or another, using this as a starting point and clearing house for gen- eral information as the teachers brought it in. Mrs. Barrett described the origin of the Oakland course of study in hygiene. This method of developing a Health Education program has been very interesting, because getting the members of the various school departments interested, and determining who should be respon- sible, is always a problem. The first thing done was to call a meeting of all the people interested, each department being represented. This group acted as a council and developed what they called their first handbook. This was published and went to the teachers. It was really a gathering together in good shape of as many suggestions as possible. The book aroused interest, and immediately following that the teach- ers were offered the 16-weeks course. The response was entirely voluntary and out of the interest of the teachers a really first-class result followed. Mrs. Collier indicated how libraries could be assembled. The pub- lishers are often willing to send their material without cost to any center where teachers are to be gathered together to go over this material. In this way a small library may grow into an extension center, the physicians, teachers and other workers coming together for an extension course such as may be desired. Miss Maud Steinbach, Physical Education Department, San Fran- cisco, described a new system whereby one teacher is selected from each school in the city, to be the health teacher, regardless of what her official position may be-kindergarten, domestic science, etc.-as long as the teacher is adapted to the work and interested. These teachers are paid by the Tuberculosis Association. One successful way which was found to help the pupils was to connect their weight with some other interest in life, such as baseball, boxing or other sport, and bar them from participation in these sports unless they were up to weight. This has produced results in many cases where all other methods failed. 70 Regarding the method of weighing and measuring, the following opinions were voiced: Miss Steinbach said she generally did most of her questioning while weighing the children and did not think there was any considerable saving of time in having pupils weigh each other. "You can learn things that you otherwise wouldn't while you are discussing the child's weight with him." Miss Lezinsky said she had secured interest from older pupils by having them do weighing, thus starting older grades in their own physical education. Mrs. Barrett said that since in the high school age it is very hard to find a project which interests, it is well to allow the older children to weigh and measure, even if they aren't as accurate, because it does create an interest in them. If the teacher is dissatisfied, she can weigh them over again herself. Miss Leila Wilson, Cora Williams Institute for Creative Educa- tion, Berkeley, said that she had charge of a group of girls consider- ably above the average in mentality and physical education. Though of the better class with better habits, the girls showed under-nourish- ment, due probably to their eating rich foods rather than practical ones. Co-operation of the parents was secured. Through somewhat social cooking classes nutrition was studied and choice of foods. The result was an unimaginable response, even in the homes, which were revolutionized. White bread was served to but one girl in the cafe- teria, the rest all eating whole-wheat bread. This applied only to girls from 8 to 14 years of age, however, as the older ones already had too many social engagements to be attracted by this source of entertainment. Part III SOME FACTORS IN A HEALTH EDUCATION PROGRAM A HEALTH Education program is successful in produc- ing its results of healthy, happy and efficient children and teachers, in proportion to its simplicity, directness and flexibility. The well functioning whole, however, is only achieved through the successful synthesis of many factors. Therefore, after having looked at a few programs in action, it became the next effort of the Conference to discuss the component factors of these programs. In this session are grouped discussions of topics, the point of view with regard to which determines the character of the aid which will be sought from the large fields of medicine, nursing, nutrition and physical education. Our reactions to these discussions will, of course, color our ideals of teacher training, and upon our success in this field depends the real effectiveness of Health Education. Dr Wood opened the session by introducing Miss Mary E. Murphy, Assistant Director, Elizabeth McCormick Memorial Fund, Chicago, Illinois, who asked the Conference to consider with her Objectives in Health Education Miss Murphy: THE objective of Health Education is essentially one with the objective of education in general. The things of value in life are not set apart, sought individually, kept for our use in a separate compartment to be produced when needed. They are rather interdependent, intricately woven together, realized only as the result of the sum of our ex- periences, every activity, every interest, playing its part. So health as one of the chief ends of life cannot be achieved in a field removed from other ends. In his "Reconstruction in Philosophy," Dewey says: "A man needs to be healthy in his life, not apart from it, and what does life mean except the aggregate of his pursuits and activ- 71 72 ities? When the endeavor to realize a so-called end does not temper and color all other activities, life is portioned out into strips and fractions. Certain acts and times are devoted to getting health, others to cultivating religion, others to seeking learning, to being a good citizen, a devotee of fine art. Who can say how much of distraction and dissipation in life, and how much of its hard and narrow rigidity, is the outcome of men's failure to realize that each situation has its own unique end and that the whole personality should be concerned with it? Surely, again what a man needs is to live healthily, and this result so affects all the activities of his life that it cannot be set up as a separate and independent good." The primary objective of Health Education, then, is to give health its place in the life of the child-in his physical activity, his mental concepts, his emotions, his moral de- cisions, his social reactions in an aggregate of values. When this Utopia has been reached our descendants will be meeting in conference on matters whose objectives are to be expressed only in Utopian hyperboles; but it is never- theless worth while for us to keep in mind this essential unity of values at a time when our enthusiasm may place the pursuit of health in too sharp a relief. We must have clearly in mind certain goals. What we mean by health must be expressed in terms of specific con- ditions, concrete measures of achievements. One such con- crete measure has been furnished in the now widely ac- cepted idea that a child's weight and height are one index of his condition, and his capacity for steadily adding to both one sign of his physical progress. The establishment of this standard has been the foundation upon which has been built a program for the promotion of healthful living among countless school children. If in our enthusiasm we have gone too far in our estimate of this standard as a measure of a child's physical progress, in too literal an interpretation of the static re- lationship found at any one time rather than the importance of continuous growth, the by-products of our overzealous efforts have in the main been good. The value of a goal, however literally interpreted, against which the efficacy of a regime of healthful living may be measured, is well illus- trated in the case of the earnest young colored woman who eagerly watched the weight progress of her five-year-old kinky haired Annabelle week by week, and when the goal had been reached, presented her with all the ceremony at- tending a graduation-with a large bouquet of pink roses. 73 There is needed at this time, as an objective of our programs, a further development of standards, an improve- ment on those already in use, the establishment of new ones whereby we may more accurately judge of physical con- dition, more light on this whole vexed question of the re- lationship of weight and height to other criteria. Just what are the other conditions which may furnish on the one hand goals for the child and on the other guides to those making a program for his well being? Shall we some day apply to boys and girls standards of physical con- trols as we now do fairly well for infants? There will undoubtedly emerge from the countless records of re- peated measurements of weight and height, from careful physical examinations, from physical measurements, from strength and endurance tests and others, a more complete body of standards of physical fitness than is now available. These will more adequately guide us in plans for the physical activities of children, for the social and educa- tional demands we make upon them; they should become a most valuable addition to the standards already estab- lished for the determination of fitness for work among that large group of early adolescents who each year leave school by special permit. Meanwhile the standards we now have challenge us. In the judicious use of a weight-height goal we have a most valuable means of achieving certain very definite objectives in a health program. We should continue to use this measure of growth, both as an end in itself as one indication of physical well-being, and as an incentive for thorough medical understanding and corrections and the promotion of a regime which will promote growth. We realize that the "normal" today, determined as it is by the "average," is not the "normal" of the future, when continued research has erected a more perfect measure of progress, and when the results of programs of health pro- motion have raised the level of the average. In our Utopia we shall think in terms of the highest degree of develop- ment of each individual. With our eyes on this image of physical perfection, we organize our program for its realiza- tion among the boys and girls. It is fairly simple to urge the establishment of habits as a means of attaining the goal, and the ease with which we outline the desired virtues makes our frequent failure to secure them the more dis- 74 couraging. In this "salvaging operation," as Dr. McCollum has termed the health program for children of school age, we are frequently setting up concepts in mortal combat with those built up through the years preceding-years of between-meal orgies and bed hours accommodated to the latest thrilling screen serial. How to reach back into the years before entrance into school, so that an understanding of the fundamental significance of correct habits as a basis of physical and mental well-being may motivate parental control ? Here indeed is an objective of any Health Education pro- gram which at present carries an unfair burden inherited from those earlier years. But the task must be under- taken-this "salvaging operation"-and we have as a defi- nite aim in the process the establishment of habits of life which shall make for health of body and mind. In the sub- tlety and difficulty of the task lies a fascination. There is no easy short road here, for health habit formation is so in- volved with emotions and a multiplicity of factors that the utmost wisdom and understanding are needed by the teacher. There is more than one line of thought in the situ- ation of the irate grandmother who visited the school and in her broken English demanded of the teacher: "What was all this nonsense about drinking milk?" Otto had repeatedly demanded milk, and in final rebellion had that morning poured the traditional coffee "down the sink" declaring, "Every time you give me coffee I pour it down the sink!" It is a wise teacher who does not widen the breach already too great between generations, and who so thoroughly acquaints herself with the conditions surrounding her charges outside the school that she maneuvers to secure her results without producing a conscious rebellion against tradition. It is a question whether the fervor of grand- mother's conversion on beholding Otto's increasing plump- ness could completely make up for the maladjustment, tem- porary, at least, within that household. It is illuminating for the nutrition worker who has been insisting on a cooked cereal every morning to learn that in that dwelling filled to bulging with negro families recently come to a northern city inadequately equipped to house them, a common kitchen is shared by all, and the hard- pressed mother wonders distractedly just how she is to manage the long hours of cooking in a receptacle shared 75 with others. It is illuminating to learn that the small boy who is in disgrace because he has again spoiled the record of his group by being unable to report, "I slept with my windows open," has no window in his room, though he has done his best to meet the requirements by leaving the door open into a room with an open window. Which was the essential in that situation-that the small boy's record should complete the honors for his group, that his tiny nose should be in closest proximity to the outside air, or that he should retain his inherent honesty which in the face of the scorn of his companions still persisted? Habits of healthy living are linked so closely with custom, conditions of life, emotions, ethical values, who can say that the observance of one habit can be considered apart from other factors involved ? All the enthusiasm, understanding and technique of motivation are needed for this intriguing task of making the habits sought function in the core of the child's being, so that there need be no umpire to assure the rules of the game, so that there may not be established a health Sabbath -possibly a blue one-far removed from the ordinary days of his life. At the same time, how to present the goal to parents, so that the achievement of physical progress in their children does indeed seem to merit ceremonial and pink roses-a conception which glorifies the frequently rather ungrateful round-and-round of parental supervision ? Of primary importance in such a program is the ideal of health in the teacher herself, and the creation of this ideal is at present one definite objective of Health Educa- tion. An ideal which gives to the teacher a consciousness of the power and beauty and happiness of health and its essential unity with other values of life, will color her con- ception of the educational task before her. It will create a standard of healthful living for herself. It will give her a realization of the importance of the physical well-being of her group in its relationship to scholarship, behavior, and attitudes. It will individualize her task so that while she uses the group method of instruction, she is nevertheless aware of the physical and social diagnosis of each individual child's failure to progress, and will bring about adjustment of the demands of his program in and out of school to meet his particular needs. A further objective of Health Education is to furnish 76 through the program of school instruction a body of sound information which shall safeguard the maintenance of health, which-at the proper age-will furnish the reason for the observance of certain habits. Behavior first, later behavior with the reason back of it which shall be so pre- sented that it produces behavior. Such aims as have been named are dependent for their realization upon certain factors within the school itself, the absence of any one of which may prove the failure of our purpose. Healthful environment; health supervision; an intelligent teaching group with enthusiasm for health and ability to interpret the meaning of health in terms appli- cable to each individual child in the group-all are necessary. Of the greatest importance, however, is a point of view among the administrators and supervisors which shall secure unity of purpose among the various departments sharing in any way the health program and which shall place physical well-being in its proper setting among other conscious ends of education. It is highly important that in any program of Health Education we address ourselves to the task of making our standards definite, our objectives clear, so that they commend themselves to the ad- ministrative group as goals, without which isolated en- deavors within the system may fail. This is indeed the "high wave of health interest"! A wonderful day! In our enthusiasm may there not be a temptation to rush into the field with "short-cuts" ? Are we not in a little danger of confusing our real objectives with the means of promoting them, of becoming so enamored of devices and methods-all valuable as a means-that we see in them the objective itself? Walls decorated with health posters may or may not house pupils healthier because of them; songs lustily declaring the virtue of health habits may or may not express convictions which are bearing fruit in action; a record of habits kept by the child may or may not be of value according to the degree that it emerges from pure mechanics remote from the child's emotional self. The wise use of devices is determined by the degree to which the teacher distinguishes between end and means, and her efficiency in health promotion is to be judged, not by the number of devices or the complication of the mechanics she uses, but rather by her ability to stimulate healthful living 77 which shall carry on when the influence of neither teacher nor device is at hand. The goal of a program of Health Education must, at any one time or place, be determined by the immediate needs. What are the objectives today may be expressed in far different terms in years to come. Those aims which we now consciously promote, may, it is hoped, become a part of life's very being, operating even under stress. There is an unlimited future for the development of capacities, for sane mental reactions, for altruistic social attitudes which beckons to us as the ultimate ideal of education, of which physical health is a part. Discussion Miss Dolfinger: There are certain points in this paper about which I am sure much more thought and discussion would be useful. It is very important to realize that in working with children we should individualize our efforts. We cannot treat children as members of groups. The value of having definite objectives is very great, because we then drive towards our end of considering each child in relation to its attain- ment of those objectives. The more we know definitely and scien- tifically about the goal and the means of reaching it, the more effective we are going to be in making each child become a healthy individual through his own efforts. Required for this procedure is laboratory and other research work to help us verify our present standards or to give us new standards as they may become necessary. These consid- erations lead directly to the papers which are going to follow. Another important point suggested by Miss Murphy's paper is the need to recognize not only the objectives we seek in the Health Education of the individual child, but objectives which we must seek in the administrative aspect of this problem. Since Health Education is a function of the school, the realization of that function leads us back to the people who administer the schools, namely, the supervisors and the superintendents, state, city and county. These people must be with us, and their active participation is another goal towards which we must aim. We must put them in the possession of standards which will enable them to discriminate between what is true and sound and what is ephemeral, in order that they may put the health program into suitable hands. We do not expect our superintendents, of course, to become health experts, but we do want them to have that appreciation of the problem which will cause them to co-operate with the people who can most adequately lead in this field. We should like to see all universities which train school administrators require, as a recognized part of such preparation, training in the proper fos- tering of a wise school health program. That, I think, is one of the important things for this Conference to consider and to promote. 78 There being no further contributions from the floor, the Chairman asked Professor H. B. Wilson, Superintendent of Schools of Berkeley, California, and Professor of Education Administration at the University of California, to present for consideration the subject Educational Principles That Should Underlie Effective Methods Mr. Wilson: AS I understand the problem of education of any type, and therefore the problem of how to make a health program effective, there are four things needful. In the first place, that we should clarify and become very definite and concrete and intimate about the thing that we wish to do, the result we wish to achieve, the hope we wish to realize. In the second place, we need to plan with more accuracy the nature of the activities and experiences with related subject-matter which is definitely and with economy and efficiency adapted to achieve those ends. In the third place, to find ways and means of launching which will need a participation in those activities and experiences and sub- ject-matter, so that the things done will have meaning, purpose, significance, inspiration for the children them- selves. In the fourth place, to find ways of measuring the achievements which we are accomplishing from grade to grade or from level to level. That is all there is to be said. But if you do not mind, I will try to put a little flesh and blood around those bones. We realize in ordinary activities the importance of be- ing very definite about our ends, and the results for which we are ambitious. When one goes about building a house, the architect first asks, "What do you expect to do with this house?" He may say to you, "I can take the same ma- terials, brick, stones, mortar and wood and make for you a residence or a schoolhouse or a library or a church. What do you want?" We do this in ordinary things, but when it comes to a program for Health Education, we seem to go about the matter in a browsing, peaceful way, with the hope that we may some day arrive approximately at our goal. So, I say again that the first thing which is important 79 before a teaching body may go about this work, before the supervisory staff can take its directions, before the prin- cipal knows what his responsibilities are, before the super- intendent can go about his business, is to set up the program with as great concreteness as possible. It is important to go about it with the greatest care and analytical insight; to use all the scientific procedures avail- able to determine in what activities children may engage, in what experiences they may be involved, and what are the participation opportunities for them. We should know what bodies of subject-matter, what facts and principles are related to the children's experiences, activities and un- dertakings. You know in what a maze we work at this time, of general information about the human physical animal, how he is put together, what we ought to do to him from time to time, and get him to do to himself, so that he shall retain all the physical vitality and energy which he possesses at a given time, and possibly add to his equipment from that standpoint. Experience, activities and subject- matter ought to be of such personal value and importance to him as will make him more concerned about his own person, his own vitality, his own interest in creating and developing a better personality; it is not a narrow, miserly, selfish thing, but a social thing to be accomplished in him, namely,-his relationship to other people as a healthy or unhealthy human animal of his community. Moreover, it is important to find ways and means to wedge every child into this thing, in such a way that he likewise will realize its significance and importance. Of course, the teacher must be concerned about it; she should see where she is going, and have method in her work, so it will be done in a way that is worth while. The teacher must want certain things to be done, and then get the chil- dren to want what she wants them to want. We have not been very successful thus far in our efforts to do that. We have relied, in matters of Health Education, as we have in geography and history, on the text-book, upon what has been gathered and printed, upon the hope of getting the child excited, waking up early in the morning, and going to school intoxicated by the lesson on pages 37 and 381 It has never happened yet, and the Lord knows it is never go- ing to happen. So long as we make the attack from the formal, booky standpoint, progress is not going to be any 80 better than in mastery of the English language. Youngsters are content to use any kind of language that will get what they want. Ordinary language satisfies the youngster just as well, if it gets the results, as the most polished language possible. On the other hand, as a teaching body, as leaders and inspirers, we have got to make our concern just this: to plan situations for all children, working democratically and intimately with them,-to plan situations in which they are, of their own wish and ambition, trying to do things they cannot yet do, bringing them face to face with certain problems and important questions, and devising difficulties and obstacles. They become concerned to turn about and try to answer or to solve the problems. When you have that sort of a situation the youngsters are going to waken up early in the morning, anxious and concerned and inspired and intoxicated to do the thing that they themselves have decided that they want to do, for the benefit of themselves, and for the benefit of other people. Finally, we need, in all the field of physical and health development, to set up standards and specific measures for determining our progress towards those ends. And this, it seems we have not yet done. Just as certainly as we need standards as to where and how rapidly we ought to go in the field of arithmetic, writing and English composition, so we need standards in health education,-measuring devices to determine from time to time the progress we are making towards our goal. Dr. Wood then introduced Monsieur Leon de Paeuw, Director General of Normal Schools, Ministry of Science and Arts, Brussels, Belgium. M. de Paeuw: In Belgium we have been teaching hygiene for several years; the Education Act decrees it explicitly. But we now realize that there is a great gap between knowledge of rules and their application. I think Child Health Education, here in the U. S. A., is going along the right path. It is interesting the child in its own health; it is giving the child good health habits, and it is indirectly influencing the parents. The means it employs are very well adapted to the psychology of the child throughout its development. On my trip throughout your large and beautiful country I heard in the Middle West a professor of a university express the opinion that Child Health Education, as it is carried out in the Eastern States, has not a sufficiently scientific character. I think this honorable gentleman is wrong. All the things which the Child Health Associa- 81 tion is teaching are scientifically true. I think this point needs no argument. Maybe he meant the ways in which this teaching is con- ducted were unscientific. I don't believe it. I think the methods used are quite well adapted to child nature, to child psychology. The young child does not reason. His judgment is not yet sufficiently developed to follow a scientific reasoning. It is thinking, in a great deal, by the means of images. The senses are the doors through which knowledge is reaching its mind. In the first years it is not able to abstract; therefore its general ideas are few. I think we have to act upon the imagination of the child, we have to make concrete the rules which are to be adapted to it. And while the child is fond of action, we have to dramatize our teaching accordingly; the fairy stories, with any hygienic aim, are not out of place in the first grades of the elementary schools. I have been pleased to see that in the same way the psychology of crowds is applied with full success. Why should the teacher not employ to a health purpose the well-known tendency of children to imitate grown-up people, and to imitate one another? Why should he not employ emulation and plays and games as a means to reach his aim? As the child is growing up, and its mind is developing, more scientific reasoning has to intervene. But in the first years the single affirmation of the teacher and his example are sufficient. The authoritative and the repetitive methods are to be followed then. Of course, all which the teacher affirms has to be scientifically exact. Here science has to bring its aid. It has to furnish exact data; and so its part is sufficiently large. It is uncontestably scientific to handle children according to their psychology, and it would be unscientific to employ those methods adapted to grown-up people. The Chairman stated that the Conference agreed per- fectly with what Monsieur de Paeuw and Superintendent Wilson had said,-that we must, in Health Education, help the children to genuinely and heartily wish to do the things that are desirable and wholesome. He added: I think, however, we all know the danger of misusing the doctrine of necessity in this, as in any other field. I am convinced that children cannot profitably do anything in education in which they are not inter- ested, but I am very sure that we may use devices to interest them which are not sound and justified. I am afraid of the statement of a person some time ago who said: "It is legitimate to use any device, to bait the hook to catch the interest of the child with reference to his health with any bait." I cannot go as far as that. We have game laws which prevent us from using certain devices to catch fish. We need game laws in Health Education to limit us with reference to the devices, the incentives. We must distinguish, if you please, between the incentive to health activity and the inducement to health activity. The incentive, as I use the term, covers the legitimate stimuli. There are inducements that we should be trained not to use. That carries us to another point, namely, that our methods of measuring the 82 results, the success, the assistance of the program, should conform to the intelligent, the legitimate and the sound methods of interesting the children. The Chairman then introduced the next topic, one of fundamental importance, "The Use and Abuse of Physical Indices in a Program of Health Education," to be presented by an authority in this field, Dr. Bird T. Baldwin, Director, Iowa Child Welfare Research Station, University of Iowa. The Use and Abuse of Physical Indices in a Program of Health Education Dr. Baldwin: IN the hands of novices and the uncritical observer, all instruments of accuracy or precision may be grossly abused. Weight-height-age tables, although frequently in- accurate in themselves, have been no exception to this gen- eral rule. Tables in the past have been in a very large measure, if not exclusively, based on single measurements instead of consecutive measurements on the same children; on children clothed instead of nude; on the use of the last birthday or gross age in place of the nearest birthday; on heterogeneous groups of children of different nationalities in place of relatively well-developed homogeneous groups of American-born children who have had medical inspection, physical training and directed play; on inaccurate mea- surements taken by numerous untrained observers in place of trained anthropometrists with standardized instruments, small units of measure and standardized technique. Accu- rate norms cannot be based on inaccurate data. The new Baldwin-Wood Tables meet the above requirements. Abuses of Weight-Height-Age Tables The abuses of a table center in main around the instru- ments used for measuring, the methods of measuring, the recording and the interpretation of data. When weight is to be taken, the scales should be standardized and balanced each day. They should be of recognized scientific make, graduated into or 1/16 of a pound, if the English system is used. (Personally, I have not found an accurate spring balance scale.) Shoes and sweaters or coats should always 83 be removed before weighing. (We weigh our children nude on their birthdays, each month and at the same time of day.) The weight of clothing varies somewhat with sex, with age, with height, with season, and to some extent with fashion, and with social status. Most of the standing height measurements taken by nurses and nutrition workers are inaccurate and vitiate the use of standards. Measurements taken by means of narrow rods, especially on weighing scales, are nearly always inaccurate. This measurement should be taken with an accurately graduated measuring scale against a flat surface at least 12 inches wide, with a flat square at least 4 inches wide and 6 inches deep. A uniform position is very important. The child stands straight with shoes off, heels together, and heels, buttock, upper part of back (and generally the head) against the board to which the scale is attached. The arms are at the side in a natural position and the head is in such a position that the visual axis is horizontal. The square may be held in either hand of the examiner, and the reading taken from the opposite margin of the scale. The square is brought down firmly on the top of the child's head, with sufficient force to feel the contact. It is surprising how many measurements in our public schools are inaccurately recorded, how many are wrongly calculated and how many dates of birth a child may have on record at the school as reported by the father, mother, brother or sister or the child. The date of birth and date of measurement should always be recorded. In calculating ages the nearest birthday is taken. Inaccurate instruments, inaccurate measuring, and inaccurate recording of data are responsible for many abuses of indices of growth and nutri- tion. Girls' and boys' measurements should be recorded on different colored cards or sheets to avoid confusion. The standards are buff for boys and white for girls. The cards should be designed to include six years of measurements. When doctors, nutrition workers and physical-training teachers are not particularly prepared for detailed, careful measuring, this phase of the health work should be under the direction of the science or mathematics department of the school. Every school in America should require height measurements of the pupils at least two or three times each year and the weight measurements at least every two months. Underweight children should be weighed monthly 84 or bi-weekly. The weight tables supplement and contribute directly to physical examinations. They are not supposed to take the place of such an examination. They are guiding instruments, not finalities. The Basic Essentials of Health Examinations The nature of the doctor's physical examination is dependent on the location of the community and the age of the children as well as the criteria of good health. For example, in some communities glandular disturbances, especially goiter, are prevalent for high school children, while in other communities adenoids and enlarged tonsils are found among a higher percentage of younger children. The physical examination should include at least an exami- nation for the after-effects of the important recent diseases and for the condition of glands, eyes, ears, heart, lungs, muscles, bone and skin. Some of these conditions affect growth more seriously than others, some apparently not at all. A special dental examination should be included with reference to the eruption of teeth as an index of develop- ment, their care and physical condition, caries, abscesses and occlusions. It is not sufficient to have a picture of the child's physical condition but its physical capacity and output of energy must also be measured and evaluated. Physical achieve- ment ratings or simple strength tests will help to give an insight into the child's physical energy. These physical ratings may include at least a short dash, a broad jump and chinning a bar for boys, or throwing a basketball for girls. It is strikingly significant how far the physical examiners and nutrition workers have neglected to use their ally, the physical training teacher. Physical development is a much more complex phenomenon than has heretofore been recognized. The health and nutrition problem is one of community of effort and exchange of data on the part of all health and educational agencies working with the child. A nutrition rating, in addition to the above, and in addition to the careful evaluation of overweight and under- weight measurements based on consecutive examinations of the same children, in order to get the gains or increments in growth, should take into account the general physical appearance and type of child, with particular reference to 85 posture, muscular development and tonus, facial expression, breathing, color and appearance of the eyes. Health habits with particular reference to food, sleep, ventilation and exercise also should be noted carefully. Intimate co-opera- tion with the nurse, hygienist, the classroom teacher, the visiting teacher, the councilor and the parent is always necessary. In dealing with a height-weight-age table in a modern school, other measurements such as breathing capacity, width and depth of chest, width of shoulders and hips, and sitting height should be included if possible. It is also essential that a rating for physiological age be included. Tall, heavy children are older, as a rule, physiologically, than small children of a given chronological age. Ossification of the bones, develop- ment of the breasts, the growth of auxiliary hair and men- struation take place earlier for physiologically accelerated girls and the characteristic stages of adolescence occur earlier for the boys. Some boys are pubescent at 12 years of age and others not until 17 years of age. Some girls are pubescent at 10 years of age and others not until 18 years of age. The writer's 10,000 individual growth curves, covering several years for 30 physical traits (300,000 individual growth curves) show that children grow dif- ferently before, during, and after pubescence. Boys also grow differently from girls. Tall children grow differently from short children, growth varies with chronological age as well as with the more general conditions of nationality, heredity, climate, social status, environment, health, hygiene, exercise and food. A mental age rating and an educational rating will very frequently be of direct service to the person applying the tables, especially if precocious or mentally defective children are among those being studied. The above basic essentials, together with a number of other facts and criteria are now being practically applied in my research experiment on the Relation of Physical and Mental Growth to School Promo- tion in the Cleveland public schools in Ohio and in the University of Iowa laboratory schools. The health work at the Elizabeth McCormick Memorial Fund is also carrying out a large part of this program. Health Education is an integral part of all first-class public school systems. Physical measurements and physical 86 examinations are an essential part of Health Education. Health ratings are just beginning to be considered a potent factor in school promotions. In a very few years every good school system will include Health Education ratings on the same basis that they now include mental examina- tions and educational achievement ratings in arithmetic or language. Doctor's Ratings and W eight-Height-Age Tables In three careful physical examinations and three series of careful physical measurements of the Oak Park children, under the auspices of the Elizabeth McCormick Memorial Fund, Miss Maud Brown has found that underweight and overweight ratings of children are correlated with the doctor's findings. That is, if physicians are asked to rate children into five classes with I as the best and V as the most defective groups in general health and development, under-nourished children, as a rule, will be ranked in classes III, IV and V. The decidedly overweight child should be as much a subject of pathological study as the underweight child. The physicians still use, and no doubt will always use, underweight and overweight as one of the best single indices of malnutrition and retarded growth. The chief difficulty has been and will continue to be to know what weight is normal for individual children. Our new tables represent the growth of the children included and may well be used as definite standards for the development of subsequent tables for different nationalities, for different social groupings and for different types of children. Since the tables are based on individual growth curves of Ameri- can-born children, and since 12 to 19 normal zones are given for each inch in height, many individual differences are taken into consideration. Variability in Growth There is a high positive correlation between growth in height and growth in weight. The correlation is higher for boys than for girls. Growth in weight is more variable for a given age and from year to year than growth in height. The variability differs with height, with age and with sex. Calculating the variability in pounds for each inch in height for each sex for our group of school children, it is 87 found that the mean variability, or 50 per cent of the cases, includes practically all of the children in the normal zone of the distribution (i. e., without marked physical defects). The mean deviations or the average variability for children seven years of age is 3.3 lbs. for boys and girls, or 6 per cent of the average weight for each inch of height. At 11 years of age the boys vary on an average 6.4 lbs. per inch, or 9 per cent, and the girls 7.4 lbs., or 9 per cent. At 15 years of age, the average variation for the boys is 9 lbs., or 7 per cent and for the girls 11 lbs., or 9 per cent. These limits are not mere magic lines which differen- tiate well and sick children, they simply indicate how the majority of children in fairly good health cluster around a central tendency or average for each inch in height at dif- ferent chronological ages. Since the children in our groups are presumably healthy and have had physical training, medical inspection and careful remedial treatment, they can be used as good standards of growth. For children less healthy than our groups, which probably means a large per cent of those in public and private schools, the average deviation would include more unhealthy children. Until further scientific ratings by doctors have been acquired, it is safe to say that all children between the ages of 6 and 11 who are at least 6 per cent or more underweight for height in inches, and all children 11 to 16 years of age who are at least 9 per cent underweight for height, should receive special examinations for health and nutrition. Increments, or Gains in Growth The greatest annual increment of growth in pounds for tall girls is at 13 to 14 years of age, where the average is 13 pounds per year, for short girls the greatest increment is at 11 to 12 years, where the average is 13 pounds per year. For tall boys the greatest increment is at 13 to 14 years, where the average is 16 pounds and for short boys at 15 to 16 years, where the average is 14 pounds. The tables give the yearly increments for tall, medium and short children at different ages. The semi-annual or quar- terly increment can be calculated, if desired, by dividing these averages by 2 or 4, and the interpolated values used. This does not take seasonal variations into account, but no 88 one knows as yet the effects of seasonal and vocational variations in different parts of the country. I now have monthly variations on several thousand children, but many other factors are involved. The increments for each inch in height and each year in age for each sex can also be readily calculated from the tables by subtracting the preced- ing measurements from the subsequent ones for each inch and each age. The resulting table will show how much children should gain for each inch in height and how much children of the same height should differ in weight for each year in age. For example, at 7 years of age children differ 2 pounds per inch in height. From 12 to 18 years of age children differ as much as 15 pounds for the same height. The Relation Between Mental and Physical Growth In an investigation in California, in co-operation with Prof. Lewis Terman, where 1,000 mentally superior children have been selected during the past two years, 34 selected physical measurements have been accurately taken on nude children, together with height and weight measurements of the parents. These data have been supplemented by inten- sive physical examinations, health histories, social case studies and nationality status. This investigation will give us additional scientific information on the relation between physical and mental growth. In my previous investigations it has been shown that good mental and good physical growth go hand in hand. Mentally superior children are, as a rule, physically superior. This was shown by means of a large number of consecutive school progress curves and by consecutive mental age ratings of school children and pre- school children. Health Education is a function of the public schools. It is for the consistent, careful and intelligent use of weight-height-age indices of growth that our health organi- zations have steadfastly stood and not for their misuse, abuse or exploitation. The Chairman: The discussion of this paper will be led by Miss Maud A. Brown, of the Elizabeth McCormick Memorial Fund; also Director-Elect of Health Education for the Fargo, North Dakota, Child Health Demonstration. I am very glad to introduce Miss Brown. 89 Miss Brown: I have been honored in being asked to discuss this highly construc- tive paper. In it the author emphasizes the importance of the class- room taking of weights and heights, as well as of the taking of a more comprehensive and technical series of measurements by trained anthropometrists. The study to which Dr. Baldwin refers is one which I have been making for the Elizabeth McCormick Memorial Fund during the last two years. One phase of this investigation has been the evaluation, by means of as complete data as has been possible to accumulate on a group sufficiently large to be representative, of a number of physical indices (thirteen, to be exact), including the new height-weight-age tables referred to in the paper under discussion. May I say, parenthetically, that my previous experience, dealing as it had with large numbers of school children, had brought me to this investigation with the conviction that it was necessary to find some other physical index to take the place of the weight-height-age relationship. This study, sufficiently well guarded to do away with the fallacy of "neglect of negative instances," has shown that the weight-for-height- and-age curve does follow the health of the children as estimated inde- pendently by three physicians. Two of them gave as complete an examination as is possible without laboratory tests-the third giving a "nutrition rating," practically the same thing as the Dunfermline rating. The result of distributing these eleven hundred children, by scatter- plot with each of the three ratings, shows that those in group I (perfect health, no defects discovered, six children only) are all above average weight; those in group IV (seriously poor health) are all below average weight. The majority in group II (good health) are above average weight; and a large majority in group III (poor health) are below average weight. An individual case study has been made of all underweight chil- dren who were rated "good" and of all overweight children who were rated "poor." Time does not permit going into detail here, but the individual study has further strengthened the standing of the weight- height-age table as an index of the condition of the child's health. Having satisfied ourselves as to the authenticity of this standard, the next point of interest is that of safeguarding it for school use-by the determining of its possibilities and limitations. The following suggestions based on my own experience in the classroom use of these tables are offered: 1. The legitimate use of the weight-for-height-and-age tables is twofold: (a) Diagnostic-as a part of the physical examination of the child. (b) Educational-as a means of stimulating the effort of the child. 2. The classroom technique can, with care, be made sufficiently accurate to be a reliable indication of the child's growth curve. May I sound the warning that "with care" means the care of the trained laboratory worker, which can very easily be exercised by the teacher 90 or nurse. The chief difficulty is in acquiring the mental habit of appreciating the necessity of fine distinctions as to accuracy. Heights are easily taken in quarter inches, if a tape tacked against a flat wall be used, and a chalk-box or block be used instead of a ruler. The measuring rod on the scales cannot possibly give reliable results because of the impossibility of standardizing the child's position. Heights and weights should always be taken by the same person-an adult in official connection with the school system. It is just as pos- sible for teachers to make physical measurements as to give mental tests, once the ideal of accuracy is established. 3. The weight should not be the sole means employed for stimu- lating the child's interest, but should be accompanied by variety of motivation and by sound instruction. 4. No further use should be made of the height-weight ratio than present knowledge and the limitations of classroom technique justify. 5. There exist no grounds for the arbitrary selection of any one degree of departure from average as a line of demarcation between zones. While, in general, the farther below weight a child is the poorer his physical condition, the establishing of an arbitrary "danger line" causes a false feeling of security in those underweight children who are above the line. 6. The separation of children into types of build is not justified by present knowledge or the limitations of the average school program or technique and, furthermore, confuses the issue in the mind of the child. 7. The limitations of present knowledge do not justify the calling of especial attention to the extremely overweight child, nor the giving of advice beyond that which applies to all children, regardless of build. It always marks a milestone of great importance to humanity when the foremost authorities of the world succeed in bringing any scientific procedure to the point where they can take the laity into their confidence and teach us to undertake the application of the principles developed by them to human welfare. This is what gives this paper of Dr. Baldwin's an importance which cannot be over- estimated. (The complete report of this investigation will be published about December of this year, and will be available through the Elizabeth McCormick Memorial Fund of Chicago.) Dr. Wood asked Dr. Fred Burger, Director of Physical Education of the Kansas City, Missouri, public schools, to describe his experience in Kansas City in the use of these standards, in schools under his supervision. Dr. Burger: Five years ago we started the weighing and measuring in Kansas City, Mo. With four scales we tried to cover twenty of the ninety-one elementary schools. This was very unsatisfactory, and caused con- siderable delay, because the scales were constantly out of order. The next year the Board of Education ordered a scale for every school. Then we weighed all the children three times, the first week in September, the first week in January and the last week in May. We 91 did that to save time. In 1920 we weighed and measured in the same months and at the same time. In addition, the nurse weighed the 1V per cent or more underweights the first of every month. The class- room teacher kept the record. We started, as I have said, in 1919, and we found 31 per cent of the children 10 per cent or more underweight. That was in September. I visited the schools again in January and asked the children how many had gained, and all the hands went up. I thought, "This is easy; inside of a year we will not have any underweights!" So in January, when we had only 17 per cent, we were happy and thought that we were on the right way. We got considerably cooled down in May when we had gone to 22.2 per cent. The next September we had 28 per cent. I will send you the figures for the last four years if you will write to me at Kansas City, Mo. The highest figures for 1921 are due to a very severe smallpox epidemic which we had in Kansas City that year. It was very dan- gerous and all the children had to be vaccinated, and as you all may realize, there were many infected arms, and other disturbances caused by the vaccine, which meant quite a loss of weight among the school children. We had an interesting experience with the negro children, of whom there are about 4,000 in Kansas City. When we had 31 per cent, 10 per cent underweights among the white children, we had only 16.3 per cent among the negro children. We were under the impression at that time that these children were of a different type, a heavier one. The next year in September they still had 16.3 per cent, but in 1921 they went up to 21 per cent, so where we have a gradual decrease of the 10 per cent or more underweights among the white children, we are having an increase among the negroes. I don't know why this is, but I feel that it is an economic question. During the war every- body had work, especially the negroes; and earning fairly good wages, they had money to spend, and they probably spent most of it for food. We try to be very accurate with the weighing and measuring. In weighing and measuring 36,000 children I had 61 physical training teachers, 41 nurses and about 1,200 classroom teachers helping, so we made rapid progress. The nurses weighed the children, the physical training teacher took the height and the classroom teacher did the recording. This coming year we will make a change and have the nurse weigh and measure, the physical training teacher do the record- ing and the classroom teacher keep order. I think that we will save time. We keep up the weighing and measuring because we believe that it is a necessary part of a physical examination. Miss Brown: I would like to ask Dr. Burger whether or not the Kansas City- School System has ever used any method of dividing children into physical types? Dr. Burger: No, we have not. We follow Dr. Wood's chart, but as soon as the new "Baldwin-Wood" chart is out we will follow that. 92 The Chairman: There is now opportunity for further questions if anyone desires to offer them. Dr. Henry Koch, Director of Health Education, Cin- cinnati Public Schools, asked as follows: We in Cincinnati are just at the beginning of our measurement scheme. We are judging these observations on the total age-total weight, rather, and not upon the increment per age per height. We found that in the first 10 years the age-weight increment is fairly normal. From 11 until maturity is reached, the deviation is very great. I wonder whether Dr. Baldwin has anything to say along that line? Dr. Baldwin: At the beginning of my talk I thought you had the tables in your hand. These tables are based on consecutive measurements. No child is included who has not been measured at least 5 times, and some of the children 12, 14 or 18 times. All of the children were measured carefully, and 95 per cent of them are American born. All have had physical training, medical inspection, etc. They are a series of individual growth curves, and we have plotted those curves. Now you cannot have an average that will account for every individual in this group. The tables are not single line averages, but we had from 11 to 19 different normal zones for each inch in height, which will allow for different types of children. The child that begins to have its adolescent acceleration of growth in weight at 10 years of age will be accounted for in the table, as will the child that has it at 14 years of age. The Chairman then announced that the next paper would be presented by Mr. C. E. Turner, Assistant Pro- fessor, Department of Biology and Public Health, Massa- chusetts Institute of Technology, Boston, on The Importance of Health Education in a Public Health Program Prof. Turner: EVERY science and art develops, not by the slow, even and continuous growth of all its parts, but rather by periods of unequal and sectional growth. Special interest in particular phases results in the rapid expansion of one aspect at a time. The state of the art, the attitude of society towards it, and the apparent needs of the people determine the phase which shall receive most rapid development at any particular time. 93 It is not difficult to see why sanitary science and public health have now reached the stage of their development, when popular Health Education is deservedly receiving commanding attention and rapid expansion. Of the three branches of science of disease prevention,-preventive medicine, preventive sanitation and preventive hygiene,- the last mentioned is now receiving the most attention. Health Education is perhaps the greatest potential force in the hands of sanitarians and educators for disease preven- tion and health improvement. If we examine some of the reasons for the present development of Health Education, we shall see the relationship of this work to the rest of the Public Health program. The present emphasis upon personal and preventive hygiene is part of a logical sequence of events. Compare the battle against disease with the science and art of na- tional defense. Primitive peoples began their improvement in methods of defense by the skill of their most able men who learned the nature of the enemy's attack and devised shields and armor. Then came the period of walled cities by which the engineer protected the entire population from the unchecked onslaught of the enemy. But later the armed city ceased to be of avail and the period of the trained soldier and mercenary troops came to an end. Our wars of the present are fought by the whole body of our citizenry, both by the organization of a huge army and by the indus- trial organization of all the rest of our adult population. So the war against disease at last demands the service of our whole citizenry. With Louis Pasteur sanitary science began with the necessary period of investigation. We learned the nature of our enemies. Then preventive medi- cine provided us with specific substances and processes, the protective armor by which we can render ourselves quite immune to the attack of certain of our foes. Then came the era of preventive sanitation. By the sanitary control of our water and food supply we have set up a wall which prevents certain of our enemies from suddenly falling upon our population. In the fifty years from 1872 to 1922, for example, Massachusetts reduced its typhoid death rate per hundred thousand from 110 to 2.2,-largely by means of sanitary science. But the bulwark of sanitation does not exclude all of our enemies. The walled city is not sufficient. We find 94 ourselves confronted with enemies like tuberculosis and common cold, the degenerative organic diseases, and that most insidious foe of happiness, reduced physical vigor, which makes life a mere existence, robbing it of its enthu- siasm and keenest joys. We have reached that stage in our warfare when the burden falls upon the shoulders of the average citizen, not only because the trained leader needs his support but also because the tide of battle turns upon his intelligent action and physical fitness. What has brought us to a realization of the need of Health Education? We have become aware of our low health standards. We have observed with consternation the physical condition of the young men who were asked to take up arms. We have been startled by the spread of com- municable disease because of the ignorance and careless- ness of the individual. We see about us nervous, organic and degenerative diseases which are the obvious results of violating the principles of hygienic living. We even find physical defects developing during the period of childhood, when the body should be growing strong. The occasional contrast of a long and busy life made possible by a good heredity and proper habits of living only intensifies our conviction of the general lack of proper habits of living. Perhaps more than we realize we are affected by the inherited religious attitudes, the conceptions of the Old Testament, which regard disease as sent by the hand of God, and maintain that we should accept our "afflictions" as part of the divine plan. Such a philosophy is dangerously comfortable in relieving the individual of health responsi- bility. We disown the philosophy promptly enough when confronted with it and perhaps the modern maiden who has ruined her arches by high-heeled shoes does not even know the origin of her false attitude when she voices the excuse that "the Lord gave me weak arches and I suppose I always will have trouble with my feet." To be sure, civilization has developed a strenuous inter- dependent community life which puts a premium on mental rather than physical labor. Social and material progress even crowd out consideration of our physical well-being. But this failure to develop and retain the habits of health- ful living comes from ignorance as well as from changing conditions of life. The great body of important facts in both communicable disease control and personal hygiene 95 has developed within the last thirty years; indeed, much of it within a shorter period. There has been as yet no opportunity for this information to find its way into the lives of the great mass of our common people. The science of disease prevention has at last brought us an appreciation of positive health, and we have begun to deal in terms of health improvement instead of disease prevention. In religion, the Old Testament commandments and laws with their "thou shalt not" produced the Pharisees and Sadducees. The New Testament with its positive teachings produced disciples and evangelists. Let us hope that in public health we are leaving the period of prohibi- tions and negations which lead to a Pharisaical and unen- thusiastic existence, and entering upon a new period domi- nated by positive ideals and the training of disciples who will build principles of hygiene into their lives. Medication and surgery are not the only weapons against disease. We have found, indeed, that many diseases are self-limited if the body has a fair chance to combat them. Sanitation has nearly eliminated many of the diseases which travel by an intermediate host or substance. Pre- ventive medicine and medical practice are making constant advances, but we are confronted by a group of both com- municable and organic diseases which will be conquered only by intelligent individual action and the development of positive personal health. These are the facts which have led sanitarians to the belief that we could markedly reduce the disease and death rates without new knowledge if we could only put into practice the information we already have. Habits do affect health. If you doubt it, study the sana- torium treatment of tuberculosis, the restriction of the spread of infectious disease in an intelligent community, both the religious and the psychic processes of mental heal- ing, the training of athletes or the physical transformation of our young men in the military training camp. To the degree in which we can improve habits of living, we may expect to improve the health status of our community. It was logical and inevitable that our health departments should increase their activities in the field of education. But the Health Education program is primarily a school problem. Here is the one opportunity for modifying the habits of our people in mass, the one opportunity to mea- 96 sure the value of Health Education in terms of health itself, in terms of habits of living, and not in terms of mere information. Valuable as popular Health Education for adults may be, and important as are the educational oppor- tunities of the physician and nurse in their personal con- tact, or the specific advice of the health department in time of epidemic, there is no way of broadcasting health infor- mation in a way to transform the habits of adults. Childhood is the period of habit formation. Not only habits of cleanliness but habits of mind, and attitudes, par- ticularly, are fixed in youth. Dr. W. W. Peter, who is directing popular Health Education in China, and who recently staged at Foochow that most striking demonstra- tion in adult Health Education, has had perhaps a better opportunity to judge the value of popular health instruc- tion than any other worker in this field. At a recent con- ference in Bangkok, it is reported in The World's Health, March, 1923, that "Dr. Peter in discussing his work of education in China, expressed his doubt as to the possibility of making any great change in the minds and habits of adults, and his reliance for the future upon what could be done with children of school age." And why is the schoolroom of primary importance in habit training? Because in every walk of life the most important factor in determining individual action is the judgment of the individual's own social group. Style in clothing, social customs and social attitudes are problems of group psychology. It is often sufficient reason for not doing a thing to say "It isn't done." You who have tried Health Education with children, have learned that the advice of the doctor, the lecture of the nurse, and perhaps even the commands of the parent are less important than the atti- tudes and habits of the boys and girls with whom the child associates. The child conforms to the judgment of his social group, and happily the development of this group's attitude makes teaching pleasanter instead of more burden- some. In no other phase of public health administration is the community more interested than in the development of child health activities. A well-known health officer recently said to me, "If I were to go to a new city, I should begin work with the child health program, for in no other way 97 could I so readily win the support and confidence of the people." Health Education not only affects the health of the child but it further provides him with those attitudes toward citizenship which will carry forward the right type of public-health administration in the community in which he later becomes a voting citizen. Another health officer told me recently that health work in the schools has brought him so close to the people and has given them such an appre- ciation of health measures that his department has not only been removed from political interference but is strong enough to carry its essential program, even if the mayor objects. I said that Health Education is perhaps the greatest po- tential force for health improvement. I must insist upon emphasizing the word "potential," for in spite of excellent school health programs in certain places, Health Education in America is far from being a national realization. Our present needs and problems are many and serious. We must not only develop Health Education itself, but we must see that it takes its proper place among the other activities of a broad and sound school health program. We need better co-operation between school departments and health departments. There should be a better standardization of the physical examination of school children. We need fur- ther improvement in the conditions of study and opportu- nities for relaxation for the school child. We need a clearer understanding of many of the problems of growth and other indices of health. We shall secure still better methods for working with children, particularly in the junior and senior high school periods. We must give careful attention to the provision of a properly trained personnel to organize this work. Willing as everyone should be to grant the value of health-habit training for its effect in later life, we need to accumulate still further evidence to prove its prompt and immediate effect upon the health of the school child, in order to convince the administrators of the public school system of the practicability as well as the tremendous im- portance of these activities to our national welfare. Health Education has a commanding place in the present-day administration of public health. Its potentiali- ties are almost limitless and yet its needs are great. Let us not be deceived as to the difficulty of the task ahead of 98 us. Let us make the program broad and sound, sane and scientific, but let us also put into it the enthusiasm and human interest, courage and idealism which are merited by so great a cause. Since time did not permit the adequate discussion of the questions that arose from this address, a Round Table was arranged for the further discussion of the administra- tion of the health program. It is interesting, as a corollary to the discussion in this session that the following resolution was among those adopted by the Plenary Session, when it acted upon the Health Education resolutions presented to it by the Conference: Whereas, we recognize the value of growth records as a partial but simple and concrete index of health, therefore be it Resolved, that we hereby recommend the value of weighing and measuring school children as a teaching project, in addition to, and as distinct from, the use of weight standards as a clinical index. The session was then adjourned. It was followed by a luncheon given by the American Child Health Association in compliment to the foreign delegates registered in the Health Education Conference. The following countries were represented: Belgium, Chile, China, Ecuador, El Salvador, Nicaragua, Mexico, the Philippine Islands, Hawaii, Japan, Czecho-Slovakia, France, England, Norway and Sweden. The purpose of the luncheon,-that of enabling all to be- come better acquainted,-was most happily achieved. It was at this luncheon that a formal request was made by cer- tain of the delegates, that the report of the proceedings be translated into Spanish for circulation among the Latin American countries. Round Table on Administrative Problems in Health Education Mr. C. E. Turner, Assistant Professor, Department of Biology and Public Health, Massachusetts Institute of Technology, who pre- sided as Chairman, stated it as his understanding that the group assembled was interested in the relationship of the Health Education program to other public health activities, city, county or state. Those in attendance, he said, would be asked in turn to relate their particular problem in administering the work of the Health Education program, and to tell something of their administrative methods, what the 99 health department does, what the school department does, and what other agencies outside of those two groups do. Dr. Miller, in charge of tuberculosis work in Missouri, stated that the matter of combating tuberculosis in childhood was a matter of edu- cation, on account of the limited funds which were available. He therefore started out early with a campaign of education, which was extended to each rural school in the state. His first question was to determine where the administration of the work should lie, whether with the Department of Health, either in the state or in the county or in the city, or with the Department of Education, and if by both, where was the line to be drawn between them. Dr. Miller expressed it as his belief that so long as the child is within the school, as a student in normal condition, it should be under the administration of the school authorities; but when it was found that the child was in a condition that might impair the health or welfare of some other child or of the community, then the administra- tion of the work done on that child should pass to the Public Health Department and remain there. The Chairman expressed the belief that in most of the states the responsibility for the control of communicable diseases rests with the Health Department by law, and that no child could be released from quarantine without the authority of that department. He suggested that as a matter of administration, the Health Department might appoint the school physician, without pay, as an agent of the Health Department to handle communicable diseases in the schools. Nurses might be appointed in like manner. He also suggested that the Board of Education and the Board of Health meet jointly to deal with problems which concern both departments. Another method suggested was the organization of a local council in which the health officer, the superintendent of schools, the Board of Health and the Board of Education and each of the private health agencies in the community would be represented. Another suggestion was that the health officer should be ex-officio a member of the school board, having a vote only on those things related to his own department, and that the superin- tendent of schools should be ex-officio a member of the Board of Health, having a vote in school matters. A Delegate (unidentified) said that in her community they had had some difficulty about the number of children in attendance at the schools, the allotment of funds being made on the basis of the number of children in attendance. To avoid this difficulty the children were dropped from the rolls during the period of sickness, and the allot- ment of funds was made on the basis of the maximum attendance at any time during the year. Dr. Wolfe, Medical Director of Schools of Lincoln, Neb., said that pre-natal and pre-school work is an educational problem for which the school should be responsible. The mothers should be brought in and Parent-Teacher Associations organized. She said she did not intend her clinic to be used just once a week by the school nurse, but to be in use as much as possible; that while children were waiting their turn in the clinic they were being educated by the nurses so that every minute would count. Asked whether tonsil operations were per- 100 formed free in this school clinic she replied that they were. A fee of five dollars is collected where the parents are able to pay. Asked what was the reaction of the local physicians to the activities of her clinic in performing free operations, she said she had made it clear to them that the clinic is taking care of children who would not get care otherwise. Miss Countryman, of Des Moines, Iowa, stated that they have a law under which the children of parents unable to pay are taken to the University of Iowa Hospital and receive treatment and care. Many of the county nurses, she said, had taken 50 or 60 children to that hospital within a few months. Before the child is taken, his papers must be signed by the physician in the community, and as a result the physicians in that locality have no comeback. Dr. Baldwin stated that in Iowa the Sheppard-Towner Act is also carried out in connection with the university, the work being done in co-operation directly with the university and the medical schools, a child welfare research station, and the extension division and the School of Public Health Nursing. That gives the advantage of hav- ing the University Hospital and the direct counsel and assistance of the heads of the various divisions in the hospital. The people of Iowa regard the work of the university as very similar to that of a public school. Dr. Greenough raised the question, which her constituents in Washington are putting up to her, "How can we introduce health work when our trustees and school superintendents do not wish it put in?" adding that to her it was one of the most difficult problems from the teacher's viewpoint. Miss Perritt of Arizona expressed the belief that when a con- ference like this International Health Education sends out its recom- mendations it will have a stimulating effect. Dr. Baldivin remarked that he did not believe that this organiza- tion realized how much it had done for Health Education, or that the public schools are just ready to take up Health Education, with a good many already doing it, and many school authorities having been convinced, by demonstrations, of what could be done along this line. He said, "I think this organization should begin to fuse right into the public school system. If we lose our identity, all right. So much the better. People are interested in Health Education, and Health Education is a larger, broader conception today than it was a few years ago. We do not speak for just a health department. You couldn't have a health department in a public school unless it was interested and vitally concerned with other departments of the public school. Education is a much broader, bigger, co-operative enterprise today than ever before, and I would make a plea that our health workers get more interested and become more acquainted with the regular work of the school and establish the work of the physical training teachers, the nurses, the social workers, the visiting teachers and the regular teachers, the psychologists and the physicians. It is a big, co-operative problem, and they are all interested. I think we have an experiment out in Cleveland which is uniting all of those various departments or activities in the school system and centering the efforts around the physical development and growth of the child. 101 This experiment, he said, was confined to five schools in five dis- tricts, and in it were represented nine different departments. Every child in these schools has had a very intensive physical examination, and a series of physical measurements, and when he is to be promoted will be evaluated on the basis of his health education quite as much as educational achievements or his mental and age rating. The Chairman suggested that in the matter of introducing a Health Education program in the various cities it might be possible to make a start in some places by organizing through the school department a health institute for teachers, such as that which was held at Mans- field, Ohio. Asked whether anyone had prepared a course for Health Educa- tion in the schools, the Chairman replied that such courses had been gotten out by Detroit, Cincinnati, Binghamton, N. Y., Oakland and San Francisco and also by the public school system of Washington, D. C. Reference was also made to the pamphlet for the first to fourth grades prepared by Dr. Andress and Miss Bragg and published as Bulletin No. 10 of the Health Series of the Bureau of Education at Washington; also to those put out by the National Tuberculosis Asso- ciation and the State Tuberculosis Society of Ohio. Dr. Hetherington expressed the belief that the problem of admin- istration was the most important one this time, saying, "We have over the country a variety of types of administrative organization, and if we reduce these to their fundamentals they come down to a very few forms of organization. . . . Most of the discussion so far has been upon the administration for the correction of defects, and a little bit upon the handling of communicable diseases. . . . There is no conflict whatever between Health Education and public health officers except in that fundamental problem of communicable diseases. "I think we need discussion, not of the details of administration, but of the underlying principles involved in school finances and per- sonnel, and the legal aspect-the authorities of the various officers. I doubt very much whether those items can be taken up in a body of this kind, but they should be taken up in an investigating body. I might make this final point: There is a tremendous amount of con- fused thinking on this whole problem because of the lack of distinction between the legal functions of the Board of Education and the Board of Health. Further, there is even more confusion because of the lack of clear-cut recognition of the functions of the school. The school has always, besides its teaching function, carried on a protective function, the care of the child, which is mainly the old home function carried over to the school. At the same time this has led to activities where the problem is to establish habits and ideals in the child's own health. That is educational. Now the school has also an administrative problem. In the discussion of the lady from Nebraska we have a reference to Health Education which possibly mixes those functions, and we do not know whether we are talking about an educational function or a health protection function, and that immediately mixes us up on our personalities. Is it a function for the elementary teacher, for the nurse, or for the doctor? We have got to do some clear thinking as to the relationship of these functions." 102 The Chairman asked Dr. Hetherington whether he believed that the confusion as to who in the community could be engaged in the work could be partly removed by some simple scheme by which the school authorities and the health departments could be brought together to consider the whole school problem. Dr. Hetherington replied: "Yes, that is exactly the difficulty at present. We have got to get together from the standpoint of the function of the school as a whole, and have a general overhead admin- istration of the schools so they will interlock." The Chairman said he felt that there would be a very definite advantage if some scheme could be found by which health and educa- tion departments could be brought togethei- for the joint considera- tion of problems, as this would allow each individual community to take into consideration its own available personnel and organization. He said: "I doubt very much whether it would be possible for any group of experts to lay out a program of activities and personnel which could be universally applied. ... In addition to the public school work we are undoubtedly in need of developing health educa- tion activities for the parochial and private school children and for the pre-school group. In both of those instances a municipal program arranged by both health and education authorities has certain advan- tages over the distinctive operation of the health department on the one hand or the school department on the other. Asked by Dr. Hetherington whether he was speaking of a com- munity health program, the Chairman said that he was speaking of "some way by which we can provide for all the children of the com- munity the fundamental health activities-protective, corrective and promotional." Dr. Greenoxcgh asked whether more results would not come if the demand for that came from the educational world, saying in her experience, the community would approve anything the school super- intendent asked for. The Chairman: "I agree with you that we need the educational leadership of the school superintendent. His leadership has been recognized, so that the community will follow him. I feel also that we have this other group of activities which is often under the board of health, or perhaps under some private organization, which is doing what a board of health ought to be doing if it had a sufficiently trained personnel. If, through the leadership of someone in the com- munity, we could bring the two groups together occasionally for plan- ning the whole school health program the difficulties of administration could usually be adjusted. Part IV NUTRITION IN RELATION TO HEALTH EDUCATION IN accordance with the general plan vf the Conference, the Chairman appointed a committee to draw up resolu- tions embodying the fundamental principles and prac- tices developed by the meeting which were applicable to a school health program. These resolutions were to be sub- mitted to the Plenary Session for adoption. The Chairman: The first paper of the morning will be by Dr. A. E. Taylor, Director Food Research Institute, Stanford University, California, on The Food Needs of the Nation in Relation to Economic Resources Dr. Taylor: CONSUMER'S wants and motives that determine house- hold selection of and effective demand for foodstuffs may be grouped under five headings: Physiological, psycho- logical, social, habitational and economic. These overlap, naturally, but such groupings may nevertheless be segre- gated. In a period of prosperity, with full employment and rising prices, in the upswing of the business cycle, the psychological and social wants claim free expression. In hard times, with unemployment, in the down-swing of the business cycle, motives of economy perforce prevail. The motive of economy and the pressure of price tend to operate against the physiological competency of the diet. We have, however, no quantitative measurement of this trend. On the other hand, the physiological quality of the diet need not improve pari passu with income. There is, indeed, a striking amount of sub-nutrition to be observed in the families of the well-to-do. Knowledge of physiology should enable the family with adequate income consistently to maintain proper nutrition. It should also afford the 103 104 family with low income protection against impairment of nutrition in periods of price pressure. On this hope is based the theory of popular education in nutrition. Under physiological wants and motives we include the nutritional requirements determined by experience and ex- periment. There is some instinct in eating, also racial experience; but experiments with animals and observations on sick human beings have provided the broad foundation for knowledge. The organism requires (a) balanced pro- tein, (b) mineral salts in proper kind and amount, (c) the several vitamines, (d) a certain amount of roughage and (e) fuel foods in proportion to the needs of the body. The relative needs of balanced protein, vitamines and salts are highest in the young and decline toward old age. It is pos- sible to cover the needs of a people in a per capita state- ment by assuming that in a mixed population, such as ours, 100 census persons correspond to 86 unit adults. This is a liberal computation that covers fully the particular require- ments of the growing children in our population. The psychological wants and motives revolve largely about the special senses and the esthetic tastes. In a cer- tain sense we may say that physiological need finds expres- sion in hunger, the psychological wants in appetite. The color, texture and other appearances of food, odors, flavors and temperature are all moments in the psychological cri- teria of the diet. In addition, the food must meet esthetic requirements in derivation and preparation and in service as well. It is commonly assumed that the psychological reactions to the diet are subordinate and tend to disappear in times of need, but this may not prove true in a highly developed population. The American people would react to famine very differently from Russians, Chinese or East Indians. On the other hand, the psychological wants in the diet are easily exaggerated and may result in gross ex- travagances. Under social wants and motives are grouped a number of heterogeneous influences resulting from creed, caste, superstition, tradition, custom in all classes and refinements in the leisure class. The Jewish abjuration of pork, the Romanist exclusion of meat on Friday, the meatless Lent, many arrangements of foodstuffs in the three meals and, indeed, within the meal, are illustrations of the social factors. Just as there are vestiges of instincts in hunger 105 and appetite, so there are relics of savagery and barbarism in the social factors. Frequently the practice remains, though the origin has been lost. These factors fall naturally into two groups. The home meal is a central function of family life and about it are grouped a large number of social, educational and spiritual motives. These are veri- table internalities. About public eating places are grouped a series of social customs which, though externalities, have an influence on the demand for foodstuffs. These social factors may operate in favor of a particular foodstuff, or opposed to it, and exercise together a considerable influence on consumption. Under habitational factors we understand the influences that are imposed by limitations or facilities in the habita- tion. The plantation type of diet was based on unlimited servants, fuel and kitchen equipment. The standard of subsistence in the modern small apartment of our cities is based partly on scarcity of servants and a minimum of fuel and cooking equipment. In response to the modern kitchenette installation, the methods of packing, preparing and serving foods are being definitely modified. The de- velopments in food manufacture have made kitchenette existence possible; on the other hand, concentration of liv- ing in cities has set new problems to the food manufacturer. Certain foods lend themselves better than others to this type of family life and thus the habitational environment reacts on the diet. In particular, the miniature apartment with kitchenette equipment does not lend itself to proper keeping of raw foods and this tends to restrict the use of fresh milk, fresh meat and green vegetables. The economic motive rests on the necessity or desire of restricting the fraction of the family income that goes into subsistence in order to augment savings or enlarge the means available for household furnishings, rent, clothing, and the innumerable sundries and incidentals that have become necessaries in modern existence. With workers' families of small income, punctilious economy may be nec- essary in order to secure a decent subsistence and avoid debt. Families of larger income frequently practice as punctilious an economy in order to secure enjoyments in other directions. The economist's theories of abstinence and waiting find illustrations in the middle-class American family supported by investments. It is common in summer 106 resorts and winter resorts to find people denying themselves their accustomed subsistence, sometimes even a proper diet, in order to enjoy the life of the resort. There is con- siderable evidence over the whole country that food is skimped in order that gasoline may be purchased. With these phases of modern existence-the over-development of the out-of-work hours' entertainments-we are not here concerned. For us the importance of the problem lies in the fact that the standards of normal nutrition must be maintained despite pressure of price on income, despite claims of competing amusements, accessories and non- essentials. What is necessary is so to educate the public in nutri- tion that the psychological, social and habitational factors are adjusted to circumstances in such manner that economic pressure does not impinge on the physiological factors. The public must be taught to save without injury to nutri- tion. It must be taught to employ the advantageous psy- chological, social and habitational wants and motives with- out ruinous result on the income on the one hand or inju- rious result on nutrition on the other hand. Between different wants are sharp distinctions in dis- pensability. Demand for certain things is almost inelastic, for other things highly elastic. Within all wants are gra- dations. Within a particular demand, the satisfaction of the first fraction of want is inelastic, while later fractions become successively more elastic. What is necessary in popular education is to tie up the economist's conception of wants and demands with the physiologist's conception of in- dispensability and adaptability of foodstuffs. This means that we must divide foodstuffs into two groups; within one, adaptations may be freely made on the basis of price; in the other, particular foodstuffs must be secured quite ir- respective of price. Such a segregation of foodstuffs into premium-priced and calorie-priced groups is given in the chart. From this chart it is clear that the indispensable factors in the diet may be secured within the first 1,200 calories. Thereafter, consideration of custom, taste, convenience or price may determine the selection of the remaining food- stuffs. As we survey the development of the American diet during the last three decades, certain trends may be dis- cerned. Some of these are peculiar to us. Others are of a 107 general character and have been observed in other coun- tries. We are a sugar-loving people. The present high con- sumption of sugar is not to be explained by the Eighteenth Amendment to the Constitution. Our consumption of sugar in the manufactured state, particularly with fruits, is very high. We have an almost universal predilection for confectionery and sweet beverages. Last year the per capita consumption of sugar was almost half that of starch in cereals. At first sight this is a remarkable state of affairs. When, however, one compares the cost of refined sugar per calorie with the cost of bread, meats or vegetables, it is clear that sugar was relatively and absolutely cheap during 1922. At twelve cents per pound, it is still relatively cheap. When a popular food is cheap relative to others, consumption is certain to rise, and this was the chief ex- planation for the rise in consumption of sugar from 85 to over 100 lbs. per capita in 1922. War experience has taught that sugar is a most effective food for workers. The educational movement in furtherance of consump- tion of milk is unquestionably having effect. With each decade, the efficiency of milk production is improved and the quality enhanced. As the practice of testing dairy herds becomes disseminated, we observe the year's output of milk per cow to rise; which means a cheapening in production. A great deal remains to be accomplished in the sanitary dis- tribution of milk, viewed from the standpoint of cost. Years ago, the countryside consumed much more milk than the cities. With the perfection of centrifugation, refrigera- tion and transportation, this deficiency of the urban popula- tion is being overcome. Indeed, in some sections of the country milk is being shipped out to cities to the nutritional injury of the rural population. More and more the dairy cow is being recognized as the central figure around which diversified agriculture rotates. It is certainly a matter of particular importance that the advantage of agriculture and the improvement of human nutrition are in accord at this point. The past two decades have witnessed a thorough-going improvement in the growing, assembling, packing, storage, refrigeration and shipping of fruits and vegetables. These have almost ceased to be seasonal. For practical purposes, it may be said that the majority of the fruits and vegetables 108 that were seasonal in their consumption twenty years ago have become staple throughout the larger part of the year. In part, this has been a response to the American demand for diversity in the diet and has been accomplished at high cost. In part, however, it is the expression of efficiency in operative procedures that have resulted in lowering of costs. The marketing and distribution of raw-leaf vegetables has not been organized and perfected as in the case of raw fruits, so that these indispensable items in the diet of the urban population at present carry a price that is relatively too high. When semi-developed countries have cheap land and a free range, the people enjoy a high meat ration. This was the case in our country in the last century and is still the case in Australia, where the per capita meat ration is about 250 lbs. per year. As the type of farming changes, as the range passes into frontier tillage and frontier cropping develops into diversified agriculture, with increasing value of land, meats become expensive and consumption declines. Our earliest trustworthy statistics on meat consumption date only from 1907. Since that time meat consumption in this country has apparently declined about 20 lbs. per per- son per year, to roughly 150 lbs. This is to be interpreted largely as the result of inefficient retail marketing and in- crease in the cost of meat and the free availability of fruits and vegetables. Cereals, fruits and vegetables have prac- tically driven meat, outside of bacon, from the American breakfast table. In part this change has been an expres- sion of taste and convenience; in part, however, it has been conservation by price. It has been the experience of Europe that with the de- velopment of urban industries and the concentration of population in cities, the bread ration rises. This is partly the result of price, partly of convenience. In a period of high urban wages, meat consumption is apt to increase, to decline again in favor of bread when times become less prosperous. The extension of baker's bread at the expense of home-baked bread apparently tends in the direction of increased bread consumption. The scarcity of servants and the modern type of kit- chenette apartment operate against the consumption of meat except for quick cuts and in general act in favor of such articles of the diet as are of easy preparation, can be 109 purchased ready to serve, and particularly are to be pur- chased in such small amounts as to be consumed at one meal. A large population in our cities lunches on tidbits and des- serts and dines on delicatessen. The obvious defects of this type of diet are only to be overcome by the inclusion of an amount of milk larger than would be necessary in the normal diet. In the broad sense, we may compare the housewife with the manager of a manufacturing plant. The latter buys new parts, replacement items and lubrication on the basis of quality, service in the long run, rather than on the basis of price. Fuel and power, however, are purchased on the basis of cost per calories. In the same sense, the housewife should purchase the articles of diet containing the indis- pensable balanced proteins, salts and vitamines on the basis of physiological need, quite irrespective of price. The re- mainder of the foodstuffs, however, like the fuel of the manufacturing plant, ought to be purchased largely on the basis of price. In the broad sense we expect the price level of foodstuffs to exhibit a more or less constant position relative to the price level of other consumers' goods. One must be pre- pared, however, to see rather marked shifts in prices of the different groups of foodstuffs at different points of the busi- ness cycle. We have been taught to expect rather constant relation- ships between the different foodstuff classes. As a rule, the price of wheat influences the prices of all cereals. The price of vegetable oils influences the price of animal fats, and the price of beef influences that of all animal products. The prices of milk, fruits and vegetables included in the indis- pensable list may fluctuate quite widely, since we stipulate that the quality must remain relatively constant, irrespec- tive of cost of production. In the field of general commodities, increase in supplies is followed by stimulation of demand with result of rise in consumption. We must expect to observe this sequence least often in relation to milk and the fruits and vegetables that are included in the list of indispensables, most often with the other foodstuffs, where the housewife selects food- stuffs on the basis of the calories price. We expect to ob- serve gluts and scarcities in the different groups, followed by increased or restricted purchase by the housewife, with 110 corresponding expanded or contracted consumption by the family. This should govern purchase on the basis of price, exactly as in the case of consumers' goods in general. The lesson that needs to be enforced is to teach the use- fulness of following price considerations with all foodstuffs in the general group of calorie-priced articles, but not to apply it in the group of indispensable foodstuffs. The out- lay for food in different Caucasian countries varies appar- ently from 39 to 60 per cent of the income. The higher the income plane of the family, the lower the percentage of the income expended for food. The lower the income plane of the family, the higher the percentage of the income ex- pended for food. Within a particular plane of family in- come, in prosperity the absolute amount expended for food tends to rise, though the percentage may remain constant or fall. During hard times, the amount expended for food may remain constant, but the percentage of the income ex- pended for food rises. The housewife has two main adapta- tions. She may save in other directions for the benefit of the food supply. She may execute the food purchases in the direction of efficiency, as represented by calories per unit of currency. With larger income more food is wasted, dearer foods are purchased, less home produce is used, more pre- pared foodstuffs are consumed, the seasonal variations are utilized more, house stocks tend to increase and more serv- ice is employed. When the income falls there is less waste, cheaper articles are substituted, more home produce is eaten, home cooking tends to be revived, fewer seasonal foods are purchased, house stocks are allowed to decline and less service is employed. In our standard of living are in- cluded a host of items of accessories and incidentals that cannot be classed as necessaries except in an artificial, psychological sense. A sound system of home economics must lead to the devaluation of these items in favor of a revaluation of foodstuffs. But one must be clear in the matter of relative values. Money can be wasted in buying high-priced foods for fuels just as easily as dissipated on calorie-less beverages, amusements or cosmetics. The chart* illustrates how easy it is in a country with our diversified food resources for any one to secure reason- able adaptations of the diet to conform to taste, custom, convenience or economy. Fixing 1,200 calories as the maxi- mum fraction to include the balanced protein, salts and *See page 113. 111 vitamines, freedom of choice finds expression within the remaining 2,400 calories. I am using the figure 3,600 calories per day as representing the present food consump- tion of the unit adult in this country. There is probably a relatively high degree of waste in this figure. There are individuals who prefer a high meat ration. Eight-tenths of a pound of meat per day at an average value of 1,200 calories per pound would represent 1,000 calories. Incidentally, it may be remarked that the experiences of armies run to the effect that eight-tenths of a pound of meat per day is practically a maximum meat ration for the ma- jority of men. One thousand calories in the form of meat added to the 1,200 calories contained in the indispensable foodstuffs would equal 2,200 calories, leaving 1,400 still to be distributed among cereals, sugar, fruits and vegetables. Such a diet would be expensive from the standpoint of price per calorie, but it is to be regarded as normal for active individuals in full health, whose tastes happen to run in that direction. People in Mediterranean countries are prone to consume relatively large amounts of cheese, legumes and nuts, just as in Oriental countries legumes constitute a principal source of protein. These substances have a higher caloric value than meats. It would be easily possible for 1,000 or 1,500 calories per day to be taken in the form of nuts, beans, peas and cheese. These 1,500 calories added to the 1,200 calories of the indispensable foodstuffs, would leave still 900 calories to be consumed in the form of cereals, fruits and vegetables. Such a ration, like the meat ration pre- viously described, would offer high figures in protein intake. Half the calories in the French diet are in bread. In this country the bread consumption probably does not cover 30 per cent of the intake. If our bread consumption were advanced to 40 per cent of our intake, the bread calories added to the calories of the indispensable foodstuffs would equal some 2,600 calories, leaving still 1,000 calories for meat, sugar, fruits and vegetables. An increase in bread consumption to 40 per cent of the total calories of the diet would represent a pronounced cheapening of the diet in the price sense, without in the least suggesting a deterioration in the quality sense. Bread is not properly appreciated as a food in this country; it is too commonly regarded as a filler. 112 A sugar ration of 100 pounds per capita per year repre- sents 500 calories per day. This amount of sugar can be introduced very easily into almost any reasonable combina- tion of other foodstuffs within the 2,400 calories devoted to fuel foodstuffs. Therefore, an increase in per capita sugar consumption from eighty to 100 pounds, as has occurred in recent years, implies no encroachment on the indispensable items in the diet. Experiences in the Orient have indicated the degree to which cheapening of the diet can be accomplished by in- crease in the use of vegetal oils. Fats are highly concen- trated foods. By and large, the price of the cheap animal fats, such as lard and tallow, are determined by the price of vegetal oil. The price of butter stands apart, the price of margarine stands midway between that of butter and vegetal oils. A fourth of a pound of fat per day would cor- respond to 1,000 calories roughly, which added to the 1,200 calories of the indispensable foodstuffs would equal 2,200 calories and leave still 1,400 calories to be distributed among meats, fruits and vegetables. A vegetarian, desirous of securing the entire ration strictly in the form of plant products, would necessarily have to consume a considerable amount of vegetal oil, in order to prevent the bulk of the diet from becoming excessive. A facultative vegetarian, the term that may be applied to the vegetarian who includes dairy products and eggs, would naturally have a wider field for selection. In either instance, however, on account of the low caloric value of fruits and vegetables in general, the vegetarian necessarily must consume a relatively large amount of cereals or vegetal oils. It is, however, clear that the markets of our country afford to the vegetarian the maximum opportunity for the selection of an adequate diet. Perfection of agricultural technique acquires full mean- ing in diversification of the diet only under condition of flu- idity in transportation, credits and finance. Granted these, we may expect to see the production of foodstuffs more and more conform to the influence of price. Only in this way are the resources of the country to be properly utilized on the dining table of the family. We expect from consumers correct standards in the matter of indispensable foodstuffs and an open mind within the domain of choice of foodstuffs purchased on the basis of price. At present, the public does not buy wisely or efficiently the foods needed for fuels. The 113 Segregation of Components of Diet 3,600 Calories per Day per Unit Adult Maintenance Foods (Calories per Pound Foodstuff) 600-700 Calories 500-600 Calories (Calories per Pound Foodstuff) 2,400 Calories Fuel Foods Premium-Priced Premium-Priced Calorie-Priced (a) Predominatingly Protein Food Beef, 800-1,800 Veal, 600-1,000 Pork, 900-3,000 Mutton and Lamb, 1,000-2,000 Viscera, 400-800 Poultry and Game, 600-1,800 Eggs, 700 Fish, 300-700 Shell-fish, 200-500 Cheese, 1,800-2,000 Dried Beans and Peas, 1,500 Nuts, 2,000-3,000 Raw Lettuce, 90 Endive, 80 Romaine, 90 Escarole, 90 Chard, 90 Celery, 80 Cabbage, 140 Watercress, 90 Carrots, 200 Tomatoes, 100 Cucumbers, 80 Apples, 260 Oranges, 210 Lemons, 170 Grapefruit, 180 (b) Predominatingly Carbohydrate Food Wheat Rye Corn Oats Rice Barley Sugar, 1,800 Potatoes, 350-400 1,600-1,800 (c) Fats Butter, 3,400 Lard Other Animal Fats Vegetable Oils Compound Fats Milk, 1 Quart 600-700 3,900-4,000 Cooked (d) Other Vegetables Greens, 100 Spinach Beet Tops Turnip Tops Dandelion and Chicory Cabbage, 140 Onions, 210 Carrots, 200 Tomatoes, 100 Artichokes, 200 Asparagus, 90 String Beans, 110 Rhubarb, 100 Celery, 80 Green Peas and Beans, 400-500 Beets, 220 Cauliflower, 140 Sweet Corn, Canned, 600 Eggplant, 120 Parsnips, 290 Pumpkins, 110 Squash, 200 Turnips, 180 (e) Other Fruits Apricots, 240 Bananas, 400 Berries, 200-300 Cherries, 320 Cranberries, 200 Currants, 240 Dates, Dried, 1,400 Figs, Dried, 1,300 Grapes 300-400 Melons, 100-300 Pears, 250 Pineapples, 300 Plums, 300-400 Prunes, Dried, 1,200 Raisins, 1,400 114 educational efforts of our schools and colleges have not yet penetrated into all classes of society. Custom, traditional practice and superstition still persist in opposition to economy. And finally, the public is deluged with a flood of motivated advertisements of foodstuffs that influence quite as often in opposition to economic expenditure as in aid thereto. Gradually the pressure of population on food supply may be expected to become more appreciable, although at present our standard of living is expanding so rapidly that of the pressure of population on food supply one observes scarcely a trace. Nevertheless, in the broad sense, relief from the pressure of population on food supply can be se- cured only through the simultaneous education of the pro- ducer of foodstuffs and the housewife in the direction of efficiency of operations. When I refer to the pressure of population on food supply, the expression is not used in the strict Malthusian sense as applied to the United States. We are not within sight of the limit of our potential agri- cultural resources, even with present imperfect methods of operation. From the standpoint of Malthus, one would have great difficulty of making out a case for conservation. We have the largest per capita income in the world and the most costly standard of living. The efficient development of our standard of living, rather than defense against de- terioration, is the object of education in the utilization of income. We have confessedly a considerable amount of malnutrition that is entirely unjustified from the standpoint of our resources and is fully amenable to procedures of relief based on education. For the present and the imme- diate future, therefore, our problem is correct management and utilization of resources rather than enlargement of resources. A brief discussion of this topic was made by Dr. Herbert M. Coulter, formerly superintendent of the Children's Colony in Siberia. Dr. Coulter, who was sent by the American Red Cross at the close of the war to Siberia for 26 months, said: I was placed in charge of 800 refugee children from Petrograd. The first problem which presented itself was a condition of scurvy, which amounted almost to an epidemic. It arose from the fact that for some time the children had been living on a ration of small dried fish and black bread. In looking for an anti-scorbutic we found that 115 in the province of Manchuria cabbage was plentiful and cheap. So, through Red Cross funds, we were able to send to Manchuria and ship in literally trainloads of cabbage. The apparent lack of rickets among these children was accounted for by the diet of dried fish from which they secured cod liver oil, one of the best known preventatives for rickets. Dr. Henry Koch, Director of Health Education in Cin- cinnati Public Schools, criticized adversely advertising propaganda of commercial enterprises who were willing to misrepresent the nutritional value of their products if it meant financial gain. He referred directly to the propa- ganda which is being carried on at the present time to pro- mote a larger consumption of meat, while nutrition pro- grams have been stressing dairy products for protein consumption. The next topic introduced was: "The Essentials in the Training of Nutrition Workers in Public Schools," by Dr. E. V. McCollum, Department of Chemical Hygiene, Johns Hopkins University. Essentials in the Training of Nutrition Workers in Public Schools Dr. McCollum: I AM unable to understand why I should have been assigned the task of discussing the training of the nutri- tion worker unless you desired to know the views of a typical laboratory worker. I believe that Miss Lydia Roberts, Miss Sally Lucas Jean, Mrs. Ira Couch Wood, or Miss Maud A. Brown could have given a better discussion of the subject because they have had more practical experience. I am sure that you will all agree with me that the nutri- tion work among children carried out during the last few years was distinctly a salvaging operation, for it was con- fined essentially to children who were obviously in need of physical improvement. They were the underweight chil- dren who exhibited various signs of malnutrition. These were segregated into groups and an intensive effort was made to find out the causes underlying their condition and remove them. The children were taught all the ordinary health rules, and in addition were either provided with lunches or were instructed in the selection of their food in 116 such a manner as was believed would improve the quality of the diet. In no case, I believe, where a group of school children have been segregated because of evidences of mal- nutrition to be given special attention, have other health habits than those relating to food been neglected. It would indeed be short-sighted to single out any one of the in- dispensable conditions of right living and set it above others in importance, and I believe this has rarely occurred. We can best agree upon what the nutrition worker should know before entering upon her work if we first agree upon what it is we desire to have her do. The problem appears to me to be nearing solution sufficiently so that we may outline certain features of it fairly accurately. If we examine any group of school children almost any- where, by weighing and measuring them, and by observing whether their tonsils are infected; whether they have adenoids, anemia, scoliosis, kyphosis, infections of eye, ear, nose or throat; whether they look tired and fall into faulty postures; whether they want to be active as does the normal child, or whether they are willing to sit still when told to do so, or actually desire to be inactive; many defects will always be found in a public school. These and other tests such as are made as a routine in chest examination, or in- spection of the teeth, will always enable one to segregate the children into two groups, one of which will be classed as undernourished, and the other as normal. The number which will be put into each group will depend upon the standards adopted as to what constitutes normality. Now any considerable number of children who are thus set aside for special attention may again be classified into two groups on a basis of whether or not they will respond with growth and improved well-being when the attention which is given is limited to improvement in the diet. A con- siderable number will do this, but others will not. The last named group must have the attention of a physician, surgeon or dentist. After having such clinical care as they need, some will respond to good feeding better than others. The extent to which they do so will depend upon how bad their condition was when they secured attention. Some children who are advised to submit to operative treatment for adenoids or infected tonsils are found to im- prove markedly without such treatment on improvement in the quality of their diet. This is, of course, not to be put 117 forward as an argument against the surgical removal of these hindrances to development. Neither is one justified in asserting, because many children whose food supply is of poor quality show marked improvement as a result of clinical treatment by a physician, surgeon or dentist, that the character of the food is of little, and the treatment in the clinic of paramount, importance. The first mistake is frequently made by the partially trained and over- enthusiastic exponent of nutrition, and the second fre- quently by those physicians who know little or nothing about foods and nutrition, and are practically unaware that this subject has been greatly advanced in recent years by methods having an approximately quantitative character. We must not think, therefore, that the nutrition worker is trying to supplant the clinic, nor that she is an upstart who has no valid excuse for being. She represents a new feature of work in preventive medicine, and her place is to supplement the work of the clinic. I believe that her im- portance in this field will be increasingly appreciated as time passes. It is exceedingly important that the nutrition worker of today should have sound training. Otherwise she is likely to make mistakes and do things which will react to the dis- credit of her work. Nutrition classes originated in many cases in the clinics, spread to health centers, and now have appeared in the schools where they properly belong. Here the child who is in need of special care will be under com- petent supervision, and every possible chance will be afforded it to develop as nearly normally as possible. It seems to me that in the near future a greatly in- creased investment must be made in this salvaging work. It is a question in the minds of many whether it should be done by nurses or by women who are college graduates with a training similar to that of the domestic science teacher, but with special training in nutrition. I am inclined to believe that the latter are the ones who should do the work of the nutrition specialist. The school nurse now has fully as much work as she can do in the school. The prevention of the spread of epidemics will depend in great measure upon the nurse's prompt recognition of the child who is endangering the health of others. It would seem that the nutrition worker has a specialty in giving individual attention to the child who is below 118 normal physically, and in planning its daily program so as to best insure its development. This makes her a teacher of a special subject which is perhaps the most important in the curriculum, viz., a teacher of the essentials of right living. In this respect she is to supplement the work of the physician, but in a different way from that of the nurse, and in a more specialized manner. Neither, it seems to me, can take the place of the other, although there may be in the well-trained public health nurse all the qualifications neces- sary for success in either the nurse's field or that of the school nutrition worker. The public health nurse will generally have a broader field of activity than the school- room, and will know many things of a special nature which the nutrition worker need not include in her training. The nutrition worker in the school should make a special study of the individual problems of the child who needs in- dividual attention, and if necessary extend her influence to its home. She can often find where the trouble lies and remedy conditions. I need not go into detail as to what she shall do further than to add to what has already been said, that she should come much closer into contact with the child than the school physician or than the family physician where there is one. She should recognize when a physician's aid should be secured and insure that it shall be provided, where now in many instances it is not. In order that the nutrition worker who is associated with the school shall accomplish essentially these things, she must have sound scientific training. It is doubtful whether she can succeed to the fullest extent without some ability to diagnose physical defects. I am not certain but that it might be wise for her to know how to use a stethoscope, in order to enable her to realize when it is imperative that a physician should give the child a thorough examination. This would also serve to safeguard many children with im- paired heart action against too strenuous effort in play, or to protect them from too severe work of any kind. Another, and from the standpoint of the national wel- fare, perhaps more important duty of the nutrition worker will be to present regular instruction to the group of chil- dren who are classed as normal on the basis of the criteria upon which the children are judged to be in a satisfactory state of development or in need of special care. These now get no instruction, generally speaking, unless it be for- 119 tuitous as a part of such instruction as they may receive in physiology. I do not mean the parrot-like repetition of a few "health chores," but an intelligent discussion of what right living is and what it means in later life. Only a trained person with good natural ability can be expected to accomplish this very important work. I should suggest none of these things if there were adequate medical attention to school children, but such is not now provided, and there seems no immediate prospect that it will be. Medical examination of school children as at present carried out is generally a farce. It must be so because of the small investment made in medical service and the large number of children served. It would seem that there is room for the nutrition worker to supplement effectively the medical service of the public schools, through giving her enough training to enable her to direct the atten- tion of the school physician or the family physician where it is needed, and avoid the neglect which now so frequently occurs. In addition she should give closer attention to all the personal habits of the child, the unfortunate circumstances which may surround it at home, and correct any fault in its habits of living. In so far as she can do so through her con- tact with mothers, either in the homes or through the parent-teacher association, she should seek to instruct them in the selection of food for the family and its preparation, and aid in overcoming any unfortunate likes and dislikes which the child may have formed. In performing these functions she will accomplish much in improving the de- velopment of children still to come, and of younger ones not yet of school age. Such important work cannot be given over to untrained or half trained persons. The women who do this type of work must have intelligence enough and training enough to make them accurate observers, and capable of using sound judgment. For this reason I would give them the training in college-for they should all have a college education- which is sound as a preparation for any kind of work re- quiring high mental attainments. Chemistry is of first im- portance in the training of anyone for any kind of scientific work, and some of the courses now in the curriculum of the departments of home economics, where the nutrition worker will receive most of her training special, should be sup- 120 planted by courses in chemistry. Physics and physiology should also be studied intensively enough to give the student a good knowledge of the laws of nature and the properties of matter, as they apply to physiological phenomena. Such training makes one with natural ability capable of accurate observation and deduction. The nutrition worker should have formal instruction in nutrition, which should include a study of the special prop- erties of each of our foodstuffs, and the effects of cooking, canning, preserving, etc., upon them; the chemical nature of the essential nutrient principles; the processes of metabol- ism as taught in the best courses in physiological chemistry. In addition she should have experience throughout at least a year in experimental work with animals. This need not involve research, but should include observations on the effects of restricting young animals to diets faulty in many different ways. There is nothing which will go farther toward training the powers of observation, or in giving a conviction as to the importance of the work which she is later to do with children. I believe there is no other way in which this conviction can be secured, and in which facility can be acquired in evaluating quality in any menu which later she may be called upon to examine. She should, also, be made familiar with the literature relating to observations made on man, as it relates to nutrition in normal and pathological conditions. I believe that there are consider- able numbers of young women in our colleges who are cap- able of the training here outlined. I would not put this important work into the hands of poorly trained persons. There is another field of usefulness for the nutrition worker with the best qualifications. I refer to the pro- fessional dietitian who will work in co-operation with the physician and supplement him in a relation to his patient which is now much neglected. The physician with patients suffering from diabetes, gastro-intestinal disease, nephritis, the pediatrician and others, now often give the patient directions about diet which it is impossible to carry out effectively in the home without close supervision. This the physician is not ordinarily in a position to give. Success or failure in the management of such cases frequently turns upon dietetic management. A trained woman with the right kind of personality could call upon these patients at the request of the physician and advise regarding food pur- 121 chases and supervise the daily menus, instruct in cookery, look after the examination of the specimens of urine where desirable, give suggestions regarding amounts of food to be given the patient, etc. In these ways she would supplement the care which the physician can give, and add to the success of his practice. I shall not dwell upon the training of the hospital dietitian further than to say that she should have funda- mental training in science as a foundation for her special work as a dietitian. In dwelling thus long upon the nature of the work which the nutrition worker will do, and on the training necessary to prepare her for that work, I have sought to emphasize her primary importance in the program of educating the youth concerning how to live so as to enjoy health, and be efficient. I am conscious that many will disagree with me as to certain of the matters which I have emphasized, even on the point concerning how important is the selection of food for the development of the human being. I know some people who question whether the great sensitiveness with which animals react to slight differences in quality of the diet has any bearing on the nutrition of the child. If someone shall bring forward convincing evidence that much of the present skeletal and tooth defects seen in chil- dren are due to causes other than failure to develop properly during prenatal life, infancy and childhood, and also that the human species thrives upon diets upon which animals grow into runts or suffer from specific types of malnutrition, the proposition which I have set before you will break down. Until that is done, those who do not favor some such pro- gram as I have formulated or offer a good substitute are on the defensive. Discussion The discussion of this very important topic was led by Dr. Agnes Fay Morgan, Department of Household Science, University of California. Dr. Morgan: The most pleasing thing that Professor McCollum has said was that about the training of the nutrition worker. The training in the fundamental sciences is something that appeals to me as being par- 122 ticularly necessary, and something which is, perhaps, not frequently enough emphasized in looking at either the training or the per- formances of applied science workers. The value of this kind of training lies in the confidence and the balanced judgment which the worker acquires from such a background. Our workers, and par- ticularly those out in the field, should have a more critical attitude towards the things that they teach than is implied by the statement they so frequently make that this was recommended by So and So as being the proper thing to do. In order to get this better attitude we must incorporate in the training of these workers actual experience with the methods that are used in obtaining these results that they are going to try to get. The animal room and the white rats and mice and guinea pigs are a necessary part of the equipment of the departments that are going to train such workers. All we do in our courses in nutrition in the University of Cali- fornia is to teach the experimental method, how the evidence is obtained, what is the evidence. The conclusions that are drawn are relatively unimportant; but to know the evidence, to know how much and what is safe to emphasize in the results as they come forth year by year, is, of course, the important thing for the field worker, as well as for the laboratory worker. I just want to mention one other thing in commenting on this excellent address. I have no criticism, even of the part about the stethoscope, which should be taught cautiously. The point of teaching nutrition in the prenatal period and of the early feeding of children is extremely important, and one which has not been sufficiently empha- sized. It is a little difficult to know where to begin teaching girls about this matter and how to do it. Moreover, we don't know very much yet what to teach about this matter of prenatal nutrition. Dr. Morgan's sanctioning of Dr. McCollum's statement that the nutrition worker should be taught to use the stetho- scope provoked an animated discussion which was led by Dr. John N. Force, Department of Hygiene and Public Health, University of California, who said that he was sur- prised to see Dr. Morgan back up this stand of Dr. McCol- lum's about the stethoscope. "The medical profession," he said, "is not jealous of the stetho- scope, but it is only one of many instruments and methods to secure data for diagnosis. Many things recently have been developed to take the stethoscope's place and to supplement it." Dr. Adelaide Brown, Miss Mary Murphy, of Chicago, and Miss Sally Lucas Jean were each asked to discuss one point in Dr. McCollum's paper. Dr. Adelaide Brown said: I have just had a trip through the East, and as one of the things I am interested in is Health Education in the public schools, I visited many places; but I saw the work at Mansfield, at Baltimore and in 123 New York, and then I went to Newton Center and saw the work under Miss Bragg, and I think those are rather high lights in nutri- tion work, and this is my conclusion: that the type of person that ought to do nutrition work is the inspired type, trained with a back- ground of science. It could be done also from the point of biology. Some of the leading women in this work have taken Ph.D.'s in biology. I was not very sure that either a physician or a nurse with no other background except training in a hospital should ever teach nutrition work. Now I have made that conclusion 100 per cent, and am con- vinced that the correct points of access to this work are by way of general science. Dr. Cleeves, of Los Angeles, made a strong plea for all physical examinations to be kept within the jurisdiction of the medical profession. The Chair added that we must have those improved methods of health examination and diag- nosis by physicians and by other people, which we are honestly trying to find. Miss Maud Brown, of the Elizabeth MacCormack Me- morial Fund, said: The one thing that I have to say with regard to the essential train- ing of all health workers is to make a plea for a preparation which has an absolute bedrock foundation. We do not want to discourage anyone-the bulk of the work has to be done by people who have to take other people's word for the fact. But the difficulty is in discrim- inating as to whose word to take, and that is where your foundation comes in, and the deeper down it is the surer you are in discriminating. Miss Mary Murphy, of the Elizabeth McCormick Me- morial Fund, added: It seems to me that certain essentials of the training of nutrition workers were left out. I feel that first of all we must train a thor- oughly all around human being, and that there are certain essentials in this training which are not recognized in the universities. One of these is psychology, fundamental psychology, the psychology that makes the nutrition worker understand the mother, her parental pride and various other things that will make her do at home what is necessary to have the child gain in weight and health. Practical child psychology should be included. I would also like to see a course in social science given part of a year, or an opportunity to come in actual contact with problems of the social worker and the problems of the home, the things that have to do with nutrition just as much as food, and sometimes more than food. Miss Jean summarized the above discussion thus: Dr. McCollum's paper brought to us the message which we all so very much need, and Miss Brown and Miss Murphy have so ably pointed out that we must have a well-rounded human being as a 124 nutrition worker, trained definitely and deeply and with an under- standing of what to teach. Medical inspection in the schools of the world is not being well done. Those of us who are familiar with medical inspection in all countries know this. I saw an examination in one of the best school systems in England, where the doctor, the nurse and the mother were present, when the doctor passed by a child who was 16 pounds below weight, without question. And when I asked why this child had been allowed to pass he said, "Oh, you know these are poor people; you can't do anything with poor people about the thin children." Now that is the attitude of the medical inspector in most parts of the world. It is his general attitude, that the doctor and the nurse are there only to remedy defects. We are never going to get anywhere with medical inspectors until we admit that it is the part of a health program to build up healthier children, and not merely to detect defects. The Chairman: Our next topic has two phases. "Nutrition Work in Public Schools" will be presented by Mary G. McCormick, Supervisor of Nutrition of School Children, New York State Department of Education, Albany, N. Y., and "Nu- trition Work of Non-School Agencies," by Margery M. Smith, Assistant in Nutrition, Extension Service, Oregon State Agricultural College. I will ask Miss Hoover to dis- cuss these together, leading the discussion on both papers. Nutrition Work in Public Schools Miss McCormick: DR. McCOLLUM has spoken of the importance of nutri- tion for the promotion of growth and the maintenance of health. Attention must be given to the nutritive require- ment during the entire period of life; that is, in the pre- natal period, the period of infancy, the pre-school period, the school period and in adult life. My paper is confined to a discussion of the nutrition program in the schools. What are the objectives in our school nutrition pro- gram? A few years ago our school superintendents, if asked to state their objectives in nutrition, would say that they hoped soon to organize an open-air class for the pre- tuberculous children; some superintendent who perchance had one open-air blass would say that he was preparing to start another. After the Great War when much thought was concentrated on malnutrition more definite standards 125 of measuring this condition were announced by the medical profession. New objectives were then formulated. In 1918-1919 the height, weight and age tables prepared by Dr. Wood were distributed by the United States Bureau of Education to every schoolhouse in the United States. Ten per cent underweight was stated by our leading pediatrists as indicating an undesirable nutritional condition in chil- dren. Weight surveys were made in many schools, and re- vealed that about 20 per cent of the school children were 10 per cent or more underweight and that in addition 13 per cent of the school children were borderline cases. A much larger proportion of the school population was thus found to be undernourished than was formerly supposed. Organizations devoted to child welfare and public health, impressed with the significance of this discovery, were ready to adopt measures for the correction of malnutrition, and nutrition classes for undernourished children were ve- hemently advocated. This was a new objective; to many people it still seems to offer the solution of the problem of malnutrition. The leaders in the field of nutrition, however, have two strong criticisms to make of a nutrition program whose sole objective is the correction of malnutrition. The first criticism is that such a program is too costly. Experience has shown that one full-time nutrition worker reaches only one hundred undernourished children at a time. In a city having ten thousand school children there would be about two thousand undernourished children candidates for nu- trition classes. To organize these children into such classes would require a staff of twenty nutrition workers. Such a program is obviously too costly to be considered in a school budget. The second criticism is this: Such a program if organized would reach directly only the undernourished children-20 per cent of the school population-and is therefore an incomplete program. The principle of the nutrition class is the same principle that we found in the open-air classes only applied to somewhat larger numbers. The leaders in the field of nutrition, however, have two big objectives that seem more far-reaching than any de- scribed above. One is that every child, not only the under- nourished, but every child, may be taught early to establish good food habits and practices; every child must be taught not only to abstain from harmful foods, but to take regu- 126 larly those foods that are needed to supply him with a suf- ficient amount of energy and building material and to see that the foods containing the growth promoting substances are given a prominent place. Moreover, every child must be taught to develop the right attitude towards food by an understanding of the functions of food. That is our first big objective. We shall not be satisfied, however, even when all children measure up to normal standards of growth. We are not "stock raisers" content when the herds are plump and sleek. Our problem consists not only in the production of physical well-being among the children by establishing in them good food habits and practices, but in giving them for use in adult life a reserve fund of informa- tion on the principles of the nutritive requirements as they apply to the different age groups and to different kinds of activity; in teaching them the response which the body makes to different climatic conditions and the dietary adap- tations which must be made to these conditions; in teaching them the economic value of the different foods so that the nutritive requirements may be met at different cost levels; in teaching them the nutritive properties of the different classes of foods, milk, meats, seeds, stems, roots and leaves, so that they may be able to evaluate foods that are unfa- miliar to them and thus be able to meet their nutritive re- quirements in different geographical localities. For this latter purpose a high school course in nutrition to be taken by boys and girls alike is necessary. The schools already have many of the essentials for a good nutrition program. Medical inspection has been es- tablished in most communities so that the children are ex- amined at least once a year by a physician and the physical defects are detected; the nurse has already proved her value in the school health program by the co-operation she has been able to obtain from the parents in the correction of these defects and in her ability to teach both parents and children the laws of sanitation and how to follow them. Oral hygiene is now a part of school health work; bad mouth conditions are being cared for and good dental prac- tices established; the physical trainer is teaching the chil- dren good posture; is giving corrective exercises to those who need them and is bringing the spirit of play and re- laxation into school life. Moreover, the home economics teacher has long been teaching the girls in the junior and 127 1 senior high schools the principles of food selection and preparation and in many places is supervising the hot lunch which is served to the children who cannot go home to a noon lunch. During the last five years our schools have been equipped with scales and the practice of weighing and measuring the children has been adopted. The mid-morning milk for undernourished children has been established in many communities. Lastly, there is a place in the curricu- lum for instruction in nutrition, for the course in physi- ology and hygiene, so long a recognized branch of study, has contained lessons also on food requirement. And yet what is lacking? Bad food habits are still very prevalent among children. Their diet often consists of foods which have been demon- strated in animal experimentation to result in nutritive failure. Underweight and defective teeth are frequently found. The great weakness in our school health program lies in the fact that our teachers have not been trained in Health Education in general and in nutrition in particular. We must have adequate courses in health in our teacher- training institutions; courses that will establish health as an ideal worth striving for, even by the teacher, and that in addition will give her a knowledge of the sciences that underlie the rules of health. The course in nutrition in the teacher-training institutes must be taught by a person who has made a thorough study of nutrition. Moreover, we must teach nutrition not only to our pupil- teachers but to the great body of teachers now in service. These teachers have no conception of the nutritive require- ment as revealed by modern research and are teaching theories no longer tenable in the light of our present knowl- edge. Their instruction is not only inaccurate and inade- quate but is not concrete enough to be personally applied by the child. A well-trained supervisor of nutrition should be placed on our school faculties. Her duties are, first, to train the elementary teachers in her community in the principles of nutrition as applied to childhood and in methods of teaching nutrition. The teachers will then return to their class- rooms with simple yet authoritative information about the nutritive requirements of children which they may, with confidence, transmit to their students. The supervisor of 128 nutrition should also instruct the teachers in their own nu- tritive requirements. While training the elementary teach- ers now in service and supervising their instruction are two of the duties of the supervisor of nutrition, they are not her only responsibilities. It will be found that a large propor- tion of the children will respond to this improved classroom instruction with the formation of good food habits and with gratifying gains in weight. A certain number of children will not respond. These children must be studied inten- sively by the physician and dentist to see if any physical defects are responsible for their continued malnutrition; by a psychiatrist to see if there is anything wrong in the mental and emotional life of the child. The home must be visited to see if there is any condition in that environment which might account for the child's failure to gain. His diet must be scrutinized by the supervisor of nutrition to see if it is faulty in any respect. In other words, an in- tensive study of the undernourished children by the super- visor of nutrition in co-operation with the other health workers on the staff constitutes an important part of her work. It must be remembered, however, that some children are undernourished because there are sociological and eco- nomic problems at home which the school officials cannot undertake to solve; these problems may be handled much more fittingly and skilfully by social agencies than by the schools. The supervisor of nutrition has a difficult position and for it she needs thorough training. Her preparation must have included a thorough study of the chemistry of food and of nutrition; food economics or the relative returns made by foods in proportion to their costs; sociology; in addition she must understand the laws of psychology and the principles of pedagogy, for after all her problem is es- sentially an educational one. The methods used in teaching nutrition should not be at variance with the general educa- tional methods that have been demonstrated to bring the most permanent good to the individual. A knowledge of school organization and administration is also desirable. She must win the confidence of the teachers and the other health workers and be able to work with them. Let it be emphatically stated that the training received by a nurse does not qualify her to conduct a nutrition program such as is here described. The person on the school staff who is 129 better prepared than any other person is the teacher of home economics who in her college course has specialized in nutrition. Our colleges and universities, however, are now realizing the special training which a supervisor of nutrition needs in order to conduct a nutrition program in the schools, and are offering all the necessary courses. In two cities in New York State supervisors of nutrition have been employed and have carried on the kind of pro- gram mentioned above. In the cities of Auburn and Bing- hamton the recently introduced nutrition program has dem- onstrated that, first, teachers do become interested in nu- trition and are willing to co-operate in a nutrition program; second, principals and superintendents become enthusiastic about it; third, results in improved food selection and in a reduction in malnutrition may be obtained. In many com- munities, however, demonstration of this kind must first be financed by organizations outside of the school until the Board of Education is willing to assume the financial burden. Such an expenditure is well justified. While we are waiting for the presence on our school faculty of a supervisor of nutrition there are several steps we may take to increase the value of the health activities we have already started in the schools by utilizing the edu- cational possibilities inherent in these activities. We would all agree that the equipping of public schools with scales for weighing and measuring the children is a necessary part of the school health program. Let us teach the significance of weight and the relation of weight to proper diet and the rules of hygienic living. The milk feeding for undernour- ished children has improved the nutritional condition of many of these children. Let us use it as an example of the desirability of having all children learn to drink milk. The school lunch room contains not only nutritious foods for those who patronize it but many lessons for all children on food selection. We must do much more than we have yet done in teaching children to like the necessary foods. The milk feeding at school has been the means of teaching many children to like milk. We must also teach the boys and girls to like vegetables, for vegetables as a class are unpopular with children. Especially in the early grades must the children be given the opportunity of tasting fre- quently the desirable vegetables. In schools having a home economics teacher this may be easily arranged. Let some 130 of the classroom lessons in physiology, for instance, consist of tasting cooked carrots which have been prepared by the girls in the home economics class. When children are of- fered carrots at home they frequently refuse to eat them, giving as a reason the statement that they do not "like car- rots." Seldom do their mothers know how to teach them to eat the desirable foods. When cooked carrots are offered to a room full of children, however, the carrots are eaten. Even the children who think they do not "like carrots" taste them. Frequent tasting will make the child familiar with the flavor of the food and then he will like it. In the same way the children ought to have an opportunity of tasting cream of vegetable soups, for these are often dis- liked by children. I hope in time we shall develop facilities for serving a model breakfast to the girls and boys once or twice a year, not for the purpose of feeding them but as a part of their food education. We have taught the children what a model breakfast should be; the children may have read descrip- tions of it in books but many children have never seen a model breakfast and many more have never tasted one. I want our children to experience the gastric satisfaction that follows an adequate breakfast. The serving of such break- fasts at cost once or twice a year by the girls in the home economics class could be easily arranged and the boys and girls would have received a most important lesson in food education. In conclusion, we may say that our conception of a nu- trition program has been extended beyond the care and feeding of the few pre-tuberculous children. We think a plan which includes even all the undernourished children is limited in scope; we must outline a program of education in the nutritive requirements that will reach every child in the schools, both elementary and secondary. A campaign of publicity is needed both within the schools and without the schools; within the schools the con- version of the superintendent to a realization of the im- portance of nutrition is the first strategic step. His in- terest will be carried over to the teaching staff and will also make itself felt in the board of education. It is necessary to convince the public that expenditure for the salary of a supervisor of nutrition will result in the development of a better physique in the boys and girls; a higher resistance 131 to infectious diseases; better attendance in school and hence less retardation in studies. It is an economy of the highest order. The Chairman: I am glad to present Miss Margery Smith, Nutrition Specialist, Oregon Agricultural College, who will discuss the next phase of the program. Nutrition Work of Non-School Agencies Miss Smith: NUTRITION activities during the last few years have crept into some and rushed into other non-school pro- grams of work, in a great variety of health, social, and civic agencies of the United States. Today, with world-wide attention centered on a program of Health Education for the school child and with the im- portance of nutrition in health recognized, these non-school agencies are asked what contribution in nutrition they have to give to a general school health program. I shall try to present only the outstanding types of nutri- tion work now being done by non-school agencies and their evident contributions to a school health program. At this point, I feel compelled to admit that the line of demarcation between nutrition work and other health work is not always clear, and that frequently the work of a non-school agency merges indistinguishably into the work of the school itself. Moreover, my point of view persists in seeing either a direct or an indirect influence on a school health program in prac- tically all types of nutrition work at present being conducted outside the school. Does not any nutrition activity in- fluence a school health program that (1) even partially succeeds in making right food and related health habits automatic in the daily lives of school children, or that (2) helps to bring the child to school at six years free from physical defects and with good health habits, or that (3) helps to raise the standard of nutrition in a community of adults and children ? Non-school agencies began their first contribution to a school health program, undoubtedly, with the establishment of nutrition classes for malnourished children of school age. Credit is due Dr. William R. P. Emerson of Boston for the 132 first nutrition class of fifteen poorly nourished children, or- ganized by him in 1908. A study of the nutrition class movement shows the rapid expansion of nutrition activities and the gradual develop- ment of trained workers for this field. Workers with medi- cal training, with physical training, with nursing training, with social training, with home economics training and with no special training have all been engaged in conducting nutrition classes. Growing with this work and fitting into a larger nutrition program in close co-operation with the medical, the nursing and other interested professions has emerged the "nutrition specialist" or "nutritionist" with her combined home economics, social service, and health training. In the beginning, nutrition classes were held entirely outside of the school, and included only malnourished chil- dren who were usually at least seven or more per cent below average weight. It soon became evident through experi- ence that where the work was on a careful basis these under- nourished children were receiving instruction with in- centives to establish good health habits equally important to children not underweight; in short, that all children needed the positive health instruction on right foods, enough sleep, plenty of fresh air and the simple essential health rules. Granted that the nutrition class has served, is still serv- ing a useful purpose in singling out undernourished children, in placing emphasis where it belongs on the correction of physical defects and bad habits of food and hygiene and in extending health teaching to all children of school age, mal- nutrition is not yet prevented when nutrition work is con- fined to the school age group. Real preventive work must be done before the child is six years of age. Perhaps the greatest nutrition contribution non-school agencies are mak- ing or can make in the future to a school health program is in preventive nutrition work with the pre-school child. If somehow children can be sent to school at six years of age with good health habits and free from physical defects, the school health program can be quite different in character than if it has to be continually providing for corrective health work. Numbers of non-school agencies whose nutrition activities at first were concerned with the school child are 133 confining themselves more and more to the pre-school child with the hope of preventing later physical defects and mal- nutrition. At the Health Center of the Massachusetts Halifax Health Commission in Nova Scotia a unique piece of work is being done in preventive nutritional dentistry. A pre- school dental clinic, the only one in Canada and the second in the world, the other being in Cleveland, Ohio, is operated by a pedodontist who has five hundred children from six months to six years of age coming to her four times a year for dental guidance. At this clinic proper nourishment of the teeth is emphasized quite as much as prophylactic treat- ments and right oral habits. Nutritional advice is given expectant mothers to safeguard the normal development of the temporary teeth. There have been observations for a two-year period on some of the children, and the school dentists report that pre-school dental work is beginning to tell in results. A few instances of pre-school nutrition classes are re- ported, as at the Babies' Hospital in Philadelphia under the supervision of the nutrition worker of the Child Federation. The classes include work with the mothers and the children. It is interesting to note here that the Philadelphia Child Federation has a plan in process for a pre-school demonstra- tion whose ultimate object is to secure a ruling of the school authorities for the registration of all children for physical examination a year prior to their school entrance. The examination, accompanied by recommendations for cor- rective measures, if carried out, would insure a reasonably normal state of health for the child entering school. Day nurseries with their supervision of children during the day have an unusual opportunity to do excellent pre- school nutrition work, and reports indicate that many nurseries are providing an environment including proper food, enough rest, and plenty of fresh air, in which right health habits will develop normally. Another organization with a vision of great possibilities for preventing malnutrition in school children and thereby lifting from the school the burden of curing malnutrition, is the New York Association for Improving the Condition of the Poor. In a small congested area in New York City peopled with approximately 35,000 Italians this association has been developing an intensive child health program. 134 This activity, known as the Mulberry Health Center, has been in operation four and a half years. The program has included from the beginning a nutrition program whose efforts have been largely confined to pre-natal and pre-school work. Rural work with pre-school children can seldom, if ever, be done on an intensive order. But through conferences in various centers, at which a physician examines the child, a nurse assumes responsibility for the correction of physical defects, and a nutrition worker gives special diet instruction, a health program including nutrition for the rural pre-school child is beginning. The effectiveness of this program de- pends largely upon the amount and character of the follow- up work with the mothers. Agencies often co-operating in this work are State Departments of Child Hygiene, Public Health Nursing Associations, Home Economics Divisions in State Agricultural College Extension Services and Parent- Teacher Associations. The non-school agency engaged in nutrition work with pre-school children is making a contribution to a school health program which will be measured by its success in securing for the school, children of six whose bodies are normally developed and whose health habits are already properly established. A school health program is primarily concerned with the health habits of school children, but any child's health habits depend very largely on the habits of his parents. Especially in food habits does the child copy after his father and mother. A health program can be effective in school only when it is also effective at home. It is then of concern to the school what adult health practices are at home, what the adult attitude toward present day health teaching is. Again, the non-school agency which helps to raise standards of nutrition for both adults and children through community work is promoting school health work. In increasing numbers groups of adults in rural and in urban sections are meeting to discuss, to see demonstrated, and later to adopt better food practices. A study in "Family Feeding" which considers the production, the selection, the preparation and the eating of foods for family health from the pre-natal period through life is being widely developed. Engaged in this phase of work are nutrition specialists and home dem- onstration agents in the extension division of State Agri- 135 cultural Colleges, Red Cross nutrition workers, Dairy Council nutrition workers and nutrition workers in industry. If all mothers were better informed concerning the factors indispensable to normal nutrition the percentage under- weight of school children reduced during the school year by a school nutrition program might not, as now frequently observed, increase again markedly during the summer vaca- tion at home. By means of laboratory investigations, research, and surveys we are gaining very exact knowledge of the prop- erties of food, of how children grow, and of other essential nutritional factors that make for optimum health. The possession of that knowledge by a few is not enough, it must be interpreted to the average man and to the child in the school. One of the outstanding features of successful health teaching is the use of graphic and dramatic devices to give added interest and emphasis. Nutrition can be taught to children in a most striking and convincing way by demonstrating to them the contrasting effect of various foods on animals. Non-school agencies can be of much service in conducting for educational purposes demonstra- tions with laboratory animals, and in preparing nutrition exhibits not for momentary propaganda but for consistent, effective use in the schools. Among agencies already assist- ing in the dissemination of the newer development in nutri- tion are the national and branch dairy councils whose educa- tional platform, including particular emphasis on nutrition, is broad and progressive. Assistance is extensively given schools promoting health work through talks and food demonstrations by their nutrition workers or in the form of illustrative material including exhibits, posters, and films or subject-matter in the form of stories and health plays. Another agency, whose value as a contributor of inspira- tion, of literature and of graphic and dramatic devices for teaching health including nutrition to children is unani- mously and universally appreciated, is the former Child Health Organization, now incorporated in the American Child Health Association. Newspapers and magazines are powerful agencies for interpreting newer developments in nutrition, but the subject-matter content of these popular articles must be sound if they are to make a positive con- tribution to a school health program. 136 It may, perhaps, fairly be said in conclusion that non- school agencies have been paving the way for the nutrition content of a school health program. The first point of attack was the undernourished school child; nutrition classes, milk campaigns and hot lunches were brought to his aid. Before long the wisdom of applying the same health measures to any child was apparent, and nutrition work with the aid of the schools began to be extended to all children of school age. With the realization of the early age at which undesirable health habits are formed and their early bearing on the nutrition of school children, non-school agencies turned their attention to the problem of preventive nutrition work with pre-school children. Since the food and health habits of children are largely dependent on home environment, adults need a new awakening to their own and their family nutritional needs, and again the non-school agency has helped to give this instruction. In these nutri- tion activities lie the contributions of non-school agencies to a school health program. The Chairman: Discussion will now be led by Miss Jessie M. Hoover, Milk Utilization Specialist, U. S. Depart- ment of Agriculture, Washington, D. C. Miss Hoover: Mr. Chairman and members of the Conference: I would like to say that I heartily agree with the thoughts presented in the two excellent papers which I have been asked to discuss. I shall call atten- tion to a few practical aspects of a nutrition program that have been suggested either for school or non-school agencies. In the successful promotion of a nutrition program we have at least two limiting factors: 1. The cost of the work (how it shall be financed). 2. The nutrition worker (how to secure an adequate number of scientifically trained workers). The expense of furnishing a college-trained worker for every 100 pupils is prohibitive. Even though funds were available it would be impossible to secure so large a number of qualified nutrition special- ists. Too often nutrition work is handled by those who are utterly unqualified to speak with authority or give advice on matters related to the sciences which Dr. McCollum outlined as essential in the preparation of a nutrition specialist. How often we see a worker who may be qualified to handle other less scientific subjects endeavor- ing unsuccessfully to teach nutrition. In addition to the knowledge of the fundamental sciences, as chemistry, physiology and others, there is the personal equation. The nutrition specialist should have a contagious enthusiasm which inspires others to follow her leader- 137 ship. She should be kindly, earnest and a good physical specimen herself. It has been suggested that the teachers be trained in normal schools to take charge of nutrition work in the schools. There can be no doubt of the soundness of this suggestion, but what shall be done about those schools that are taught by the 52 per cent of teachers who have not been trained to teach anything. Not only is the teacher untrained, but her tenure of office is so brief that the successful com- pletion of even a short nutrition program is impossible. To meet this problem, as well as the problem of nutrition work for the pre-school child and the adult, the development of local leaders has been undertaken by the extension service of the State agricultural colleges, and the U. S. Department of Agriculture co-operating. One or two representatives from each community attend a training school for leaders. This school is conducted at a readily accessible place, under the auspices of the local representative of the college, by a nutrition specialist who is a graduate of a college of recognized standing in scientific subjects. Subject-matter relating to the selec- tion and preparation of food is given in a clear, concise, simple, organized way to these leaders, who return to their communities and act as go-betweens to carry the practical lessons presented by the nutrition specialist. Records are kept of the work done and results secured. These records are taken to the next training school, where they are discussed with the nutrition specialist as a part of the regular lesson. The plan of training local leaders is practicable in both city and rural communities. In rural communities it is especially valuable. It is hoped that through the extension of the scientific knowledge of nutrition an effective machine for combating malnutrition is being set in motion so that the percentage of underweight children in the country homes will be greatly decreased. In the sixty or more milk- for-health campaigns in which the U. S. Department of Agriculture has personally co-operated, our surveys of hundreds of thousands of children show that frequently there is more undernourishment in the rural schools than in the city schools, and that rural school chil- dren are often non-users of milk. On my way from Washington, D. C., to San Francisco I stopped off in one of the western States. A little girl of five who had been in a nutrition class said, "I've had three of mine today." After questioning her as to what she meant she replied, "Well, I've had my milk, my graham bread and my vegetables. I didn't like my graham bread, but I ate it." This little girl had been under the direction of the local leader of the nutrition project, who was surely giving a real service to her community. In closing I wish to emphasize the importance of a well-organized plan for the training of teachers and local leaders by qualified nutrition specialists, in order that both city and rural people of all ages may learn the simple principles of nutrition. By this method it is believed that malnutrition among growing children will be reduced and their physical and mental condition improved. The Chairman then introduced Miss Margaret Sawyer, Director of Nutrition Service, American Red Cross. 138 Place of Home Economics in the Health Education Program Miss Sawyer: WHAT is the contribution of home economics to the Health Education program? At the present time there are 25,000 home economics teachers and supervisors in our public schools, whose work contributes directly to the health of the pupils with whom they come in contact. The courses in foods and food preparation are built around meal planning, and emphasis is placed upon the selection of food for health and the factors that must be considered in selecting an adequate diet. While teaching the girls how to make thick, thin and medium white sauce-milk, its place in the diet, its care in the home, its production and distribu- tion, are also considered. The sewing classes offer a splen- did opportunity to teach the hygiene and care of clothing as well as the construction and aesthetic value of it. This course also gives a chance to study posture. The making of dress forms in these classes has revealed in a most striking way many crooked backs, and has been the means of im- pressing Mary with her real appearance. Thus through the elementary and secondary schools, as well as the normal schools, colleges and universities, the teachers of home eco- nomics have a unique opportunity to give information to these girls-the future mothers of the country. In addition to giving them actual subject-matter which in itself is valuable, the courses give them a point of view and appreciation of the relation and importance of their responsibilities as home-makers, to the welfare of their entire family and to the community in which they live. Home economics teachers also have an opportunity to function through the Home Economics Education Service of the Federal Board for Vocational Education. This serv- ice is organized to carry out the provisions of the Smith- Hughes law in as far as they pertain to training girls and women for the vocation of home-making. This education is conducted in three types of schools-all-day schools, part- time schools and evening schools-all of which must be under public supervision and control, and the students four- teen years of age or above. Federal money is provided to aid the work but all Federal funds must be matched by an 139 equal amount of State or local funds and the education itself must be of less than college grade. The all-day school is designed for the girls who can attend a full-time school, the part-time school for those who are in wage-earning pursuits or are home-makers or household assistants and cannot attend a full-time school, while the evening schools meet the needs especially of adult home-makers. However, in the States where there is no provision for part-time schools, many young people are found in the evening classes. The vocational home economics teachers and the home economics teachers in the non-vocational schools endeavor to first interest the girl in herself and her own health, and then extend her interest to the small brother or sister or to the smaller children in the school. The food classes provide an opportunity for the girls to check their own diets and their own general physical condition. Many of the older girls in the high school classes assist the home economics teachers and nurses in the special classes for the mal- nourished children. In this way these girls are getting splendid pre-vocational training for the vocation of home- making, which 90 per cent of them will enter. The clothing classes may begin with the girl's interest in her own clothes, giving her an opportunity to learn about line and color and their application to her own clothing prob- lems. From this point of approach many teachers are able to convince the girls that clothes need not necessarily be uninteresting or commonplace or "out of style" to conform with the principles of good line and color and hygiene. The vocational teachers may go one step farther. To be effective, vocational education must provide for contact with the vocations. To this end vocational education em- phasizes the importance of the home project, as a part of the school program. In the home, through such work as menu planning, marketing, meal preparation and sewing, the study of elementary nutrition and clothing in the school is made effective. The home projects are supervised by the teachers and through this contact with the home, the teachers are able to give more intelligent and sympathetic help and more pertinent suggestions. This also offers an opportunity to meet the mothers and encourage them to enroll in part-time or evening classes. Many sewing classes have made layettes, to be used by the public-health nurse. The garments in this case are the instrument through which 140 the related study of child care is introduced and taught. If the physician or nurse on the school staff is able to par- ticipate, a more inclusive course is possible. The home economics teachers in many schools are re- sponsible for the management of the school cafeterias. This offers an opportunity to reach a larger number of pupils and also provides means whereby instruction in the selection of food may be inaugurated for the entire school. The classes for adults have been most encouraging. Many mothers and older sisters have been persuaded to join the evening classes through the influence of the younger girls who were members of the all-day or part-time school classes, or through the influence of the teacher when she made her home contact. In some States special appeals have been made to mothers of pre-school children to join the part-time or evening school classes, so that they might learn how to get their children ready to enter school. Other States have urged the mothers, whose children were in the special classes for malnourished children, to enroll in one of the adult classes. Thus the schools are offering to the mothers the only equipment which will aid in the perma- nent betterment of the human stock-namely, information. Home economics makes a contribution to the Health Education program in rural districts through the home demonstration agent, who is generally a woman trained in home economics. In the United States there are over 1,200 State and county agents, over 900 of whom are in counties. The county home demonstration agents are supervised by State leaders and are given help in developing their local programs by specialists from the State colleges of agri- culture. At least once a year the agents are brought to the State college for a conference when their problems are discussed with them and where specific help is given. The home demonstration agent works with rural women. She is part of the community and is recognized as a leader in it. Although many activities are carried on under the direction of the home demonstration agent, last year every county in which there was a home demonstration agent carried on at least one phase of a nutrition program, re- sulting in one million two hundred and fifty thousand im- proved home practices. One of the most valuable services the agent has rendered to the community is the help she gives in introducing the hot noon lunch in rural schools. 141 Not only does she help the teachers in the establishment and organization of the lunch but she gives suggestions as to how it can be made a real educational factor. Many agents meet the teachers in institutes and give them talks about food in its relation to health and have planned with them nutrition programs for the year. The agent gives the mothers suggestions about the food that should be included in the lunch brought from home, thus getting the mothers interested and co-operating with the school in carrying out the school program. In all parts of the country the public health nurse and home demonstration agent are co-operating in developing health programs for rural schools and communities. The training and experience of one ideally supplements that of the other and together they are able to give much more effective and adequate service than can either one working in a community alone. From the foregoing discussion it will be seen that ave- nues have already been provided through Federal, State and local channels for the instruction of women and girls, both urban and rural, to prepare them for the vocation of home-making. Many communities have availed themselves of the opportunity and were it possible to measure the results in statistics it would be evident that at the present time the 25,000 teachers and 1,200 State and county home demonstration agents are really making a considerable contribution to the health movement. Both the home eco- nomics teacher and the home demonstration agent approach the problems involved in carrying on any one of the home activities from the point of view of the mother who is re- sponsible for the whole family and for the business of man- aging that home so that it will meet the needs of all. The provision of food for the family means more to her than the mere filling of a formula which has been prescribed by a specialist. There are many factors that will have to be considered by the mother in making her selections, and ad- justments have to be made. As Dr. Taylor has shown so effectively, the head of a household is the head of a big business having many departments; all of these departments of the household have to be considered in relation to each other, and the importance of each will vary with the house- hold and the ability of the manager. If we are going to try to change home practices, let us use a teacher who can 142 appreciate the problems of the mother, and who can help her solve them to the benefit of the whole group, including the mother herself. Are we making maximum use of our home economics teachers in the public schools? We will all agree that health instruction should include all the children in the school system and should begin in the kindergarten. We will all agree that nutrition instruction is a part of any educational health program. The home economics teacher has had spe- cial training in food and nutrition and the related social and natural sciences and should be used in carrying on the nu- trition part of the school health program. The contribution that she has to make should not be confined to the group of girls above the fifth grade, but should be made to all girls and boys. However, this additional responsibility should not be assumed at the expense of the regular home economics courses. If all children are to receive instruction and if the re- sults are to be expressed in permanently improved food practices, the grade teachers must assume the responsi- bility for most of the classroom instruction. However, if the children are not to be exploited and if the information given them is to be appropriate and in usable form, the teachers must be given authentic subject-matter. Many school programs have been worked out following this general outline and with surprisingly good results. The grade teachers were enrolled in special classes in food selection, which were conducted by the home economics teacher. Thus the grade teachers were equipped to assume the bulk of the responsibility for the classroom instruction to the children. Following the formal instruction continu- ous help and supervision was given by the home economics teacher. This was made necessary on account of the chang- ing subject-matter and of the large turnover among the grade teachers. The home economics teachers also met the children regularly in order to check the subject-matter that was being given by the teachers and to correct any false impressions. Concomitant with the instruction to the children, the mothers were enrolled in food selection classes so that the homes and the school were working together. Unless the mothers are given information and are given basic principles, we need not expect the results of the edu- 143 cational work carried on in the schools with the children expressed in permanently improved food practices. Such a program will mean adjustments in our present school organization and faculty in order to solve the problem in the most economical and efficient way. It means a new conception on the part of school administrators and of many teachers as to the function of the home economics teacher and it also means that many home economics teachers now in service must get supplementary training, which will equip them to assume their new responsibility and fit into a unified health program. Home economics teachers must appreciate their opportunity and measure up to the privilege that is theirs. I have not mentioned the other specialists now in our schools, and the relation of the home economics teachers to them in carrying on this program. I have been speaking only of the nutrition activities. Each specialist has a very definite contribution to make to the health program of the school, but too often each one has worked independently because her relation to the other members of the staff has not been well defined, and the problems in her own special field were so large that she hesitated to raise the difficult organization questions involved in establishing a unified health program, and therefore continued to work alone. About a year ago Secretary Wallace announced that a Bureau of Home Economics would be established in the Department of Agriculture, to give to the women of the country the same kind of service that has been given to the farmers through the Department of Agriculture. A fortnight ago Secretary Wallace called to Washington a group of the leaders in home economics to discuss plans for the establishment of this Bureau, and also the divisions of work that should be undertaken. I have been given permis- sion by the Secretary to give you the tentative plans. There will be six major divisions: (1) Food and nutrition; (2) economics and sociology; (3) eugenics, under which will be included child care; (4) equipment; (5) clothing and tex- tiles; (6) art. The Bureau will be concerned with the problems of the home-maker and will be directed by a woman trained in home economics. It will provide an opportunity to conduct research which will be directly applicable to the problems 144 of the home, and will make a real contribution to the im- provement of child life. Home economics departments in normal schools, colleges and universities are developing courses with more extensive and intensive supervised field work, so that their graduates will be better equipped to carry their share of the respon- sibility in the Health Education program in the home, school and the community. Only through the universal dissemination of knowledge can the health of the indi- vidual and the community be permanently improved. Discussion Louise Stanley, Chief, Bureau of Home Economics, U. S. Department of Agriculture, spoke as follows: Miss Stanley: My discussion is going to be very brief. I want to touch only this one point that has not been fully covered. It seems to me that the contribution that home economics can make to this program is, first, research, original work and interpretation of original work and its application to home economics. Dr. McCollum has told us that he is able, with a number of animals in one room, through modification of their diet, to produce any kind of death that he will. We also see a stimulation of this work in the new Home Economics Bureau, and 1 further want to call to your attention that we did have before the last Congress a bill which would stimulate the home economics service, the Smoot bill, and we hope that that bill will be reintroduced in the next session, either by Mr. Smoot, or through modification of one or another bill, so that we will have available Federal money for this purpose. And I hope that this may be used in connection with this department in which we are now having home economics people trained. The second point is the fact that home economics has a service to perform in the dissemination of information in regard to health. I want to emphasize the need of classes for adult women, and the fact that in vocational education work we are given money which may be used for this instruction of adult women. Also, there is another bill which has been for the past three years before Congress, which gives an increased appropriation for this purpose, the so-called Fess bill. We hope to have that reintroduced and passed in the next Con- gress. That will give us increased money for teaching home eco- nomics in schools, one-third of which must be used in the instruction of adult women. The value of the extension worker has been touched upon, and I shall not go back to it; but I do want to emphasize the importance of women trained in home economics, in journalism and in commercial enterprises. One nutrition worker was quoted in the morning paper as saying: "The main thing is to understand food 145 calories. Twenty thousand calories a day is the maintenance at present weight diet. To reduce cut the number of calories to 1,000." Now, the press is of great value in getting out these health facts to the people, and we must have trained home economics women going into journalism if we are going to get these facts out. My third point is that the home economics people have a big job to do in the training of health workers. We have discussed the train- ing of the nutrition worker. I think we home economics people have something to contribute to the training of the other health workers. All the new economics people in their training should be trained in such a way that they get this proper point of view, that their work is not confined to the classroom, but that they are putting over a health program, and we must give them that point of view. And it seems to me that we need to contribute more than we have up to the present time to the training of the social workers, not only of our own social workers, but of the graded school teachers, the nurses and the medical men. I was very much delighted at the Medical Association yesterday to hear a physician say that they had to pay more attention to diet, that at the present time the lay person knew about as much about diet as most physicians, and they were going to fall behind if they didn't learn more about dietetics. Better health, mental, moral and physical, is the aim of the home economics program, and this work centers in the home. We ask the aid of the groups here in promoting our aim, and your sympathy in promoting our work in the period of its greatest growth. We need and want your help in directing this program along health lines. You know where we are failing to give you the help you wish and how we can help you most. We stand ready, as home economics people, to carry on our part of the program, and we call upon you and ask you to call upon us when we can help you. The resolutions prepared by the committee and later adopted by the Plenary Session, will be found on page 343. Part V THE RELATION OF PHYSICIANS AND DEN- TISTS TO HEALTH EDUCATION DR. WOOD announced that the first business of this important session was the appointment of the com- mittee which would draw up resolutions for the Plenary Session, based upon the discussion of the day. After this was done Dr. Wood turned the direction of the meeting over to Dr. Richard A. Bolt, Director of Medical Service of the American Child Health Association, who had arranged the program. Dr. Bolt at once introduced Dr. Harold K. Faber, Professor of Pediatrics, Stanford Uni- versity Medical School, to discuss from the standpoint of the pediatrist The Contribution Physicians Have to Offer to Health Education Dr. Faber: ANY proper program of Health Education must embody two interdependent functions, one educational, the other medical. The purpose of the first of these is to transfer into conduct the principles of healthful living, the second is to remove the obstacles in the way of healthful living. It is obvious to the unbiassed observer that man's battle against disease and unfavorable environment in general is and will indefinitely continue to be active and unceasing, that casualties will occur and must be cared for and that it is the physician who must meet this problem. It is in the recognition of the potentialities of foresight, not only in prevention of disease but in its early diagnosis and treat- ment, that the great advances and improvements in public health of recent years have been attained-marking a changing attitude of hopefulness toward the health of future generations. There has at times been noticeable in the more optimistic a tendency to regard the battle as practically won, to consider that healthful living alone will 146 147 insure health. This is unhappily not true. Battles were never won by underestimating the enemy. It is the physician's task-unpopular at times-to gauge the enemy's strength and to study his attack. In the Health Educational movement the physician, and particularly the pediatrist, has two chief functions and means of usefulness. The first and more general one is to advise and direct the content of the teaching program in so far as it deals with matters of physical welfare. It is his expert knowledge and experience on which a sound superstructure of instruction can only be built. This should apply not only to the initial program but to its whole course of expansion, development and inevitable alterations. Con- stant medical supervision is and will be needed to prevent faddism and faults of emphasis and to make available to the teacher at the earliest moment new discoveries and im- provements or changes in medical science. Unnecessary and harmful to the attainment of the ultimate object of improving the health and happiness of the community through the child is the too frequent antagonism between Departments of Health and Departments of Education. No program will be successful which does not build on a firm foundation of co-operation between these two primary agencies so largely in control of the lives of children. Such co-operation is and should be a matter of spirit rather than of machinery-a spirit of willingness and eagerness to work together towards a common end. In San Francisco a joint committee of the Board of Health and the Board of Educa- tion, formed a year or so ago to discuss common problems and formulate recommendations, provided not only a symbol of the desired spirit of co-operation but a practical means of solving the problem. The second and more particular function of the physi- cian in detecting, eradicating and preventing disease also calls for the closest co-operation with the educator and her associates. The prime essential of effective control of dis- ease is its early recognition, and here the teacher is in a peculiarly advantageous and responsible position. In daily continuous contact with her charges, familiar as she is with their usual and normal behavior, she can better than any one else, excepting perhaps the parents, detect at the earliest moment those deviations from the normal which are the first indications of disease. 148 It is through the alertness of the teacher in this respect and from the story told by the scales and measuring tape that the physician can make a great contribution to the health of childhood. It is here that he must be used. The observing teacher or school nurse can note the outstanding symptoms of faulty vision, impaired hearing, of postural defect, of adenoids, of severe anemia, of St. Vitus dance, of lameness, of heart disease, of diabetes, of epilepsy, of feeble- mindedness, of incipient tuberculosis, of insanity. She may well realize the possible seriousness of the symptoms, but it is only the physician who can interpret them truly, for symptoms themselves may mean little or much. Faulty vis- ion may mean slight deformities of the lens of the eye, or it may mean congenital syphilis; deafness may be due to accumulation of wax or to middle ear infection; postural defects may come from the need of glasses or from in- fantile paralysis of the trunk muscles; a child may make faces from imitation or habit or from a serious rheumatic infection associated with severe heart disease; he may limp because he has a nail in his shoe or because he has tuber- culosis of the hip joint; he may have fits of absentminded- ness because he is putting up a radio set at home or because he has incipient epilepsy; he may be dull because he is deaf or because he has a defective brain. Finally, to consider the most common and generally recognizable symptom of disease or disorder, malnutrition, children may be underweight or pathologically malnour- ished for an enormous number of diverse reasons, ranging from incorrect habits to the most severe chronic disease. While the correct diagnosis in any individual case of any of these conditions calls upon the knowledge and investiga- tive resources of all the auxiliary agencies-teacher, nutri- tion worker, visiting nurse-the final burden rests squarely on the doctor. He alone has the skill, experience, trained scientific accuracy and judgment which correct diagnosis, so vitally important to the child, demands. This leads me to the statement with which I think every fair-minded per- son will agree, that every child with whom there is some- thing wrong that indicates the possibility of disease should at once have a careful and most thorough physical examina- tion, with such of the laboratory aids to diagnosis as may be advisable in his case. There is too much unintelligent opposition to this in the minds of the lay public. It is often 149 looked upon as something to be avoided instead of as a valuable privilege. At present in this city it is difficult for school physicians to accomplish more than a visual in- spection, with auscultation through the clothes. No proper and complete examination can be made without the clothes removed to the waist, but there is no valid reason why this cannot be done with all consideration for modesty and pro- priety in the school when necessary, and of course in the doctor's office or in the clinic. Parents readily give their consent when the thing is explained or taken as a matter of course. The good that can be so accomplished is truly enormous, and the effectiveness of the physician for good is certainly quadrupled. Further than this the physician can perhaps make his greatest contribution to a child health program when the public is educated to the need of having children examined regularly once, or better twice a year, even in the absence of symptoms of disease. Many mothers bring their babies to the doctor regularly for inspection and health advice, and school children receive at least a certain amount of atten- tion, but in the ages between, very little is done, with the result that large numbers of children enter school at the age of six with various defects, many far advanced. The public does more in this sort of prevention dentally than medically, which may at least be taken as a sign of what can be accomplished by the proper sort of education. The truth is that the public has the fear of medical ex- amination which is born of ignorance, that this ignorance can be overcome by education and that when it is overcome the physician will be free to make the contribution to health which is now within his powers. The place to overcome it is largely in the schools, where the coming generation is being given its ideas and ideals, and this is to my mind one of the great services to the common weal which Health Education can perform. The Chairman: There is none whom I would rather introduce to present another phase of this topic than the distinguished admin- istrator and teacher, Dr. Haven Emerson, Professor of Public Health Administration, Columbia University. 150 The School Physician Dr. Haven Emerson: LADIES and gentlemen: After hearing Dr. Faber's de- scription of the services of physicians or what they are capable of doing, there is little that one can say except to emphasize those points in which one is particularly in- terested. If I were to sum up what I believe to be the chief con- tributions of the physician in the care of children of school age, I would say it was honesty and accuracy. Lacking those two things, our whole school health program becomes a farce, and brings into disrepute the medical profession which is called upon to give the final answer as to the rela- tive importance of physical findings among the children brought before them. We require honesty of opinion, based upon facts, not upon generalities. Do you realize that if you accepted from physicians the kind of care in sickness which you tolerate in much of the so-called health work you would get nothing but generali- ties in treatment? When you are sick you do not want to be treated as one of the statistical majority, but as an in- dividual, and you cannot treat children as the sum of an age group, but as individual personalities, and that is in- compatible with sloppy, superficial medical service to the child. Observations upon healthy children should be as carefully controlled as upon those in sickness. We support the diagnosis of sickness by a variety of exact methods of verification. In health work we are apt to take it for granted that anybody who holds his head up high and has a good appearance is healthy, and we accept his own per- sonal estimate of his health, regardless of the facts as shown by medical examination. We should demand hon- esty in opinions and accuracy in observations. The physician can give the personal point of view to help education by individual medical examinations. Peo- ple need to be taught individually how to keep well, because there are a great variety of ways of being healthy. There is no one way of being healthy. There is no one kind of diet or exercise or medicine for health which is effective or perfect for all people. There is general agreement as to certain elementary principles; but health is in part a mat- 151 ter of personal attainment and not merely the result of general dispensation. Another thing that the physician can give is the balanced judgment which a background of many human lives provides him with. The physician has seen so many people, his patients, recover spontaneously without the specific aid of treatment, that he has learned to trust the powers of nature in accomplishing health, and he is less ready to insist upon any panacea of food, or habit or exercise than many of the people who wish to use him in school medical work. The physician knows from experi- ence of the way people will recover from sickness how thev can individually accomplish their health. Physicians have been steeped in sickness up to the present time almost ex- clusively. They have been saturated with symptoms, and they have learned the relative significance of things which, as Dr. Faber says, the average observer might overlook, things that are merely indices calling our attention to the contents, like labels on bottles. The physician knows the labels, and is familiar with the many kinds of normal, the wide range of health performance. We have gone far in these last few years of our experi- ence in nutrition. It was not many years ago when we felt that the scales and the measuring tape were conclusive. After we determined the difference between good and bad nutrition, we set a sharp and narrow line below which a person must be considered a pathological specimen, if he did not attain a certain standard of weight. Now we find that is not a line, but a zone, and there is a range of normal above and below the line within which we may consider that a person is not necessarily abnormal or needing cor- rection. The physician is, on the whole, providing the com- munity a reasonable balance wheel. He provides a margin of safety in public opinion, so that individuals with slight variations from the average will not be considered neces- sarily abnormal. May I discuss the question of the periodic examination of the school child. There are rarely made in the United States, anywhere, complete, accurate, honest, thorough medical examinations of the school child. We have a multi- tude of school inspections. We have a great number of records of inspections, "once over above the collar." We have developed infinite ingenuity in searching for the pedi- culus capitis. We are familiar with the official portraiture 152 of the child which does not betray the functional capacity of the heart at rest and after exercise. Our examinations rarely reveal the nervous reflexes and the capacity of a child to tolerate a variety of helter-skelter diet thrown in at home or abroad. We are constantly accepting, in place of a medical examination with accurate record, the super- ficial glimpse of the child above the neck. Admitting all the value of such inspections, with all the amount of work put upon them, we have not begun to detect the real child beneath the shirt. The conversation that is commonly car- ried out when parents come to a school with the child is somewhat as follows: The physician says to the mother, "Will you take the child's clothing off?" And she says, "Oh, do I have to take its clothing off?" "Yes. Has the child ever been exam- ined?" "Oh, no." "Has the child ever had any sickness?" "Oh, no; the child had measles and bronchitis and whooping cough, and the itch, and perhaps it had poison ivy, or some- thing of that kind." "The child has never been examined?" "No, it has never been examined." "Well, wouldn't you like to have it examined?" "Well, if you think it is neces- sary, all right." So, you do think it is necessary, right then, and this cheerful little child is stripped, and you find out what there is to him. You at once enter into a perfectly honest relationship with the mother and with the child, and there will be no uncertainty as to what that mother will expect when a medical examination is offered on other occasions. But how can a doctor responsible for 9,000 school chil- dren give a thorough examination to each? What would would you do to a physician who had 9,000 cases of typhoid fever to take care of, and who walked through the hospital wards, patting them lightly on the head as he walked by? You would be inclined to hang that man, deny him his license to practice, force him out of the practice of medi- cine. That kind of man would make more blunders in five minutes than could be cured in a lifetime. You are per- mitting our childhood to be handled just that way. Hon- esty, accuracy, and thoroughness must enter the examina- tion of the child. You are not examining a dry goods stand. You are interested, not in the clothes, but the child that carries them, and you cannot do it through the clothes. The physician must become the director of research in 153 health and its attainment. That is another of his contribu- tions. He should be the person who knows the relative value of the lines of study which must be generally prose- cuted by the teacher or nurse. He is likely to be able to give you methods for such research, and to analyze the relative importance of the different facts and elements of truth which you will begin to accumulate. He is a source of information for those who do the teaching, the parents, the teacher and the nurse. His business may be said to be to teach the teacher in the particular professional work for which he is asking her to take over the responsibility. It is impossible to reach all the school population through the spoken word of the physician. They are rarely gifted or trained as teachers, and they know little or nothing of the psychology of education. They are students of the human body and its functions, and they can give the facts, but the interpretation of those facts to the children will have to be carried by the teachers. There are three situations in which the physician finds himself essential. First, he is a practitioner of medicine, and may I say that, perhaps the greatest contribution that can be made to the health of the school child would be to have every practitioner of medicine make himself per- sonally responsible for the detection and removal of de- fects of all the children in families which come under his private care. Until that is done, we are not going to handle our project. We are doing the stop-gap work at the schools which should have been done before the children came to school. It is just as much the duty of the parents to pro- vide this service for the child as to provide it with shoes and bread and milk. Until every practitioner of medicine considers himself as much responsible for the health of the children that are brought to him as he is now held to be for the specific treatment of disease, we shall not make use of the real function of the physician. As the practi- tioner of medicine, the physician's greatest contribution is truly the direction of the health of children in the families to which he is called. The next function he serves is that of the health officer, and here, in addition to his technical knowledge as a physician, he must bring in two other important relation- ships, his services to make liaison between the practitioners of medicine and the administration of the government, city 154 or state, and to make liaison between the Department of Health and the Department of Education. As a health of- ficer, perhaps the most important function is to see that there is a difference neither of opinion nor of policy with regard to the service for the child, regardless of who is paying the bill or what is the administrative authority which directs the service. As a school medical inspector, whether under the Department of Health or Board of Edu- cation, the physician must use first and always his ability as a diagnostician. There are a great many kinds of peo- ple who have faith that they can treat disease, but there is only one group of persons in the community who are edu- cated to detect disease and to distinguish between it and health, and these are the physicians. They are the best trained persons whom we have developed up to the present time, to detect the difference between disease and health, and to distinguish between one disease and another. Train- ing in diagnosis is the chief distinguishing quality of the physician which cannot be claimed honestly by other peo- ple. I believe that treatment should only be done after diagnosis; but we cannot deny people the right to try on themselves any kind of treatment they choose. Diagnosis for themselves they cannot accomplish. Thirdly, as teachers of hygiene, physicians are becom- ing continually more helpful and more necessary. School systems are finding the advantage of combining with physi- ology some familiarity with preventable disease in those who are to teach hygiene. I do not deny that hygiene can be taught, and taught accurately, by people who are not physicians; but I believe that a greater depth of un- derstanding, and a greater fullness of experience in the teachers of hygiene are to be demanded in the future, and that these will chiefly come through medical training and experience. Another function of the physician of the medical school is to prepare physicians for school medical inspection work. It is time that we began to consider this a sufficiently im- portant specialty in medicine to justify our trying to pre- pare physicians for this task. At the request of the State Department of Education in New York, and with the co- operation of several physicians who are engaged in school medical inspection, we mean to start this summer at Co- lumbia University a class of physicians who wish to learn 155 the theory, principles and practice of school medical service on a scientific basis. I do not consider that a physician is doing honestly when he has ten times the patients he can serve honestly. If in the medical inspection the physician takes three times as many minutes as he does now for each child, and only examines one-third the number, he will prob- ably be serving the community better. If we have a com- munity with ten schools, and one-tenth the amount of medi- cal service that is required, I believe it is good policy to have the physician who may be employed spend all his time on one school, and do that well, rather than to spread his services so thinly that every school has a superficial, incom- plete service. Well, you say, for political reasons that can- not be accomplished. The taxpayers pay for the inspection, and that must be spread equally among all the school chil- dren. Are we talking in terms of medicine, and of honesty and service, or of compromise and opportunism? I think that the greatest contribution of the medical pro- fession will be the decision that they will be honest and thorough and accurate in health work as in the care of the sick. Discussion Dr. John Foote, of Washington, D. C., said, in relation to the f oregoing addresses: We hear much today of the attention and appropriations given to animal industry as compared with the amount of money provided for the health and education of the child. We have heard these claims for centuries but have paid little attention until modern times. The evolution of the care of the child in the school has followed the lines of health teaching generally. First came the period of quarantine to prevent the spread of communicable diseases in the community. In the past, emphasis has been laid on diseases, and, as this came first in the minds of those having to do with school hygiene in its early days, this idea prevailed. In the minds of many the con- trol of contagious diseases appeared more important than constructive health. It is very difficult to substitute in the minds of the people the standards of health maintenance or the positive idea of health. Physical education has helped to sell the positive idea of health. Much difficulty has been encountered in interesting the proper type of man in health work, because if he does his work well he is doing it at a very great sacrifice. I do not think that we need to be alto- gether pessimistic about this. Health teaching is coming into the medical schools. For example, the University of Pittsburgh and Yale University are doing a great deal of their teaching in the dispensary and the health center. When a new generation of men come from 156 such medical schools, is it not possible that the necessity for medical inspection in the school will be made less urgent and the medical man will periodically examine his well patients in his office or at dis- pensaries? The Chairman at this point asked Dr. McCollum if he would elucidate the position he took regarding the physical examination of children in the session on nutrition. Dr. McCollum: Dr. Emerson has said what I want to say, and better than I will probably be able to say it. I will simply add that I want to reiterate the fairness and truth of the statement which I made, that the medical examination of the school children as ordinarily carried out is a farce. We might just as well face the situation squarely and admit it. Now if we are going to do anything that is worth while along the lines of carrying out the program that you discussed here this morn- ing we must remedy that defect. We can do that in one of two ways. The medical profession may see its opportunity and accept its obliga- tion to see to it that this work is done as it should be done. Other- wise, somebody else is going to do it. There is an opportunity for the medical profession to learn about scientific nutrition. It does not in general at present understand that subject. It is a relatively new subject. There are a few physicians who are well informed in it, and there are a considerable number who are trying to learn, and who will learn very rapidly. We must understand and appreciate that there are young women with about the kind of education we want, who have come out of courses of home economics in the last decade. These young women are perfectly capable of doing this work, and it seems a sound policy to have them take it up. Now, just a word about the stethoscope. Apparently if I had not mentioned that I would have fared pretty well with the rest of my talk. What I had in mind was this: A good many physical trainers are people of limited educational experience. There was a strong tendency twenty years ago, and I was the innocent victim of what I am now talking about, to believe that the way to build up anybody who was in poor condition was to give exercises. But little judgment was exhibited in regard to the kind and amount and the strenuous- ness of the exercises that were given to various children. There is much improvement in that situation in recent years, but I do think there is still great room for further progress along that line. The thing I had in mind when I unfortunately talked about the stethoscope was this: You will recall that I said that we can have a group of young women nutrition experts who are thoroughly competent to make a physical examination up to a certain point. If you will look at the stenographer's report you will find that I said somewhere that at a certain point the child was to be turned over to a physician. I said that the nutrition worker was not to replace the physician, but to supplement and extend the work of the physician. I do not wish to antagonize the medical profession. I work with them, and I have a great many friends among them. I think very highly of the medical profession, but I do think that wherever the profession is 157 failing to live up to a very important obligation in respect to medical examinations in the schools it is time for someone to say something like my remark about the stethoscope, which makes them think, and which will ultimately lead to discussion and a solution of this problem. The discussion was closed by Dr. William Palmer Lucas, of the University of California, who said: As Dr. Emerson noted, we are coming to find that the normal is a zone. Now that zone of normality is one of the most important things, and one in which the physician is interested, in finding out what a normal child is. We need the assistance of accurate, honest observation by those who see the child day after day. I would like to know how many physical educators, how many teachers there are who feel that they are competent to make accurate observation. If you will just try this year to make accurate observations of the functional capacity of what you think your normal children are you will bring a great deal of data which will be of tremendous value, if properly gathered together. There is no division of ideas or ideals between the medical profes- sion and those who are teaching. We are all working together, and what we want in this particular study is to know what the normal is, and the one thing that is lacking today is a knowledge of what that zone of normality really is. We have got to know that there is no single line of weight and age. We know that it varies with your height and with other factors that make that zone wider or narrower for different types of individuals. Another thing is the function of the heart. How many of us know what the normal function of the heart is during the growing period? I doubt if many physiologists could tell us that. And if, as Dr McCollum says, there are only a few American physicians prac- ticing medicine that know nutrition so as to feed their patients prop- erly, I doubt if there are three medical men in this country who know the norm of the heart. Once I thought I knew something about normality, but now I am sure I don't, and what we want is some assistance from you who have the daily observation of the child. No further comments being offered on this topic, the next subject for discussion was introduced. The Chairman: It is with very great pleasure that I present Dr. Guy Millberry, Dean, Dental Department, University of Cali- fornia, San Francisco, who will discuss The Contribution of the Dentist to the Health Education Program Dr. Millberry: IN submitting a title for this paper, Dr. Richard A. Bolt was kind enough to suggest sub-topics which the essayist appreciates and hopes you will too, for it limits the dis- 158 cussion to pertinent things and may thus register a definite impression. The sub-topics embrace (1) training the dentists in mouth hygiene; (2) the relation of nutrition to the teeth; (3) health habits, particularly those related to mouth hygiene. There is a tendency in all fields of health activity for specialists to lay stress on the importance of their problem. Dentistry offers no exception to this tendency. Dentistry has been silently, diligently absorbing the general health point of view, and it has been practicing a form of individual health activity, namely, the prevention of dental disorders by consultation and advice before pro- fessional service is required. In addition, dentistry has un- hesitatingly trespassed the sacred field of medicine by daring to study biochemistry and discuss diet and nutrition with patients, and has encroached on the field of public health by incursions into the subjects of personal hygiene and public sanitation. Pressed on the one hand by those who believe that the art of dentistry in repairing and replacing lost teeth or parts thereof is most important, and on the other by those who believe that pathology is the basis of all scientific den- tistry and surgery is the only cure, the dentist who believes that the simple and desirable procedure is preventing the conditions which require the service of the above groups, finds little solace in his profession and much support from the public. Training the dentist in mouth hygiene is one phase of this problem. We have modified our courses of instruction from the ancient practice of cleaning teeth to the modern procedure of mouth hygiene, periodontia and prophylaxis, with perhaps an unfortunate economic result, the specialty of treating pyorrhea. Modern concepts of teaching mouth hygiene demand that everything shall be done in preventive and restorative dentistry which will establish normal function of the teeth, mouth and jaws, so that the natural methods of cleansing the teeth by the excursion of fibrous foods over the surfaces in mastication shall be effective. Recently a course in general hygiene has been added to the curriculum in dental schools, and, surprising as it may seem, it is necessary, for many of the matriculants have 159 little knowledge of personal hygiene, especially the care of the hands, those potent carriers of infection in any walk of life. The next step in teaching mouth hygiene in dentistry was the introduction of the course of instruction for the dental hygienist. In the University of California we urge the adoption of school or institutional hygiene service for children, as a vocation for dental hygienists rather than civil practice service in private offices. The relation of nutrition to the teeth is a simple ques- tion in that we know that the teeth receive their structural elements from the blood stream both during foetal life and after birth, for the teeth begin to develop about the tenth week of pregnancy; and it is a very complex question in that we do not know what chemical processes are going on within the body by means of which the various cells are able to abstract from the blood stream, or lymph, the necessary chemical compounds or elements that are required to con- struct enamel, dentine, cementum, peridental membrane and pulp. No less than five different types of cells, each with a special function, are concerned with the development of a single tooth, and when we realize that the only known place where we find fluorine in the body is in the enamel of the teeth, we appreciate the wonderful selective properties which these small units in our economy possess. The element, calcium, of course, plays an important part in tooth development, though its utilization in the body is not well understood. Members of our own profession and of the medical pro- fession have protested that we have no business engaging in the study of diet and nutrition. We believe, however, that it is essential to learn of the character, quantity and utilization of food so that we may intelligently advise our patients and, therefore, render a better service to human kind. We have been told by Dr. McCollum that very slight modification in diet may seriously affect the developing teeth, and we have proven the truth of this statement by animal experimentation here. Formerly we believed that all pitted and deformed teeth, except Hutchisonian teeth, were caused by skin diseases acquired in early childhood. Now, we are convinced that dietary deficiencies are quite likely to be the cause. Also, we should remember that leafy 160 and fibrous foods are stimulating to the mechanical act of mastication and aid in cleansing the teeth, that fruit stimulates the salivary flow, that fresh milk is always good, and that starches and sweets are detrimental to the teeth, especially if eaten between meals. Health habits in mouth hygiene should be inculcated very early in childhood, so early that before the child knows it he has become an addict. Simple methods of brushing the first teeth, as early as the first year, are commendable, using a small, soft brush and, if bribery is necessary, a small amount of palatable tooth paste. Regularity as to time and thoroughness as to procedure are essential, and, of course, the home is the place of primary instruction. In the absence of home instruction, the next best point of attack is in the schools, beginning with the primary grades. Where this is efficiently carried on by a well trained corps of dental hygienists and supervisors remark- able results have been achieved. Latest reports from Bridgeport, Connecticut, show that every child in the public schools was promoted from the fifth to the sixth grade, where in the past an average of forty per cent of retarda- tions was not uncommon. In a school in McDowell county, West Virginia, where 250 pupils are enrolled and mouth hygiene has been taught and practiced for ten years, there has not been a single retardation in six years and many chil- dren have jumped grades. This is the economic form of evidence we use in inducing school and other civil officials to adopt a program of health activity that carries with it mouth hygiene. In California most of the public health officials are anxious to introduce a mouth hygiene program into the schools because it permits them to carry on other forms of health activity that might otherwise be objected to. The older graduate in dentistry, with few exceptions, is unconcerned with any public health program. The younger graduate has been trained in the particular phases of health activity that the dentist is fitted for, and in addition is asked to participate in this phase of civic life. We are anxious to become a responsible part of the great public health movement and to contribute our share of this civic work. 161 Discussion The Chairman: The discussion of Dr. Millberry's very valuable paper will be opened by Dr. W. M. Cameron, University of Cali- fornia, College of Dentistry, San Francisco. Dr. Cameron: Research work by dentists has shown that the causes of the two principal diseases of the mouth are complex and associated with nutrition and metabolism, and therefore the control must come through education in relation to diet and hygiene. The question arises, "What are the dentists doing to educate the children?" It is hopeless to wait for the children to come to the dentist, so the dentist must go to the children. I believe that we should have com- pulsory health as well as compulsory education, and that as dental service is required by so nearly 100 per cent of the children, it could be given better and more economically at public expense than it is at present. More children are affected dentally than by all other dis- eases combined. The necessity for prevention is obvious. One plan is to build large monumental institutions where children are brought from the schools and treated by a staff of operators under supervision. They are the poor children unable to pay in the usual way, selected by the school nurses and social workers. The children's teeth are repaired and they are dismissed, only to return after a period with another crop of cavities. They are instructed to clean their teeth, but without regular, systematic training not much can be hoped for as to health habits. This is a laudable activity but not radically preventive. Then there is the school clinic which is organized in cities and towns all over the country. The dentists began by giving voluntary service, then some school boards were convinced of the necessity and voted funds to maintain a clinic. Sometimes a school dental clinic is maintained by local charitable and philanthropic organizations. Occasionally it is an activity of a Board of Health. This is more constructive, as the dentists and hygienists so employed do a great deal of lecturing and training both in the school and at meetings of the parents. As Dr. Millberry indicated, we are developing a supplementary profession in dentistry as nursing was developed in the medical profession-a trained assistant whose business it is to put the mouth of the patient in a sanitary condition so that our operative procedures may be carried out to the best advantage, and also that the patient may not be so likely to have recurrence of decay. This person is always a young woman and she is doing a splendid service for the children. She frequently works in the schools and institutions and besides doing operative work she trains the children in the care of the teeth, and so is able to accomplish an educational result. In Bridgeport, where hygienists have been at work in the schools for eight years, they have produced a remarkable result not only in 162 reducing dental disorders, but have also reduced the incidence of other children's diseases such as measles and whooping cough. When we have accomplished clean mouths in our school children we shall have taken a long step forward in health education. Dr. Nobbs, Chief Instructor, Clinical Dentistry, Uni- versity of California, College of Dentistry, San Francisco, continued the discussion, thus: I am glad that the dentist is joining his fellow workers in the child health program. We believe that he can make an important contribution. In dental education one of our principal objectives is to prepare our students as active workers in their community, along the lines of disease prevention and health promotion. We also want our students to appreciate the necessity for both the individual and the community disease prevention and control. I wish to emphasize the importance of dental service to the health of the pre-school child. Dental hygiene and correction of dental disorders must play an important part in the program of prevention during the pre-school age. The age group five to six years represents the time of greatest mass assault upon the first teeth and is therefore a critical time in the development of the child's teeth. The consideration of this topic was continued by Dr. John E. Gurley, Assistant Professor of Chemistry, Uni- versity of California Dental School, who said: The child's development should be threefold, mind, body and spirit. In the attention to the body, of which the teeth are a very positive part, digestion is of great importance. The teeth play a prominent part in this process, and should receive in very early life especially regular attention by the dentist. Abscessed teeth are often difficult of diagnosis and are intimately related as a focal infection point with the physiology of the body. In prevention and repair the dentist has a place of responsibility among those who are working for better health among children. The successful dentist must realize his oppor- tunity to broaden the child's understanding and win his confidence. The dentist who serves children must win their friendship. Dr. Emerson said in further discussion: We are much indebted to the vision of the dental profession, which has carried them beyond stopping holes in rotten teeth to the program of creating healthy mouths. I believe that it would be unsafe, however, for us to accept as a conclusion that all children can pass their grade in school if they have good dental care. Expe- rience in schools in the United States makes it fairly clear that there are some children who are incapable of carrying the grade regardless of the fact that they have no twisted back or diseased teeth. There is no evidence at present that the distribution, incidence or death rate from measles, scarlet fever or any other communicable disease of childhood has been in any material way modified by a denial cam- paign, during the period of the astonishing results which we have 163 heard quoted. During the same period there has been the introduction of the pasteurization of milk, the persistent campaign for the removal of diseased tonsils and other focal points, general school inspection, and aroused public opinion for the general health of the child. To attribute to any one factor such as a campaign for dental improve- ment alone the change in incidence or mortality would lead us to erroneous conclusions. The knowledge of the effect of prenatal nutri- tion upon the teeth of the child is perhaps the greatest benefit that we have got from the involvement of the dentist in this great move- ment. The third division of the subject under discussion was that of the practicable using by the school of the service and thought contributions, proffered by the technical assistants just described. The Chairman, therefore, continued the meeting, saying: "It is a great pleasure for me to intro- duce Dr. John M. Dodson, Dean, Rush Medical College, Uni- versity of Chicago, who will present the practical topic How the School Can Best Use Professional Health Workers Dr. Dodson: THE health program in the schools rather naturally divides itself into three parts-the environment, the physical condition, and training and education for health of the school children. The environment, by which is meant the location, structure and care of the school buildings and grounds, is so obviously of importance that there is no dis- agreement about it. Our numerous unsanitary school- houses, especially in the rural districts, have resulted from ignorance, thoughtlessness or niggardly economy, and not because anyone would for a moment undertake a defense of such conditions. Even those who are not sympathetic with the advancement of modern medicine are either convinced or are readily persuaded of the necessity of providing a healthy, clean, sanitary environment for school children. When we come, on the other hand, to the discussion of the physical condition of school children and the importance of their physical examination for the detection of hamper- ing defects, the opinion is not so unanimous. There are still a considerable number of people who object to having their children subjected to physical examination of any sort, or to the correction of these hampering defects. Such physi- cal examination has for its object the accomplishment of two ends: 164 1. The detection of any child who might be a source of contagion to others because of recent illness from a communicable disease, or because he chances to be a carrier of such disease. 2. The discovery of hampering defects such as of vision, hearing, speech, locomotion or otherwise. Little or no objection is now made to the examination of school children for the first purpose. Whatever views one may entertain as to the causes and cure of diseases or de- fects of the body, the majority of the people have legislated in positive terms to the effect that children with communi- cable disease shall not be permitted to attend school, and there is little disposition to resist conformity with the laws and ordinances regulating these matters. Concerning the hampering physical defects, three steps are involved: First, the physical examination of the school children in order to detect such defects; second, the correc- tion of those which are found to be remediable; third, the provision for the teaching of children with defects which cannot be remedied, by methods especially adapted to their condition. It is evident that the differences of opinion, as to what should be done about such defects, are only differ- ences in degree and not in kind. No one questions the necessity of providing special schools for the blind, for the deaf, for the hopelessly crippled and for certain types of those who are mentally subnormal. If it were possible to restore sight to one totally blind, surely everyone would re- joice no matter what his views of scientific medicine might be. It is only in the case of lesser degrees of impairment of vision which can be remedied by treatment, surgical or otherwise, that differences of opinion arise. Every child has the right to demand that his school life be conducted with the greatest possible freedom from annoying, hamper- ing physical defects. If he be crippled so as to interfere with his running and playing like other children, it is his right to demand that his deformity be repaired in any way possible, and that he be made as nearly like normal children as the various medical and surgical resources can make him. Happily, in many such cases, his club feet, bow legs, curved spine, or what not, can be so completely corrected as to make him like normal children. It would, indeed, be an in- human, heartless group of school officials who would deny him this right. Needless to say, the correction of any or all physical defects and deformities is primarily the duty of parents and should be attended to before the child enters 165 school at all. In many cases, however, parents are unequal to the expense of the necessary treatment, and where such is the case, it is the duty of the school officials, in the in- terests of all concerned, to see that such defects are cor- rected if the consent of parents can be secured. The individual who first detects the presence of the minor or less obvious defects is the school physician, the school nurse, or the teacher. As to which of these is most competent to detect physical defects, when they are of slight degree, and especially when they are situated within the body, there can be no room for doubt. Only one who is thoroughly trained in the medical branches and has had con- siderable experience in the examination of human beings is really competent to examine school children for this pur- pose. However, until such time as school physicians are provided for this work in all schools, no matter where located, it will be necessary to rely on the less highly trained school nurse, and even in many places on the teacher. Where it is possible to obtain the appointment of school physicians for this work, they should be employed in prefer- ence to all other persons. Certain conditions are indispen- sable to securing the best results: 1. The physician should have had special training in the methods of examining school children who are apparently well. 2. While a physician needs a certain amount of special training for this type of work, it is not well that he should devote his time exclusively to the duties of a school physician. He will be a better examiner of the well child if he is in more or less constant touch with illness in the sick child. He is, in other words, a general practitioner, or perhaps one who is giving his attention exclusively to practice among children. This does not apply to the physician-in-chief of a large school whose administration duties demand his full time. 3. Physical examinations, both for the purpose of detecting com- municable disease and physical defects, should be completed in the case of every child in the school as soon as possible after the opening of each session, following a vacation of any length. To delay such examinations beyond the first three or four days (with the children carefully segregated during this interval) is to nullify their results in large part. It takes but a very brief association with others for a child who has been recently ill with some one of the contagious dis- eases, or is still a carrier of a disease like diphtheria, to convey the disease to other children; or again, hampering defects, such as vision, hearing, or crippling of any sort, may interfere with the child's progress in school to such an extent that even a brief delay in arriving at a diagnosis and correcting a defect may result in a child's being so retarded in the beginning of his school work as to be unable later to catch up with the class. Every school physician, 166 therefore, should have a sufficient number of assistant physicians to enable him to complete a reasonably careful examination of each child in the schools assigned to him within a week. 4. On the other hand, he should refer certain children to physi- cians with special training and experience. It is not possible for the school physician or general practitioner to be equipped in all of the special lines of practice. For example, while the school physician should be able to determine whether or not a pupil's eyes are defective, the nature and extent of such eye defect can only be determined accu- rately and suitable lenses adjusted by an expert ophthalmologist. In certain cases of deafness only an expert specialist in defects of hearing and diseases of the ear can determine the nature and extent of the trouble and institute the proper measures necessary for its correction. Certain remediable operations, for example, on the tonsils and adenoids and for certain other disorders of the nasal passages, can be properly done only by one who has acquired special skill through limiting his work to this particular line. 5. Careful records must be kept of the physical findings in the case of each child, a record as careful as those which are demanded in practice among the sick. 6. Every school should provide suitable rooms for the conduct of such an examination, including the necessary appliances. Says Dr. S. J. Baker, of New York: "The most important physical examination to be made in the school life of a child is the one occurring at the time the child enters school for the first time. Such an examination should be made before the age of eight or at most ten years. If this can be done with 100 per cent efficiency, combined with a follow-up that is 100 per cent effective, and 100 per cent of proper and corrective treatment obtained, it should not be necessary to make a regular physical examination after the eight or ten period, reliance being placed after that time upon the routine inspection of the children in the classroom. This routine inspection will permit the doctor, nurse or teacher, to pick out cases of physical defects that have been in any way overlooked in the routine physical examination or which have originated after the eight or ten period. An annual test for defective vision is desirable." Great emphasis should be placed hereafter upon the pre- school age period as the time when physical defects should be prevented or corrected. An analysis of the age and sex incidence of physical defects in Dr. Baker's series shows that proper and adequate physical examinations made in the early life of the child are essential, and that if these are properly followed up and suitable treatment obtained, the appropriation for this work will be spent in the most eco- nomical way, the child's health will be most thoroughly protected and future disease and sequelae of physical defects be more adequately guarded against than by any of the present methods of school health supervision. In short, in 167 a properly ordered community in which every parent was awake to the importance of detecting and curing defects in their children at the earliest possible age, these children would be examined and all remediable defects corrected before they presented themselves at school. The work of the school health officer would thereby be greatly lessened. The dentist occupies a position in this work, somewhat different from that of the other specialists, in that while he is called upon to conduct the necessary treatment, he must also make the necessary diagnosis, that is, ascertain whether any of the teeth of the children are in need of at- tention. In the majority of minor dental disturbances only the experienced dentist with his elaborate armamentarium is prepared to detect the minute changes in the teeth, which constitute the beginning of deterioration and decay; and of course, only such person can institute the necessary dental treatment. Such defects may show their beginnings at any time of childhood, and therefore periodic examina- tion of every child by the dentist is necessary if this incipi- ent decay is to be detected and arrested in an early stage. Defects of one sort or another having been discovered by the school physician, what is he to do about it? Ob- viously, the physical examination is of little service unless the defects found are corrected, or if that be impossible, the methods of education adopted for that child be such as to take into consideration his handicapping defects. Wherever these are found to be such as can be remedied by any means whatsoever, steps should be taken to see that the remedy is forthcoming. The cost of the correction of these defects is, of course, no proper charge on the school funds. It should be borne always by the parents of each child. Only in the case of children whose parents are quite unable to defray the ex- pense of the necessary treatment should that expense be borne by the community, and this should be charged against a special fund, provided for that purpose by the community. It is most just and in the best interests of all concerned that, so long as such provision must be made for any children in the community, the cost should be borne by public funds, obtained by taxation. Up to the present time very few communities have made anything like adequate provision for charitable medical service of any sort, and, therefore, private philanthropy has been necessary to supply the need. 168 Charitable dispensaries, or outpatient departments, hos- pitals, special clinics and the like have been established in most of the larger cities, and are prepared to give the neces- sary treatment to school children as they are to afford relief to others of the indigent afflicted. It is better that the schools should utilize these agencies, where they are avail- able, than attempt to organize and maintain clinics for this purpose. The business of treating such remediable defects is not a proper function of the school system. On the other hand, it is, of course, an essential duty of the schools to provide special methods of instruction for the children who are handicapped with defects which can- not be completely remedied. This has long been recognized in the case of certain groups-the blind, the deaf and the subnormal. In the case of other groups-the crippled, the tubercular, the anemic, the supernormal-their need of special schools, teachers and pedagogic methods has only been recognized in recent years, and as yet quite in- adequately. In the smaller cities and rural communities where there are no dispensaries, hospitals or clinics, provision for the correction of remediable defects must be made in some other way. In some of the States, especially in the South, the State Department of Health has solved the problem by pro- viding travelling clinics for defects of teeth, nose, throat, ear and the eye. When these are properly organized, when due care is exercised to render free service only to those who are really indigent, and where the local members of the medical profession are consulted and their approval and co-operation is secured, the plan works admirably. The extension of this plan or of some adequate substitute to all of the other States cannot long be delayed. One item of importance should be emphasized, the serv- ices of the physicians engaged in this work must be ade- quately compensated. It is unjust, and must ultimately work to the disadvantage of all concerned, to impose on the medical profession the task of caring for these patients without pay. Every physician who serves on the staff of a dispensary, hospital or charitable clinic should be paid for his work, a sum proportionate to the amount of time, money and energy which he has had to expend to fit himself for his work, and to the skill required for the particular service rendered. 169 The School Nurse An important branch of public health nursing which has developed rapidly in the last decade, is that of public school nursing. As an adjunct to the school physician, to assist him in his work in the examination of school children and in the operating room, she is all but indispensable. One of her most important functions is the follow-up work in the homes, in securing a betterment of home conditions, in educating the parents to a keener appreciation of the im- portance of health, and in securing a more intelligent and effective co-operation between home and school-parent and teacher. In very many communities, as yet, she is called upon to do much of the work which properly belongs to the school physician, such as the examination of school children to detect contagious disease and hampering de- fects. This is always a makeshift and never a satisfactory solution of the school health problem. The nurse is a very important help to the physician-never an adequate substitute. It is a fortunate day, indeed, for the people of any com- munity, and especially for the school children, when the school officials awake to a realization of the fact that a well organized health service for the schools, comprising com- petent physicians, and dentists especially trained for the work-adequately paid for the time they give-aided by a nurse, or, rather, by as many school nurses as are needed to do the work, is the best possible investment for any city or village, and will yield returns in the assurance of healthier, happier, better children many times in excess of the cost. The School Physician The work of the school physician necessitates his inti- mate relation to two distinct departments of the community government-that of health on the one hand, and of educa- tion on the other. To the Department of Health belongs the function of preventing the spread of communicable disease among children in the schools quite as well as among other groups in the community. To perform this duty either the medical officers of the department must have the right of unquestioned entrance to any school at any time, or the school physician, being charged with this duty, must be responsible to the chief of the Health Department and must 170 be for that particular function, under his control, even to the extent of his having the power of removal of the school physician for dereliction of duty. On the other hand, the physical examination of teachers and pupils for any purpose must be so arranged as to in- terfere as little as possible with the school program, and be reported to the school officials and teachers. They can- not deal wisely with the pedagogic program for any child unless they are fully informed as to his physical status, and, moreover, no school health program can be successfully de- veloped and executed without the intelligent, sympathetic co-operation with the school physician and nurse, of teach- ers, supervisors and superintendent. But the interest of the Health Department has not to do merely with the matter of communicable disease. The con- ception of the functions and duties of public health service has broadened very much in the last few years. As defined by Dr. C.-E. A. Winslow, of Yale University, one of the recognized authorities on preventive medicine, "Public health is the science and art of preventing disease, pro- longing life and promoting physical health and efficiency through the organized community efforts for the sanitation of environment, the control of community infections, the education of individuals in principles of personal hygiene, the organization of medical and nursing service, for the early diagnosis and preventive treatment of disease, and the development of social machinery which will insure to every individual in the community a standard of living adequate for the maintenance of health." A properly conducted school system is bound to make training and education for health the fundamental item in its program. With such a broad conception of the func- tions of a Health Department on the one hand, and the De- partment of Education on the other, a thorough mutual understanding and a harmonious and cordial co-operation between these departments is a sine qua non for effective service to the community. If they are divorced from petty politics, the department heads selected with sole reference to their fitness and training for the work, and their zealous desire to render the best possible service, and with the em- ployees in all subordinate positions under a just, sanely ad- ministered civil service, adequately paid and assured a term of office as long as their duties are properly performed, there ought to be no difficulty arising from dispute as to scope of authority. 171 The selection of all medical officials for service in any capacity should be made by Civil Service examination con- ducted by the Department of Health, as the body most com- petent to make such appointments. Physicians for service in the schools should be assigned to duty, by the health officer, or requisition of the superintendent of schools. School physicians should direct and supervise the work of the school nurses (appointed also from a Civil Service list) and should make duplicate reports, one to the health officer and one to the superintendent of schools. The superintend- ent should have the right to veto the assignment to work in the schools of any physician whom he believes to be unfit for such service, and to demand the removal of any school phy- sician whose work is unsatisfactory. Frequent conferences between the head of the Health Department and the school superintendent should settle any differences of opinion and result in a smooth, effective operation of the school health program and its harmonious correlation with the other phases of the health service and of the educational program. Joint Committee on Health Problems in Education I cannot forego the opportunity here afforded to speak briefly of the work of the Joint Committee of the National Education Association and the American Medical Associa- tion on Health Problems in Education. Twelve years ago this very week, the A. M. A. held its annual meeting in Los Angeles. The House of Delegates, the governing body of the Association, appointed a committee to convey greetings to the National Education Association, which met the fol- lowing week in San Francisco. This committee was instructed to call the attention of the educational body to the importance of health in school children and teachers and of their training and education therefor. The response to this suggestion was very prompt and effective. The matter was referred to the National Council of Education, the president of which, for that year, was Dr. Charles H. Keyes, president of the Skidmore School of Arts, Saratoga, N. Y. President Keyes appointed an exceptionally strong committee of twelve of the leading educators and a smaller committee was appointed by the Council on Health and Public Instruction of the American Medical Association. This Joint Committee held its first 172 meeting in St. Louis in February, 1912, during the winter session of the N. E. A. Dr. Thomas D. Wood, of Columbia University, your chairman at this Conference, was made chairman of the Joint Committee and has continued to serve as such. The Committee during the past eleven years has held two-sometimes three meetings annually. The mem- bers of the Committee have worked in utmost harmony. Almost all of the work in gathering data and preparing the text of the reports issued has been done by the Chairman, Dr. Wood, and to him is due the major part of the credit. The growth during the last decade in appreciation by the educational world of the vital importance of "Health in Education and Education for Health" has been remarkable. It is a reasonable assumption that the work of the Joint Committee of the National Education Association and the American Medical Association which has been reported at frequent intervals to the members of both associations, and has, in other ways, been given wide publicity, has been an important factor in this growth of interest in the health problems in education. In no field of human interest is it more true than in the field of health, that prevention is vastly more important and effective than cure. The one most essential and potent agency of preventive medicine is training for and education in health, especially of the young. That is in large part the function of the teaching profession, but the medical pro- fession and its closely allied groups can best furnish the scientific facts which must be the basis of such education and can render valuable aid in arousing the parents of the several communities to its importance. United as are the teachers of the United States on the one hand, and the phy- sicians on the other, in the two national associations which are larger numerically than those of any other profession or vocation, their cordial co-operative activity in this great movement is a matter of especial significance and im- portance. I take this opportunity to express the deep appreciation by the medical profession of the whole-hearted response of the National Education Association to the suggestion of the American Medical Association made twelve years ago. We congratulate you on the splendid work of your committee. 173 Discussion Dr. John Sundwall, Director, Division of Hygiene and Public Health, University of Michigan, said: There is no doubt a great deal of the examination of school chil- dren that must be and will be contributed by the school teacher. In the past two or three years tests along that line have been conducted in the city of Detroit, under the careful supervision of the Detroit City Health Board. In several schools where the results have been tabulated carefully, it was found that teachers, after some instruction in the fundamentals of inspections and examinations, have done very well along these lines. In fact, in a certain test, as I remember, of some two thousand students, first the teachers were given some pre- liminary instruction by the physician-the city physician or the school physician. After this preliminary instruction they were given certain tasks in the process of the examination, and it was found that in these examinations if there was any erring at all, it was in the right direction, that is, in being able to recognize some of the more or less gross defects. We must be very careful to have the very closest co-operation between the physician and the teacher. In fact, every physician ought to look at the teacher very much as the specialist in medicine looks at the average physician or the general practitioner. So we want that co-operation, and we ought to feel that the teachers can contribute a great deal to the finding of defects. I was very much interested in Dr. Dodson's talk, and in connection with that the results of the very extensive examinations in New York City. One of the most perplexing problems, I believe, before school men and women at this time is this problem of physical examination. Just how extensively and how frequently must it be performed? If associated with 100 per cent follow-up and 100 per cent treatment it is not essential to repeat these examinations every year, but an annual inspection will serve the purpose to a great extent. Now the importance of this first examination, as Dr. Emerson also has brought out, is to get hold of all that neglected field in the pre-school period. We have learned in general that outside of prob- ably the defect of vision there are very few if any defects developing during the school period, although we have been taught from time to time of nervousness and tuberculosis and hosts of other things developing during the school period. So I think that one of the important things to do in our school work is to see to it, in that initial examination at the time the child enters the school, that we emphasize, above everything else, 100 per cent follow-up; and then after that we may have our annual or semi-annual examinations, or as frequently as we need them. But these inspections can be done in a very large measure by the nurse and the teacher, as long as we have a very close co-operation between the nurse and the teacher in associa- tion with the physician. In other words, I want to emphasize this: We cannot hope for many years to come that the physician is going to take care of all of the children. It can't be done. 174 For the present moment there exists, in most quarters, an extreme inadequacy of trained physicians and personnel for conducting fre- quent efficient, positive health and physical examinations of all school children and because of the paucity of funds for providing the desired personnel and facilities, this Conference might consider recommend- ing that school authorities concentrate their resources upon the thor- ough physical and medical examinations of school children at the time of their entrance in the schools. I feel that these physical and medical examinations should be conducted by physicians who have been thoroughly trained in the highest grade medical schools and hospitals. To conduct, to analyze, to interpret a physical and medical examination from the standpoint of positive health and physical efficiency, with particular reference to school children, requires a more extensive and special training than that generally provided in medical schools. It should be urgently recommended, therefore, that medical schools in general make provi- sion for this training so that the school children may be better served. I feel that the physician should utilize in every way and at all times, all the resources which the school and outside health agencies have to offer in conducting these physical and medical examinations. Experience has shown that the school nurse, the nutritional expert, the physical director, the teacher of biology and physiology and the teacher in general who has ever been given preliminary instruction in the methods of conducting physical and medical examinations-all can contribute much towards facilitating these examinations. The physician should at all times regard these agents as indispensable co-workers in the school health program and of special value as such in conducting physical examinations. In discussing Dr. Dodson's paper, Dr. E. A. Layton, Director of Health of Public Schools of Tacoma, Washing- ton, spoke as follows, on the subject of co-ordination in the school health program: Dr. Layton: It is taken for granted that doctors and dentists and other profes- sional workers have a valuable contribution to make for the promo- tion of health in the schools, which the educational authorities are only too glad to accept. On both sides the motives are good, but the problem is how these agencies and activities can be articulated with the school system so that they function properly. The first step is proper organization. The school, home and com- munity must join to produce health. The entire school corps have a part in the health program. If there is lack of team work among those who try to help it may be because the forces have never been "hitched up" right, or perhaps lack of direction. The work should be so organized that the work of doctors and dentists (medical inspec- tion) is an integral part of the school program and considered as natural and as necessary a part of school life as reading, writing and arithmetic. 175 Then, a school health program itself is a valuable means of coordi- nation. By outlining the scope, aims and methods of the work, it helps each to take his part in the program. This program should show the relation between teaching and practice and should correlate health with the whole school program. It must be co-ordinated with the work of the teacher; the health program must "head up" in the classroom, where the children are found. A plan for better co-ordination in the school health program is shown in the "Health Register." This is a classroom record, developed in the Tacoma schools, designed to show the health needs of the pupils and to co-ordinate the efforts of all for the promotion of health. By means of the Health Register, a health survey of the class can be made, the teacher can record her observations, the nurse, physician and others the results of their examinations, together with the atten- tion recommended and given. The Health Register may be described, briefly, as follows: The names of the whole class appear on one sheet. Under the heading, "Weight Index" are columns for age, height, weight and per cent underweight. Under "Health Habits" are five columns: (1) cleanli- ness, (2) eating, (3) sleeping, (4) mental, (5) posture. Under "Defects" are: (1) nutrition, (2) vision, (3) ears, nose and throat, (4) teeth, (5) mental-nervous. Then there are headings for "Atten- tion" and "Remarks," with columns for nurse, doctor, dentist, etc. On the cover are general directions, formulation of health habits, plan for grading, height and weight tables, diagnostic table of defects and table of communicable diseases. The working of this simple and practical plan tends to correlate health teaching and medical inspection, shows how the corrections of physical defects and habits of right living are interdependent and how the efforts of the teacher, nurse, doctor, dentist, the home and every health agency must be correlated for the promotion of health. Here the Chairman introduced two delegates from Mexico to the Conference. It was with keen interest that the Conference heard the progressive plans for popular health education in Mexico, as they were presented by the two physicians who were Mexico's representatives. Dr. Antonia Ursua, the delegate to this Conference from the Secretary of Education in Mexico, spoke as follows: Dr. Ursua said that she believed it important to have a general program of health work. Since all children are the result of parents' physical condition, the school health program should begin by the popularization of eugenics. She said: This knowledge of eugenics should include the laws of procreation and prenatal care. Such knowledge should be given to the public through popular conferences, through pamphlets and through teach- ing in the professional schools for nurses and teachers. If the chil- 176 dren are born strong, then the later health work in the home and in the school will be much easier and more fruitful. This, Dr. Ursua said, was the first part of the program that she would suggest. The second part of the program, she thought, ought to be the study of the hygiene of the child during the first two years of his life, and this should be given to the fathers also, not only to the mothers or nurses. Courses in this care of the child during the first years should be given in the primary schools as well as in the normal schools and household art schools. She continued, saying: The third part of the program should be the application of physical and mental hygiene from the kindergarten on all through the grades and the professional schools. For this it is necessary that government officials should also have an ample knowledge of hygiene. Also, hygiene should be taught to engineers and architects and, of course, to physicians, nurses and teachers. In the medical schools we should have school hygiene taught to doctors and nurses, of course, but we should also have hygiene taught in the schools of engineering and architecture, because it is only natural that engineers and architects would have great influence in the planning of buildings, both schools and homes. In normal schools and household art schools there should be ample courses in anatomy, physiology and hygiene, but these should always be given by a physician, who will also have the training of a teacher. A special committee of physicians, engineers and teachers should meet annually, and it is they who should be the ones to work out the health program in the primary schools, because they are the experts who have the knowledge and the experience for such a program. Medical inspection should not include only the children, as has been often mentioned on this platform. It should also include teachers and buildings. There should also be a course in social hygiene as it applies to abandoned children, retarded children, and this should be prepared and given by special agencies for this purpose. Use should be made, in health work, of whatever conserves health, improves it, retards old age and prolongs life. Dr. Alfonso R. Ochoa, the representative in the Confer- ence of the Secretary of the Bureau of Health Education and Propaganda of the Department of Public Health in Mexico, then continued the account of health conditions in Mexico. 177 Health Education in Mexico Dr. Ochoa: LET my first words to this Conference be that my country has sent a delegate to this International Health Congress, not believing that he will be able to report great progress in the important field of Health Education, but because it wishes to learn from other nations, and also because it wishes the world to know that in spite of the political convulsions which it has suffered during the last years, it is working so that the knowledge necessary to pro- duce morally and physically strong citizens will be popular- ized and practised, and that Mexico is placing its hope of progress and peace in this very important field of learning. In Mexico, as in other civilized nations, the study of hygiene was limited to those who studied medicine. In the colleges, which were under the direction of priests, and which were the only source of learning till the middle of the 19th century, hygiene was not part of the curriculum, and the school teachers not only did not teach it, but instead created prejudices in the minds of the pupils against health, thus forming harmful customs. From the time of the foundation of the secular schools by the philosopher Don Gabino Barreda in the last quarter of the 19th century, hygiene began to take its place in the curriculum of the Escuela Nacional Preparatoria, although it was not yet an obligatory subject, worthy of being taught in the professional schools. About the same time, the normal schools for men and women having been founded, a few special classes in hygiene were given in them, but without attaching to it the great importance it has, especially for the primary schools. From that time the study of hygiene has been improving, and now it is a very rare exception to find a secondary or manual arts school where hygiene is not taught. Since 1914 the subjects, anatomy, physiology and hygiene, are obligatory in the Escuela Nacional Pre- paratoria, where there are more than 2,000 pupils every year. The program of those courses was formulated by 20 physicians under the direction of Dr. Jose Terres, and in- cluded everything that a civilized man ought to know, and excluded everything which was of no practical value for a 178 hygienic life. And since many private schools follow the programs of the Escuela Nacional Preparatoria, the health program in this school is reaching out and influencing many others. One of the proofs that public as well as private schools are paying much attention to hygiene is the fact that they all wish to have modern buildings, with the proper require- ments as to ventilation, and other sanitary conditions; that physical exercises are obligatory, with shower and tub baths for use after the gymnasium, and that open air excursions are part of the regular school program. The Board of Public Health did impart, during the last years of the last century, some hygienic teachings to the masses, but these were presented in such manner that they seemed to be legal dispositions or rulings, and not wise advice given for the benefit of the individual and the com- munity. But now, the idea of carrying the correct form of propaganda in favor of hygiene is prevalent among the Mexican doctors, and some have already begun the practice of giving public hygienic conferences. And so among the Mexicans there are now those who know, at least in theory, what should be done to keep healthy, those who wish to know, and those who do not yet feel the need of acquiring any knowledge of the kind. There are also of course those persons who by profession have chosen the study of health, and all its implications, and wish to impart that knowledge to all. In 1912, under the direction of Dr. Alfonso Pruneda, the "Universidad Popular Mejicana" was founded, and in it were given free courses in hygiene and moral practices, so that the pupils, adults in the majority, would lead better and cleaner lives. The professors of the Popular University not only gave conferences in the university buildings, but also went to the buildings of the Mutual Societies, Young Men's Associations, and all other centers where they could reach large numbers of people, and gave important lectures on hygiene. Dr. Pruneda gave a series of lectures on the im- portance of vaccination in all the Protestant churches. The Popular University also published propaganda pamphlets, among which were two Almanacs, in which the predominant topics were health teachings. There are also in Mexico many people who are interested in the Health Education of the masses and maintain asylums 179 and dispensaries for adults and children, and who make use of the press to spread the saving ideas of hygiene. Among those beneficent societies are: "Sociedad Para Evitar la Ceguera en Mexico" and "Sociedad Protestora del Nino." The need for health work in Mexico is already widely felt, and the press willingly publishes all articles and news concerned with it. The newspapers called "El Universal," "El Mundo," "El Heraldo de Mexico" and "El Democrita" accept all material on health which is sent to them by the Bureau of Propaganda and Health Education. The first accomplishment of importance in the field of Health Education was "La Semana del Nino" (The Child's Week), which was one number of the program in celebration of the Centenary of Mexico's Independence, in September, 1921. There was also at that time the "Exposition del Nino" (The Child's Exposition), and in this there were de- partments illustrating and giving information about chil- dren's plays, conferences, health, rest-rooms for women and children, exhibitions for fathers and for mothers, for pre-natal care and care of the child as it relates to food, clothing, ailments, etc. There were also departments ex- hibiting the Mexican laws for children's welfare and the work other nations are doing in that field. There were during the exhibition open clinics for vaccinating, and many made use of them. The program for the "Child's Week" was as follows: First day, celebration in the schools with an appropriate program with health as the most important topic; second day, a children's parade; third day, emphasis on importance of the civil registry, corresponding to American birth registration; fourth, a visit to the most important institu- tions engaged in children's welfare work; fifth, visit to the Maternity buildings and giving away of clothing to mothers and children who needed it; sixth, conferences with parents. Presents were given to all children born during that month. Literature was given out, and this included pamphlets on: "The Child," "The Care of the Mouth and Teeth,"' "The Care of the Eyes," "How the Health of the Babies is Kept," Calendars with daily inscriptions in health, "Message to Parents," "Advice to Future Mothers." Besides the fine work accomplished during this special week, there are permanent establishments for the care of the health. One of the most important is "El Centro de 180 Higiene Infantil Eduardo Liceaja," 20 Colombia St., Mexico City. The purpose of this health center is to give to poor mothers all the help and knowledge necessary to keep children healthy and strong. Expectant mothers are examined and advised free and children are taken care of and prescribed for, a card catalogue being kept of all the patients. The work of publicity and propaganda in health is carried by a special bureau of the Public Health Department. One of the most effective means used is the publication of the small newspaper. This little newspaper is written in popular style and well illustrated and has given wonderful results. In some schools it has taken the place of text- books, since the hygiene class studies some of its articles. The newspaper has awakened also the need for more in- formation about hygiene, and hundreds of letters pour into its office with questions whose answers have come to be another section of the small newspaper. There are also as part of the propaganda and publicity bureau, conferences for workmen, given in their own build- ings or associations. These conferences are given by two doctors and a dentist exclusively engaged in this work. Also there are exhibitions of films about health and hygiene in all the suburbs of the cities. Dr. Ochoa had with him samples of the interesting and original printed material, films and slides referred to, which could not be shown, unfortunately, owing to time and space limitations. Discussion The Chairman expressed the keen interest of the Con- ference in the aggressive and modern program described by the representatives from Mexico. Upon his invitation to further discussion Dr. True, of Los Angeles, said: Our plan in Los Angeles we hope to improve by your suggestions. We as physicians leave to the person of sufficient training, the exam- ination, but we reserve to ourselves the right of assaying the findings and prescribing what shall be done. We believe that the teacher, the nurse and the nutrition worker will find things that will be of immense value in the prescribing. We believe that the teacher should teach and the physician should examine and assay. The school exam- ination has been criticized and in many places it is a farce, but it has done the very thing to which the president of the National Associa- 181 tion called your attention yesterday. It has brought forth the call for additional service. We believe that everything we are doing today came from the pioneer work of the physician and that these millions of examinations have made many children living today in their twenty-first year in better shape for that examination. Dr. Wolfe, of Lincoln, Nebraska, said of school medical service there, that in Lincoln they get the medical profes- sion organized in this work and get individual specialists to make special examinations; nurses go with them and take the sociological history to save their time. The day's work was brought to a close by Dr. Alvin Powell, Director of the Public Health Center, Oakland, Cali- fornia, who spoke as follows: This afternoon people have discussed problems who have had before them a definite dilemma. "We know that in the United States at the present time, if the call really came for expert workers, we would need about 25,000 physicians trained in doing public health work. They are not available. It seems to me that it is almost a waste of time for us to insist on having that 25,000 when they are not ready for us and probably will not be for some time. We acknowledge, of course, that they are important and necessary. Such organizations as the Rockefeller Foundation recognized that, when it set aside a considerable sum of money for the education of public health workers, expressing their belief that for the next 50 years it would be the medical profession that would have to carry on the Health Education work of the United States. The American Public Health Association now has a committee working on this subject, and it reports that in addition to these 25,000 public health officers, we need at least three additional trained physi- cians in each community that has a population of over 100,000. The way we have been solving this problem to a certain extent has been to have good administration. This has been a very valuable develop- ment, but administration cannot do everything for all of our communi- ties. Neither does it seem that the physicians, even when we have enough of them, will be able to do everything. Even with the nurse who goes through with her training, people who have not medical degrees will still be able to weigh and measure the child accurately with instruction along these lines, and will still be needed. And so, for the present at least, besides the technique of admin- istration, we must develop definite general school health programs, the technical part left with the physician; but the other things the physician should not take the time to do, being done by people under his direction who have sufficient skill to do them. This program, however, needs to be more than definitely stated. It needs a catalyzing agent to put it into force. The resolutions offered to the Plenary Session as the result of the day's discussions will be found on page 343. 182 For a discussion of Child Hygiene, by Dr. Mary Evelyn Brydon, Director of Bureau of Child Welfare, Virginia State Board of Health, and of the West Law of Virginia as it applies to the participation by teachers in the physical ex- amination of children in the health program of Virginia schools, see page 54 in the session devoted to "Functioning Health Programs." Readers will be interested in the following synopsis of the Health Education situation in present day Germany. The report of which this is an abstract, was prepared for the Conference and sent by Dr. Wilhelm Hagen, of Hochst a. Main, Germany. Public Care of Health in Germany-1923 People in foreign countries are accustomed to consider the heavy damage done to the health of the population of Germany and Austria from the point of view of malnutrition alone. This certainly was quite true during the war and the first years after the war, but since that time conditions have changed somewhat. It is now possible to afford the absolute necessities of food, but many restrictions with respect to clothing, increased cultivation of the land, and loss of recreation must be practiced. Inquiries made in schools of Germany have shown that the number of children reduced by malnutrition is largely restricted to the families with many children and small incomes. The price of milk is now so high that a workman with three children cannot afford more than one- fourth his daily income to buy milk. Professor Pfaundler of Munich has recently pointed out the number of infantile diseases is increasing extraordinarily. The most important of these is tuberculosis. Mal- nutrition during the war damaged bodily resistance for a long time and not only for the few years during the war. Damages remain which cannot be amended now by sufficient nourishment. The shortage of dwellings in Germany is very acute. There are in Germany families of eight or more persons who have to dwell in two rooms, and as a sad rule, young married people up to the fourth year of their marriage, even with some children, have to live in a single room. At least one-third of the German population cannot sleep alone, but have to share their beds with another. The danger of infectious diseases has increased primarily on account of these terrible housing conditions. As a consequence, mortality from tuberculosis has greatly increased during the last two years. The work being done in Germany at the present time to combat sufficiently the diseases is very great. Instead of private organiza- tions carrying on a large part of the work, it has now been taken up more and more by single communities and united communities of larger districts. Since the war it has been found more expedient to install physicians especially charged with health "care-work." These 183 physicians have to care for the health of the baby and older children in a certain district and are assisted by a staff of public health nurses. The officer of public health is immediately notified of the birth of a child by the registration office. One of the public health nurses is informed of the birth in the district where she works and a visit is made to the homes of as many babies as possible. The public health nurses gain an intimate knowledge of the families of their district. Every mother of a new baby receives a letter from the health officer with congratulations and an invitation to avail herself of the infant welfare stations. It is to an ever-increasing extent less necessary to place the babies in special institutions which were of so great importance in the begin- ning of the "care-work." Tuberculosis demands an increasing atten- tion in the earlier ages. It is the foremost task to lessen the possibil- ities of infection through sick members of the family. The supervi- sion of young children is carried on partly by medical inspection in the kindergartens. On entrance to school a schedule of health is put down after an exact examination of each child. This examination is carried out by the school physician in the presence of the mother, and the schedule accompanies the child throughout its whole school life. Every child has to undergo a yearly medical examination, the weaklings or sus- pected and doubtful cases being submitted to repeated examinations in the presence of the mother. This exact supervision of the children carried out always in close touch with and with full information of the parents, forms the basis for our measures. We consider it as our primary task to instruct indefatigably the parents how to bring up the children in a rational way. Considering the great food difficul- ties and the common misery, this is often a very difficult task, and our demands must fail on account of the impossibility of their being car- ried out. Thanks to the large foreign gifts, there are still means for the feeding of the children, but the holiday camps and the open-air classes are threatened with ruin on account of lack of means. What we are doing to fulfil the task is as follows: From the medical service at school in which our work is centered, we turn to the family of the pupil and endeavor to find out the cause of the contagion. That means, we shall always care for the whole family if the medical examination at school will give us reason to do so. We try to improve the bedding and dwelling conditions at least to such an extent as to lower to a minimum the risk of infection pre- sented by dangerously ill older members of the family, parents, grandparents or others. This scheme requires a continuous supervi- sion carried out by the nurse, the necessary measures of disinfection and, in the heavy final stages of tuberculosis, the isolation preferably in an infirmary. But whereas the isolation at home will be very difficult for want of rooms, it is likewise the case with the isolation in the infirmary for want of money. There is danger that our new laws, the Prussian law against tuberculosis, as well as the corresponding Act of Parliament, and the laws against venereal diseases, may be negatived by a lack of funds to 184 carry them out If so, the picture of conditions to be met by German health "care-work" is rather disheartening, but we still cannot forget that we have made extraordinary progress in experimentally elab- orating the working methods. It means an essential progress to get the single branches of the "care-work" in close accordance with each other and to range our activities under the lead of principles of polit- ical economy; indeed, we believe we are justified in saying that we have taken part in creating for the first time the science of the "care- work" as a special branch of "pedagogics." Our need has been our teacher. It has made for us the solution of these problems a vital question, and we believe that we shall solve them. We know that we have to add to foreign gifts a certain ferment which will make them properly efficient and this ferment is our work. A gift accepted only to enjoy it would be no blessing. While we may differ in many respects from the religious views held by relief organi- zations in Germany, we heartily agree with them in the conviction that it is the working for the welfare of humanity which only will build strong bridges between men. Part VI THE NURSE AND HEALTH EDUCATION DR. THOMAS D. WOOD, as General Chairman of Ses- sions, opened the meeting by announcing the subject of the morning as "The Nurse and Health Educa- tion." He introduced as the chairman of this session Miss Elnora E. Thomson, Associate Director of the Portland School of Social Work, affiliated with the University of Oregon. Before turning the meeting over to Miss Thomson, Dr. Wood appointed a committee on resolutions, who in accord- ance with the plans of the Conference were to embody the sense of this meeting in resolutions for the Plenary Session. Miss Thomson thereupon took the chair, saying: Nursing education has been a long time coming into its own. It has been considered more as an apprenticeship than as a pure education. It has not been a part of educa- tional organizations or educational institutions until com- paratively recently, and this is the first time it has had a part in any way in any division of the National Education Association, and it is for the nursing profession a very sig- nificant moment. It is, then, with a great deal of pleasure that I present as the first speaker on the program a woman who has been for some time in the fore ranks of nursing education, Carolyn E. Gray, Department of Nursing Educa- tion, Western Reserve University, Cleveland, Ohio. Courses of Study in Schools of Nursing Miss Carolyn Gray: FRIENDS and Fellow Workers: Miss Thomson stated that nursing education has been a long time coming into its own. I am sure that those of us who have been in the work have felt that way, and yet the first thing on my paper is to call your attention to the fact that nursing education, or nurse training of any kind, is only fifty years old in this country. 185 186 Since I have been in the West I have heard a great deal about the forward-looking attitude of the people, and the absence of hampering traditions, which I am told is due to your pioneer spirit and the youthfulness of your part of our country, so it seems encouraging to recall the extreme youthfulness of nursing as a profession, for only this year three of the first schools of nursing in this country have celebrated their semi-centennial. My paper is built around the subject of the curriculum of schools of nursing. That is not exactly the way it is stated on the program; however, courses of study and cur- ricula are rather definitely related. I would like you to go back with me to the first schools of nursing and think in terms of the curriculum they had. It is true the first schools patterned their curriculum on the Florence Nightingale plan. Usually when a new school was to be started someone went to England to consult her, but it is equally true that the curriculum was determined by what the hospitals needed to have the nurses know. In other words, the needs of the hospital were paramount and determined the content of the curriculum. This condition held good from the time the first schools were started in 1870, 1871, and 1872 until 1893, when that group of pioneer women met in Chicago and formed the American Society of Superintendents of Training Schools for Nurses. One of the subjects listed for discussion was the curriculum and how to standardize the teaching in schools of nursing; how to make it more valuable; how to get away from the shackles put on the teaching by the needs of the hospitals. And, of course, those needs varied very widely. It was not as though all the hospitals were doing the same work or had the same standards. Running all through the reports fol- lowing the formation of the American Society of Superin- tendents of Training Schools for Nurses-now the National League of Nursing Education-we find much discussion about what student nurses should be taught, and how they should be taught. In 1915, the Educational Committee of the National League undertook the task of formulating a curriculum. That committee worked for four years. It was all volunteer service. They had no accepted standards to go by, because even Florence Nightingale's plan was intended for totally different conditions from those that many of the women in 187 the schools in this country were facing. Consequently, it was necessary to consult with as many of the women in the field as it was possible to reach. Letters were sent to women who were doing conspicuous work in their schools, asking for outlines of what they thought would be adequate in their particular subject. For instance, women in charge of children's hospitals were asked to outline courses in pedi- atrics ; women in charge of obstetrical hospitals were asked to outline courses in obstetrics, and so on. After this ma- terial was gathered together and the committee attempted to put it into shape it was found it would require many more hours of classroom teaching than had ever been thought possible. Accordingly, the outlines were all sent back to the original makers with a request that each course be short- ened, thus decreasing the number of hours required. In some cases this procedure was repeated more than once. It really was a very difficult, time-consuming piece of work. In 1919, the Standard Curriculum was published. May I call your attention to the democratic way in which this curriculum was built up. It was not an ideal or vision- ary scheme, but represents what actual teachers in schools of nursing considered the minimum and essential subject- matter that student nurses should know if they were to be capable of the service which the hospitals expected them to render. It was not superimposed on the nursing body by an outside group, but rather grew out of the nursing body itself. It was the best we were able to do at that time. The Standard Curriculum met with a very warm re- ception. Warm in both senses of the word. The women in charge of the schools welcomed it. The standards suggested served as a measuring rod, something by which they could measure the work they were doing, and it was an enormous help. But the other side of the question. Many of those who do not believe in nursing education have centered their attacks on the Standard Curriculum, and ever so many times when meetings have been held to protest against standards of nursing education, that book has been held up as the object of scorn and ridicule. On the other hand, educators and specialists have analyzed the book and they have thought the work was scrappy; the time given to the courses was too short, there were too many courses; we were attempting to do too much; and above all, if we asked 188 anyone connected with educational institutions to teach the sciences, they threw up their hands and said it couldn't be done in the limited number of hours allowed. For instance, the eye, ear, nose and throat specialists felt that enough time had not been given them; obstetricians thought the time devoted to that subject was inadequate; pediatricians maintained that the teaching of their specialty was inadequate; teachers of chemistry ridiculed the idea of attempting to teach even an introduction to chemistry in so few hours. There was a good deal of justification for all the criti- cism. In all the many subjects, we were trying to teach much more than it was possible to teach in the time allotted, and yet it was not more than the students needed to make them intelligent workers. Nevertheless, the Standard Cur- riculum has served a very great purpose, and will go down in history as one of the landmarks of our progress, showing that even though we were laboring under many difficulties we were alive to our problems and struggling to meet them. And the fact that the Standard Curriculum has gone into the fourth edition shows it has been widely used. Now another curriculum is being proposed. In 1918 a committee now spoken of as the Winslow Committee was appointed to study the schools of nursing and the whole problem of nursing education, to find what were the best things that were being done, and how they could be im- proved upon. I presume all of you know about the Report of the Committee on Nursing Education. I would like to say a few words about this committee and the report it has issued. The committee was composed of nineteen members. It represented doctors, educators, lay people and nurses. They were of very diverse minds, and spent three years studying this whole problem, studying the material gath- ered by twenty-one different workers-different types of workers- nurses, educators, statisticians. The study in- cluded the work of 164 public health nurses, working in forty-seven different organizations. This naturally led back to the schools in which the public health nurses were trained, and it became necessary to study schools of nurs- ing. Obviously, it was impossible to study eighteen hundred schools intensively, so it was decided it would be better to study a representative group of schools intensively rather than the entire group in, perhaps, a less intensive way. 189 Twenty-two schools were studied. They were schools con- ducted in large hospitals, small hospitals, general hospitals, and special hospitals. This included the different types of hospitals in which schools of nursing have been developed. All of them were above the average. It was not an attempt to find out the worst features of nursing education, but the very best that it had been possible to accomplish. It was a co-operative undertaking, because the investigators only went to hospital schools that invited them. And then they went with the full co-operation of the people in the schools, and an enormous amount of information was furnished them beforehand. I cannot say too much for the courage and the spirit shown by the women in the schools which were studied; women who were willing to give every bit of information possible, to show where there were weak places in their work as well as strong places, to help the investigators in every way. Truly, many of those women loved their schools, just as parents love their children, and something of the spirit that prompts a mother to take a sick child to a surgeon was exemplified by the women in those schools. I shall always feel proud to be a member of the group that was willing to have such work done. The work of 118 private duty nurses covering a period of three months was studied. The result of all of the study and deliberations of this committee is embodied in the Re- port of Nursing and Nursing Education. This advocates two years and four months of basic train- ing instead of three years, because it shows it is possible to reduce the length of the course by eight months if the non- essential routine work is lessened. As a result our Stand- ard Curriculum is again up for discussion, and the Educa- tional Committee of the National League has for months past been studying how to make the changes this report advocates. I had hoped to have the conclusions of this com- mittee to present to you today, but I have not been fortunate enough to get them. I find the distance beween Swamp- scott, where the annual meeting of the National League of Nursing Education is being held and these conclusions are to be presented, and this part of the world is really consid- erable, even for the United States mail. First, may I call attention to one point which the report brings out with remarkable clearness. It has always been 190 assumed that the kind of nursing service needed by the hos- pitals, and the kind needed by the community was exactly the same. This is not true. There is a wide difference be- tween the kind of work the hospitals need to have done, and the many kinds of nursing service the community expects nurses to be prepared to render. And the report advocates that the preparation of student nurses be based on com- munity needs, not on hospital needs. This is really revolu- tionary, and if followed will prove far-reaching in its effects. Four months of preparatory work during which time the student should be free from routine hospital work is outlined. During this preparatory period the fundamental sciences on which nursing is based are studied. The sub- jects have been grouped together reducing the number of required courses from ten to eight, and the hours have been increased from 265 to 290, an increase of twenty-five hours. For instance, the Standard Curriculum suggested sixty hours for anatomy and physiology. The Winslow-Goldmark report suggested ninety hours, and anyone who has at- tempted to teach anatomy and physiology in sixty hours knows that ninety hours is much nearer the time required. For bacteriology the standard curriculum suggests twenty hours. The Winslow-Goldmark report suggests forty-five hours, which is justified by the growing importance of this subject. If each suggested change is analyzed it is very easy to discover the reason for it, and I am confident all teachers would agree that the increased time allowed each subject is none too much. Increasing the number of class periods is only half the problem. Educational institutions require an hour and one- half of study for every hour spent in class. It is easy to calculate that in a four-month period, 390 hours spent in class, plus sufficient time for study does not leave any time for hospital duties, hence the recommendation that students be entirely free from hospital work. The aim and purpose of this preparatory period is to make the student a more intelligent and consequently more valuable worker, better able to conserve her own health and not suffer needless infections. There is ample evidence that four months' intensive preparation accomplishes this purpose. 191 Educators are constantly reminding us that we have unusual opportunities for correlating what is taught in the classroom with the actual work in the hospital. If our teaching is properly planned it should be possible for the student to apply the principles taught in the classroom to the work in the wards, and apply them at once, not six months hence. But we know that class instruction and practical work have rarely been correlated. Moreover, such correlation is difficult under the conditions controlling our teaching. If put into effect this recommendation will prove quite as revolutionary and far-reaching as any one we could imagine. Following the preparatory period of four months, a basic course of two years is outlined. The number of sub- jects to be taught during these two years is reduced from twenty-nine to fifteen, with an increase of ninety hours, making a total of 450 hours. We are told we have split our subject-matter into too many small units, and this repre- sents an effort to group all the subjects bearing on a par- ticular problem together, emphasizing the connections and relations existing between them. This new curriculum is built around the ideal of positive health, which necessitates the teaching of what positive health means for people in different age groups. Those who have criticized us for emphasizing the abnormal at the ex- pense of the normal have been justified, and yet a true appreciation of abnormal conditions must be based upon a clear picture of what the norm or normal is. This new curriculum is based upon a full high school education as an entrance requirement. This is a point about which there has been a great deal of discussion for many years. Many of us who believe in it firmly were very much disappointed when Missouri gave up the wonderful oppor- tunity it had to do pioneer work, and to show that it would have been possible to operate under a law that required high school graduation. It does take courage to pioneer, and its does require willingness to withstand attacks. I am not from Missouri, and I do not mean to be hard upon the people there. But to give up such a wonderful opportunity is pitiful, particularly when the enrollment in their high schools shows a steady increase, and the number of girls completing high school is also increasing. The repealed law was in accord with the trend of the times. 192 However, the work done in another state is in sharp contrast. At the time the law in Missouri was first at- tacked several other states were very much interested in this problem of high school education, and various groups were formed to study it. In Ohio the State Medical Asso- ciation appointed a committee of representative men from different sections of the state to study this question, to study the reasonableness or unreasonableness of this standard. Fortunately, a very fine group of men were appointed to that committee, and they took their task in earnest. They asked the members of the various nursing groups to meet with them. They spent whole days in conference, debating this and many other questions. The problems of nursing education were studied not only from the standpoint of nurses themselves, but from the standpoint of the needs of the community. The April number of the Journal of the Ohio Medical Association contains the report of this committee and defi- nitely recommends working up to a high school requirement. The significance of this report is that a thorough study of the problem convinced these open-minded men of the rea- sonableness of this standard and has helped to bring the medical and nursing groups in Ohio nearer to a sympathetic understanding. In this connection it is well to remember that we must work with and not against the high schools. In every state the high school authorities are making serious efforts to hold their students until the completion of the four-year period. Is it reasonable for us to try to defeat their plans, and tempt their students to give up sooner? Whether we mean it so or not this is what less than a full high school entrance requirement really does. There is just one other point I want to emphasize, and it is to consider the complete care of the patient as a unit of work. We must not allow the work to be broken up so that one nurse makes all the beds, another gives all the baths, and another takes all the temperatures, et cetera. We want the student to have the complete care of the patient. This includes the history of the patient, so that the student nurse knows something about the pre-hospital conditions, and other conditions which may have contributed to his illness. She should also have an opportunity to follow the patient into the visiting nurse or social service department, so that 193 she knows something about the post-hospital conditions, thus getting a complete picture of the patient's illness, not j ust of the time in the hospital. In order to give our students a proper point of view in regard to their work, they should know something of the hygiene, of the economics and eugenics, as well as the nurs- ing care of every case. They ought to have a background of eugenics so that they know why it is we have so many de- fectives and feebleminded people. They ought to know something about the economic conditions that have to do with bringing many of our patients to the hospital. They ought to be able to teach prevention. Every patient should be taught how to prevent a condition that will cause his re- turn to the hospital. We must teach every nurse to do her share in this work. The goal we are aiming for is a nurse who can do bedside work and make it an opportunity to teach prevention of disease, and promote the spread of ideals of positive health. Discussion Miss Maude Landis, Superintendent, Stanford Uni- versity Hospital, said in discussion of Miss Gray's topic: I think we shall want to keep constantly at hand the report on Nursing and Nursing Education, so that we may know more about the things of which Miss Gray has spoken. There have been many changes in schools of nursing in a short time. The entrance age for students has been lowered considerably, and the vocational opportuni- ties that are open now as compared with earlier times are many. There is abundant evidence that young girls are very much interested in nursing. In the preparation of courses of study, as suggested by the curricu- lum, very much has been contributed by the high schools and other educational institutions. Not only are the high schools preparing the students for this work, but educational affiliations are being ar- ranged with colleges and universities. Central schools of nursing are being organized also to meet a need that perhaps individual schools of nursing are not able to care for, and through which the preparatory courses established in the schools of nursing are given by several groups of institutions. In sixteen universities this combined course is given. This, as you understand, is three years pre-nursing work and two years hospital work. In that five years the student earns her degree of Bachelor of Arts, and also her diploma as a graduate nurse. The physical equipment for giving these courses is analogous to that in any other form of education, as to class rooms, lecture rooms and laboratories. 194 The changes that are coming about must be met. The apprentice system in nursing must go. The theory and the practice must be correlated. The value of the contribution that nurses make to the wel- fare of the community is in direct proportion to the soundness and thoroughness of their preparation. The development of nursing as a scientific profession is one of the largest health problems of the present day. The Chairman: We will now hear from Miss Mary May Pickering, Director School of Nursing, University of California Hos- pital, on Injecting Health Education into the Curriculum of Schools of Nursing Miss Pickering: NURSING education is slowly passing from the stage of training by the apprenticeship method to training by the methods used in educating for any other profession. By economic necessity, the school of nursing has in the past been obliged to provide nursing service to wards and other hospital departments. The consequent crowding of the student's time has in many instances even resulted in her exploitation as a worker at the expense of her education as a nurse. It has been with the greatest difficulty that the curriculum has been broadened to include some of the less practical and technical and therefore seemingly less vital subjects. Ten years ago, a course in hygiene probably con- sisted of two lectures; bacteriology was covered by one or two talks in practical nursing; pediatrics and mental hygiene were conspicuous by their absence. Bit by bit, the curriculum has been so rounded out that a nurse graduating today from the average nursing school has been drilled not only in practical nursing, in dietetics, in medical and surgi- cal diseases but as well in the basic sciences, in pediatrics, in communicable and mental diseases so that she is singu- larly well equipped to intelligently nurse the sick. That our curriculum has still a vital and fundamental lack is clearly pointed out by Josephine Goldmark in the report of the Rockefeller Committee on Nursing Education in the United States, when she says: "Stress upon curative medicine to the detriment or total ignoring of preventive medicine is one of the most serious handicaps in the 195 training of the nurse. For nurses, pre-eminently those in public health work, are to be engaged primarily in the prevention of sickness; nay, more, they are to have the more difficult office of teaching the prevention of sickness in people's homes. This is their special function. It is therefore of the first importance that they should be equipped not only to recognize symptoms of disease and learn methods of cure, but they should be more fundamentally equipped to recognize symptoms and conditions antecedent to disease and learn the means of combating these before disease appears. It is then surely an anomaly that their training should deal so largely with cure alone. . . . This new emphasis on something greater than pill and bottle, this stress upon the now well-established principles of hygiene and prevention, is perhaps the cardinal need in the nurse's didactic instruc- tion." That schools of nursing have been slow to recognize their obligation to train health teachers is probably due to the same reasons that they have been slow in developing a system that will turn out thoughtful, intelligent nurses for the sick. The purpose of this paper is to outline a plan by which Health Education can be incorporated in the cur- ricula of nursing schools as they are organized today. The plan would require the expenditure of little money and could be carried out by the existing teaching and medical staff-provided its members have the necessary initiative, interest and enthusiasm in the project to put it over. As a basis for the teaching of Health Education there must exist, first of all, in the nursing school and hospital proper, hygienic conditions. No amount of didactic in- struction in disease prevention can be expected to make any impress on the minds of students if they feel that the prin- ciples taught are not being applied to their environment. We must see that they have right living conditions-clean, comfortable, properly lighted and ventilated rooms, facili- ties for daily bathing, well-balanced, wholesome and attrac- tive meals, reasonable hours of work, means of relaxation and sufficient recreation. We must provide a yearly health examination for the individual student as well as the entrance examination, now almost universally practiced. We should require monthly weighing with the opportunity for comparison of the actual weight with the normal; we must provide the mid-morning lunch; immunize against infectious diseases; correct physi- cal defects. If the student has carious teeth, they should be treated; if infected tonsils, they should be removed; if poor 196 posture, she should be taught its correction; if she is under- weight, she should be nourished; if overweight, dieted. In addition to these things, she should have sympathetic and stimulating health advice and supervision throughout her course. At her first physical examination, she should have "sold" to her the positive health ideal, and have im- planted in her mind the thought, that one of the chief serv- ices a nurse can render is to teach health to individuals, and that she can most effectively teach health to her patients by being radiantly healthy herself. At subsequent conferences, interest can be sustained by observing progress made through her own efforts as well as by outside guidance. Her ability to give service by personifying health is one avenue of appeal; her inherent desire to be beautiful or at least attractive, forms another. But more important than either of these is an understanding attitude on the part of her physician-adviser. The provision of healthy environment and the opportu- nity to realize her own health ideal is the first step in pre- paring the nursing student to become a teacher of health. The second step is to give her methods which she can prac- tice with her patients. Most nursing schools give in the senior year a course of sixteen hours in so-called occupational therapy, in which the student learns to weave baskets, mould beads and to do other craft work, which in my experience I have rarely, al- most never, seen applied to her patient's needs. Why not substitute the same number of hours in Health Education methods and transfer the course to the second half of the first year? This would seem the logical place for it. By the end of her preparatory period, the student has developed her nursing technique to the point where she is beginning to follow it subconsciously; her mind is reaching out for something new; because she has done comparatively little actual work with the patients in the hospital wards, her attitude of mind towards that work has not yet crys- tallized. What an opportunity for the direction of her mind along health lines-for the teaching of methods by which she may interest her patient in positive health while she is performing for him the routine nursing procedure. This course, following close upon her first physical examination and subsequent health instruction by her physician-adviser, would seem the psychological place to develop in the student 197 a vast enthusiasm for health-a natural and intelligent in- terest not only in caring for the sick patient but in trying to influence him and his environment so that he may keep well. Trite as it sounds, she has entered the nursing school be- cause of her desire to be of service in the world. While her mind is still plastic, while she is eagerly trying out her new found powers, why not capitalize that desire for social ser- vice and teach her to use it in her everyday routine work- along with the making of beds, the serving of trays, the giving of medicines? It is unnecessary to describe the well-known methods now being used in teaching health. It has been demon- strated that the majority of nursing students may be in- terested in learning and applying them. For the less imaginative, interest may be sustained by a judicious dis- tribution of craft work throughout the course with prac- tical application to Health Education. Beauty examina- tions, short, snappy debates on health, and the working out of practical suggestions by the students themselves, serve to stimulate the imagination and develop initiative. When she begins to apply to her patients what she has learned in the classroom, the student finds that the work with children is usually play but that just as the health ideal has been made vital to her by the physician who is her health adviser, so must she be able to get health teaching across to the adult patient by studying him as an individual. In doing this, she finds she must know something of his background, his environment and social history. She dis- covers, too, one of the greatest compensations of the nurse, the realization that, because she is able to relieve his suf- fering and help his body, the patient looks upon her as a friend and helper, and that because of this feeling of grati- tude and confidence, he is willing to be influenced by her. She may find that while many adults cannot be reached by definite and direct instruction, they will quickly respond in helping with health projects for children-as in making posters, the health house, healthland, the health theatre, et cetera-and probably absorb some of the rules of health. Here, too, she sees the psychological importance of her ability to radiate health as a practical example, to the pa- tient, of the results of playing the game. Her eyes are bright, her skin is fresh, her carriage erect, her disposition happy, her whole body radiating wholesome vigor. 198 That the student would have time to direct the health work being developed by the social workers in the hospital wards and clinics could hardly be expected, but her knowl- edge of the Health Education movement, her interest in the health program, and her instinctive desire to give the pa- tient something of herself, something more than routine nursing care, will find many outlets in her daily work, thereby vitalizing that work and establishing within herself the habit of thinking in terms of health. In this course, while she learns the history and progress of the Health Education movement, most of the emphasis is placed on actual methods. Our third step is to carry the teaching into the second year where it can be broadened and made to include medico-social aspects of health work, or sickness and health in relation to the community. Again quoting Miss Goldmark, "The school of nursing should give to every student in classroom and ward that minimum of social interpretation, and instruction in the social aspects and prevention of sickness, which is indispensable in the modern treatment of disease." These classes could take the place of some of the unrelated lectures now being given in most schools in the senior year, or could be given in addition to those lectures and could be made most interesting and stimulating. They could consist of original study of indi- vidual patients in the hospital wards and the out-patient department, with conferences on the actual and possible methods of handling them from the point of view of ef- ficiency to the patient, to the community and to the state; lectures by people doing various phases of social and health work, with emphasis on the nurse's relation to this work; visits to organizations and agencies; outside reading and reports on the great pieces of public health work being done throughout the world,-the anti-tuberculosis program of Framingham, Massachusetts; the organization and develop- ment of the health program of Mansfield, Ohio; the health center of Alameda County, California; the work being done with heliotherapy and nutrition in Vienna; the work for undernourished children in Belgium. An important consideration in giving both these courses is not to lose sight of the individual patient, in the study of methods and organizations. Practical application of means and methods should be made throughout, with the aim to stimulate not only the nurse who plans to do public 199 health work, but to open the eyes of the private day nurse to a vision of her opportunity and obligations in the teach- ing of health. While we confidently look forward to the day when schools of nursing will be established on an educational basis-when our first consideration will be to provide in the approved pedagogic manner all the fundamentals neces- sary, not only to care for the sick, but to teach health and the prevention of disease, we must recognize that, with the time available in most nursing schools today, it would seem impossible to crowd into an already overcrowded curricu- lum a course of thirty hours in preventive medicine, such as is recommended by Miss Goldmark. Is it not easily possible, however, to have Health Educa- tion and disease prevention stressed in every course given in the curriculum-in hygiene, in nutrition, in dietetics, in bacteriology, in physiology, in pediatrics, in obstetrics, in every branch of medicine and surgery, in communicable diseases and in mental diseases? Will not this emphasis on the necessity for teaching prevention challenge the at- tention and interest and efforts of the student, develop her imagination and initiative, and animate and vitalize all of her work? If she is interested to see that children eat their meals, will she allow the dessert to be served simultaneously with the soup and consequently eaten before the soup? If she is to teach the undernourished patient the vital im- portance of assimilating his high caloric diet, will she not be interested to see that the meal she serves that patient is well balanced, well cooked, hot and appetizingly served? If she is telling the mother the importance of skin elimina- tion in the care of her baby, is she not likely to emphasize that instruction by giving the mother the best bed bath she knows how to give ? If she must teach health by radiating health and happiness, will she feel that she dare go about any of her work in a half-hearted, listless manner? I have said that we must provide a hygienic environment as a basis for training the nurse in the teaching of health. Our fifth step in that training is to demonstrate to her the function of the hospital as the health center of the com- munity; as indicated by Dr. Willard Cole Rappelye, we must show her the hospital "as a co-operative organization of workers and leaders devoted to the ideals of their respective professions; not merely an institution for the salvage of 200 human wreckage but a co-ordinator of activities-profes- sional, economic and social-in their application upon the problem of health." What she observes about her will in- fluence her more than what she hears in the classroom. In the out-patient department, she should see preventive work being done in the tuberculosis clinic, in the pre-natal clinic, in the well-baby clinic, in the dispensary and in the wards; she should find the patient diagnosed socially as well as medically. She should observe the hospital reaching into the homes of the patients to educate and make social adjust- ment. She should see plans evolved to give adequate pro- fessional care to that great group-the people of moderate means not eligible for free service but not rich enough to pay for private medical and nursing care. She should, in short, learn to look upon sickness as not merely a hospital case but as a family and community problem in whose so- lution she as a professional worker has a definite part. To summarize: The hospital and nursing school should provide in the curriculum didactic instruction in the pre- vention of disease, in Health Education methods; and a study of the social aspects of disease and the world's health program. This instruction, however, must be reinforced and emphasized by the student's daily observation of the way in which the nursing school gives her the opportunity to attain her health ideal, and by the way in which the hos- pital itself handles the sickness and health problems of the community. The first result of developing Health Education in the curriculum will be to make the individual nurse healthier, happier and more efficient. Even under present conditions, faulty as our organization is, we can, if we will, give her the opportunity to realize her health heritage. But more than that, we can, if we will, develop in her a habit of thought, an attitude of mind, that will impel her, even in private duty, to seek out opportunities to teach health and the prevention of disease. It may seem difficult, even im- possible to plan for, but if we are to prepare our nurses to fulfil their dual function of caring for the sick and of pre- venting disease, we must find a way. 201 Discussion Miss Anna G. Jamme, Director of the Bureau of Regis- tration of Nurses, San Francisco, California, who has been for many years in the forefront of every movement for the further development of nursing education, said of Miss Pickering's comprehensive paper: The fact that schools of nursing have been generally connected with hospitals, and that hospitals have taken as their function in the past the curing of the sick, has influenced the viewpoint that stu- dent nurses receive while in their school of nursing. The student in all this training has been, and is still, largely concerned with the problem of sickness. As she goes about her duties in the wards she is concerned with records that have to be filled in; with the patho- logical records that must be made; and she has before her always, as the medical student has, the picture of the patient in bed. Where the patient came from has not concerned her, and where he goes when he leaves the hospital has not concerned her. Consequently, it is little wonder that the nurses, in the majority, have been sent out from our schools, with the idea that their mission in life must be to take care of the sick, and that if they do not take care of the sick they cannot earn their living as nurses. The enlarging viewpoint on the value of health and the destructive forces of sickness bids us pause and consider how we shall prepare our future teachers of health, and no more valuable teacher of health can there be than the nurse, if she is properly trained for it. George Newman said that nurses are missionaries of health, and I think that is one of the most beautiful terms we can apply to them. If a nurse is to be a teacher of health, we must concentrate all of our efforts to see that she is properly prepared. There should be no justification for the existence of a school of nursing unless it plans to prepare its students for that which they shall have to meet after they leave the school, instead of preparing them only for the work that they shall do in the hospital. We are beginning to feel that the, school of nursing need not be attached to a hospital, but that it can be operated independently and then, with greater freedom of action, it can work out such a curriculum as you have had presented to you this morning by Miss Gray. That does not necessarily mean that the student will not be in the hospital to learn how to take care of the sick. The hospital is but the laboratory, where she can be taught. An interne is taught in the hospital, and yet the medical school is not controlled by the hospital. Neither should the training school be controlled by the hos- pital. In working out our plans for such a curriculum the nurse could have access to the dispensaries, the clinics and social service departments in her community, and there be given the whole picture of the patient, not merely as a hospital case, but as an individual, with a family to take into consideration. Should that come about, and it looks as if it might, for now we are working out two plans along this line in different parts of the United States, one at Yale 202 University and the other in California, the student can be given her health work concurrently with her work in school without over- burdening the curriculum. It illuminates and vitalizes her work, as Miss Pickering has said. She would feel that her patient did not merely mean poultices but living conditions and something far be- yond his sickness. Miss Pickering touched on a vital point when she spoke of the health of the student. It is a very sad commentary on a hospital if it admits to its school of nursing young women who are not physically fit, and if it maintains them in the school still unfit, in order that the needs of the hospital may be satisfied. The National League of Nursing Education has, for many years, advocated shorter hours of duty for student nurses, but if we could look over into our schools of nursing we would find that the long hours of duty are prevailing still, and the students are over-fatigued, a condition which has a great influence on their general health. Fortunately, you are today in a State where the hours of duty of student nurses are regulated by law. When this was first attempted the educational body of nurses rose against it, but it has been most beneficial and for ten years our students in California have been protected by the arm of the law in their hours of duty. I think I can say that nursing education has not had half a chance to develop its great possibilities. It has been shackled by the hospital and kept down to a minimum by legislative bodies in the United States, as Miss Gray has shown. Here and there some remarkable men and women have risen in defense of the standards that the League of Nursing Education has advocated. The educational groups of the country have been most helpful. We have knocked at the university doors and they have been opened to us. Teachers' colleges and junior colleges have come forward to give us help in our problem, and the high schools are doing everything they can to prepare students for our training schools. In spite of handicaps it is surprising how many nurses have led health teaching. I think that nurses are born health teachers. There is something inside of them that one can train and bring out, and we must use that tremendous, potential instinct. There are today up- wards of 51,000 students in our schools of nursing in the United States. Two-thirds of them may never enter into active nursing work. They will become mothers of families, and may they not be the most helpful health teachers? Do not allow our deliberations on the training of nurses and health teachers to rest here. As nurse educators we have discussed this many times, but now we have the privilege of bringing it before the great body of educators of the United States, and may we not say to them: "Go back to your different countries and to your communities, and do not let the students in the schools of nursing be isolated groups set aside for the use of the hospital. They are being trained for the use of the community.' Take an interest in them. See that those schools are measuring up to the ideals that we are trying to put before you at this conference. 203 The Chairman then introduced Dr. Walter McNab Miller, of the Tuberculosis Association of Missouri, saying: "As public health women, we have a sense of very close con- nection with the tuberculosis associations, for the rural work in the United States, from the standpoint of public health nursing, had its initiation through the activities of the Tuberculosis Association." Dr. Miller: About two years ago there was passed by our legislature a model health nursing law, and this law has secured the attention of the people of the nation. At the last meeting of our legislature it was repealed, and to this repeal reference has been made in the papers here this morning, so that I feel that I am called upon as one of the repre- sentatives of Missouri to speak in explanation of the action of the legislature. I am not speaking in its defense, for I am on the other side; but I want to speak in defense of the public health workers and of the practicing physicians and the practicing nurses of Missouri. 1 want to say that the public health officers, the volunteer health agen- cies, the practicing physicians, and the organized medical profession in Missouri have had common cause with the nurses in counteracting the influences which have been brought to bear, to lower the grade and standing of public health work in the State. The same forces that brought about the repeal of the nursing law succeeded in the last two years in striking from the Medical Practice Act the word "reputable" as applied to the medical schools from which physicians graduate and may be licensed in the State of Missouri. This has emanated from medical schools which desired to furnish practicing physicians whose training in medicine was less than that of the Medical Practice Act. It was from this source, backed up and sup- ported by revolutionary untrained nurses in St. Louis and other cities that the repeal was brought about. We are determined not to let this matter stand as it is today, and we hope in the course of the next two years to recover the ground that has been lost. Here followed a paper on methods of Health Education, by Miss Edith S. Bryan, Assistant Professor Public Health Nursing, University of California. Health Education as a Subject for Graduate Schools of Public Health Nursing Miss Bryan: THE subject of Health Education as a Subject for Post Graduate Schools of Public Health Nursing is one which needs thorough consideration at this time. To find a place for it should be considered by the nursing profession 204 as one of the greatest opportunities and obligations of the time. To use an influence demanding a place in the nursing curriculum, for the preparation of the nurse in this sub- ject, should be the duty of the non-nursing groups inter- ested in Health Education. In this way such training may be more easily secured by students desirous of teaching in the field of Health Education. In turn, all groups desiring teaching in this subject will gain help. It is the graduate nurse who has studied pre-natal life with its influences from heredity and environment and who has cared for the mother and child during the early hours and weeks of the infant life. With all the knowledge of health and illness thus gained, it seems only fitting and right that the nurse should be prepared to present this knowledge in the best form to the families who can better conserve life only when they have had such help and teach- ing. In the study of child life, in its normal growth as well as with its illnesses and handicaps, the nurse is given a most excellent foundation for the teaching of health to the pre- school and school child. In the work with specialists in the medical profession, the nurse gradually gains a knowledge of the early history and symptoms of the various diseases of man and should look to the time when she can use the knowledge to awaken in the minds of suffering mankind the great need for early care and the prevention of sickness with its consequent physical, mental, moral and economic difficulties. The nurse, before entering a post graduate school for public health nursing, has been thoroughly trained in the elementary subjects of physical life and its development. In the post graduate schools of nursing, she is given a deeper, more comprehensive knowledge and vision of health. She learns more of the normal growth and devel- opment of life. Working in the various fields of public health, she becomes a teacher of the individual and of the family. She teaches the expectant mother what care is necessary for herself and the expected child. As the child grows older, the nurse becomes teacher and guide of the individual and of the family. Thus she strives to secure for each and every one a safety from disease, through varied preventive measures, and a healthful development and growth through proper nutrition and health habits. 205 These are great forward steps from the old path of cur- ing disease. The possibility of preventing disease by cer- tain measures which have been discovered was one forward step in health. Another great forward stride was accom- plished when it seemed possible to teach each individual his peculiar need for care and precaution. Like a great "Mother of Humankind," a nurse, with such a background of knowledge of life, sickness and health, and with such a vision of prevention and protection for the individual, will brood over all those under her care and, in the real fashion of mothers, spend herself in their behalf. What is it that the nurse lacks ? Wherein have we failed in training her? The failure in training lies in several points. First: In not filling her with a vision of the possibili- ties of every child, trained to self-care and a determined self-development. Second: In not presenting to her all the material which could be used in teaching health; and in not considering with her all the methods of the presentation of her subject. Third: In not showing her how her work of teaching health should be linked up with the work of the teachers in the schools. Just here we must recognize and emphasize to ourselves and to the nurse that her training has been along professional medical lines and has not included the psychol- ogy of teaching. It seems to be self-evident that it is the nurse who has in hand all of the material for teaching Health Education, and the teacher who has the power to present it. One of the great questions to be solved at this time in Health Education is whether we should require more time to teach the nurse the educational methods or whether we should develop a means by which she can prepare the material and give it to the teacher for presentation. I have always believed the latter method the better of the two. The method adopted by the group training the public health nurse, is a matter of great importance, without a doubt. The success of the teaching of Health Education rests in great meaure on the decision. This is, however, surpassed in importance by the need to persuade the leaders of post graduate courses in public health nursing that Health Education as a subject for these post graduate schools must be adopted. In the end, time and experience 206 will show us who best can be the teacher of health and how best we can teach the public. The Chairman: It is appropriate that this paper be discussed by one of the medical profession who is closely allied with public- health nursing, and I take pleasure in introducing Dr. Estelle Warner, Director of the Department of Child Hygiene of the Oregon State Board of Health. Dr. Warner: As to the method of teaching Health Education as a post graduate course for our public health nurses, we feel with Miss Bryan that the nurse is not really the one to do the actual teaching in the schools so much as she is the one to direct the teacher in teaching Health Education. But we do feel very strongly that the nurse, as well as the teacher, the physician, the nutrition worker and all interested in Health Education, must base her training on absolutely scientific investigation and scientific facts, which shall be given in the most scientific way possible. And, too, we feel very decidedly that each and every one of us engaged in Health Education has her own part to offer; that Health Education is not to be presented by physicians alone or by nurses, physical educators, nutrition workers or teachers alone. Health Education is in the crucible for mold and shape and form, and we each share a part in bringing about the desired result, which is the education of health workers, teachers, mothers and all. It took at least 20 years to develop a curriculum for nurses in their training, and it was only very recently that one of our leading physicians developed the idea that infection could be prevented by cleansing the hands and by the use of rubber gloves. We have now adopted that as a way of preventing infection, and still that man long stood alone among physicians in advocating such an idea. And so we are each of us offering our contribution to make Health Education what we wish it to be. We may stand alone in the face of all other educators, and of all other people interested in Health Education, but we must realize that we are absolutely dependent on other men or women to help us promote the idea. Health Education, then, as a post graduate course for public health nurses, is a course that should be based upon absolute science. It is also a course that should develop a co-operative plan of work in which every single one of us has a part to play. And finally, Health Educa- tion as a course in post graduate schools of public health nursing must emphasize again the fact that public health nursing or public health education is going to go just so far as the physician goes with it; that Health Education is absolutely dependent upon the research that is contributed by the physician in his technical laboratory or the laboratory of the practice of medicine, and that Health Education cannot go far unless the physician goes hand in hand with it. 207 Miss Thomson said of Miss Bryan's paper: The subject of Health Education in post graduate schools for nurses is one to which I have given much attention in the last few years. I think we all believe that each of us, in our separate way, has a contribution to make to the whole Health Education scheme. Miss Bryan brought out a very splendid point, I think, when she said that the nurse could not, in the nature of things, be expected to present the material in many instances, nor does it seem to me to be desirable that she should. As we have considered it in the development of the curriculum in training schools and its injection into this curriculum of Health Education, we have thought of nursing education as being fundamentally a part of other forms of profes- sional and technical education. As nursing education comes into the universities, the preliminary work of the student nurse, the student of social work, the student teacher, whether for public school or for special teacher in nutrition or physical education, and the preliminary work of the pre-medical student will be similar. These students will be getting the same general background. If we all have the same background it will be rather simpler for us to co-ordinate our later programs; and it will not be so difficult for the nurse to talk to the teacher, or the teacher to come in contact with the nutrition worker who has her special information, and with the student day by day. Health Education, then, has to be something which is given by all of us to all children, considering the child from before birth until he becomes an adult, and it must be related to everything else which the individual does. Health habits will have to be given to the child in connection with other things. Health Education must be in the hands of the mothers and the teachers, and our contribution is to give to those coming directly in touch with the child the thing which they may use. Post graduate schools for nurses in public Health Edu- cation will go out of existence as we develop a better preparation. But when we have all necessary education as a part of educational institutions, the post graduate school can look forward to doing something other than teaching Health Education. Having concluded these remarks on Miss Bryan's paper, Miss Thomson said: "No discussion of public health nursing or public Health Education from the nursing angle would be complete with- out a contribution from a representative of the American Red Cross because of the large part that organization has played in the development of public health nursing." Miss Mary L. Cole, Director of Nursing of the Pacific Division of the American Red Cross, was then introduced. Miss Cole: Health Education in the schools has undoubtedly come to stay, and nearly everyone is willing to concede that the nurse is an impor- tant factor in this field. 208 In the past-and it is true even today-it was only the exceptional teacher who gave the child's physical condition more than a passing thought. .It was in this capacity that our public health nurses have acted as pioneers all over the United States. The statement was made yesterday, by one of the eminent speak- ers, that some 52 per cent of the school teachers in this country were scarcely equipped to teach the elementary subjects. Little wonder that in the isolated, rural districts the hygienic conditions of school- rooms and premises are frequently appallingly bad. These young, inexperienced teachers, ignorant of, or indifferent to, the most ele- mentary laws of hygiene, have been entirely unable to cope with this big question of the physical fitness of their young charges. General knowledge of hygiene and sanitation, or intelligent dietary habits, has been notoriously lacking in our rural districts. Our public health nurses, trained to detect and point out to the teachers and trustees the unhygienic conditions of the schoolrooms and prem- ises, have brought about numberless improvements in the school en- vironment. They have followed up their physical inspection by friendly contact with parents in the schoolroom and in the home, getting corrections of existing physical defects which would never have been accomplished without them. The nurse in going into the schools and the homes with her gospel of better health for children has given an unprecedented impulse to Health Education in America today. It has been pioneer work. She has made mistakes and has had to suffer for them. She has too often regarded the problems as exclusively her own, forgetting sometimes that they belong as well to the teachers, the doctors and the parents. Nevertheless, the public health nurse has been a "prophet crying in the wilderness" with the result that the educators of America are seeing that their teachers will be fulfilling their tasks only when they include in the education of the mind of the child, the necessity and value of a healthy body. The Chairman: The first visiting nursing on the Pacific coast was done in Portland, Oregon, under the leadership of an interested group of women, and we are fortunate in having the present superintendent of the first visiting nurse association on the Pacific Coast, Miss Marion G. Crowe, of Portland, Oregon, who will talk to us from the standpoint of the Superintend- ent of the Visiting Nurse Association. Miss Crowe: In this topic, "The Place of the Nurse in Health Education," I find a degree of difficulty. From my point of view, Health Education means more than a correction of physical defects. Unless the nurse carries into her work a deep appreciation of its significance, she fails to give it her full "human interest." It is of the fundamental training of the public health nurses I wish to speak first. The foundation is a thorough hospital training 209 based upon a high school education. In the past we have found training schools accepting nurses who have only gone through the eighth grade, and this low standard affects not only their own status but the standards of the profession. The mental discipline of high school is quite as essential in the nursing profession as in any other, and a college training is still better. We are now facing a "stiffening up" of educational requirements for admission. There has always been a shortage of applicants. There are several reasons: first, long hours; second, strict discipline. There are other difficulties of more or less importance, and when to these we add higher educational re- quirements, they are not always welcome. After leaving the hospital, we find ourselves divided, and those of us entering the public health field face a new responsibility-a neces- sity for further training. In the hospital, the activity of the nurse is confined to individual work, but in public health she encounters for the first time the community problem. Every case which she meets in her daily work is considered not only from its physical and indi- vidual standpoint, but also from its social standpoint, its relation to that greater group we call "Society." The nurse finds herself one of the responsible units in the community, perhaps the more responsible because of her knowledge of the principles underlying individual health, and she must now apply those principles in com- munity health. She knows, if the social health of a community is below par, that she shirks her responsibility if she does not point out the danger spots. She admits neither creed, color, race prejudice nor politics in her scheme of things, and she has but one standard-that of the good of the community. We enter a field where every child is entitled to: 1. A healthy body, 2. A healthy mind, 3. Adequate preparation for his life's work. The last epitomizes your responsibility and mine. The teacher must train his mind, the nurse must help to give him a sound body, and together we must interpret life to him in its fullest significance and prepare him to enter his life's work with a deep sense of its spiritual significance. It is the nurse's part to interpret for the child the fact that a healthy body is secured only through proper health habits, and that it is his sacred duty to care for that body through these proper health habits. The nurse should carry this message into her work with chil- dren, through pre-natal work, well baby clinics, pre-school program, and then through the schools. All of these are but divisions of our work, in the homes of the parents. Here the uniform is a key which unlocks the door of many a home. In our pre-natal work we teach the expectant mother how to care for herself so that the new baby faces life with a healthy body. She is taught the value of proper food, rest and exercise, while we watch for danger signals and interpret their significance. After the baby comes, the young mother, and many an older one, is shown, through our teaching, how to keep the well baby well. Our pre-school work is not as fully developed as we would like. We are not as active as we 210 should be with the toddlers of what Dr. Lucas calls, "mud pie age." May I recommend a careful reading of the chapter on "Habits" in his book, "The Runabout Child." He tells us that it is during this period that we should watch the development of habits most carefully. Then comes the large program in the schools with which we are familiar, but which from our point of view has never been as fully developed as we would like. We know the reasons which have ob- structed the realization of the plan, and it is through our work in school that we have realized the neglect of the pre-school child. It is in the school that we have found the physical defects such as bad teeth, adenoids, defective vision and hearing and malnutrition, all of which help to produce the backward child who is the absorber of the energy of the teacher, the future delinquent, and the most expensive pupil in the system. For the backward child we maintain specially trained teachers, special equipment and care, special items in the tax budget. If only for this one group-that of the backward child-the school nurse is justified in her existence. The teacher has neither the technical training nor the time to meet all the needs of this child; she is concerned with her task of get- ting him through his grades, and with the present system of over- loading her strength with large classes, she has little time to see that the child is inattentive because he cannot learn all that he should or cannot see the work on the blackboard, or is dull because he cannot breathe his full share of fresh air. No one knows better than the nurse how much of the teacher's energies are absorbed in her class, and how exhausted it leaves her when the day's work is done; and when to her difficulties is added the task of meeting the handicaps of the backward child, how her problem is intensified. It is here that the school nurse is especially valuable; she is the link between the home and the school, and she finds in the home the real cause of the difficulty, perhaps a mother below grade mentally, or perhaps a father of low earning power who cannot provide the food required by the growing child. Here the nurse can bring about an adjustment through her knowledge of social resources. It is in school work that we meet the full social value of the work of the nurse. She meets in the home the full failure of society to protect those who cannot protect themselves, either because they are men- tally unable, physically incompetent, or criminally inclined, and the children in the school are the visible consequences of these anti-social groups. The nurse finds herself interested in housing when she traces John with his tuberculous hip into a home where there has been a Sv irce of infection from infancy, through a tuberculous father or mother, crowded into rooms with little ventilation. She points out the way to the new education methods, and suggests the open air school or day camp for this unfortunate child, and she carries her message to the public, pleading for definite prevention through proper housing and careful segregation of incipient or active cases of tuberculosis. The nurse through technical knowledge opens visions of active play to the little cripple, where mind and body are both neglected and, through her contact with other agencies, brings to the child the 211 opportunity to be straight and strong and brings to him the special teacher to help in his mental growth. We find that the children themselves are intensely interested in health work, and the Health Fairy of our Portland Visiting Nurse Association is a familiar figure. One of our nurses is a skilful trained dancer, and is literally a fairy, when she trips out on the platform dressed in fairy costume and carrying a Pandora box of good health, containing health symbols-Micky potato, Cry baby onion, Mistress bread, Sparkling water, Fluffy spinach, pure milk and fresh eggs. These she explains to the children, after she has captivated their atten- tion with a fairy dance, and winds up the program with a dumbbell drill and toothbrush fantasy. We usually find the children going through the dance and capering about in imitation of the fairy after the performance. The teachers say it is one of the most attractive methods that has been devised for getting into the child's conscious- ness, the value of the different articles of food, and it is a demonstra- tion of the new method of teaching "positive health" principles instead of the old-fashioned method of teaching them "don't." The Chairman: Teachers, nurses, lay people, everyone, for some time have looked to the Child Health Organization and to Miss Jean for inspiration. Miss Jean will now speak on The Nurse's Opportunity in Health Education Miss Jean: THIS is the first attempt that has been made on the part of any group at an educational conference to consider the training of the nurse. It is a very significant event, a forward step symbolizing the advancement of the universal movement for Health Education. Because the eyes of the whole world are directed to America for guidance in train- ing leaders for the building of healthy human beings, we must prove worthy of our recognition in health progress. All women have the maternal instinct; in some it is more fully developed than others. We have not used that element sufficiently in attracting the finest material to the doors of our nurses' training schools. I am very sure that women want to do the difficult and the hard thing. Nurs- ing is difficult; it is hard. The nurse who has service for her motive has experienced all sorts of difficult, hard things. With the plans that are being laid today to ease her course, to carry her more readily towards this goal, we want to be very sure that we are not softening the fiber of this woman. It is necessary for her to be willing to sacrifice, to be willing 212 to do the hard thing. If she has not that spirit of sacrifice, we are not going to make her a good director or a good teacher, whether at the bedside or in the classroom. As teachers we are inconsistent, for in no place in the training school curriculum have we provided for the student nurse's physical welfare. We are training her to teach health, to be a living example of health, but we have lost sight of the fact that she is a human being. The girl who must study at night after ten or twelve hours of work- and she is still serving that number of hours in the majority of hospitals in this country-the girl who must study after long hours of physical work, cannot be expected to be very enthusiastic about the practice of health habits. What is the result? Look at any group of training students. They look like all college students at graduation, below par. As leaders, we should take definite steps to remedy this partic- ular condition. Judging from a recent conversation of student nurses in a hospital connected with one of the largest American uni- versities, I conclude that the diet offered them today is similar to that which you and I had in training school. Have we applied our knowledge of nutrition and dietetics by correctly feeding these girls who have entered the hos- pital at so great a sacrifice? We must not let them leave us with their ideals of healthful living shattered, with the belief that we are not interested in giving them proper food and sufficient physical exercise during their training course. We nurses have had an idea that we had a monopoly on health teachings because we are representatives of health, because we know pathological conditions and because of the years we have spent in time, physical energy and mental energy in training to care for the sick. But how very little training in actual knowledge of the normal human being have we had for work in a school with normal children. Picture a school of pupils with twenty-five teachers, one nurse, and an occasional medical examination. This exami- nation is about to be held; the nurse is there; the teachers are there. The teachers look upon the nurse as a person who will help them prevent the spread of contagion. They think she will help them prevent absences, through the cor- rection of defects. They had not thought of her at all as a person to teach in their classrooms; really to teach those children, through the teachers, to keep well, so that they 213 would not have to drop out of classes. It is evident that the nurse must establish this new place for herself. After the usual training and an additional bit of public health work the nurse leaves the hospital, later to enter our schools to work with children in the schoolroom. We expect her to know how to interest them in cleaning their teeth, drinking milk, going to bed early and practicing other health habits. How can we expect a woman to do such work unless she has studied the principles of teaching? The nurse should have an understanding and appreciation of pedagogy. In addition, she might well have applied psychology and a knowledge of biology. I remember a little girl in my training days, Adele, very pretty, golden-haired, most attractive, with that quality we call charm. She was the pet of the hospital. She had an amputation, keeping her in the hospital a long time. She had the best that science and skill and love could give her. She went home, dismissed, and came back for observation the second week. We scarcely recognized her. She came back the same little girl we all know, the same little girl whose mother is not intelligent in her care, the same little unbathed body, the same uncared-for teeth, the same lack of proper diet and lack of sleep. We had had Adele for three months, and it had not occurred to any of us that it was our business to establish health habits which she could carry home with her, as well as pretty clothes. She carried home the best that surgery and nursing could give her. We had given her love, care, attention, proper diet, and had seen that her teeth were cleaned and her body washed, but we had not interested Adele in following out those ideas after she left us. It had never occurred to us that it was worth while to interest Adele in cleaning her teeth and in drinking milk every day. We had lost an opportunity to promote Health Education. Such opportunities are being lost every day. If we have, as nurse in our school, such a well-trained, fine, radiant human being as we idealize, what is the rela- tionship to be between her and the teachers? It is unde- fined, but it is the crux of the situation as it exists prac- tically everywhere. The school nurse was superimposed after the establishment of the school system, and the edu- cators of the country do not know just what to do with her. 214 She herself does not quite know how to get school authori- ties to use her effectively. We come to another problem. When the nurse selects school nursing, she frequently accepts opportunities under a political regime. A director is appointed, usually, to take charge of the nursing division of that city or State. Some- times she is a fine person; sometimes she is not. She ap- points her nursing staff, and each nurse attempts to do the impossible. There are cities in the United States where nurses are attempting to do health work with six or seven or eight or nine or even ten thousand children. I attempted some years ago to take care of 20,000 children over a period of three years. What a stupid thing to do! How can any- body even try to supervise the health of 20,000 school children? Yet we foolishly continue doing that sort of thing. What is the remedy? How can we change this situ- ation? First of all, the public must realize that it is not worth while to pay the salary of a nurse, whether it be $50, $100, $150, or $200 a month, if she has more work to do than she can do well. We have assimilated more duties than we can do justice to, in the field of public nursing, including school nursing. How can we make the public appreciate this? We have failed to get our story to them: That we are ready and will- ing to serve, but we must have an opportunity to serve skillfully. If a city with 10,000 pupils decides it can afford a school nurse, that city can be brought to realize it is more beneficial for her to give a demonstration in a small section where she can give real service than to ask the nurse to spread herself over 10,000 children. The nurse, I am con- vinced, cannot take care of more than a thousand school children. In order to back up the work of the school nurse, we must have dispensaries that are really teaching centers. We have awakened to the importance of making a dispen- sary not merely a series of rooms with clean, white walls and benches, doctors and nurses. Children come to a dis- pensary in a receptive mood. We allow them to sit there for an hour or two hours, as the case may be. Then they leave us without having any more impression made upon them than that the doctor said they were to do this or to do that, a bottle of brown medicine, or a treatment of some sort. We have not gotten over to them in what should be a great 215 teaching center, a single health idea, and we ought to send them out with a sense of understanding of some of the great fundamental principles which would make it possible for them to live bigger, fuller and better lives. A while ago I heard a nurse in one of our large hospitals say: "You know that little Greek girl who gave so much trouble in the ward? Well, she is scarcely ever naughty now since we gave her a little book of health rhymes." It was one of our best hospitals. Yes, the little patients were spotlessly clean, beautifully clean; their diet was quite all right; it was measured and weighed and carefully super- vised, but there was no attempt, as the children lay there, to interest them in health by games, stories or other devices though they were surrounded by health. The nurse has an opportunity to use these children as her health-teaching laboratory. How often the dispensary fails to function as a teaching center. A little girl with anemia had been one of the school nurse's troublesome cases. The mother was a usual mother, the child a usual little girl of eleven. The school doctor had made his examination and found no particular difficulty, but asked for a thorough physical examination such as could be made at the hospital. The mother was asked to take the child to the dispensary. After some detail of arrangements, borrowing a hat, for instance, from one neighbor, finding another neighbor to take care of the baby, putting the dinner on the back of the stove for father, and making plans to cover car fare, Isabelle and her mother started for the hospital. It had taken weeks to get up their courage for the trip, as you know it often does. Isabelle was entered as a dispensary case, was examined by one of the most skillful physicians in America, passed through the hands of several excellent nurses, and finally she left the dispensary. When Isabelle went back to school the nurse asked eagerly: "What did the doctor say?" "He didn't say nothin'." "Oh, yes, Isabelle, he must have said something. You had Dr. So and So; he must have told you something. What did he say?" The nurse was anxious to know, just as thousands of our school nurses are anxious to have the word of the master who guides them. The child said: "He didn't say nothing, except those things you were always telling me about-drinking milk, going to bed early, and eating spinach and things like that, and I don't like them." That was all 216 the effect that a fine bit of diagnosis had had on that child. A little slip of paper announced anemia. It gave the nurse the information she needed, assuring her she was doing the right thing. But wasn't it a waste of time and money and skill to have that child go into that splendid dispensary and to leave without any impression of health habits having been made on her mind? Capture the child's imagination and make him under- stand something about health; otherwise all the advice in the world is valueless. During the first visit, interest him in milk; next week, spinach; next week, open windows; and so on through all the simple laws of health. Of course, it is useless to teach open windows if children are sleeping four or five in a room without windows, as is often the case. So we come to the final problem, that of making the nurse a socially minded human being, one who realizes that her job includes the opportunity to influence the public and assist in changing present economic and social conditions. I see the school nurse of the future of such great value that we shall make of her a leader, not a teacher in the class- room. She is to be a teacher of teachers. She must go into the field as a leader of the people. We have heard this morning that we have 52,000 pupil nurses in the training schools of America. We are inclined to make them fol- lowers. That is one of the weaknesses of our training schools all over the land. We must be sure that before they leave us they understand that their job is a big one, that their opportunity is a very big one, and that they are not just followers, but leaders. The Chairman: I have been given the privilege of an- nouncing the scholarships that are to be given to nurses by the American Child Health Association, These scholar- ships will range from $200 to $1,000, and are to be given to nurses who have already done some phase of child work. The object of these scholarships is not so much to help the nurse to a degree as to help her perfect herself along some special line which has to do with building healthy children. If you are interested, write to the American Child Health Association, 370 Seventh Avenue, New York. The resolutions on Nursing Education approved by the Health Education Conference and adopted by the Plenary Session will be found on page 344. 217 Since a large number of those present desired an oppor- tunity to discuss this subject further, a Round Table for Nurses was arranged, a summary of which follows: Round Table on the Nurse in Health Education The Chairman, Miss Thomson, stated that the object of the Round Table was to discuss informally nursing problems in Health Educa- tion. Problems suggested by many nurses were: The maximum number of children to be assigned to one school nurse; how many patients can an instructive visiting nurse carry; and, what prepara- tion does the nurse require for her part in Health Education? She said: "The last problem is particularly important as the representa- tives of the three national nursing organizations delegated to attend this Health Education Conference are preparing a joint report which will be presented to each of the boards of directors at their January meeting. These reports should include recommendations for adequate preparation of nurses who are to be health educators and the ideas of the individuals making up this group will be most valuable in help- ing to formulate such recommendations." Dr. Miller, of Missouri, made a plea for instruction in tuberculosis nursing for undergraduate nurses and especially for public health nurses. Miss Perritt, of Arkansas, suggested the possibility of the nurse, in the remote community, finding the use of the stethoscope valuable in locating the child who especially needed a doctor's services. Miss Anderson, of New York, stressed the importance of studying the whole field of work in connection with the school child and the need for the correlation of the home and school. She said the nurse should take the family, as the unit for health work, and not the school child, and suggested that co-operation could be established between the school nurse and the district nurse whereby a complete service could be given; that while health habits were important, their permanence could not be assured if the home environment was unsatisfactory, and the nurse should feel that this part of the work demanded her best effort. Miss Friend, of Missouri, said it would be necessary to stimulate community interest for the support of nursing education if nurses were to have the scientific training which seemed necessary; the burden could not be entirely carried by training school superintendents. Mrs. Blakely, of Oregon, spoke of organization for public health work, by the use of community groups in various parts of a county, through which the nurse did a great deal of her educational work and made her contacts with the families. Miss Wood, of California, stressed the importance of recognizing the patient as an individual, normal as well as abnormal, and recom- mended more training in connection with social service departments in hospitals. Miss Cole, Director of Nursing, Pacific Division, American Red Cross, said it was the consensus of opinion that public health nurses 218 are trying to cover too much work. She said it was time for nurses to endeavor to inculcate the idea that a nurse does not accomplish very much for the public good when her work is spread over too large a territory, and that it would be a great deal better for her to spend her time making a thorough demonstration in a small terri- tory. She continued by saying that the community itself was an important part of the whole scheme of public health work and if they are not interested in it, it is because they have not been brought to realize that it is a community problem. Mrs. Isabelle W. Baker, of the Pacific Division of the American Red Cross, brought out the importance of careful preparation in pedagogy for the nurse who is to teach Home Hygiene and the Care of the Sick. She said that many requests were coming for such properly equipped individuals and courses were to be offered to sup- plement the nurse training, which would give the normal rather than the abnormal viewpoint. She also asked for constructive criticism of text-books which are used in schools of nursing. Miss Jean questioned Miss Perritt relative to her work in the locality where she used the stethoscope. This brought out the fact that there was a county medical organization and that the physicians did not object to her work. Miss Jean said that Miss Perritt's prob- lem was similar to that of hundreds of other nurses and that she felt it was a mistake to spend time using a stethoscope when there was so much to be done. She said, "Is it worth while when a nurse's time should be devoted to becoming a leader of the people, permeating them with health thought, raising their standards so that it will be possible to do the right kind of school work and dispensary work?" She stated her belief that it is impossible for a nurse to give physical examination to 1,600 children and at the same time act as a stimulator of the com- munity in health matters. She expressed it as her personal view that no nurse could take care of more than a thousand children in a school and at the same time afford the stimulating influence of which she is capable. Referring to the nurse in the home, Miss Jean agreed that there is much there for her to do, but that on account of the limited number of nurses it was impossible to think of putting a nurse in every home. She said that a doctor whose views she had asked about work with pre-school children had expressed the belief that the pre-school child belonged to the family doctor. She said, however, that excepting in a few communities it was absurd to talk about family doctors, because so many people did not have them; that in New York City only about 1 per cent of the people had family doctors. Facing that sort of situation, the nurse must learn to work with the group to save herself. Mothers, she said, must be interested and prevailed upon to be present at school examinations. The gauge of efficiency of the school nurse was going to be the extent to which she got the interest of the mothers. In regard to the training of the nurse, she said she did not believe that the nurse without the background of scientific training would get very far in actual service to her people, because to become a leader in the community she must be respected intellectually. 219 A delegate here asked Miss Jean why she wanted the parents at the physical examination, to which she replied: "I think that is a very natural question. We did not use to do that. There were two reasons. First of all, we are trying to socialize the school today. The school used to be like a jail; it belonged to the teachers; it was not a socialized place. We are trying to break down that barrier, and the nurse has a real place in that effort. Her part of that is to have the fathers and mothers come to the school and know it." Miss Jean stated that a committee of the American Medical Asso- ciation and the National Education Association, with Dr. Wood as chairman, decided on the question of the number of children to be cared for by a school nurse, that a nurse should take care of 2,000 children in schools which are closely situated geographically. She expressed it as her personal conviction that no nurse could properly or wisely take care of 2,000 children, and she hoped to see the standard set at a thousand. Miss Anderson, of the National Organization for Public Health Nursing, stated that in New York City they are working on a demon- stration with a nurse for every 2,000 of the general population, and that the more nurses they had the more work was developed. In this demonstration they have had to discontinue their propaganda because they are unable to render the service called for. She added, "I do not think anyone has ever evaluated the cost of a real, honest, scien- tific health program. We are always afraid of it. We have done what he could, but we have not gone far enough." Miss Davis said: "We are going out as health teachers, and we are not prepared as teachers." She asked where and how the nurses were to get this preparation. She asked whether it would be feasible for some of the nurses in training schools to teach some of the classes and give some of the demonstrations, in order to get training for their work. Miss Pickering said that the nurses who are doing community work are usually women who have had a public health course. She added that in the nursing schools there have been no courses in psychology. She thought that everyone was working to get psychol- ogy into the curriculum, but she did not see how the nursing school could be expected to provide the special preparation needed for the special type of work. Speaking of further training for those who have not had normal school training, Miss Jean said that there was much that they could do for themselves, calling attention to the numerous new books which are being published on applied psychology, mentioning "The Power of Suggestion and Auto-Suggestion," by Boudman, and "The New Psychology and the Teacher," by Hugh Crichton Miller. The Chairman stressed the necessity of training in pedagogy, and said that those nurses who do not have it could get it, pointing out that this course, and many others are available in many schools, and that the nurse should plan to go to the summer session of the university or normal school in her locality where she will always be welcome, either as a regular or special student. In conclusion, it was decided that we are not yet ready to begin 220 in all of our communities what could be called an adequate service but that an inadequate service carried too long is unwise. Adequate service was interpreted to mean the number of individuals or families who could be well served but that that number varied greatly ac- cording to the type of work being done. PHYSICAL EDUCATION IN RELATION TO HEALTH EDUCATION THIS program was prepared by the officers of the Physical Education Section of the National Education Association, elected at Boston during the 1922 ses- sion-Miss Ethel Perrin, Chairman; and Doctor William Burdick, Secretary. In making this program the committee had two leading ideas in view: 1. To connect physical training with some phase of edu- cation which would be of special interest to general educators. 2. To give the physical training teachers the most pro- gressive and sound ideas on one present-day problem of importance. The endeavor was to make the program general and technical in order to interest both audiences. It may appear that boys and men receive too little attention, but as a matter of fact their big muscle needs have received so much attention in this country that their program is fairly stable, and, while it is just as important and interesting, it does not need our individual attention as imperatively as the program of our girls and women. The committee in charge of the International Health Education Conference invited the officers of the Physical Education Section to hold the 1923 meeting as a part of the large health program, and after holding several conferences with this committee it was decided to accept this invitation because all people interested in health subjects, of which physical education is such a vital part, would be assembled at this one center, and because all contributing health fac- tors should work together. Miss Perrin not being present and Doctor Burdick pre- ferring to enter into discussions from the floor, Dr. Thomas D. Wood consented to act as chairman. 221 In accord with the general plan of the Conference to have resolutions based upon the meetings to present to the Plenary Session, Dr. Wood appointed a committee from among those present. The resolutions prepared by this committee and adopted by the Plenary Session will be found with all other resolutions of this Conference on page 344. This business having been taken care of, the Chairman introduced as the first speaker on the program, Dr. Herbert R. Stolz, Supervisor of Physical Education, State Board of Education of California. Behavioristic Psychology and Physical Education Dr. Stolz: I DID not select this topic for discussion nor did I elect myself to discuss it. I am reminded of the preacher who announced that in the remaining twenty minutes of his time he would speak of Heaven, the World, the Flesh, and the Devil. I hereby serve notice upon those who are to discuss the paper that I do not feel qualified to dis- tinguish between behaviorism as a doctrine and behaviorism as a method in psychology, nor will I be drawn into any argument as to whether behavior is expressed exclusively in muscular and glandular activity or whether it includes other hidden reactions in the makeup of the person who is behaving. I am not a psychologist and I do not believe that those who planned this program expected me to deal with the topic in any such technical fashion. In the brief time allotted to me, I cannot even tell you what little I know of the very significant implications which behavioristic psychology holds for education in general and for physical education in particular, but although I am sorry that an abler person was not selected to make this presen- tation, I am very glad to see this emphasis placed upon the vital relationship which exists between the findings of psychology and the activities which are carried on in the gymnasium, the swimming pool and on the playing fields. In the past, we have neglected the psychological aspects of our particular problem in education. The traditional treatment of psychological data, in so far as it was appli- cable to school education at all, was shaped to meet the needs of teachers of arithmetic and reading, of geography 222 and Latin. The foundation stone of the older psychology was the assertion that mind and spirit were things quite apart from the mere physical body. But the revolt against this concept is growing stronger and more widespread every day. The demand is that the child in school be considered and treated no longer as though he were a physical shell containing more or less of the precious mental stuff and surrounded by an invisible spiritual aroma. On every side we hear the demand that the child be dealt with as an integrated whole, rather than as a bundle of separate physical, mental and moral traits. On the one hand, the classroom teachers of traditional subjects are becoming aware, as never before, of the physical aspects of the child's growth and development, and upon the same premise we as leaders of physical activities must become increasingly aware of our responsibility in guiding children in their mental and social as well as in their physical development. Of course, this is already being done as a matter of common sense in spite of the opinion of some very dis- tinguished educators that physical development is the only legitimate objective of physical education. But, at this juncture the definite experimental findings of the behavior- ists have given an added push and significance to the educa- tional theory underlying the public playground movement and the public school physical education movement. There is an unmistakable effort to throw off the philosophy shaped by Aristotle and intensified by mediaeval scholasticism which stigmatized the body as an unavoidable encumbrance to mental and spiritual growth. The behaviorists, upon the basis of experimental data, boldly assert that conduct is dependent not upon hypo- thetical intellectual ideals, but upon the interaction of im- pulse and habit with each specific situation which the indi- vidual encounters; and furthermore that habits are laid down in the living stuff we are made of, by doing things. Thus education becomes the progressive improvement of the learner's behavior. But I must pass on to a consideration of that specific implication of behavioristic psychology which seems to me 223 to be of especial interest to physical educators; namely, that we can select, organize and guide physical training activities so as to develop habits of leadership, follower- ship, forbearance, good fellowship, courtesy, loyalty to school and to ethical principles of fair play, while at the same time we guard against situations and methods which might tend to establish habits of bad social conduct, such as taciturnity, overbearing conduct, revenge, disregard for the spirit of fair play, carelessness of the rights and wishes of others. Assuming that moral character and social adjustment can be moulded to some extent by school procedures as well as by home and community influences and that physical activities such as tag, folk games, basket ball and calis- thenics performed simultaneously with a group, have a positive and permanent effect upon the habitudes, attitudes and ideals of a boy or girl engaging in them, because, as Dewey says, "Every ideal is preceded by an actuality," and "Morals has to do with all activity into which alter- native possibilities enter," the findings of behavioristic psychology and of practical experience point to the unus- ually favorable opportunity which the physical educator may command to develop in his pupils the habits particu- larly needed in our highly organized civilization. It is true that in our larger elementary schools and in all of our high schools the program of regular curricular and extra curricular activities is so extensive and so varied that there are many constantly recurring situations of physical education which may be used and should be used to accomplish this same result. There is opportunity for developing leadership in connection with class organiza- tions and school clubs, in student body meetings and in scholarship societies. There are situations in class instruc- tion and in the many administrative relationships within the school which can contribute if the teachers are able to command them. Physical education has no monopoly in this matter, but it holds a key position. In the first place, in the very nature of physical training activities there are more opportunities for the boy or girl to make a choice between two or more actions than the conditions in a classroom afford. Contact with other boys and girls recurs more frequently and under constantly changing circumstances. The chances to be friendly or 224 taciturn, obliging or selfish are greatly enhanced by the relative freedom from restraint in the dressing room or on the field. For this reason, an observant physical director usually knows more about the real character of a body than any one else on the faculty does, although teachers of manual training and home economics have similar advan- tages of observation. In the second place, the quality of the situations arising in connection with games and sports is certainly very dif- ferent from that of situations in, let us say, the English class. The natural hunger of all young animals for big- muscle activities, which is enhanced in the case of children by the enforced inaction in the classroom so that they leave the building with a whoop; the physiological reaction to ex- ercise with its increased circulation and the increased tone of the muscles and glands, and finally the rivalry which is a part of every game,-will combine to give an emotional drive to physical-training activities which renders their situations peculiarly effective in moulding character, and incidentally, particularly difficult to handle. Character is formed most enduringly by choice of action under the stress of emotion. The boy who can be thoughtful of the rights of others while he is playing basket ball can be trusted to be thoughtful under most of the conditions which he will encounter. The girl who can be sympathetic towards the players of the opposing team when her own team is losing has developed an asset of no mean social value. A third circumstance that gives the teacher of physical education exceptional power and, therefore, added respon- sibility, lies in the fact that of all the activities of the school, the physical training activities are most likely to carry over into the child's leisure time before and after school and at recess, and consequently habits established in con- nection with these activities during the physical education period are the most likely to survive because they are the most frequently practiced. This carry over of habits of social adjustment is quite distinct from the also desirable carry over of habits of activity into leisure time of later years. I realize that any systematic attempt to use physical training activities in developing moral and social qualities adds very appreciably to the work of the physical educator. It makes of teaching a fine art rather than merely a leading 225 in the technique of the subject. Its successful practice en- tails a knowledge of child behavior, the habit of carefully observing and recording the traits of individual children as they are expressed in action, the devising of plans to prevent or correct dangerous social habits and to firmly establish desirable ones, and finally the checking of methods against results as expressed in the child's behavior. But in undertaking this physical educators are render- ing a service to the individual boys and girls and to the community of the utmost importance, and such service is not without its rewards both in satisfaction and recogni- tion. The splendid effort of the physical educators in De- troit to place sportsmanship above victory shows what can be done, and I have found that in rural districts where the cow, the plow, and the vegetable garden are considered as affording ample opportunity for muscular exercise, farmers can be won over to support physical education when they are shown its significance in character formation. The connection between proper training in social ad- justment on the one hand and worthy membership in a family, club or community on the other, is just as clear as the bond between accurate training in mathematics and a successful engineering career. As Dewey so well says: "A predisposition formed by a number of specific acts is an immensely more intimate and fundamental part of ourselves than are vague, general, conscious choices." The Chairman: To lead in the discussion of the last paper, I am very glad to announce Mr. George Hjelte, Assistant State Di- rector of Physical Education, Sacramento, California. Mr. Hjelte: Mr. Chairman and delegates to the Conference: Dr. Stolz has spoken very admirably and I do not wish to discuss the specific points of his paper, but prefer to point out some of the general implications of behavioristic psychology concerning the general field of physical education. Behavioristic psychology, I think, has given us two general con- tributions which I should like to emphasize. There are two points of view in regard to physical education. One of them is that the only sound basis for the formulation of a program of physical education is the instructive nature of the human being, and especially of the child. In the past, whenever there was something we thought would be valuable to him as a member of a society, we would put it in the 226 curriculum. The new conception is that we think first of what the instinctive tendencies of the child are, and second, what it is de- sirable that the child do, and third, how we can take these instinctive tendencies and develop him so that he may become a good member of society. Now, I wouldn't dare to give you the impression that 1 think that behavioristic psychology has alone been responsible for giving us this point of view; but at any rate, it has given us support in the adoption of that view, for we have the behaviorists now ob- serving the child and determining just what his instinctive impulses are, and determining how far those tendencies may be retarded or changed, and third, how best they can be changed to make the child a member of the social group. In accordance with this point of view in the field of physical education we are forming programs of natu- ral physical training activities. This is the sort of program that Dr. Hetherington has set forth in his book, and the program which he so successfully introduced in the State of California. The second point of view is that behaviorist psychologists are telling us that the early years of childhood are the most important years from the standpoint of the child's general education, and also from the standpoint of the child's physical education. One reason is that it is in those years that the instincts of child health first crop out, and unless we take hold of the child at that time he is likely to be badly trained or developed, and not given full expression. I can illustrate that. We have all observed that it is very difficult to teach one swimming after he has achieved maturity. Why? Because the instincts which underlie swimming are most prominent in the early age of the child. Unless we take the child at that period and give him the opportunity to exercise those instincts they become dwarfed. The behavioristic psychologist also tells us that these years are the most important from the standpoint of education because the instincts of human beings are very likely to become conditioned in the very early years. Situations which ordinarily call out the motions of fear do call them out, because of accidental conditions which occur through bad home training, or lack of home training at all. The child is thereby hampered all through life. However, the behavioristic psy- chologists have shown us quite conclusively that specific fears, the fear of the boy who is afraid to do the thing which he ought to do for his best physical development, is a result of the conditioning of his instincts in early life and not due to heredity at all. This empha- sizes the importance of providing the very best teachers during the early ages of the child's school experience and of giving the necessary supervision in his activities while he is a small child, even before he enters the public school. The old psychology, it seems, has not given us much help in the field of education, but I think we can look with some promise to the investigations of Professor John Watson and others for much help in the future, not only in arranging our programs for physical educa- tion, but also in devising means whereby the above ends may be obtained. 227 The Chairman: The topic "Athletics for Girls" will be presented by Miss Alta Sims, Director of Physical Education of the Oak- land public schools. Athletics for Girls Miss Sims: IWAS asked to tell you something of the program that we are trying to carry through in Oakland for our girls, both in regard to our physical education program and our recreation activities. We are striving to organize child health through the medium of big-muscle activities or physical-training activities. In other words, we are trying to make the play life of the child more efficient. Since adult leadership is essential to the normal progress of the play life of the child, it may be interesting to know first of all something of the administrative side of the program. We have a very close cooperation between the school department and the recreation department. The superin- tendent of the recreation department is also the director of physical education in the schools. This permits a very close articulation between our instructional periods during school time and play periods before school, after school and at recess time, Saturdays, Sundays and holidays, and all during the vacation period. In addition to this our play- ground directors, for the most part, are people who have handled the physical education during the day time. In nearly all cases where there is a physical education in- structor in the school he or she carries the work over on the playground out of school hours. In other cases, people who are trained on the outside come in and work on Sat- urdays and holidays. The very core of our whole program, I think I may say, is the decathlon system. By means of that system in our physical education period the physical stress and strain of activities is removed and the child still feels the competition which is so essential, because it is instinctive. We have some 12 or 14 events from which five events are chosen for practice during the fall term and five for practice during the spring term. At the very beginning of the term the child's record is taken in each of the five chosen events. 228 Say, for example, in the fall, it may be basketball, throwing for accuracy and for distance, or it may be baseball, throw- ing for strikes or batting. Two days a week are spent on the decathlon, and the rest of the week the practice is in the form of games. At the end of the term again-the term is taken for com- parative purposes, so that the child may see his own im- provement-the culmination of this decathlon program for the girls comes in two different periods. The big events are play days. We have two groups of play days, one in the fall for girls of the sixth grade and junior high school, and in the spring for our senior high school girls. The play days have been divided into three sections, interclass play day, neighborhood play day and city play day. We try to place the greatest emphasis on the interclass play day, for that is the place where every single girl in the school can take an active part. At the very beginning of the term each girl above and including the fifth grade is classified according to age, height and weight, and practically all competition takes place under this classification. In organizing the interclass play days Class A children, that is, the smaller ones, play bat ball; Class B, kick ball; Class C, net shuttle; Class D, baseball square; Class E, replays and obstacles, and Class F, volley ball. The little children below the fifth grade generally have spaces assigned, and from the kindergarten school to the eighth or ninth grade every girl in school has an active part in play. Probably the most interest of all is shown in the posture parade. At the opening of nearly all our play days and track meets we have what we call a posture parade. During our physical education period the children have received training in posture. They form by classes and march around the yard and are judged on standing and march- ing posture, on marching order and rhythm, and in neat- ness and cleanliness. At first it would seem that it would take a great deal of time to judge each individual child, but at our largest schools we finish the work in 10 to 20 minutes, as the computing is done when the organized games are started. In the posture parade the children march in classes, the classes competing one against another. As soon as that is over they break up into other classifica- tion groups for competition. We never play any final or championship games except at the regatta. The children 229 play for the activity and for the pure joy of playing. The neighborhood meets are organized similarly when three or four schools get together. No single team consisting of a small group of children picked from a large group because of superior ability ever travels to another playground to compete with a similarly picked superteam. Instead, every member of the group has an opportunity to participate in some activity with children from a neighboring center. Many varying games are going on at the same time, which eliminates the objectionable features of the cheering or jeering crowds on the side lines. In our city play days, we have grown so rapidly that it has been necessary in place of one play day to have four play days each for the junior high schools and for the eighth grade schools. I do not want you to think that when we have finished these rather highly organized play days that we have finished our play-day program, because constantly throughout the whole year the various playgrounds are having their interclass play days or neighborhood meets. The senior high school girls' play day is on a different plan. This last year we tried a pentathlon meet, and it probably is what we are going to do with the lower-grade girls. We have the posture parade, the same as with the other meets, with 2,500 girls taking part. After that we go through the five events from our decathlon, making it a pentathlon meet. In the fall we have handball and other tournaments, conducted in much the same way as play day. In the city finals groups get together and have these handball tourna- ments. Swimming meets and regattas fill up a considerable portion of our time, and every child is free to take part in dramatics if he or she cares to. Emphasis is placed not on training them to be actors or actresses, but to give them a mode of self-expression. Then we try to do something for the girls who have passed the school age or who have completed school and gone to work. In the industrial plants which desire our services the Department sends someone to organize the work and for a time material is furnished with which to conduct the game, so that we can bring something to these girls, an hour at noon time or in the evening, say an hour a week for each plant. We also have adult women clubs that meet on the playgrounds semi-weekly and engage in 230 such activities as volley ball and basketball. Also, for the older women we have a rowing club, which has been in existence for seven or eight years and has a membership of something over 50 people. Dr. Hetherington says in his book "The School Program in Physical Education" that a playground should be con- sidered as a laboratory of moral and self-discipline as well as physical development. In so far as we have met that ideal I think we have succeeded. The Chairman: The next topic will be presented by Florence D. Alden, Director of the School of Physical Education, University of Oregon, who will discuss A New Program in Physical Education Miss Alden: NEVER in our history has physical education made such strides as in the last two years. While we have been petting it as an infant it has suddenly entered the period of rapid growth and in addition has taken unto itself seven- league boots. To keep abreast of its growth, to say nothing of contributing to it, accelerates our mental heart beat and respiration, and stimulates most healthily our mental metabolism. A few years ago governments, religion, education, rested firmly and complacently on accepted facts-one's thinking and acting were direct and assured. Now thrones are top- pling, democracy is questioned and, according to Dewey and Robinson, all that has passed for social science, political economy, politics and ethics is mainly rationalization. Physical education also is going through this period of questioning and searching, and we are glad that it is. Not long ago we gave our elaborate anthropometric ex- aminations, then stowed them away in dusty files or pored over them, according to our natures; we handed out formal work to our students, or sports, according to our mental bent and rested happy in the conviction that we were saving the youth of the country. Now most of our methods are scrapped, most of our convictions have become doubts, and instead we are trying, searching, testing. I asked a man, one day, if he knew the age of a friend of ours. He said: 231 "I can't remember exactly, but she is at the age when she prefers to be comfortable rather than stylish." As physical directors we would rather have growing pains than to have comfort. To be in the physical education world right now is one of the most stimulating pursuits imaginable. It is uncomfortable but isn't it thrilling? The topic that was given me, "A New Program in Physical Education," is large enough for a thesis for a master's degree. I will confine myself, therefore, to a few of the newer movements. One of the phases that is being strongly stressed now is the more careful adaptation of work to individual differ- ences,-consideration of the weak as well as the strong, the unskilled as well as the skilled, and more thought put upon age and sex differences. In our "required work," with the regular classes, restricted classes, individual or corrective work, we have been doing this, but in the field of games and sports it has not been as carefully thought out. Our ath- letics have tended to be run for the upper one-third. It was this upper one-third who could win the prizes or champion- ships, who could break records, draw audiences and bring athletic reputation of commercial advantage to the school. More and more the feeling is swinging against this intensive training of the few at the neglect of the many. Programs are being planned with a view to meeting all varieties of organic vigor, of skill and of taste. Many schools are offer- ing a classified and graded list of sports, ranging from quoits, archery, canoeing, up through golf, volley ball and tennis to swimming, basket ball, and hockey. After the student's class has been determined by tests of organic vigor he is given freedom of choice of the sports in his class. At the end of a semester or a year he makes another choice so that he receives a fairly all-round training, and in the course of four or five years he has learned to play several games well. At the University of Oregon, running parallel to this program are Do-nut and class contests in several sports. The Do-nut contests are between the living houses and the others between the freshmen, sophomore, junior and senior classes. In the class contests each class may put out as many teams as it wishes-first, second, third, and so on, so that not just the best players, but everyone who is inter- ested has a chance to compete. As the victorious class is 232 the one who wins the largest per cent of the games played, there is an incentive to turn out as many teams as possible. In order still more to stimulate all, the Athletic Association has a point system. For winning five hundred points the girl receives a small O, for one thousand points she receives a large 0. She may win these by playing on the first class team in more than one sport for three or four years, but she may also win it by a combination of fifth team or Do-nut team places in several sports, for instance, or a combination of fourth or fifth team places and hiking, passing a dancing test, and making a good score in the Caucas race. So that not only the few specialized athletic girls are stimulated and rewarded but the ordinarily active, all-round girl as well. The award, costing but a few cents, is valued most highly. By these plans an effort is made to meet the needs and desires of every girl, and to establish recreation habits and tastes that will continue through life. More and more attention is being paid to the type of sports and athletics fitted for younger boys and girls. Too long our high school athletics have been a cheap imitation of the college brand-the same events, the same standards of achievement and also the same faults of exploitation and commercialization. Basket ball is too commonly played by junior high school girls and younger. Why do this when there are such excellent games as volley ball, bat ball, hit pin ball, captain ball, etc. One reason is that no group of women has gotten together to standardize these games as they have basket ball, hockey, and others, and as a result these games have many radical faults, such as unequal of- fense and defense, too strict or too lax rules; and these faults destroy the interest. Another difficulty is that the rules of these games are hard to find. Every little rural school knows that the basket ball, hockey and swimming guides may be bought in any Spalding store for ten cents a copy; but where can they find hit pin ball? In the Basket Ball Guide Book for 1923-1924, will be an article by Miss Lydia Clark on the types of games advisable for girls below the basket ball age, and telling where the rules may be obtained. Too long, also, our girls' work has been men's work warmed over. Unless girls are a cheap imitation of men, why give them cheap imitations of men's work? The Track Athletic Committee, recently appointed by the General 233 Committee on Women's Athletics, has taken a most scien- tific stand on this subject in their determination to go slowly until they know what is adapted to girls. For me- chanical reasons, such as the low center of gravity, the broad pelvis, etc., the girl who excels in most track events is the one who is built like a man-heavy of shoulder, nar- row of pelvis and slender of limb. Do we want generally to advocate events fitted to that limited class only and stress- ing the more masculine type? The Track Committee is ex- perimenting and doing research work and will soon have some valuable data to offer. The Baltimore Playground Athletic Association held this year a meet of 2,800 girls, ranging in ages from the kindergarten to the older women in the night recreation centers. All the events were strictly girls' events. They ranged from an egg and spoon race for the little tots, shuttle relay, dodge ball, etc., for the younger girls, up through field ball throw, golf drive and basket throwing relay for women over twenty-one. In the selec- tion and administration of this, the age and sex were carefully considered. Also, the whole thing was planned, managed and judged by women trained in physical educa- tion standards. Another phase that everyone is working upon is the problem of interest. The need of interest in education is too generally accepted for any discussion of the theory to be necessary. The new movement in physical education is making rapid strides in the practical application of this principle. In games the problem is fairly easy. In gym- nastics and dancing the method is not to sugarcoat or attach an extrinsic interest by holding out some remote benefit, but to link it up with their inherent interests, with their experiences outside of school and to base it on the instincts at our command, such as the play and dramatic instincts, rivalry and the desire to excel. This is being done in our mimetic exercises, our story plays and dramatic dances. Columbia University offers "natural gymnastics," as it is called. Their drill work is based upon the technique of games and athletic events and trains definitely in the skills necessary for these. To motivate our regular work with the girls, we utilize the spirit of competition in the form of a "Caucas Race." You remember in Alice in Wonderland the Dodo says: 234 "The best thing to do would be a Caucas race." "What is a Caucas race," said Alice. "Why," said the Dodo, "the best way to explain it is to do it." First it marked out a race-course, in a sort of circle ("The exact shape doesn't matter," it said), and then all the party were placed along the course, here and there. There was no "One, two, three, and away!" but they began running when they liked, and left off when they liked, so that it was not easy to know when the race was over. However, when they had been running half an hour or so, the Dodo suddenly called out "The race is over!" and they all crowded around it, panting, and asking, "But who has won?" This question the Dodo could not answer without a great deal of thought, and it stood for a long time with one finger pressed upon its forehead (the position in which you usually see Shakespeare, in the pictures of him), while the rest waited in silence. At last the Dodo said, "Everybody has won, and all must have prizes." In our Caucas race everybody wins. The girls are scored on some elements of the physical examinations such as in- crease in chest flexibility, posture, grip, some events taken from the floor work, such as deep knee bending and prone falling, some apparatus work such as rope climbing and swing jump, some stunts such as somersaults and tip up on the stall bars, and some sport events such as base ball pitch- ing and basket ball shooting. The scoring system is an adaptation of Reilley's Rational Athletics.* A maximum is set beyond which no points are scored in order to prevent strain and the winning of too many points on one event, and a sliding scale of scoring is used which stimulates the girl to keep on trying. The class scores are averaged and announced at Field Day. This utilizes many types of the spirit of competition-the desire to beat one's own record, the pleasure in coming up to a standard, the joy of getting ahead of someone else, and the satisfaction of contributing to the group. As everyone's score adds something, even the least skilled are stimulated to improve. This has served to vitalize the work very strongly. Much time is given in most schools to posture training. We may give posture drills daily to the end of time, but if the ideal of posture and the desire for it is not present we shall obtain small results. The seniors in our training school of physical education put over a posture drive this spring with a double purpose of learning how to do such things for their future positions and for the effect on the *New Rational Athletics for Boys and Girls.-Reilley. 235 university girls. In order that-as they expressed it-the girls might get "some kick out of it," it was put over with all the pomp and splendor of a political campaign. Advance press work in the college paper was used and posters with punch, such as "The Daily Doings of the Hump Family" (apologies to the Gump Family). They tagged the trees and statues that carried themselves poorly. There are rhymes, skits, songs, stunts and movies. As posture is not a matter of physical education alone, the psychology de- partment took up the psychology of good posture, the edu- cational department discussed posture as a vocational asset, the art department dwelt on the beauty of posture, etc. On the final night the girls went to the different houses and gave the posture test to all, presenting a perfect posture tag to those passing. The house holding the largest per cent of tags received a bronze placque made for us by the sculpture department. As the girls said, they not only walked and talked posture but they thought it, ate, drank and dreamed it. More attempts of this sort to enlist popular interest would do much to put our work over into the lives of the girls. Into the field of dancing especially have come new life and interest. The interpretative dancing so many are giv- ing now is truly educational. It is based upon firm princi- ples of anatomy and kinesiology, and in its fundamentals gives strong corrections of ordinary postural faults and a splendid smooth, all-around development. It aims directly at establishing habits of relaxation, so much needed in our hurried, tense lives. It is happy, joyous and spontaneous, for the child is given a chance to express what the music means to him-not what it means to the teacher-and after he has gained the technique and control necessary takes genuine pleasure in expressing it with the body as his in- strument. He learns music not merely on the side of rhythm, but phrasing, tone values, moods and how to ex- press them. His pleasure in self-expression and his cre- ative powers are given play by little pieces of original work. He learns color values with costumes, flowers and back- ground, line and group values in making and re-making groups. It is full of content, rich with meaning and feel- ing, and withal, free and happy. The attempt to vitalize the medical and physical ex- aminations is another happy movement in the new physical 236 education. For years our children have patiently endured these as a necessary evil, but that there was any possible connection between them and their physical activities and hygienic living has seldom dawned upon them. At Oregon each girl received a test for organic vigor, a medical ex- amination, an orthopedic examination and a schematogram of her posture. Then with all this data and her history card, she goes to a final "station." Here the doctor, or the physical director, has a friendly, unhurried talk with the girl. Her faults, disabilities and needs are gone over care- fully, what the university offers as means for the better- ment of these is pointed out and an effort is made to put the main responsibility for improvement upon the girl herself. Follow-up work is done where necessary. At the next ex- amination improvement is checked up. Is there improve- ment? If not, why not? This method has changed the whole spirit of the examination period and made it of much greater value to the girls. In our games is it not possible to establish a different kind of interest-more of the joy in the sport as play, more of the real amateur spirit. Do you remember the hockey game in "Mr. Britling Sees It Through" ? "Hockey as it was played at the Dower House at Matching's Easy before the war, was a game combining danger, physical exercise and kindliness in a very high degree. Except for the infant in the per- ambulator and the outwardly calm but inwardly resentful aunt, who wheeled the child up and down in a position of maximum danger just behind the unnetted goal, everyone was involved. Quite able-bodied people acquainted with the game played forward, the less well- informed played a defensive game behind the forward line, elderly, infirm and bulky persons were used chiefly as obstacles in goal. Sev- eral players wore padded leg-guards, and all players were assumed to have them and expected to behave accordingly." Then it goes on to describe the game-full of raillery, fun, laughter and much mutual helpfulness. At the end Mr. Direck (an American) finds that he "had a sense of physical well-being such as he had not experienced since he came aboard the liner at New York. The curious thing was that it was not quite the same sense of physical well-being that one had in America. That is bright and clear and a little dry, this was-humid. His mind quivered contentedly, like sunset midges over a lake-it had no hard bright flashes- and his body wanted to sit about." His sense of intimacy and friendliness with the family had increased a hundred 237 fold. Would it not be worth while to let go a little our de- sire to develop expert players and our intense spirit of competition for the sake of this lovely, friendly, leisurely spirit of the game? The progress in the development of tests for our work is most encouraging. Many are seeking to define physical efficiency and to evolve a series of tests for it looking toward the possible finding of physical quotients to cor- respond in function to the intelligence quotients. Clas- sification tests are valuable. The Western Society of Directors of Physical Education in Women's Colleges is doing some experimental work with the Schneider test as a possible workable index of organic vigor. The tests for classifying the child not only as to his organic strength but as to his skill and quickness of reaction help to place him in his right group so that he is not held back by the less skilled or spurred beyond his powers by the more skilled. Some of the pentathlon and decathlon tests, Reilley's test, the Caucas race and others serve many purposes. They make clear and definite some immediate objectives both to the child and the teachers and mark the progress toward these objectives. They stimulate the interest of all. They serve as a method of grading. They show to the teacher herself the quality of her work and the efficiency of her methods. They offer to the supervisor a means of keeping up standards and of comparing the work of different schools. As the tests become more and more scientifically worked out, they will serve to prove to ourselves and to others whether or not we are getting results in physical education. We are fond of claiming that we, above all other edu- cators, develop leadership, initiative, the square-deal, the power of impersonal judgment, etc. But are we really do- ing it, and are we doing it in a form that transfers to life situations? Doctor Williams in his "Education of Emotions Through Physical Education"* has shown us that games and sports in and of themselves do not develop these desir- able traits. If this were true, he says, "professional baseball players who engage during the season in 154 games of base- ball would be the most successful examples of self-sacrific- ""'Education of Emotions Through Physical Education."-Dr. Jesse Williams, Teachers' College Record. 238 ing, social human beings." The law of effect must be applied to strengthen the proper reaction-desirable con- duct be attended by satisfaction and undesirable by annoy- ance. The coach must reward and praise clean, open play, good sportsmanship and self-control, and make unprofitable tricky play, crabbing, and producing alibis. Thus by per- sistent, untiring effort, a definite ideal of sportsmanship is developed. The term "sportsmanship" in itself is too ab- stract and too general to take a hold upon a child's mind. Detroit has done a great deal along that line.* They are trying to break up the abstraction into concrete terms descriptive of acts, and then to score the children on these tangible elements. The children evolve their own code of sportsmanship out of their own experience. The instruc- tors stimulate sportsmanship songs, and last year a dinner was given to which was sent the best all-round sport from each school. By this method they build up a concrete standard. Doctor Hetherington** says it is an easy transition from the ideal of keeping fit for athletics to keeping fit for living. I agree with all but the word "easy"; it does not come easily but it is worth the effort. "Moral Character," ac- cording to Kilpatrick,*** "is primarily an affair of shared social relationships, the disposition to determine one's con- duct and attitude with reference to the welfare of the group." Our games are full of shared social relationships, out of which the sturdiest traits of character may be built and so built that they will carry over. Dorothy Canfield, in "The Brimming Cup", describes sportsmanship standards in business. Two men are talking- together about different possible ways of running big corporations. One says: "Why, sometimes it looks to me like the difference between what's legitimate in baseball and in tennis. Every ball player will try to bluff the umpire that he's safe when he knows the baseman tagged him three feet from the bag; and public opinion upholds him in his bluff if he can get away with it. But like as not, the same man who lies like a trooper on the diamond, if he went off that very afternoon to play tennis would never dream of announcing "out" if his oppo- nent's ball really had landed in the court-not if it cost him the set *"A Study in Sportsmanship."-R. C. McClain, American Phys- ical Education Review. **"School Program in Physical Education."-C. W. Hetherington. ***"The project Method."-Kilpatrick. Teachers' College Record. 239 and match-whether anybody was looking at him or not. It's 'the thing' to try to get anything you can put over in baseball, anything the umpire can't catch you at. And it's not 'the thing' in tennis. Most of the time you don't even have an umpire. That's it. That's not such a bad way to put it. My wife and I wanted to run our busi- ness on the tennis standard and not on the baseball one. Because I believe, ultimately you know, in fixing things-everything-national life as well, so that we'll need as few umpires as possible. Once get the tennis standard adopted and business will be a different affair." Can't we get the tennis standard in all of our games, and from this develop a general concept that will transfer to business? We, as physical educators, are not justified in giving a larger and larger place to the play side until we make it truly educational. Where there is an indoor season with more emphasis on gymnastics, apparatus and dancing, and an outdoor season of sports, the moment the sport season starts there is an unconscious but noticeable let down by both instructors and girls. If something happens to their class period we hear, "Oh, no matter, it's only baseball!" Baseball should be worked out with as careful consideration to the technique of the game, to the building of neuro- muscular responses, to the laws of learning, as history or mathematics, so that the players and the teachers will know not only their objective but the progressive steps to reach it. This will increase, rather than diminish the interest, as a growing sense of mastery holds as just playing does not. Swimming has perhaps progressed the farthest along this line. Frost and Wardlaw have made splendid contributions to basket ball, baseball and hockey.* Some day a prophet will be born among us with a knowledge of anatomy, kinesiology, physics, pedagogy, psychology, physiology of exercise, who will do for games and sports what Dr. Skar- strom has done for gymnastics. Then, and then only, will these phases be able to claim a really large place in an edu- cational program. These problems upon which we are all working are not distinctive of our field of work; we have them in common with all educators: (1) Interest-vitalizing our work, hav- ing it grow out of the child's own needs; (2) consideration of individual differences-varying grades of ability, age, sex; (3) tests; (4) better and better pedagogy; (5) trans- *"Basket Ball and Indoor Base Ball."-Frost & Wardlaw. 240 fer. The more we can work along such scientific lines the more we will be recognized as educators in the largest sense of that word. This is all experimenting, trying, testing. We may be wrong and change tomorrow; but it shows we are growing. Is it too much to hope that when our boys and girls go out from such a program they will have not only a splendid physique, good bearing and vigorous health, but an ideal of these, knowledge of how to keep them, and the technique and control for doing it; they may have standards of fair play that will transfer into life and color their future re- lations with their kind; that they will have established the habit of daily exercise so that it is an urge, always with them-a life hunger; that they will have developed tastes for recreation, a wholesome hobby or two to help keep life sane; that they will have life and have it more abundantly, be joyous, whimsical, spontaneous, eager-be imbued through life with the spirit of play. Discussion The Chairman: The discussion of these two papers will be led by Dr. R. Tait McKenzie, of the University of Pennsylvania. Dr. McKenzie: I have listened to these two papers with great interest, and the impression that I come away with is that there are no traditional sports for women, and that they are in process of being formed. Nearly all the games that were mentioned are games that have been designed and have been invented within our own lifetime, so that there is really a new program of sports being devolved that has to be applied particularly to the needs of women in contrast with the needs of men. Most of us as educators will, I think, agree that most of the exercises and of the sports that are suitable for small boys can be played equally well by small girls, and it is only when we come to the dawn of maturity that we get a distinct and radical diversion of opinion as to what sports should be taken part in by girls and young women and what should be confined only to men. I had this brought to my attention very strongly many years ago when a certain artistic problem came before me, and that was to make a statue of the ideal American college student, and for that purpose we took the measure- ments of a selected number of students who had a certain strength test and who excelled in the various forms of sport, and we took the average of those students, a picked set of 400 men, and the statue was constructed according to the measurements that we got from this 241 compilation. Shortly after that the question was asked me, why do you not do the same thing for the college girl, and I found myself before a very great difficulty. It was a simple matter to say that the young college student who can run, who can move weights, who can play ball and who can do the othei' strenuous sports, who is a machine for the doing of muscular work, that he might be looked upon as the ideal of young American manhood. But can you apply those same tests to the college girl? I think not. I think it is a very different question that we come to consider when we try to get the ideal to which we are driving in the girl. We all know if we examine a hundred boys or young men and a hundred young women that physically and anthropometrically they show a certain border line. There are certain young men who have strongly developed feminine characteristics in their build, the relative size of the shoulders and hips-the proportion. And just the same way if we examine a hun- dred college women we find a certain number that approach more or less closely to the masculine type. And we find that where strenuous competitive sports are carried on it is this masculine type, usually, that excels. Now, if we were to pick out a hundred thousand women students and take those who excelled in these sports we could not get, I believe, the ideal college girl, but we would get the college girl that showed the masculine characteristics, which, I do not believe, are the things that we want to cultivate. Why, then, is it that there is such a movement at the present time to emphasize strenuous indi- vidual competition before crowds, and even international competition? I believe that the main thing of it is the desire to have an attractive center to put in the spotlight of the sporting page of the newspapers. I think that it makes a good picture to have a girl scantily clothed in some athletic posture or engaged in some athletic sport, and I believe that it will be kept up only by this desire for notoriety. I do not look upon it as a very serious menace, because I have had some experience with trying to get one or more women to do something which they were not intending to do, and I may say that after the smoke of battle had cleared away I found that they usually did what they intended to do from the first. I believe that if left to them- selves, in spite of compulsion, you will find that the girls of this generation are not going to go into very strenuous individual public or other competition to any great extent, and that is why I look with the greatest possible hope to the various programs that are laid out, two of which have been described accurately today, in which we get those group competitions, and what may be called the more conserva- tive forms of athletics applied to the large masses of our girl students in the schools and in the colleges. The Chairman: Since these two formal papers were presented by women, it balances the program very nicely to call upon two men in physical education to discuss them, and I will call on Dr. Burdick, Director of the Playground Ath- letic League, Baltimore, to continue the discussion. 242 Dr. Burdick: It has been a delight to hear this discussion. It has been particu- larly well worth while, because it is a program of using play and athletics for the individual girl rather than for professional sports. It is important that all of these things are preparing girls for life rather than for a temporary game. The important thing, it seems to me, is that the sports and play and arrangements are for all of the girls and not for a few. It is particularly proper, as I take it, that all of the discussion has been that the policy is that these activities must be for all of the girls, and all of the boys, and not for three or five per cent of them. The most important, it seems to me, and perhaps in this I might differ from Miss Sims, is the value that comes in the emotional con- trol gained by the girls as a result of games of their own. To sud- denly inject girls into very high competition, with the intense rivalry of State competition, would be a serious mistake. But by taking part in the more highly complicated games, I believe in that way our girls are going to gain a type of emotional control that is most necessary if they are going to share with men in all of their activities. I believe that the old type of individualistic running and jumping of the boys will not have the appeal for the girl as will the social values that come as a result of the responsibility of each one of the team, as individuals and as members of the team. A program of athletics for girls should be organized simply for the girls, 60 to 75 per cent of the 4,500 girls, to take part in the relay games or the team games rather than in individualistic competition. I think these things are extremely significant of the future athletics for American girls. The Chairman: The next topic is the "Co-ordination of Health Teaching and the Play Activity Program," which will be presented by Miss Marguerite M. Hussey, Department of Physical Education for Women, State Teachers College, Fresno, California. Co-ordination of Health Teaching and the Play Activity Program Miss Hussey: HEALTH instruction as an integral part of the school curriculum is more or less a new departure. How the esthetics and schoolmen of the scholastic era would have held up their hands in righteous indignation at the thought of a mere bodily state or condition being of the slightest importance in the scheme of education, and even now there are those who feel that health teaching is a side issue and not to be ranked as an academic subject. But these people 243 are steadily becoming fewer in number. One of our promi- nent educators places health as the first and most important aim of our educational process. Another, in a classification of educational objectives, places health in the same group- ing along with ethics, breadth of view and the scientific attitude of mind, and also mentions health as the most im- portant factor in such objectives as citizenship, morals, vocational efficiency and the wise use of leisure time. The education of a people in healthful living is the base upon which the other aims of education are built as a super- structure. Without health, gone is the capacity "to live most and serve best." The "good life" is impossible of attainment. But now to come to the question of how we are to educate the child so that ideals, attitudes and information will lead toward the fixation of those habits of daily living that ex- periment and experience have found most workable for the care of the physical and mental processes. The learning process should be one of growth. It should be the result of a desire on the part of the child to want to do something. The stronger this purpose the more definite is the end in view, and the greater the inner urge the greater the readi- ness of all the stimulus response bonds pertinent to that purpose. Again, the greater the interest the greater will be the results in the actual learning of the habit or fact. Lastly, if the method of teaching is scientific, the con- commitant learnings or, in other words, the attitudes and marginal thoughts that the child is building during the learning process will be of the right sort. It is these attitudes that are so important in the teach- ing of health habits and information, for, unless these are of the right sort, no health standards will be definitely es- tablished and health information will not be a factor in the regulation of the life of the individual. In teaching health, we must first discover what the child wants to do. Has he any interests that can best serve as the driving force? When we investigate we find some very interesting desires. The boy is, by and large, interested in physical accomplish- ments and perfection. The following are a few expressions of fourth grade children: I would like to be like Jack Dempsey. I would like to be an athlete. I want to be strong so that I can bat hard. How can I get to be a strong swimmer? 244 I would like to be as good a baseball player as Babe Ruth. These are a few questions selected at random to show the trend of the boy's interests. Mr. Clark W. Hetherington, as a result of an extensive investigation last year, came to the conclusion that there was a marked interest displayed by both boys and girls in physical attainment. In the case of the girl this may be true in some cases, but my experience has shown that, while she is interested in the physical, it is mainly physical ap- pearance and especially the appearance of the face! She wants to look attractive. But there is the desire on the part of the boy to accomplish things in the physical line, espe- cially in the play activities. He wants to be a good base- runner, a good soccer player. He longs to be fleet of foot, sure of aim, a good catcher, to be efficient in his play activi- ties. The need is clear-cut and definite in the mind of the child. All of his responses are in readiness to bring about the desired result. The play activities, then, offer the strongest motive on the part of the child for keeping fit. Play, then, serves not only as one means of keeping "in con- dition," a means that is fundamental to the deepest needs of the organism, but also as the reason for observing those other rules of living that also keep him "up to the mark." Under guidance the child can find out that the way he lives will definitely affect his play abilities. Late hours make his arm less sure of hitting a ball, overeating slows his running. In the study of the training of athletes, he will find that no athlete can play his best when he has broken any training rule. He will learn that expert coaches can tell instantly, by the way a man plays the game, whether he is living hygienically or not. The playground offers a natural situation for health problems. The following are a few questions that have been asked by children in connection with their play activities: Why does my head ache when I run ? I would like to know why both ankles hurt when I run. What makes you feel stiff after you fall? Why do I get a pain in my side when I run ? Why do I get out of breath when I play hard? These questions serve to show that the boy is interested in his physical reactions. He has not connected them with his manner of living nor has it occurred to him that there 245 is any way in which he can, within limits, control his play ability. He may have been told that fruit and vegetables are good for him, that plenty of sleep with windows open will make him feel well, but that the way that he plays can be improved by following the rules of the health game has not occurred to him. We have, then, a purpose on the part of the child. He wants to be a good player in the games of the playground. We have an inner urge, for nothing is more natural to child life than the play activities, and we have an interest not only in playing well but also in general bodily reactions that occur during activities or after them. "Why do I have a pain in my side when I run?" How many hundreds of children have asked that very question! The training process-in other words, healthy living-will eliminate that pain in time. The child should be guided in the hunt for facts along these lines of his interest, stimu- lated to find the best ways of living so that he can carry on better in those activities in which he is interested. When a question arises during any activity, take a few minutes then and there to discuss the matter. This is the "systematic- incidental"* method of teaching. It takes skill and knowl- edge, vast knowledge on the part of the teacher or leader, but it offers an ideal laboratory method of health instruc- tion. The child can see a direct relationship between cause and effect. And that result is very vital to his happiness and success in the child world. Later, in the classroom, the problem can be taken up more fully and the children di- rected to hunt solutions and make decisions. Then is the opportunity for the use of such teaching devices as health plays, stories, rhymes, posters, etc. As a result of this approach and method of health in- struction, the formation of health habits-which are so ob- viously a means to the end that the child so greatly de- sires-will bring satisfactions and so tend to be permanent. That is the big problem-how to make these habits perma- nent, the continued performance of the satisfying. How many health habits have we thought well established in our- selves, only to have them unregretfully neglected when con- ditions were a little unfavorable for the performance of them. But if, from childhood, our manner of living had been closely connected in our minds with our success or * Clark W. Hetherington. 246 failure to accomplish that in which we were whole- heartedly interested in accomplishing, then those habits would not be so easily cast aside. The process of keeping "in training" in order to play the games of childhood would, with the advent of years, merge into a habit of mind of keeping "in training" to play and serve one's part in the affairs of this world. Discussion The Chairman: Mr. J. B. Nash, Director of Physical Education and of Play Activities in Oakland, will discuss this paper. Mr. Nash: I think that Miss Hussey brought out very well the relationship of health teaching and the playing methods, and the only emphasis I have to offer is this one thing-that it will contribute activity which involves exercise. I believe that exercise stands as one of the great piers of health, one of the three great supports of health. I am not going to discuss the other two. But it is through the play instinct, and only through the play instinct that we can get the child of today, the adolescent boy and girl of today, the man and woman of today, to take sufficient exercise to keep them in good condition. We do not have to exercise today. One can be just as lazy as one wants to be, and most of us want to be. You couldn't hire, for a million dol- lars, possibly, John D. Rockefeller to start down here on Market Street with an old broomstick and knock a tin can from Market Street to the Ferry Building. But he will pay $10,000 a year to do the same type of exercise, out in a pasture field with a golf stick and a golf ball, because one involves the play instinct and the other does not The play instinct is the instinct that we must tie to with the boy, with the older boy, the older girl and the man and the woman. It is to a large extent the only way we can get exercise in sufficient amount over on this program. The Chairman then introduced one who wanted to make a plea for personal gymnastics, even though "formal," namely-Miss Christina Stael von Holstein, of Sweden. Miss Stael von Holstein: I have been in so many schools in America where they told me they had Swedish exercises, but I have never seen anything that looks like Swedish exercises in any of those schools. They say, "We do not believe in formal gymnastics. We believe in games." That is the same thing as saying to a Swede, "We do not believe in walking on one leg." Now, we believe in formal gymnastics and also in plays and games, that is, in using both our left and our right leg. Most of the gymnastics I have seen have been in the classroom. They will have a recitation and after that stand up and do some exercises. 247 There is something in the air in America that makes for haste and speed, and I have been in so many classes where a physical exercise teacher says, "Make it snappy, snappy." I have climbed the highest mountains in Sweden and Switzerland, but I became breathless even to look at those children. I am sure that that kind of exercise hurts those children. It is not good for them. My advice is that you do not let anyone give the Swedish exercise who is not specially trained in it. There is another feature. That is corrective exercise. We have physicians that examine the children, and if they have fallen arches, or not the right lung capacity, or something the matter with the heart, then they give them corrective movements. But it must be fitted to your nature and physical condition. The other feature of Swedish exercise is the game. We have half an hour of physical training every day, and we have half a day every week only for games. So while we have more of the games than athletics, we believe that in doing those games it is better if they have had some of the training before. I have seen what you call the relay races here, where the posture of all the runners was bad. If they had had Swedish exercise I think they would carry themselves in a different way. We want formal exercises along with athletics and games, not to put one in the place of the other, and that is what I think many of you here in America do not understand. You say that it is not inter- esting, that the children do not like it. That depends on how you put it up to them. You can modify the program and take the children into your confidence, and they will help you to make up the program and will become very much interested in getting these various exercises. The Chairman: A conference on Athletics and Physical Education for Women and Girls was held in Washington, D. C., on April 6th and 7th, 1923. This conference was called by Mrs. Herbert Hoover at the suggestion of the National Amateur Athletic Federation. Because of Mrs. Hoover's inability to be present at this session the committee invited Miss Helen Bunting, Assistant Professor and Director of Physical Edu- cation for Women, Stanford University, California, who took an active part in the Washington conference, to present this report, which will be discussed by a woman promi- nently and officially connected with that conference. 248 *The Washington Conference on Athletics for Girls Miss Bunting: SINCE many people have only vague knowledge concern- ing the National Amateur Athletic Federation of America, it has seemed to me that a brief survey of the history of the Federation should form a part of this report. The astounding lack of physical fitness of the young men of this nation, as shown by the draft of the Great War, came as a shock to the thinking people of the country; and after the war was over they began looking around to see what constructive thing could be done to remedy the con- dition, and as they looked back over the experiences of the war they saw that the one thing which stood out above all other things in building up the physical condition and sus- taining the morale of the soldiers was the mass of athletics winch were carried on in the army camps. So they decided to organize a nation-wide program of athletics for men and boys. Therefore, in November of last year, at the sugges- tion of the Secretary of War and the Secretary of the Navy, there was organized in Washington, D. C., the National Amateur Athletic Federation of America, with Col. Breck- enridge as its president; and the Governing Board held its first annual meeting in New York in December, less than a year ago. The avowed purpose of the Federation is to raise the health level of the nation, and to train the youth of the land for citizenship. The tools with which they are to work are amateur sports. The method of procedure is: (1) To federate all existing athletic organizations, so that they may work together and not at cross purposes; (2) to organize local federations everywhere throughout the country; (3) to stimulate wholesome athletic competitions, and (4) to have formulated, if possible, a series of progressive tests of physical fitness, for testing contestants in all competitions. When the Board of Governors was deliberating upon the problems of the boys and men they immediately saw that if the aim was to raise the health of the nation and train the citizens of the nation, then girls and women must also be included in the program. Therefore they asked Mrs. Her- bert Hoover, as president of the national organization of *Miss Bunting's speech includes the points made by Mrs. Hoover, in an informal discussion of this subject, at the time of her address on the Girl Scout movement, reported on page 313. 249 Girl Scouts, to be one of the vice-presidents of the N. A. A. F. Mrs. Hoover accepted, and the board then asked her to undertake the organization of this important work for girls and women. With her usual efficiency Mrs. Hoover immediately called a conference of the women in physical education who were trained and experienced in the profession. She sent invitations to the leaders in all phases of physical education throughout the entire country, with the result that there gathered together in Washingon the most representative group of women engaged in physical education that has ever convened in this country. A preliminary meeting was held the day preceding the conference for the purpose of approving or modifying the program as arranged, and for forming a conference or- ganization. Mrs. Hoover was elected temporary chairman, the program was approved, and tentative committees were appointed on organization, resolutions and publicity. At the first session of the conference, held the following day, Mrs. Hoover was elected permanent chairman of the con- ference and the committees were approved and enlarged, with Miss Blanche Trilling, University of Wisconsin, chair- man of the organization committee; Dr. J. Anna Norris, University of Minnesota, chairman of the resolutions com- mittee, and Mr. E. Dana Caulkins, Playground and Recrea- tion Association of America, chairman of the publicity committee. There were three main questions before the conference: (1) Are athletic competitions for girls and women desir- able ; do we want to put athletic activities within the reach of every girl and woman in this country? (2) If we do want to do this thing, then what kind of an organization should be formed for making it a reality? (3) What are the specific problems involved? It was voted to leave the question of organization to the closing session, but to have the organization committee make suggestions which the members of the conference could be thinking over during the conference. The com- mittee made the following four suggestions: (1) That we do nothing at this time, but leave entire control in the hands of the Women's Committee on Athletics of the American Physical Education Association; (2) that we form an inde- pendent federation for girls and women, separate from the 250 N. A. A. F.; (3) that we form a temporary organization, looking forward to later affiliation with the N. A. A. F., and (4) that we form an organization affiliated with the N. A. A. F., but consisting of an autonomous body composed of women. The members of the conference were asked to think over these four suggestions, and any other sugges- tions which they might have to offer, and to be ready to vote on the subject at the closing meeting. The conference then proceeded to the consideration of the special topics upon the program. In order to determine the value of any activity one must know what its broad objectives are. Dr. Thomas D. Wood, Columbia University, who was chairman of this session of the conference, led a discussion on "Recognized Aims of our Various Activities." This discussion showed the broad objectives of physical education to be to improve the physi- cal fitness of the individual and the race, to develop the mental, social and moral qualities of courage, presence of mind, sportsmanship, loyalty, team play, co-operation, leadership and fellowship-in a word citizenship. There are two things the N. A. A. F. is after, improved physical fitness, training for citizenship. If physical education can make a contribution to these phases of education then our first question is answered, and we should carry the benefits of physical education to all girls and women of the nation as well as boys and men. Miss Margaret A. McKee led a discussion on the "Means by Which We Work," and showed that if we are to accom- plish the above objectives in physical education then par- ticipation in physical education activities must be made possible for every one from the pre-school age, through the grades, high schools, colleges, industries, and all through life. And at present we are barely scratching the surface of the whole field. In the matter of the schools alone, many states require physical education in every grade of every school, but no adequate provision is made for it in space, equipment or instruction. Recreation in the industrial fields is scarcely yet begun. A discussion on "Limitation of Athletic Activities for Girls and Women" was led by Dr. J. Anna Norris, and it was shown that many times there should be strict limita- tion of such activities, owing to the fact that certain anatomical and physiological conditions may occasion tern- 251 porary unfitness for vigorous athletics. It was felt most emphatically by all the delegates of the conference that be- cause of this fact particularly all athletics for girls and women should be under the direct control of women, and not men instructors and coaches. Miss Blanche Trilling was chairman of the discussion on "Athletic Ideals and Standards," in which discussion it was made clear that our standards in all phases of physical education must be educational standards, keeping in mind the high objectives as outlined above, and keeping all ath- letics for girls and women upon a high plane, free from any taint of spectacular and commercialized sports which ex- ploit the individual for the athletic reputation or com- mercial advantage of any organization. This section also discussed the suitability of outfit and uniforms to be worn by girls and women; especially in track and field sports; the feeling being that an effort should be made to have always as conservative an outfit as is con- sistent with the sport. The great need for adequate, trained leadership in all sports was brought out by Miss Gertrude Dudley, Uni- versity of Chicago, who showed it is just as possible to form wrong ideals and standards as to form right ones, and that training for the right sort of citizenship depends largely upon the leadership supplied; therefore we must train more leaders. Miss Ethel Perrin, Detroit Public Schools, led a discus- sion on the all-engrossing topic of "Tests for Athletic Achievement." It was shown that if we are to promote physical activities for everyone, we must be sure that the weaker ones are not allowed to overdo. If there is anyone, anywhere, who can devise a test for physical efficiency which will give us the "physical quotient" of an individual as we now can get the "intelligence quotient," that person will render a great service to the world. The great desir- ability of having some such test by which to classify con- testants in sports is obvious to all. In the section on Organization and Administration, which was led by Dr. Burdick, it was shown: (1) That a great many types of athletics should be developed, from the least to the most strenuous, so that there might be indi- vidual adaptation suited to the needs and capacities of each individual; (2) that great play days should be organized in 252 which many activities are held, with many people taking part; and that everyone should discourage the specializa- tion of a few at the expense of the many, but rather have "sports for all" the aim; (3) that the director of the activi- ties should aim to be more of a leader, and less of a director, of sports, and try to develop leadership and initiative within his groups. As a result of all of these valuable discussions the spe- cific problems involved in this ambitious program gradually took shape and we saw that our obligations are: (1) To see that the broad objectives of building up the health of the individual and developing the highest moral, intellectual, and social standards are kept always in mind; (2) to see that opportunity for this training is given to every girl and woman throughout the length and breadth of this land; (3) to see that all activities are conducted along sane educa- tional lines, and that girls and women are protected from exploitation; (4) that because of the specific problems in- volved in women's athletics we must see that such activities for girls and women are supervised and coached by women; (5) we must devise, if possible, some means of measuring physical fitness. These are, of course, only a few of the outstanding problems of this program.. The resolutions committee which had been working throughout the conference, brought in a series of sixteen resolutions embodying the sentiment of the conference on the various subjects discussed. These were voted upon one by one, and a complete report of them may be found in the June number of the American Physical Education Review. The final question was then before us as to the type of organization best adapted to put over an effective program. Col. Breckenridge was asked to express his opinion on this subject, and after giving a brief review of the need for this movement, and the aims and purposes of the Federation, suggested the organization of two autonomous groups-one composed of men, and dealing exclusively with the problems of boys and men; and the other composed of women, and dealing exclusively with the problems of girls and women; and that these two groups be united in a governing board of the National Amateur Athletic Federation to deal with matters of general policy, finance, etc. This in substance was the type of organization embodied in the fourth sug- gestion of the organization committee. It was felt that a 253 nation-wide program could better be accomplished by united than separated organizations, and it was voted to form an organization of this type. A committee of seven women was appointed by Mrs. Hoover following suggestions received from votes of mem- bers of the conference, to form a special organization of women to stand as a deliberating, investigating, legislating, promoting, advising, and finally controlling body on the special problems of athletics for girls and women. The ap- pointed committee on organization is as follows: Miss Blanche Trilling, Vice-Chairman, University of Wisconsin, Madison, Wis. Miss Helen Frost, Teachers College, Columbia University, New York City. Miss Louise French, Assistant Supervisor of Physical Education, State Department of Education, Boston, Mass. Miss Helen McKinstry, Director of Central School of Hygiene and Physical Education, Y. W. C. A., New York City. Dr. J. Anna Norris, Professor of Physical Education for Women, University of Minnesota, Minneapolis, Minn. Miss Ethel Perrin, formerly of Detroit Public Schools, now Asso- ciate Director, Health Education Division, American Child Health Association, New York City. Miss Agnes R. Wayman, Head of Department of Physical Educa- tion, Barnard College, Columbia University, New York City. It is planned to form sectional organizations all over the country, probably upon the basis of geographical units, to handle local problems and carry out the national organiza- tion in all parts of the country. Discussion The Chairman: It is very much worth while to hear from another mem- ber of the group that met in Washington, and I am very glad to call on Miss Helen McKinstry, Director, Central School of Hygiene and Physical Education, Y. W. C. A., New York City. Miss McKinstry: I am reminded during this discussion that very frequently during the three days of that conference we were told that the term "ath- letic" did not cover all that we were discussing. We were discussing physical education for girls and women, athletics occupying, perhaps, rather a large place in the discussion, because of some of the very great things that had been done in the last year or so. 254 It seems to me that some very significant results of that conference were these: A group of representative women from all over the country came together in such a way as to make it possible for us to pool all of our ideals and ideas and our standards of physical educa- tion for women and girls, and to get together immediately on a broad basis for the purpose of formulating a program of physical education activities for women and girls from infancy to maturity. The next would be the setting up of the Women's Division of the N. A. A. F., which has been done. Then, the setting up of standards, the goals of this program, and means of checking up the results of our efforts as instructors. And the most significant thing is the fact which was brought out that at last men and women are realizing that immedi- ately we must get together on a program, the men and the women. Also that we must outline a program as quickly as possible; already requests are coming in from all over the country. It must be a pro- gram which is not a revised or expurgated or half-baked program for boys and men. As the full time allowed for this session had been used, the Chairman adjourned the meeting. The resolutions on "Physical Education in Relation to Health," presented by the Committee appointed, and adopted by the Plenary Session, will be found on page 344. Part VIII THE TRAINING OF TEACHERS AND LEADERS FOR HEALTH EDUCATION ALL of the preceding discussions are to be thought of as leading up to today's, namely-how are effective teachers and leaders in Health Education to be trained-in increasing their personal health, in securing appropriate subject-matter, in methods of handling subject- matter, in recognition of helpful agencies, and in working out effective modes of co-operation with them. The Chairman, in launching the day's work, made a special request that the foreign delegates outline to the Con- ference, the Health Education needs of their countries and their plans for meeting them. In accordance with the general plan of the Conference, a committee of the day was appointed to draw up recom- mendations, based on the session, for the approval of the Health Education Conference before being offered to the Plenary Session for adoption. Dr. Wood next introduced Miss Sally Lucas Jean, Di- rector, Health Education Division, American Child Health Association, who made the following important announce- ment: Miss Jean: The American Child Health Association last summer announced fellowships and scholarships for teachers to be given at the normal schools and universities to the extent of $10,000. This contest has been closed, and the awards will be made within a few days. You will be interested to know that fifteen of the scholarship holders are already attending summer schools, and taking tours of observation to demonstration centers. Five scholarships and five fellowships are to be awarded in a few days-for work during the coming school year. Holders of the fellowships are expected to be primarily research workers and, through research and investigation, it is anticipated that they will contribute further to our knowledge, relative to the promotion of health and the prevention of disease as applied to school children, and to the content and methods of successful health teaching in the public schools. 255 256 The scholarships are primarily set apart for the training of teach- ers, supervisors or directors of school health administration and teaching. It is expected that the recipients of these scholarships will return, after the completion of a specified program of study, to the public schools to become leaders in promoting school health in its various phases-administration and teaching. Those participating in these scholarships are expected to be effect- ual agents in getting other teachers interested in health teaching, thereby markedly extending the field of school health administration. Opportunity to do undergraduate work in normal schools is de- signed primarily for the classroom teacher who will later return to her classroom and, as a result of the training received, be interested in, and qualified to teach or supervise, some phases of school health activities. Opportunities in summer schools at Chautauqua and traveling scholarships are designed for the classroom teacher who is interested in Health Education and can devote only the summer vacation to studies along this line. I have, however, another scholarship announcement to make here. The Metropolitan Life Insurance Company has given to the American Child Health Association $25,000 to be used for teachers' scholarships, 50 scholarships of $500 each to be given to teachers who demonstrate during the next school year their ability to do unusually good health work in their classrooms. The sole purpose of all of these scholarship offers is to help teachers at every level of the school system to increase their success in health teaching. We need to feel that out of every conference such as this we are going to gain help in planning courses and opportunities to meet teacher's needs in order that these scholarships may yield rich returns to their holders. Surely we know something more about the matter today than we did even a year ago, and such being the case, we begin today's Conference with high hopes. Dr. Wood then introduced Miss Mary I. Preston, teacher of hygiene in the San Francisco State Teachers' College, San Francisco, California, who spoke on the subject of Putting the Practice of Health Into the T eacher-Training Program Miss Preston: MY small part in this big program comes in the training of teachers, and the first step in the training is to make health a vital issue to the student teachers, and finally to make health work a vital part of schoolroom procedure. On taking up the work, the closing injunction of Dr. Burk to the new physiology teacher was, "For heaven's 257 sake, let us find a new way to teach physiology. This mem- orizing stuff out of text-books is not learning. A student to learn, in any real sense, must have a personal motive. The only persons who have personal interests in health are the unhealthy or those who have acquired a social philoso- phy. Youth rarely has either. To make health appeal to healthy bodied and healthy minded youth, we must arouse in them natural motives and instincts. Young women have a native and legitimate interest in their good looks; why not address your appeal to this sound and sane instinct?" He felt that under the present text-book system of teach- ing the repeated inoculations of text-book doses develop so high a resistance to germs of knowledge, that they are promptly eliminated as soon as examinations are passed, or if any germ should possibly linger, it is immediately walled off and exists only as an isolated tubercle here and there. I did not doubt the truth of this one bit, and realized it was up to me to find a natural portal of entrance for physiology germs so as to get them into the general circu- lation instead of remaining sealed up in safety deposit vaults. "Interested in their looks." Could it be that looks might prove a natural portal of entrance? And wouldn't it have a scientific basis? Haven't men always insisted on women being good-looking, and therefore through the process of natural selection haven't the women interested in good looks been the ones to survive? So with the help of Mrs. Collier, Western Representative of the American Child Health Association, I listed the charms of perfect health with their physiological explanations, and then the idea occurred to me to put the whole into chart form with a scale for scoring and thus be in the swim with the other scaly folk. This was done and with Dr. Lucas' assistance in evaluating points, we rounded the chart out to this form: 258 Are You as Attractive as Nature Intended You to Be? Score Yourself Score-Points. 5 (a) Hair. "A woman's chief glory lies in her hair." Glossy and free from oil; not dry and brittle. 5 (b) Eyes. "Eyes that sparkle like the stars at night." 2. Bright-sparkling-alert; not dull and heavy. 1. Not strained; no puckery lines or frowns. 2. Clear white of eye; not muddy or yellow. 5 (c) Mouth. "Smile and the world smiles with you." 2. Pleasing expression. 3. No mouth breathing. 5 (d) Teeth. "The charm of your smile comes in your teeth." 3. Well cared for. 2. Good apposition (teeth meet properly). 10 (e) Skin. "A skin you love to touch." 2. Clear; without eruptions. 2. Good color; not anemic. 1. Moist and smooth; not dry and scaly. 2. Tissue firm and elastic; not flabby or soggy. 2. Skin under eyes smooth and clear; not dark and baggy. 1. Lips naturally red. 5 (f) Hands. "Beauty at your finger tips." 3. Skin immaculately clean. Smooth, without abrasions or cuts. 2. Nails and cuticle clean and carefully cared for (no extremes). 5 (g) Feet. 3. Normal (of good shape). Shoes worn evenly on heels and soles. 2. Feet properly shod (no extremes). 10 (h) Posture. Graceful Carriage. 1. Head well poised. 1. Shoulders level (one shoulder not lower than the other). 1. Graceful body line unbroken by abdomen; chest high. 1. Feet in good position-slightly apart and par- allel. 1. Arms in graceful relaxation. Good lines and grace while seated. 1. Lower spine against chair-back. 1. Knees almost touching each other. 1. Feet parallel or one crossed over the other. Harmony of movement while walking. 1. An elastic step-firm, not heavy. 1. Good rhythm of entire body. 10 (i) Correct weight for age and height (see table). 259 10 (j) Good hearing. Can you hear ordinary conversa- tion at 16 feet? 10 (k) Good vision. Can you read ordinary print at arm's length without strain? Can you read the usual billboard sign across a street? 20 (1) The All-important First Impression. 5. Radiating good health and spirits (full of en- thusiasms and interests; magnetic). 5. Poise. A perfect control of self, often inspiring others with confidence and admiration. 5. Voice. The depth, the warmth, the force of your personality should speak through your voice. 5. "Pep." The power that makes the world's wheels go round. Total, 100 Is your score what you would like it to be? If not, why not remedy it? "Health makes beauty." Please understand that this is not a matter of mere vanity alone. It is only the entering wedge, the hypodermic needle, so to speak, which gets in under the girl's skin; once in, all the physiology and Health Education desired can be shot into her every day circulation. Of course, it goes without saying that had the appeal been made to men it never would have been made along such lines. We should have talked about strength, prowess, a good eye, emanation of power, personification of force, keeping in good form; in short, all that goes to make a really good-looking fellow, but we'd never dare mention looks. It simply isn't done. I was quite interested, how- ever, to see that the majority of the M. D.'s at the medical convention just concluded were very well groomed looking specimens of homo sapiens. The point of attack in the use of the chart is personal. It is each girl's eyes, feet, digestion, etc.; not an abstract, analytical description of such. It is not the study of a life- less text-book figure, but of each one's functioning body with its play and interplay of life forces. Then, too, we do not forget that the professional work of the student teachers is going to be with living, impres- sionable beings with many and varying physical idiosyn- crasies, not just so many machines into which to pour geography, history, etc. We hear a great deal about indi- vidual differences in the psychological field. What about the physical? Don't we vary just as much physically as mentally? And don't the physical differences affect the 260 child's development and progress, as well as the mental? So throughout the chart, we discuss the physical differences found in the schoolroom and their interpretation. Further- more, the vital part played by the emotional life on both physiological and psychological processes must not be lost sight of. If you doubt the power of the emotions, just study advertisements, the most successful means known commercially of putting anything over. Is their appeal made to reason? Never. Always to sentiment and emo- tion. And, by the way, why are we not utilizing this force more in our Health Educational field? Where does the practice of health habits come in? All the way along. If in discussing bright eyes, you ask a girl, "Why do you look stupid at seven in the morning after danc- ing till two the night before?" she gets the point, not enough sleep to sweep out the stupefying wastes. "Why are your eyes bright and sparkling after a brisk walk?" The stimu- lation of exercise; and so on, over and over. The method does seem to work, according to the grown-ups who have outside contacts with the girls. So much for making the subject vital to the girls. Now for carrying it over into the classroom. To accomplish this, I instituted health projects as the initial step. These again had to be based on an instinct, a stimulus connected with the child's natural development. Health habits should en- gender strength, but what does the grammar school child, for instance, want to accomplish with his strength? Why, of course, to compete with his fellows, to prove he is no in- ferior, but an equal or superior. There was the keynote to the solution of the problem: we would connect the strength gained in the practice of health habits with the child's rank in the compulsory state athletic contests, in which every grammar grade child takes part. Good. So the health habits donned a new dress, that of a machine, always a fascinating object to boys or girls of this age. This is the form we use: My Machine Record 1. Kept spark plugs scrupulously clean (hands, especially before eating). 2. Removed dirt from carburetor (brushed teeth). 3. Gave machine 4 glasses of water. 4. Put no tea or coffee into gasoline tank. 261 5. Put in oil (fruit and vegetables) to keep it running smoothly. 6. Straightened up any sagging as it interferes with good work. 7. Gave headlights good treatment. 8. Provided a cheerful driver. 9. Exercised 2 hours to get a bigger, more powerful machine. 10. Took 9 hours sleep to clean and repair machine. Machine Improvements Searchlights made stronger (glasses). Removed a dangerous part (tonsils). Repaired a bad spot (teeth). A chart was used, so arranged as to enable the child to keep check on the above points. You will notice that the mental side is co-ordinated in the child's being a cheerful driver, the value of which state of mind is not appreciated sufficiently by parents, espe- cially at meal times. So far, good enough; but I found to my sorrow that projects did not carry over to a study of the individual child in the classroom when the students started their practice teaching. Any belief, to become an integral part of one's being, must be acted upon, and the girls' activities had not included the individual in the classroom, and in the new and bewildering mechanics of schoolroom procedure, the in- dividual differences are easily lost sight of. In an attempt to correct this, I met with the beginning teachers of the training school, in an effort to evaluate the effect of such differences, on the progress and success of both child and teacher. If these prospective teachers could just learn the tangible signs of a lowered vitality, in the classroom or out, and how much they have a right to expect from such a lowered vitality; how to tell when to blame the machinery and when the driver; and, above all, to detect flaws that can be corrected, they would thus save misunder- standings and injustices without end. We discussed the various physical differences and their effect on the child's progress, but I left it to the student teachers to make their own applications in their classrooms. Again I was disappointed. The question of health was an extraneous one. Was it that the presentation was too abstract, that I was isolating the physical and trying to study it as an entity, when like scrambled eggs, one phase of life cannot be separated from the others? So I planned 262 another attack, and sought the aid of the psychologist to fully round out the study. Types of physical differences were brought before the teachers, thus making the abstract concrete. Discussion followed as to reasons and results of the same. Search in each teacher's class was made for similar types, with fre- quent consultations with me in the classroom itself (a very necessary part of the work, I found) ; then a study was made of such pupils, which was correlated with the intelli- gence level, social reactions in room and yard, home envir- onment, and mental and physical attainments; and a report of the same made at the next meeting. At last I began to see success ahead. The teachers now began to realize that every step of their progress toward successful teaching was indissolubly linked with the health of the living material with which they work. The desire for Health Education now came from within, and was not superimposed from above as another burden to the already overloaded curriculum. This short experience has con- vinced me that at last we are probably on the right track. Discussion The Chairman: The discussion of this paper will be led by Dr. Clara M. Greenough, of the State Normal School of Eugene, Oregon. Dr. Greenough: My method of attack on health teaching is very different from Miss Preston's. It would certainly not do in the training school with which I am connected to make my approach through good looks. The men would immediately turn me out if I did. Also, the conditions are very different. I am dealing with a class of students who must go into rural districts. And they do reach into the homes. Having done more or less lecturing before the Parent-Teacher Association I had thought that one of the best methods of reaching the parents, but I found that though 20 per cent of the lessons the lecturer gave reached the home, 50 per cent of those the teacher gives reach the home. From my long experience as a physician, and school inspector, I realize that our teachers are very lacking in content on health sub- jects. Therefore, my problem has been to get over to the teachers enough knowledge of the working and environment of their own bodies to make it possible for them to appreciate the conditions in their children, and in the homes from which those children come. We all realize that habit formation is most important, but we must know why. I feel that the lack of this is one reason for the failure of a good 263 deal of the Health Crusade work in rural districts. So many teachers come in and say: "I put it in for a year, but the second year it became monotoncus. The parents became tired of it." I think the reason is lack of understanding, on the part of the teacher, of the wonderful machine which is given to her to run. So in Cheney we have tried to make our twelve weeks of health work function as a vital subject. We have given them a text-book (I realize that I have fallen from grace). But we must have the foundation of knowledge. I have heard from this platform: "Why teach bones and blood?" Because they are fundamental parts of the body! Teach them, but correlate them in such a way that they mean something. Each student is given a personal examination when he or she enters school, with a little time given to personal conditions. For three years I tried working through the personal equation and found that I got very little response. Now we have taken a new stand, and are turning the personal equation work over to the health nurse. One of the methods we have used to good advantage is the morning health inspection. Realizing that the prospective teachers are going to the classrooms, we believe that a morning inspection with a little bit of machinery will perhaps be one of the useful ways of helping them. So we have adopted a method given to us by Miss Rood of the Mansfield Health Demonstration, to very good advantage. The demonstrating teacher stands with her back toward the window, and the children come toward her, so that the student teachers can watch the child as it approaches, and see whether it has the right posture. Then the teacher stands with her back to the window, so that the light falls on the child. Without touching the child, he goes through these motions. He counts for himself, (1) raising the hand and giving the teacher a chance to see the fronts of the hands and arms. (2) Open- ing the fingers so that the teacher may look. (3) Rolling up the sleeve. (4) Rolling up the opposite sleeve. (5) Bending the head forward and giving opportunity to see if there is anything wrong on the head, if there is a low water mark on the neck, and what the condition of the clothing is, which helps to check up Johnny, about the Saturday night bath. (6) The girl undoing her hair so she can get her hand behind it. (7) Opening the mouth and showing the teeth. (8) Opening the throat, at first saying "ah," which gives the teacher an opportunity to see the condition of the throat. Now what is the advantage of this? It gives the student-teacher a chance to see what physical defects there are, and to detect uncleanli- ness and bad health habits, and it accustoms the child to being in- spected and to taking it as routine. The teacher does not usually handle the children while they are being inspected. Children needing extra attention are taken to one side. Before the teacher handles a child who requires it she washes her hands before the child. This may seem too much routine to some people, but it is working out well in the rural districts. Afterwards an explanatory talk is given to all of the student teachers. A direction slip is given to them, and they then study every child of the group they are observing or teaching, and at the end of 264 the morning hand it back to me with their notations. They have to note the defects of posture, mouth breathing, the defects of speech, enlarged tonsils, defects of the eyes, hearing, personal cleanliness; they weigh a certain number of the children, according to the size of their group, reporting whether they are underweight; they report why the children are absent from school when more than two days. I give each child a physical examination once a year, and that gives me an opportunity to check up, to see how many children need a second examination. It is very interesting to watch these student teachers open their eyes. In the meantime, as was said at the beginning, we are teaching in the classrooms practical physiology, hygiene and sanitation, trying to make the students realize that the body is a wonderful machine with all the parts working together as a whole. The very superior, broad- minded man under whom we were working said that there was one fact that he wished we would never lose sight of. He said: "You are not only training teachers, you are training mothers and fathers of the future." I have found that idea has been a tremendous help in the work. The men students are much interested in the problems of the home, interested in the boys, the work that they are going to do among them, and the help they are going to give them in their com- munity life. These men students are willing to accept and study facts, and to study the social side of the problem as well as what we do in the schoolroom. We do not have time in our twelve weeks course to do much with actual devices and methods for health teaching, but it is not neglected. It is put into the general methods courses. We have three to five lessons on health teaching, in which the student makes posters and health books and does all the things with which we interest the chil- dren in health work. The main thing for us as trainers of teachers is to see that we really accomplish something in the end, and that our teachers are helped to make American children better citizens, freer from physical defects and from mental and spiritual defects. For we cannot teach hygiene, physiology and sanitation, without bringing in the mental, moral and spiritual side of the question. Miss Alice Wilmarth, Head of Department of Health and Physical Education, at the State Normal School, El- lensburg, Wash., added to the discussion, as follows: Miss Wilmarth: I have been asked to tell you something of the type of work that we do at the Washington State School at Ellensburg, and I will try not to duplicate the two previous speakers, but tell you of some of the additional things, which we are trying to do there. You have heard during this Conference of the major part to be played in any health program by the physician, the dentist, the nurses and the physical directors. All of them contribute, and we are all trying to assure you how much co-operation on the part of all these agencies is necessary to a successful health program. Now, our school is rather low in funds, but we have some factors which offset this very mate- 265 rially, the chief one being a very close association and co-operation on the part of all the members of the faculty and the executive, who is unusually interested in this field of work. So we are given a free hand in carrying out the program. It has been found that we cannot do much in the short time with which we have to work with our normal school students in the forma- tion of health habits, but we can do a very great deal in creating right attitude, and that, I think, is our greatest success. The greater part of our student body is accommodated in the dormitory. This dormitory furnishes a laboratory for the work in nutrition and in personal hygiene. The head of the Department of Health lives there and directly supervises the health of her students. Associated with her is a graduate nurse, who has for her particular use a small well-equipped infirmary, which also is in the dormitory. The nurse is employed twelve months in the year, and has classes in Home Care of the Sick and in First Aid. The students have learned to take a stitch in time, and rarely do we find a patient confined in the infirmary. In this same building the head of the Home Economics Department has supervision and control of the dining room, and the Director of Household has supervision of the living quarters. Out- side girls are also supervised as to their living conditions. Students entering are given a physical examination, the results of which determine the number of hours work they may schedule themselves for, and the type of activity best suited to their needs. All students spend an hour a day out of doors, the weather permitting, unless we believe the rest hour is better for them, when it is substi- tuted for the activity hour. As to the informational courses, for the last four years graduates of all two-year courses have been required to complete a composite course in health, consisting of a quarter's work in health problems, a quarter's work in nutrition, a quarter in household economy, and a quarter in sociology. By that time we believe they have been exposed to a general field of health work, and may have a better understand- ing of the whole field. During the first quarter we try to create in the students a real desire to make the most of their own natural equipment in health. During this same quarter we give them an opportunity to detect the ordinary defects found in children in the elementary schools, that is, things easily detected by the schoolroom teachers; and they have practical experience during this period, in the examination of the training-school children. Following this quarter, we try to interest them in the people about them and in their general surroundings. They have a quarter in nutrition, which is given by the home economics department. There they study the fundamental food values and general nutritional work. Then following that is a quarter in household economy. The last quarter is one in sociology. On the campus we have a training school in which the students have two quarters of practice teaching, including supervision of play- grounds. That our health program has succeeded in some measure is, I am 266 sure, due to the co-operation on the part of all of the various agencies in our institution. The Chairman: Professor Clark Hetherington is with us this morning, and I take the opportunity of calling on him for a few words. Prof. Hetherington: One of the great problems of teaching health is due to the fact that all of the most important health processes on the part of the child take place out of the school and not in the school. That is, the children eat at home, they sleep at home, and the teachers have no opportunity to directly supervise these great vital health habits. Consequently, I feel that if we confine our efforts in teaching health habits to those processes which take place in school, or which take place directly under the teacher's supervision, we will fail. That means we must put into the hands of the teacher a procedure which will reach the health processes which take place outside of the school. From a psychological side, this means that we must find in child nature those tendencies and instincts which the teacher can use to control the health processes which take place out of the school. That is the problem in the psychology of teaching health, which must be worked on. From the things that have been said this morning it is clear that there is a good deal of thinking going on, going right back to those fundamentals in the psychology of child nature on which we must base our methods of teaching health. I believe that this meet- ing, and the general efforts that are being carried on by such organi- zations as the American Child Health Association, are epoch-making events, and that it will not be long until we will have a procedure in teaching health which will line up with our procedure in health super- vision. Personally, I would like to make a clear distinction between these, because we know a procedure in health supervision or medical supervision which is scientific and concrete, and which, if we could apply it everywhere would practically eliminate the health handicaps. We have not .yet any such procedure in teaching health, but I think we are all on the road to establish it. The Chairman: We will pass to the consideration of the next subject on our program. Dr. Edna W. Bailey, Supervisor of the Teaching of Science, University High School, Oakland, Cal., will discuss Scientific Foundation of the Health Teacher's Professional Training Dr. Bailey: THE proceedings of this Conference have been most en- couraging to all interested in making permanent and fruitful the present widespread interest in Health Educa- 267 tion. In regard to that most vital and urgent of our prob- lems, the training of teachers for Health Education, the Conference speakers seem agreed upon certain funda- mentals. These include the recognition of the imperative need for sound scientific knowledge, familiarity with the field of chemistry having been especially emphasized. This command of scientific material and method are to be coupled with training in psychology and educational method, and, to some extent first-hand acquaintance with social problems related to health. In other words, the teacher of Health Education should have skill in teaching, a wholesome per- sonality and social viewpoint; should be free from super- stition, dogmatism and fads; possessed of sound scholarship in the field of fundamental sciences, and be well posted as to the latest developments in the fine art and unfinished science of "How to Live." Our immediate problem is to determine what can be done to help the ordinary, every-day teacher to qualify for so exigent a task; remembering always that she may have few assets beyond good-will and skill in han- dling children. The teaching of hygiene has fallen into such discredit that even the name of the goddess of health has unpleasant associations for most people who have gone to school during the last thirty years. The newer term, Health Education, has been coined not only to escape the curse of "hygiene" but also to include a broader scope of subject-matter and activities. The teacher of hygiene sought to impart knowl- edge. The test of her success was what her pupils knew, measured by what they could write or tell. The objectives of the newer Health Education are the establishment of personal health habits and the development of certain standards, attitudes and ideals with regard to public health conservation. The most frequent and serious criticism of Health Edu- cation has been that it showed a tendency to minimize the necessity for a solid background of knowledge. This ten- dency undoubtedly arose through a clear perception that copious knowledge has no effect on action. Physicians, for example, know very thoroughly the facts concerning intelli- gent care of the body, but no other professional man breaks the rules of personal health so systematically as the average hard-pressed, practicing physician. The kind of knowledge which could be relied upon to form habits and develop 268 standards had to be knowledge "with teeth in it," with a carry-through into action. Putting this carry-through into the teaching of hygiene has been a very interesting and successful instance of the application of modern psychology to the teaching process. The youngster is first aroused to interest in his own health standing; he then has a problem to solve, namely, that of improving his condition, and he is eager for knowl- edge which will be useful in solving that problem. Conse- quently, he will accumulate that knowledge quite painlessly, with the minimum of friction and the maximum of interest. Having accumulated it, he will use it, because that is the reason he went after it in the first place. He learned it be- cause he wanted to use it. But just because this new knowledge is to be put to the test of application, it must be rigidly honest and trust- worthy knowledge; else it will not work. And to select and impart knowledge that will work in individual application is a task which calls for broad training, open-mindedness and sound common sense on the part of the teacher. The program for teacher training proposed at the Lake Mohonk Conference gives evidence of having been planned with these various and insistent problems in mind. The whole spirit of this Conference Report is enquiring, un- prejudiced and free from dogmatism. It both invites and stimulates constructive criticism. Emboldened by this atti- tude, this paper ventures a critical summary of its teacher- training recommendations. The plan includes a long list of recommended courses, falling under the following heads: I. Hygiene (personal and community), eight kinds. 2. Nutrition. 3. Home-nursing and First-aid. 4. Physical Education. 5. Principles of Health Education and Practice-Teaching. 6. As preliminary work, the general principles of applied chem- istry, applied physiology, applied psychology and applied bacteriology. Without stopping to emphasize the many excellent fea- tures of these recommendations, certain points seem to the writer open to criticism. 1. Too little emphasis is placed upon the fundamental sciences. A high school preparation in chemistry and biology is inadequate, not because the ground is not covered, 269 but because of the immaturity of the student. A mastery of scientific subject-matter and method is not attained so easily or so early; and stuffing with facts does not meet the need. 2. In organizing instruction, larger and more closely co-ordinated units would yield better results. Such further organization may have been intended, though not here ex- plicitly stated. 3. There is indication of unfortunate separation between the fundamental sciences and their application. This is not peculiar to this program, but a general tendency, against which all socially-minded teachers of science must be on guard. 4. There seems to be a good deal of emphasis on various sorts of "hygiene." The laws of hygiene are not like the laws of the Medes and Persians, and the teacher who knows nothing but these (so-called) laws is apt to wake up some morning and find that someone has fed a few more rats and discovered that all children should drink coffee and go to bed at ten o'clock. 5. This program does not appear to provide enough op- portunity for the teacher to obtain a correct perspective of the slow growth of our knowledge of health and disease. It is good to recognize the hoary old health fads and fallacies that crop up generation after generation. Such study helps us to a better understanding of the public, which has always accepted its health regulations on the basis of blind obedi- ence to authority, and cannot be expected to become rational overnight. 6. A modern program should include some provision for field work; for first-hand contact with those problems the teacher is being trained to solve. Any community offers some opportunity for such contact, and both community and training school will profit. While criticism is easy, construction is not so simple. The program to be suggested is open to many objections; it is hoped that it may serve to stimulate discussion. It has been formulated through several years experimenting in supervision and in teacher-training work, and has profited by constructive criticism from many fellow-workers. Dr. John N. Force, of the Department of Hygiene and Public Health of the University of California, has been especially 270 generous in bringing to bear his specialized knowledge and teaching experience on this problem. A program in teacher-training must consider both the subject-matter to be included and the manner of presenta- tion. The material needed is found in many fields, and must be so synthesized as to yield a clear and well-integrated body of knowledge. This should include, first of all, a thor- ough knowledge of the human mechanism, from the stand- point of its functioning. It is not necessary to know anatomy as the surgeon knows it, or physiology in an ex- haustive sense. But it is necessary to understand the meta- bolic process, by which the living creature maintains life, does work, grows and reproduces; and to understand the mechanism of sense-organs, nerves, muscles, and glands by which living things become aware of surroundings and re- act to them. Such a dynamic conception of the human mechanism cannot be got without a background of knowledge of chemi- cal and physical relationships. A teacher of Health Educa- tion without a command of the fundamentals of chemistry is worse off from many points of view than one lacking in knowledge of anatomy and physiology. The kind of work- ing knowledge of the living creature needed is better ob- tained from general biology than in any other way. The more specialized sciences put too many details in the pic- ture, and usually place too little emphasis on physio- chemical relationships. Next in importance will come a familiarity with modern knowledge of human and animal behavior, or general psychology. This is desirable, not only as an instrument in producing more skillful and efficient teaching, but as a means of helping boys and girls to solve the problem of how to make the most of themselves and enjoy life rationally. Also, the teacher needs a command of the resources of modern psychology in her business of education in health. The healers, the prophets, the quacks, the painless dentists, and a host of others, are using these resources to their own advantage, and to the detriment of the public; there is no reason why the forces of evil should have a monopoly on applied psychology. Finally, we can make excellent use of material from the field of epidemiology. There is so much we do not know about the human machine and how to operate it most effi- 271 ciently, that it is a satisfaction to deal with the compara- tively large areas of solid achievement in the field of control of communicable disease. Curiously enough, a study of school texts and programs seems to show that we have spent most of our time and effort teaching what we know the least about, and have given little attention to the triumphs of applied bacteriology and parasitology. This is in part explained by the fact that this material cannot be taught to young children, except as involved in a few simple health habits. It is best suited to presentation in secondary schools, where our health program is comparatively un- developed. The teacher needs familiarity with general bacteriology and preventive medicine, especially in its historical aspects. She needs this even for teaching little children. It will help to create a correct perspective, and prevent her from prom- ising too much as results of keeping ''health command- ments." For older children, the facts concerning the cause and control of infectious disease should be presented so vividly that they will bring home their own lessons. Such teaching calls for more than hearsay or book-learning on the part of the teacher. But the greatest service this particular part of her train- ing can perform for the teacher is to make an enthusiast of her. The inspiring record of the age-long fight, the self- sacrificing heroes of medicine with their undisputed achievements, and the fields yet unconquered, all combine to fire the imagination and arouse the determination to help "carry on." It is paradoxical, but true, that one of the most fascinating, encouraging, and stimulating fields of Health Education is found in the "detective stories" of control and prevention of infectious diseases. Arranging this material in briefer form, we have the following: Suggested Program 1. General Scientific Foundation. Chemistry (including organic) and physics Biology-general and human. Psychology-general and educational. Bacteriology (including immunology). 272 2. Specific technical information and training. Elementary preventive medicine, including communicable and degenerative diseases, sanitation and housing, industrial risks, child welfare, vital statistics, governmental and other health agencies. Nutrition. Physiology of infancy and childhood. Psychology of childhood and adolescence. Physical education. 3. Practical training in health teaching. This program differs from the plan previously discussed in placing greater emphasis on the fundamental sciences, involving additional branches and at least one year of work in each beyond the high school, and in providing fewer and larger units of instruction in order to do away with multi- plicity of courses and consequent confusion and over- lapping. Fewer "rule of thumb" courses, usually described as "hygiene" of one sort or another, are included, and no courses for obtaining special skills, such as First Aid and Home Care of the Sick. These involve no new subject- matter and should be learned as practical phases of the fun- damental subject-matter by applying it in home and school situations. Additional material is provided for perspective, freedom from fads and superstitions, and a sane recognition of the limitations of our knowledge of how to live. But after all, the problem of choice of subject-matter, though important, is not the only factor in successful teacher-training. A set of courses, covering the material outlined, could be so organized and presented that the pros- pective teacher would not be the least bit better prepared for health teaching by having taken them. Indeed, she might be worse off, because we humans are so frequently obsessed with the impulse to tell what we have learned, es- pecially if we have learned it recently and can't see any other use to make of it, that a teacher stuffed with facts is more of a liability than an asset. The courses suggested should be adapted to the ends of Health Education through careful choice of subject-matter, but the subject-matter must also be so organized and presented as to make use of the best we know in educational psychology. We must also recognize that our teachers-in-training learn what to teach and how to teach it, by example, far better than by precept. 273 Therefore, not only must we insist on sound scholarship in fundamental sciences, but we must strive for such prac- tical teaching in those sciences as will bear fruit in action. This cannot be obtained through laboratory teaching alone. The laboratory attack on a problem provides only a partial solution. The industrial chemist works out many a process, under laboratory conditions, which can never be made to function in commercial production. Exactly the same difficulties arise in dealing with the application of the fun- damental sciences to health. No teaching is adequate which does not carry the student beyond the laboratory environ- ment, with its conditions of controlled experimentation, into real life situations, where observation rather than ex- perimentation becomes the most fruitful method. We have assumed that the method and mental attitude learned in the laboratory will be carried over into life; the sternest lesson psychology has for us as teachers of science is that this is largely an assumption contrary to fact. All the train- ing we can give prospective teachers on the fundamental sciences will be practically worthless, unless it has been presented in such a manner as to include the solution of practical problems, not as a means of applying what has been learned, but as the commanding motive for learning anything at all about science. We cannot lecture and quiz our students through normal school and college, and then expect them to go out and teach by the problem method. They will teach as they have been taught. Nor can we teach "pure" science to inexperienced youths, who have spent most of their lives in the narrow environment of schools, and expect them to make the appli- cation of these scientific generalizations to the complicated and confusing situations they will meet. The only way out is to break down the wall between schools and practical concerns, and learn even the fundamental sciences in rela- tion to the world's need of them. This applies not only to the group of fundamental sciences, but also, and even more emphatically, to the spe- cific and more technical material included in our second group. This may be successfully presented in problem fashion, beginning where the students are, and working from local to broader problems. This program seems ambitious. We must admit it is fairly intensive, extensive and expensive. It may be said 274 that such a program would be possible for specialists, directors of Health Education, but impossible for the mass of teachers. But we must recognize the tendency in this field to emphasize the work of the individual teacher and to minimize the interference of the specialist in the class- room situation. This was marked in the Lake Mohonk re- port and even more clearly expressed during the present Conference. No amount of knowledge on the part of the supervisor will help the teacher answer those class ques- tions which "it is a disgrace not to know." A supervisor is most useful as an admiring audience; he can help some by rustling money and books and material for the subject, and fighting its battles in general; but a supervisor is not on the firing line; he is only a humble "service of supplies." Moreover, Health Education is not a particularly harm- less subject on which to loose amateurs. Teaching Latin or spelling or arithmetic with poor preparation and little skill has no such explosive possibilities as has a subject which attempts to influence the health, sanity and growth of boys and girls. Sacrifice quantity if necessary, but hold to the standard of quality. Less work, if we must, but sound. We have only to show that we can "deliver the goods" in the shape of healthier and happier boys and girls, to have fully ade- quate support, financial as well as moral, for any program necessary to insure good teaching. The Chairman here introduced Dr. John Sundwall, Di- rector, Division of Hygiene and Public Health, University of Michigan, to discuss Dr. Bailey's paper. Discussion Dr. Sundwall: Such a movement as the scholarship plans described by Miss Jean, together with the needs of our teachers, should stimulate our universi- ties, colleges and normal schools to provide adequate courses of instruction in the fundamentals of health promotion and disease pre- vention and control. As opportunities for study are provided, more and more will avail themselves of these opportunities. Where one per- son is the recipient of the fellowship or scholarship, others not thus compensated will become interested in, and pursue studies in, hygiene and public health. Health Education in its various phases will be developed and stimulated throughout the country. Naturally, institutions of higher learning will be interested in determining just what programs in hygiene, public health and school 275 health they must offer in order to have fellowships and scholarships placed with them. The courses offered, to be acceptable, must be determined in the largest measure, by the qualifications that should be demanded of those who are to function as our future school health supervisors and health teachers. What are these qualifications? In the first place, it is absolutely essential that all teachers who are going into school health work should have a definite understanding of modern public health interests and practices. Let us, therefore, proceed to outline. First, Hygiene and Public Health. In this course the funda- mentals of health promotion and disease prevention should be duly considered. Modern public health has two chief objectives: (1) The promotion of health through physiological hygiene, which is what the individual himself must know, appreciate and practice in order to attain and maintain positive health, and (2) the prevention and con- trol of communicable disease. The two, although they require some- what different sets of machinery, are closely interrelated. The contents of the health promotion, physiological hygiene or positive health and physical efficiency, phase of this course in general hygiene should include ample consideration of the following: (a) Food and nutrition: the balanced diet, quantitative and qualitative daily needs, including water, weight, overingestion, undernourishment, deficiency disease, (b) Air: ventilation, temperature, humidity, air in motion, air pollution, climate and health, (c) Physical activity and exercise: strength, endurance and fatigue, (d) Rest and sleep, (e) Bodily poisons: endogenous and exogenous, with particular reference to focal infections, autointoxication, alcohol, drugs, patent medicines, (f) Degeneration diseases, and the role they play in our nation's mor- bidity and mortality, (g) Shelter: clothing, home construction, (h) Mental hygiene: emotional instability, psychoses and neuroses, ration- alization, social adjustment, (i) Prevention and correction of bodily defects, based on studies of draft examination, school examinations, and examinations of other age groups, (j) Physical examinations: importance of annual examination in the early detection of degenera- tion diseases and its relation to life extension and longevity, (k) Sex physiology and hygiene: sublimation of sex thought, imagination and desires; continent life and the single standard of morality; penalties of illicit sexual intercourse; venereal diseases. (1) Heredity and eugenics: role of heredity and environment; Mendel's law; transmis- sion of defective qualities, etc. (m) Cancer, (n) Goiter, especially where it is endemic, (o) Accidents and injuries: "Safety First" and First Aid. The second phase of a course in modern hygiene and public health should deal with the prevention and control of communicable diseases. This is largely a community problem, the school being the community of particular concern in school health. It is "seeing to it" that those going about in the school are not disseminating disease germs and that environmental conditions are conducive to health. Carefully building up the health of an individual does not free him from the dangers of communicable diseases. Ingestion of sufficient virile typhoid bacilli will give the disease to the most vigorous. 276 The contents of this second phase of a course in general hygiene should include ample consideration of the following: (1) Nature of communicable diseases. (2) Source of diseases. (3) Spread of dis- eases by bodily discharges, by insects and contact infections. (4) Routes taken by communicable diseases. (5) Blocking the routes taken by communicable diseases, as (a) by special or specific prophylactic treatment, with special study of vaccines, vaccinations, serums, specific drugs, etc.; and also the relation of animal experi- mentation and vivisection to progress in curative and preventive mea- sures. (6) Blocking routes of diseases due to close social contact and intercourse which are difficult to block as people object to laws regu- lating their personal behavior unless they understand the significance of these laws; hence, values of isolation, quarantine, proper use of handkerchief, masks, clean hands, etc. (7) Water: boiling, storage, filtration, chlorination, etc. (8) Milk: certified and inspected milk; handling and shipping; pasteurization; tuberculous cattle. (9) Food: dangers of carriers infecting raw foods, hence examination of food handlers, food infections, meat infection, canning, food sterilization, etc. (10) Insects: destruction of flies and other insects, privies, drainage and oiling of swamps, insecticides, destruction of disease- carrying animals, etc. The contents of this course should include ample consideration of the special interests and activities of health promotion and disease prevention as applied to child hygiene, school hygiene, and adult hygiene, including the industrial phase. Furthermore, the student in this course should be made familiar with the objectives, activities, organization and administration of both official health agencies, federal, state and municipal, and voluntary health organizations, and how these can be utilized in the school health program. It should be supplemented by visits to and studies of health agencies engaged in the various phases of applied hygiene. The course first described should be a pre-requisite for this course. Dr. Sundwall then described a more detailed course in school hygiene for those who planned to become supervisors of school health activities, explaining how it should include ample instruction along three main lines: school health problems; matter and methods for teaching health to school children and training them in health habits; organization and administration of a school's health service. He believes that such a course should give the student some training in the recognition of various abnormal body-processes which are prone to appear in early life such as various types of physical defects, malnutrition, retrogressive changes, com- municable diseases, etc.; in measures for their prevention, and in proper attention to them, such as reference to com- petent physicians or to other specialists or outside health agency when wise, etc. Methods of co-operation with nurses, with the city's health department and with homes, 277 in the prevention and control of communicable diseases, should be duly considered. He emphasized here that it is not the intention that such a course should in any way pre- pare the student to handle personally the physical abnormal processes which occur in school children. He continued, saying: School health problems include consideration of: (1) Physical examinations, physical records, follow-up system, anthropometry and physical efficiency tests. (2) Promotion of school health through the various approaches. (3) Prevention and control of communicable dis- eases. (4) Environment and sanitation. (5) First Aid emergency treatment. What fundamentals of health promotion and disease prevention should be taught in each grade and how to teach them should be given due consideration in this course. Hence the matter and methods of teaching hygiene and of training school children in proper health practices are of paramount concern. Of course, special and more extensive training in Health Education methods must be acquired in special subjects designed for this purpose. In imparting information on health to school children, effort must be made to develop in them a keen and impelling appreciation of and desire for positive health and physical efficiency. Pupils must be made to feel that good health is a moral obligation they owe to the society in which they live. To achieve this realization on the part of pupils and of mankind is perhaps the most important of our public health problems. Again, the future supervisor and teacher of school health must know how to organize and administer an efficient school health service. The essential activities, personnel and machineries of an effective school health service must be understood by the future supervisor of school health through definite concrete teaching and experience. No institution of higher learning is able to train school hygienists unless it has an efficient health service of its own. In general, one may state that the school's health service must include the following interests and activities: 1. A personal phase: through physical examinations, provisions for maintaining positive health, prevention and correction of defects, prevention and correction of emotional instability and potential neuro- paths; through prevention of communicable diseases by early detec- tion in the school, isolation and treatment of those exposed or infected and through blocking the routes taken by communicable diseases. 2. An environmental phase: by sanitary sewage disposal and a sanitary water, milk and food supply at the institution; by play- ground facilities-space, equipment, etc., with adequate time for their use; and through equally good sanitation of homes of students by co- operation with outside health agencies. In the administration of a school health service, every opportunity must be taken to augment the general hygiene instruction with per- sonal instruction, and advice to those who are in need of it. This is the most effective way of teaching health. 278 Concerning the theory and practice of physical educa- tion and athletics, Dr. Sundwall said that if the new super- visor of school health is to correlate and direct all the physi- cal welfare activities of the school, and a well balanced health program is difficult otherwise, he must have some training in the theory and practice of physical education and athletics. The interrelationship between physical educa- tion and the school's health service must be duly considered; hence, the school's health supervisor must be made familiar with all of the objectives of physical education. The objec- tives he stated as follows: 1. The promotion of health and normal growth by means of proper exercise, gymnastics, games, etc. 2. Harmonious development of the body: (Greek ideal) personal- ity, securing an erect and self-respecting carriage of the body and neuromuscular control required for prompt and accurate response, and graceful, agile, co-ordinate and effective movements. (Of greater importance in secondary schools and colleges.) 3. The correction and prevention of abnormalities due to bad posture, asymmetrical development, etc. 4. Activity: the development of a lasting desire to be active, to do many things with a fair degree of strength and endurance. 5. Recreation: the profitable utilization of the pupils' time during the intervals between mental application, games, sports, gymnastics, etc. 6. The proper guidance of the fundamental interests and instincts of play: rivalry, pugnacity and mastery, through competitive games, sports and athletics. 7. Utilizing every opportunity to develop these important social, mental and moral qualities afforded in physical education and athletics. Hygiene and Public Health, School Hygiene and Theory and Prac- tice of Physical Education and Athletics should, therefore, be required of all who are to become health teachers. Applied Hygiene is highly desirable for all, but it need not be required of students who can devote only a summer session to initial training. Dr. Sundwall believes that the completion of such courses should give the student a rather comprehensive in- sight into what public health, in general, and school health, in particular, really mean. This knowledge he declared was paramount for all who expect to teach school health. No one can successfully supervise school health without this fundamental training. Dr. Sundwall said: One of our reactionary collegians has facetiously remarked that the function of a school of education is to train young men and women to teach though ignorant. Of course, educators resent this accusation. At any rate, let me reiterate, no one can function successfully as a 279 supervisor of school health and physical welfare activities who has not been trained in the fundamentals of health promotion and disease prevention as applied to the public and to our schools. Fads, non- essentials and what not will be included otherwise. The relative values of the different interests and activities will not be appreciated. Unimportant details will be emphasized, while important ones will be lost sight of. School hygiene, its teaching and supervision, is now saturated with empiricism and with faddism. Scientific knowledge, alone, will cor- rect this evil. Unbounded enthusiasm for and extensive training in teaching methods will be of little or no value unless the school health supervisor is well grounded in the sciences making up hygiene and public health. These must be mastered in the same sense that physics or history must be mastered before successful teaching can be antici- pated. One cannot be trained to supervise or teach school health "though ignorant" of public health. Recognition of this fact is vital to successful school health administration. Like Dr. Bailey, I am not in sympathy with the attempts, in many institutions, to break up the study of hygiene and public health into a number of courses for those beginning their preparation to be school health supervisors. For example, the following fields in public health are frequently referred to and study of these fields is arranged for in separate courses for beginning students: (1) Personal Hygiene, (2) Nutrition, (3) Community Hygiene, (4) Social Hygiene, (5) Mental Hygiene, (6) Health and care of infants and young children, (7) Health of childhood and adolescence, (8) First aid and safety, (9) Hygiene of the worker, (10) School Hygiene, (11) Home care of the sick, and so forth. A serious objection, to my mind, in so listing these separate courses for those who are beginning their train- ing for school health supervision, is that they are not arranged in proper sequence, they are more or less detached, much repetition is essential and the relative value of health practices is not easily seen. After all, hygiene and public health, whether applied to the com- munity, to infants, to schools or to the industrial worker, is the appli- cation of the general fundamental principles of health promotion and disease prevention to each of these units, with special emphasis on certain approaches which are of special importance for each particular group. Every effort should be made to encourage all students who anticipate going into health supervision to pursue a four-year pro- gram of study. Graduate work for fellowships should be open only to those applicants who have had training equivalent to that outlined above. Finally, it would seem that scholarships and fellowships like those described by Miss Jean should be placed only with those institutions wherein the following conditions are met: 1. A department of hygiene and public health which is amply prepared to teach scientifically all the courses outlined. 2. The health administration of the institution should be an ex- ample of that which it desires to teach. Hence, a well-equipped student's health service with its personal, sanitation, laboratory and educational phases must be maintained. 280 3. A department of physical education. Now that public health is becoming more and more interested in physical education and phys- ical education in public health, it is well to have the two combined for teaching purposes. Let us call it a department of hygiene and phys- ical education. 4. A department or school of education should be maintained by every institution that seeks eligibility for these scholarships and fel- lowships. The teaching of health, and training in correct health practices, are paramount. Successful teaching of health must depend in a large measure on training in methods of teaching. It is assumed that practice schools will be maintained in connection with these departments or schools of education. 5. Strong departments of physical sciences, biological sciences, nutrition or home economics, and psychology. 6. It goes without saying that the living conditions and the approved daily program, in such eligible institutions, should be such as would constantly promote the student's personal health and well- being. Miss Dol finger: May I call your attention to this: Today our country requires a hundred thousand teachers, more or less, and we have to send them out scantily prepared. We cannot give a beginning teacher in a two years' normal course all the subject-matter she should have for teach- ing health, any more than we can give her, all at once, everything she should know to teach geography or Latin. We can make teachers intelligent about health, give them the correct and vital point of view, and knowledge of where they can safely go for instruction. We should put at their service some kind of supervisor who will really keep them straight, and see to it that they are prepared to accept the latest findings from the laboratory without getting a brain-storm about it. The proper supervisor will keep her teachers in a receptive mood towards advances in science. Many things are developed in the scientific laboratories which are still matters of experimentation, and, as such, probably not at once to be incorporated in the school program. Having been a supervisor myself, I have come to believe that a supervisor's chief job is to be an extension- teacher to teachers, and if the supervisor does not so help the class- room teacher she is failing in her work. As the supervisor goes visit- ing from class to class she is in a position to find out what the teacher needs and to arrange to give it to her as fast as the teacher can take it at the time, and to inspire her later to go to the university or the college, and there study the type of work which she needs to make her the specialist she should be. The Conference at Mohonk, June, 1922, recommended that the fundamental subject-matter for the preparation of the teacher in Health Education should be derived from the following fields: a. Personal Hygiene b. Nutrition c. Community Hygiene d. Social Hygiene e. Mental Hygiene 281 f. Health and Care of Infants and Young Children g. Health of Childhood and Adolescence h. First Aid i. Hygiene of the Worker j. Home Nursing and Care of the Sick. k. School Hygiene 1. Physical Education m. Principles of Health Education and Practice Teaching. Prac- tice Teaching to include practice in all types of contact with children incident to health work in the school. Training a person to be a health teacher is training a person in a synthetic, rather than a specialized course. It is necessary that the person who directs that training should appreciate the need of filling gaps in students' training, and of recognizing gaps when he sees them. Everybody realizes that teaching the "rules" is not sufficient unless the fundamental principles are behind, but also we realize, that train- ing our teachers in the fundamental principles without giving them the spirit is equally unfortunate, because, after all, what we are after is results, and what we must do is to give the teacher a picture of what she is to produce, and then as fast as possible train her so that she produces it intelligently. The Chairman: We should now like to hear from some of our foreign delegates as to the problems of teacher train- ing or Health Education in some of the other countries than that of the United States. The Chair will therefore take the liberty of asking M. Leon de Paeuw, Director General of Normal Schools, as well as a member of the Ministry of Education, of Belgium, to take up the discussion at this time. M. de Paeuw: In the past, Health Education did not retain our special attention although hygiene has always been taught in our elementary and normal schools, but now that the Educa- tional Foundation of the Commission for Relief in Belgium has given us the opportunity to study Health Education in the United States, and to meet leading personalities like Dr. Wood, Miss Jean, Professor Turner and others who de- vote themselves to the diffusion of rational health habits, we have decided to start, with the help of our American friends, a great crusade in favor of more and better health practices. The first thing we want to do after our return to Bel- gium is to gather all the supervisors of our elementary and normal schools and to explain to them what they have to do. 282 Our Minister of Education, who is a most distinguished physician and a professor of medicine at the University of Liege, has decided to sustain our efforts energetically. Miss Bragg, assistant superintendent of schools in Newton, Mas- sachusetts, will come over to Belgium in August and explain the methods for Health Education which she is employing with enormous success in her schools. I myself will deliver a few lectures in order to tell how American methods can be adapted to particular Belgian situations. All our teachers receive their training in normal schools. The first thing to do there, is to interest the future teachers in their own health. I want our young graduates leaving normal school to be enthusiastic health workers because they realize, by their own experience, that health is a price- less treasure. I expect to organize Health Education in our normal schools according to the resolutions adopted in this Con- ference, and thus our new organization will be a child of the great Health Conference of San Francisco. And our people will be shown that the Sun of Hygiene does not rise in the East, like the real one, but in the West. Three times a year, the teachers of our elementary schools are brought together in small meetings, under the leadership of their supervisors. Health Education will be, next year, the principal, if not the only subject of discussion. Since education has been made compulsory in Belgium until the age of fourteen, we have in all our elementary schools for girls, classes in cooking, laundry, etc. A whole day each week is devoted to the practical teaching of home economics to girls twelve to fourteen years old. The girls of a class are divided into groups of five or six, each group representing a family. Each family has at its disposal a stove and the needed utensils as they would have in their own homes. Meals are prepared in a scientific way and then served and eaten. You understand that we want to make use of this organization for the diffusion of the knowl- edge of rational diets. It is a step in the direction of prac- tical health teaching. A message to the Conference, from Japan, was pre- sented by Miss T. Ueda, member of the Department of Justice of Japan, and translated into English by Professor 283 K. Hata, of Kobe. Professor Hata said that when he was asked by Miss Ueda to interpret for her, he told her that it would be more interesting and the audience would be more pleased if she read this translation herself, but her modesty would not allow her to attempt to undertake a task to which she was not accustomed, so he would read it for her. It is a presentation of the problems of Health Education in Japan. Miss Ueda: At the early stage of the Japanese history, children were looked upon as a possession of the parents; in the feudal age they were considered a family possession; and now they are regarded as a social possession. As the view changed, so the attitude of the parents and the public and their sense of duties toward the children changed. Education which once aimed at the production of war- riors of gallantry to serve the parents, the family, the clan or the lord, now aims at the production of champions of love and truth to serve peace and humanity. Cultivation of sound spirit and training of strong bodies of these cham- pions involve many and varied problems and difficulties and Japan is now facing numerous problems relating to child welfare. Studies of these problems have taught all thinkers that they must go back to the protection and education of motherhood, and the problems arising therefrom are engag- ing the thoughts of social workers at present-actual works and movements. It is a matter for congratulation that they are progressing along the lines of preventive and construc- tive measures in our country also. In order to educate girls for motherhood, a new de- parture was made in the school system several years ago. The high schools for girls were divided into two classes, the high schools for general education and the high schools for practical training. A great number of new high schools belonging to the latter class were founded at the time. In these schools the principal courses given and encouraged were the domestic science and natural sciences. Continua- tion schools were established in all parts of the country with a purpose of bringing the practical side of the elementary school training to a more pronounced effect. For women who could not avail themselves of these educational advan- tages various organizations were formed even in the re- 284 motest parts of the country-women's clubs, maidens' clubs and similar organizations which made all possible effort to spread useful knowledge. As a result of such educational reformation and campaign, health problems began to draw keen attention, and studies of food chemistry and kindred subjects, which are so important for the promotion of child health, began to absorb the interest of women. They came to be treated in a new and scientific fashion in periodicals and other literature for women. In spite of these encouraging movements, the death rate of children, especially of the foundlings, is very high in Japan, the highest in the world, as statistics show. What does this fact indicate? I hesitate to make this remark for my dear motherland, but the inevitable fact is that there are in Japan too many mothers who know how to beget but who do not know how to rear children. Far more numerous are the women who would starve both their children and themselves if they attempted to take care of their own babies, for they have to work from morning till night to earn barely enough to get rice and pickles for themselves. This is a sad fact, but how can we expect these unfortunate women to do more? Somebody else must look after the children, and who? Our relief works and equipment are limited and inadequate to meet our situation, but we have five maternity hospitals, fourteen or fifteen stations for traveling midwives, some stations for traveling nurses, two hundred day nurseries, some child welfare consultation offices, child health consultation offices, and mothers' con- sultation offices, all of which are scattered in cities and rural districts. In all such places where child welfare is taken care of a physician or a nurse is always placed. These medical people are there to do preventive and construction work rather than relief work. In elementary schools an important place is being given to Health Education. In each of the eighteen public schools in Tokyo a nurse is placed, the example being followed by many local schools. Public school teachers who have not practical knowledge in medical science, nursing and sanitation are considered to be inadequate, and in order to give better training to these teachers, the department of education called a gathering of women teachers last year and gave a Health Education session in Tokyo, which helped the teachers very effectively. 285 Besides, open-air schools, sea-side schools, evening schools, and other plans of Health Education are being discussed and studied. The Japanese women who are awakening to the im- portance of promotion of individual health and knowledge of Health Education, are also awakening to the value of or- ganized movement. They favor universal suffrage, for they know that the love of the mother will supplement the wis- dom of the father and that in the state where the mother sits in vigilant care of children, humanity will be the safest. The Japanese women must co-operate with the women of the world in building a new world, by developing strong manhood and womanhood in their children. It has been, therefore, a great joy for me to meet educators from all parts of the world and sit in conference on problems relat- ing to child welfare. I have seen with my own eyes the great spectacle that has never yet been seen and I have felt the invisible power that is moving the social workers and edu- cators of the world. It is this spiritual power that will rebuild humanity. It is the inspiration and contagion of this power that will strengthen the social workers in my country and accomplish works of humanity. I shall take back this great spirit of the Conference to my country for my own constant encouragement and also for the encourage- ment of my co-workers. The Chairman: We are glad to have the opportunity of listening to such addresses. It is my pleasure to also be able to present to you Miss Hortensia Balarezo, of Ecuador, who will give us a statement with reference to the health needs of Ecuador. Miss Balarezo: When I accepted the gracious invitation to attend this Conference, I knew I was coming to hear lectures of great interest to me personally and to my country, but I did not know that the interest in the program for school hygiene would rouse me to the pitch that I would ask permission of the Chairman to address you. I am going to report back a great deal more to my country than I was sent here for by my country. In the first place, I have compared the difference of the problems of this country, and those of my country. Here 286 you already have problems which are related to the needs of a health program in the schools. You have associations that are working to the end that you will put in practice what you need, but your great need is for further scientific investigation in the field, and co-operation between those different agencies who are working on your problems. The problem in Ecuador is very different from that. We know now that we must begin to educate the public to this great need of health work in the schools. We need hard workers rather than the narrow researcher in special fields. Besides the general problem of educating the public to the need of health work, we need the immediate inauguration of some kind of a program of health work in the schools, and for this we need trained teachers. We now have to count on the services of physicians, because we still do not have trained school nurses, and trained teachers, to carry on the health program in the school. Then we need also to correlate the work between the normal courses and the nurses' courses. May I say that we now have a very good nurses' school which is being conducted by a doctor who received his edu- cation in this country. When he went back he established this first nurses' school, a few years ago, and if we correlate the courses given the nurses with the courses in the normal schools, we shall have a greater advantage in teaching pub- lic health work than we now have. There should also be co-ordination between the department of public health and the schools. We have a very efficient department of public health. Its duties are to see that the streets are clean, to inspect food, to handle sanitation problems, and in addition, it maintains three clinics for children. But this department should have its work outlined in Health Education. Now, how will the United States help us? In the first place, I would suggest perhaps an International Association for health work, or if we narrow it, a Pan-American association for the improvement of health conditions and for the train- ing of health workers. I should also suggest that great as- sociations such as the American Child Health Association should prepare translations of literature that they pub- lish-translations in many languages and especially in Spanish, because the Latin-American countries need that literature. Then I have heard of your scholarships for American teachers. I would suggest that some amount of that money 287 be put aside, and dedicated to train teachers-one or two from each of the Latin-American countries. Send adver- tisements to these countries so that nurses or teachers would avail themselves of these scholarships and come to this country and study health work. Then, when they come here, I would suggest a program specially adapted to their needs-not to require them to go through the definite course you have outlined-but to have a course made up for Latin- American nurses or teachers who have had previous experi- ence and to adapt a course to their special needs, having them do the practical work, visiting clinics, caring for chil- dren, going to public nurseries, and the carrying on of perhaps several weeks' practical work there. May I just mention at this time the great work that the Rockefeller Foundation has done for the health of people in Ecuador. We had a few years ago a great plague of yellow fever all along the coast, but now not a single case is reported, thanks to the expert advice that the Rockefeller Foundation has given us. Besides, it has given us some financial support. But Ecuador has co-operated in that work with much enthusiasm, and last year, of the $55,000 necessary to carry on that work to prevent the plague again, $40,000 were given by the people of Ecuador and only $15,000 by Rockefeller Foundation. Soon we shall be able to carry on the problem of sanitation in connection with this work. Now, will not the American Child Health Association take up the problem of health training of teachers and nurses and inaugurate a health program in the schools of Ecuador? Mr. Thomas Yuan, of Peking Teachers' College, Peking, China, spoke as follows: Mr. Yuan: As you all know, China has a very long history of more than 4,000 years, and there are so many traditions that have influenced the education of the Chinese people. I will only tell you about the work that has been done in the past fifty years. At the beginning of this period physical education was introduced into China. The first thing we did, I think, was to put military training in the schools. At that time the educators thought that military training was the most important physical education for the young. Later, some 288 students returned from abroad who had learned some of the formal gymnastics in other places, and they began to teach formal gymnastics, either German or Swedish. Then about fifteen years ago athletics were introduced, with the pro- fessional spirit. After all of these were introduced in China there was a great struggle between people of different opinion about their own work. The schools employed teach- ers of all three kinds. First, the military trainer; second, the drill master, that is, the teacher of formal gymnastics; and third, the athlete and coach. It was not until five or six years ago that the educators were convinced of the fact that physical education is not only recreational, but also hy- gienic, and then the need for scientifically trained leaders and teachers was greatly felt. Therefore, the department of physical education was established in some of the na- tional teachers' colleges. One of these was the Peking Teachers' College, with which I am now connected. As to the need of training of leaders in Health Educa- tion, it really has not been adequately supplied in China yet, and the only thing we have had so far is the training of the physical educators. After listening to the speakers regard- ing the fundamental scientific training, I should like to say a few additional words. Of course, all of this comes from experience I have had in China; I do not know much about conditions here and in Europe, and possibly the points I will make are not suitable for other nations. Physical educators, I think, need a very thorough scien- tific training, and especially on the subject of biology, and this has not been very thoroughly taught in China to the physical directors. And the physical director should not only look upon the human body from the structural point of view; he should look upon it also from the evolutional point of view. Moreover, every physical educator should always maintain a high, noble attitude in everything he does. And lastly, a noble character should be cultivated, as well as a skilled performance of the bodily activities, and executive ability in organizing athletic meets and competitions. As previous speakers have said, physical education should not be looked at from the physical point of view only but from the social, hygienic and educational point of view. The Chairman: I am going to ask Miss Juanita Molina to tell us something about the teaching of health in the schools of Nicaragua. 289 Miss Molina: Health Education in the public schools of Nicaragua, C. A., is given in a limited and impractical manner. Many prejudices based on false modesty still prevail; therefore the teaching of hygiene is necessarily restricted, making it impossible to instruct the children about certain funda- mental facts of life, the knowledge of which is absolutely essential for the preservation of the health of every individual. Inasmuch as the girls get no definite and practical prep- artion for the rearing of children, when they come to face the problem of motherhood they are unable to solve it suc- cessfully. Therefore, the infant mortality attains a very large percentage. Furthermore, mothers are handicapped by the total nonexistence of institutions which might help them with modern scientific information for the care of their children. There are no dispensaries, visiting nurses, clinics or maternity homes. The only organization which in any way helps the in- habitants in the improvement of sanitary conditions is the Rockefeller Foundation, which concentrates its efforts in fighting the germ of tropical malaria. This institution is planning to establish courses for the teaching of hygiene in the public schools, and no doubt if this idea is carried out it will prove to be most beneficial. If the American Child Health Association or any other organization of similar interests could extend its services by sending trained health workers to Nicaragua or by giv- ing scholarships to native students to prepare themselves for service in their own country, the results would be most satisfactory. The Chairman: I am sure you feel, as I do, that these contributions of our foreign friends are the most vital and thrilling thing that we have had in the Conference, so far. It somehow makes you feel that there is a great brotherhood and sisterhood of people working in different parts of the world for the welfare of the child. I feel that we have had a tre- mendous contribution from these people who have told us something of their problems. It has helped to get before us the bigness of the task and the ideals toward which we want to move. Miss Edythe Hershey, of the Home Economics Division of the Extension Department of the University of Texas, closed the discussion. 290 Miss Hershey: In Texas we are trying to help do this work of teacher training through what we have called the nutrition program of the Extension Department. We put a nutrition program into a community for a definite length of time, holding classes for teachers in problems of teaching health, and holding classes for all of the children (including nutrition clinics), and holding regular classes for the mothers. We try to show the teachers what can be done, and then leave with them a definite suggested program of Health Education to be carried on in the schools. We have done that this last year, and hope to enlarge the program. We hope to offer teacher-training classes in centers throughout the state next year, so that the teachers who join them may be given university credit. We also hope to offer some definite work through the division of correspondence teaching, giving uni- versity credits. We also expect to offer group State courses for interested clubs. For seven years we have carried on a definite program for the pre-school child, and some work for mothers. We have only reached the school program in a few centers. We have had in the State a long time a very completely organized "Interscholastic League" pro- gram, and we hope by fall to be able to get these leagues into our Health Education and enlist the schools in the League Health Educa- tion work by offering them a definite program to carry on, using the children who are enrolled in the League. We are hoping to be able to reach individual children, giving them opportunity to join something like a "Keep Fat" club. We can keep in touch with each child through our monthly bulletin. In regard to teacher training, we hope to make our legislature see that it might be a good idea to appropriate a little more money, and to have a Division of Hygiene and Health Education in the University which will lead to a degree in Health Education. I think we must make the following distinction when we talk about training for health workers. We have to train these specialists who are going to direct the work, and for such people we must have a very thorough, scientific training, which cannot be gotten in less than four years, and really needs more, to accomplish the kind of work we want to have them do. But we have to think of all the classroom teachers who will do health teaching. We cannot begin to give them the background that the other people will need, nor do we expect them to have it, in making our plans for school health work. At this point, Dr. Wood summed up the topic of teacher training in his capacity of Advisor in Health Education, Teachers' College, and Professor of Physical Education, Co- lumbia University. Dr. Wood spoke on the subject of 291 Training Teachers and Supervisors for Carrying out a Health Program Dr. Wood: THE elements recognized as essential in the preparation of teachers and supervisors of Health Education should be determined by the scope and content of Health Education and by the factors directly and indirectly involved in this process. Health Education is the sum of the experiences, in school and elsewhere, which favorably influence habits, attitudes and knowledge related to individual and community health. Health Education is, in principle, and should be in prac- tice, an integral part of the comprehensive program of edu- cation. It is dependent upon all the rest of the educational process. The teacher and supervisor of Health Education should have clear understanding and appreciation of the principles of education in general, so that Health Education may be understood and directed in relation to the whole, of which it is an inseparable and essential part. The teaching of health requires the best of the modern and approved methods of instruction, recognized in gen- eral by educational authorities; beyond this, special adapta- tion of materials and methods are desirable and necessary for successful teaching in the distinctive field of health. The most thorough training available in psychology, pedagogy and allied subjects is of fundamental consequence in the education of both teacher and supervisor of this subject. Health Education depends for accuracy, reliability and final efficiency, upon a wide range of the fundamental sciences. The simplest, clearest and sometimes the most elemental precepts relating to health require, for their in- terpretation and convincing presentation, a nice under- standing of the basic facts and principles. It is of great importance that the supervisor in this field should be well grounded in the essentials of physics, chemistry, biology, bacteriology, anatomy, physiology, hygiene and nutrition. Every teacher of health is greatly helped by as much fa- miliarity with the subjects mentioned as circumstances may permit. Health Education depends upon experiences out of school as well as in school life. Health Education involves 292 twenty-four hours a day; seven days in the week; fifty-two weeks in the year through all the years in succession; and efforts in health teaching in the school will fail of much of their practical success unless they are intelligently, tact- fully and successfully articulated with the related experi- ences which affect the child's life in the home and in other parts of the community, away from the school. Again, the attainment of the objectives in Health Edu- cation, in health habits, attitudes and knowledge will de- pend in an important way upon the provisions made for other health values in the school. The teacher and super- visor must have adequate knowledge, and practical skill and efficiency in their share of the supervision and care of the children's health;,in maintenance of a healthful school en- vironment; in contribution to, or control of, a hygienic school administration; in a rich and abundant program of rational physical education activities; in attainment of standards and practices of health among teachers corre- sponding to or surpassing those set up for the pupils. It will be apparent, then, that Health Education involves a definite range and content of ideas and conduct, and is de- pendent upon a variety of important and closely related factors. The personality of the teacher and supervisor of Health Education is of very great importance in this field of teach- ing, as pupils and students of all ages are peculiarly re- sponsive to the influence and example of their teachers in all phases of instruction and associations affecting health. It is desirable that the teacher and supervisor of Health Education should be in the best possible state of health; in truth, should exemplify in person and in conduct a fine quality of health of body, mind and character so that, in the highest degree, the direct and the more subtle, valuable influences of personal association of teacher with students may be assured. However, much more important than the robustness and attractiveness of physical personality should be esteemed the fine spirit of devotion and enthusiasm for the health of others and the intelligent consistent health conduct of many inspiring teachers and leaders of limited physical resources and endurance. These illustrate in im- pressive manner the superiority of mind over matter, or even better, the manifestation of a splendid soul in a deli- cate frame which should be estimated in qualitative and 293 spiritual rather than in quantitative and physical values. The exceptional, the very rare, person who is favored by gift and accomplishment with all the desirable qualifications already briefly mentioned, should appreciate that the social obligations and responsibilities are even greater than the personal grace and fortune of such possessions. Both teachers and supervisors of Health Education should be, in personal, social and professional conduct, wholeheartedly and mindedly devoted to the physical, mental and character health of children and youth. They should present a stimulating and healthful example for their students and fellow teachers in thinking, and in atti- tudes and conduct affecting health, personal and social. By instruction and suggestion they should be able to influence the students to participate constructively and progressively in a life of health, of helpfulness, and of the highest satisfaction. Beyond these fundamental qualities it is of great im- portance that supervisors of Health Education should pos- sess as many as possible of the following: 1. Broad cultural, and general education with graduation at least from a teacher-training institution, and when possible, with the addi- tion of graduate study in some university providing satisfactory pro- fessional training with advanced study in the field of Health Educa- tion. 2. Experience in teaching health as a valuable background and preparation for supervision. If the supervisor in this field has been fortunate enough to teach other subjects than hygiene under com- petent criticism, this auxiliary teaching experience may prove of very great advantage. 3. Thorough grounding in the fundamentals of: (a) General educational principles and methods. (b) Psychological and pedagogical principles and methods in special adaptation to the field of Health Education. (c) Natural, biological and social sciences, with as extensive knowledge as possible of sanitation, public health, hygiene, nutrition and allied subjects. (d) Skill in observing, criticizing and guiding acceptably teachers under supervision; tact in combining successfully a minimum of adverse criticism with a maximum of constructive stimulation and help. The teacher of Health Education may with great ad- vantage possess: 1. As large an amount as possible of the desirable elements and training previously stated as important for the supervisor. Conclusions 294 2. Ability to accept criticism and supervision, with grace and skill in recognizing one's own limitations, and in manifesting not only will- ingness but desire to seek advice wherever and whenever this is avail- able. 3. Appreciation of the fact that the more limited is the general and special training of the teacher for the work of Health Education, the more necessary and advantageous are supervision and guidance wherever and whenever these may be found. 4. Practical desire and effort to improve as rapidly as circum- stances may permit, one's general and special preparation for Health Education. No teacher who has the indispensable and fundamental conviction regarding the importance and worth of Health Education and a sincere desire to participate in this work of health teaching of children should decline, or be refused or discouraged with reference to, opportunities in this field because of lack of professional training for Health Educa- tion, or because of limitations in general education or pro- fessional training for teaching. The teacher, then, who has (1) a sincere conviction with reference to the importance of Health Education; (2) a genuine desire to participate in Health Education; (3) a sincere desire to learn whenever and wherever there is opportunity to learn; (4) a willing- ness to seek help and to receive supervision and guidance when reasonably given, should be encouraged to go ahead and do the best which he or she is capable of doing in the health field. At the close of his address, Dr. Wood once more took up his duties as chairman. He called attention to the fact that the teachers and leaders in Health Education, referred to in the subject of this session, included parents, as the group of first importance, both chronologically and socially, in this question. He introduced Miss Alma Binzel, Assistant Pro- fessor of Child Training, Home Economics Department, University of Minnesota, to discuss Education's Obligation to Parenthood Miss Binzel: RECENTLY I attended two conferences. One of them was in the State of Oklahoma, where there were gath- ered on the Agricultural College campus at Stillwater, teachers of home economics and nurses. The meetings were also open to the community. It was interesting to see that 295 those people whom you have mentioned very, very infre- quently these past few days were as numerous in the audi- ence as were the teachers and nurses, namely, the fathers and mothers. From Oklahoma I went over to Ames, Iowa. There the conference embraced people who came all the way from Delaware and Oregon and the States in between. There were also home economics teachers and State super- visors of vocational home economics. Again the meetings were open, and it was interesting to see that fathers and mothers attended those meetings. Now, I come to you from these two conferences and bring you a very specific plea. The teachers and super- visors of home economics, and nurses, are asking that some institution face the problem of modern parenthood, and I back that plea from these teachers and supervisors of home economics, and the nursing group, and I back it with the request of the parents, that they too be given a chance to know of some university, some college, some scholarship, some fellowship somewhere honoring their professional possibilities by instituting real research study on their problems. Now, my presence at those two conferences came about possibly because five years ago I had the daring nerve to say that I, an "old maid," was going to talk on education for parenthood, and I met a lot of doubting Thomases who be- lieved that no old maid could do it. I have in my own family one who said to me, "What do you know about children?" And I said, "Well, brother, you have two, and you do know something about children I don't know; but in the many years that I have been in the schoolroom working with children from the age of three up to the age of thirty in the university classes I have had contacts with children into the thousands; and not only have I had such contact, but I have subjected myself from time to time to the classroom performance of listening to very distinguished doctors and other sorts of distinguished people, in order to know some- thing about children and something about their parents." Now, if you are interested in the course that we have already developed at the University of Minnesota for the student who is getting a doctor's or bachelor's degree in home economics, the central purpose of which course is to educate for parenthood; and if you are interested in the higher graduate course which we plan for such people down 296 at Ames, Iowa, which I am going to have the experience of teaching this summer at Chicago,-you can get hold of some of those courses of study by writing to me. A certain school in Minneapolis was the scene, some years ago, of a very pleasant party. The chief speaker of the party was there to indicate that the inefficiencies of a certain modern institution were so appalling that it would be almost immediately necessary to start a new department in the school of which she was the principal. That new de- partment was to be a department for the training of social workers, since, according to this principal, the children of today were defective, physically, mentally, socially, morally, aesthetically and spiritually, to such an extent that it was a question whether these young people could possibly be sal- vaged for decent citizenship in this country of ours. The speaker sat down, and a man who was there because he was a trustee in this school, and also the father of three very fine and successful children leaned over to his neighbor and said: "What are fathers, anyway? Merely biological ne- cessities and economic by-products?" His neighbor said that it would seem so, judging from most of the plans that we hear about reviving the world; and mothers are practi- cally evaluated in the same way. Then he hastened to add: "Oh, yes, I know that we do say and print nice sentiment about these parents during mothers' and fathers' week, but what are these compared to what we get at other times in mingling contempt and rejection of parents?" A certain pediatrist stood before a body of social work- ers, telling them how important their work was in the cor- rection of the awful things that parents do to their children. He said: "When parents bring children to me with such and such habits I blame the parents." I went to him later and said, "You said thus and so." "Yes," he said, "I did." I asked, "What have you ever done to teach a parent that such habits might quite naturally come into the life of the child?" He replied, "Nothing." I put one further ques- tion: "What have you ever done to teach parents that that habit having come quite accidentally or naturally, might also easily be eradicated?" And again he replied, "Nothing." A few weeks later I was visiting in another big middle west city and I called upon the Director of a large pro- tective association, and asked: "What preventive work are 297 you doing?" "Not anything," said she, "we wait until a child has gone wrong and then we put a worker on the case." But social workers are not the only offenders. A certain college professor, on the staff of one of our greatest eastern colleges for women, received a puzzled mother who said: "My daughter has been at your college for three months, and I do not find her behavior improved." The reply she got was: "You had your daughter for nineteen years. Why didn't you train her in such a way that she wouldn't need improvement by our college?" That pro- fessor has admitted to me that her answer was a superficial and unfair one, and that the mother had a right to make rebuttal thus: "I came to this institution; I studied the things that the authorities said would prepare me to lead the life of a woman in the last part of the nineteenth and the first part of the twentieth century. I achieved, at the end of four years, a bachelor's degree, and it was well named, for it fitted me for the life of single blessedness." "But," she might have said, "marriage and parenthood came to me and I did the best with these that I could,• and now the fact that my daughter needs improvement in 1920 is at least in part attributable to the fact that my Alma Mater didn't recognize as worthy and weighty enough for credit towards a bachelor's degree, training in the care and management of children." Well, this learned professor is not unlike another who, having made a study of more than 500 babies and children, addressed a number of distinguished audiences. In one such address, given to the International Kindergarten Union in Baltimore, he said, "I could, without abusing a child, or starving him, so twist and thwart his nature that by the time he was four years old he would be permanently ruined." Then he said that because parents do not know how important the first four years are, children have tre- mendous kinks kinked into their dispositions and char- acters, and the unkinking of these kinks is the business of the kindergarten, and the kindergartner is, for that reason, the most important person in the entire school syst.em! In this, the poor parents are ignored altogether. In January, 1921, the National Education Association published a statement saying that society cannot insure to every child a good home, a devoted and intelligent mother and a wise and provident father, but it could insure to 298 every child a good school and a competent teacher. Now, I maintain that society has not, as yet, attempted to provide any child with intelligent mothers or wise fathers. I main- tain that schools could do effective work if they once faced the problem of training for parenthood so that in their early years, which are so important, as well as in later years, children might be wisely as well as lovingly managed by fathers and mothers. Yet why multiply statements indicative of our old atti- tude toward parenthood? Let us confess that we have ig- nored parents, that we have blamed them, and that then we have set up extensive machinery for re-educating them in the ways in which they should go. I think we will have to confess that our policy of letting any Tom, Dick or Mor- timer unite with any Susan, Jane, or Clarabelle, to enter upon the sea of matrimony and parenthood, with haphaz- ardly gathered charts and compasses for the voyage, has been most costly to them as husbands and wives, as well as parents and children. Each new generation of lovers and parents have been left to the chance influences of un- scrutinized direction and contradictory examples. A new era is at hand. The twentieth century is going down in history as the century of the child. The first twenty-five years discovered childhood to people who had not recognized it before 1900. In consequence, our attitude toward family life is undergoing a very rapid change, and I think there are at least three factors which contribute to this change of attitude. The first of these factors is the fact that infancy and childhood are the significant, formative periods in every individual's life. Second, there has been a search for norms and averages which has resulted in the formulation of tentative standards which constitute goals to be achieved at the different ages. And third, there is the realization that the relative value of a pound of cure is still as great in comparison with the ounce of prevention, as it was on the day when somebody first made a statement to that effect. Now, it is a shock to most parents to learn that the first six years of a child's life are so important. But the parents of the next generation ought not be so shocked if we make our schools do the thing that they should do for parenthood. It is a shock to administrators of education to realize that kindergarten should become universal and reach down to 299 below the fifth year, not only to cure the mistakes of unin- formed but loving parenthood, but also because the educa- tional capacity of the years before six is so very tre- mendous. It is a shock to those who distribute the city, fraternal and religious funds. It is a shock to those people who have been providing facilities for adults only. Now, as to the second factor, the standards to which we have referred many times this week are as yet prac- tically unknown to the parents of this generation. We can make, and are making those standards a matter of knowl- edge to the oncoming generation of parents. An illustra- tion of how unknown these standards are to parents, as well as to a lot of professors, on the agricultural campus, at least, was well proved in January, 1921, at a certain farmers' and homemakers' week in a great university in the middle west. On a certain Thursday evening, with great pride, the director of the farmers' week announced that a new film entitled "Partners" would be released. The theme of the film was excellent, as it portrayed the relation- ship which should exist between fathers and sons, mothers and daughters. This illustrated the fact that the people of the farms could work together properly and do the right sort of thing. It was a shock to have the professors who were responsible for this film learn afterwards from a cer- tain doctor who knows much about children that, though the makers of the films knew the difference between prize and scrub animals, so far as prize and scrub children were concerned, they knew not the difference, because there was only one child in the entire production, as revealed by the film, that could have met with even moderate standards in entering a prize contest for children. The Sheppard-Towner bill is one evidence that we are beginning to spend money in prevention. The three million dollar fund for the school of motherhood in Detroit (the Merrill-Palmer School) and the other $500,000 fund which has recently been raised in Detroit for another school of motherhood, is also evidence that money is coming in the direction of this work. Then, the introduction of the infant and the toddler into the home management courses, is further witness of the fact that we are willing to give the girls training with reference to the handling of children in the home, as we have long given training in the handling of pies and dress forms. Most of these home economics 300 departments are asking that on every campus there be a nursing kindergarten school containing young children, in order that every home economics student, not just a few selected ones, may have contact with much child life. And then, for the parents who are already at work with children, some new developments in extension service have been taking place. Oklahoma bids fair to be the first of a number of States. There, I found the State director of vo- cational economic work, the director of the child welfare bureau, the administrator of the Sheppard-Towner funds and the superintendents of city schools, actually getting to- gether and facing the problem of the modern father and mother. Imagine the surprise of Superintendent Parsons, of Oklahoma City, when, instead of having to serve 120 mothers with mother classes this last winter, 600 mothers actually enrolled and took the course. Oklahoma is plan- ning definitely that in September and January there shall be general popular lectures on parenthood, and I sometimes think that perhaps Oklahoma will honor parenthood by es- tablishing in one of her higher institutions of learning, either a chair or a department of parenthood in which real research along these lines will be worked upon. When that time comes we will have some new themes for doctors' theses. I know the person who wrote on the fatty tissues in the wings of insects, and of another who wrote on the relationship of the length of the intestines of fishes to the depth of the water in which the fish resides. I question whether these theses will ever give to life the abundance and the richness that a work in the department of parent- hood could do, if it really set itself to work in finding out what the father and mother have to do when they have to direct and launch child life in infancy or childhood or adults. There being no discussion, the session was adjourned. The resolutions growing from this Conference and adopted by the Plenary Session will be found on page 345. Part IX THE CONTRIBUTION OF NON-SCHOOL AGENCIES TO A HEALTH EDUCATION PROGRAM THIS meeting was planned to meet the need for a more complete reciprocal understanding of the health aims of various groups. It was conducted in the form of a symposium in which all groups who felt they had a Health Education program for children and young people of school age, were enabled to contribute in five to ten minutes, a description of their plans and experiences. The program was not formally worked out as to subject and speaker, in order that the greatest possible number of contributions could be made. As President Owen pointed out in his address during the first session of this Conference, schools of today are not con- tent to confine themselves to text-books for their materials of instruction, but look to life itself for enrichment. They are prepared to consider it legitimate to include in their programs, either for classroom or extra curricular activi- ties, whatever will really help the children to meet their needs-when these needs are not already properly met by the home or the community. So, in the Health Education field, where so great a part of that attitude essential to success comes obliquely, through wholesome, often indirect, influences, educators will eagerly examine the programs of these non-school agencies to dis- cover their useable contributions to a school health program. Dr. Wood introduced as the first speaker, Monsieur Ed- mond Dronsart, Director General of the Belgian Red Cross. The Belgian Red Cross Mons. Dronsart: THE question of popular education along the lines of hygiene is at the moment the order of the day in Bel- gium. We hasten, however, to add that the results are not 301 302 yet sufficient, and one can say that it is only popular educa- tion which can now render efficacious the action undertaken by the Minister of the Interior and of Hygiene and by the private associations. The most important private Belgian organizations are: the National Organization for Children, the Belgian Red Cross, the Anti-Tuberculosis League, the Anti-Venereal League, the League of Mental Hygiene, the Anti-Alcoholic Societies and the Society of Eugenics. All have their own activities, possess the resources necessary to carry on their work, and enjoy the sympathy and co-operation of the pub- lic and governmental authorities. It is then to preventive activities that the Belgian Leagues have given their greatest efforts. National Council of Hygiene This council, whose direction has been confided to the Red Cross, has for aim the co-ordination of all public health efforts, the creation of a constant link between the different organizations without ever impinging on their internal functioning. It is a sort of central office, which is in con- stant relation with, on one side the activities of the various organizations, and on the other the public, and so utilizes all private initiative along the lines of popular hygiene. The cordial spirit which animates the directors of the co-ordinating leagues in the National Council and the dis- cretion which governs the work of the council, assures us that its activity will be fruitful and that the results of the individual hygiene organizations will gain much from it. The Red Cross and Popular Education Red Cross Leagues have on their programs the popular- izing of hygiene; all have organized, since their beginning, conferences and lectures, have distributed posters and pamphlets, etc. But the methodical initiation of the public in a program of popular hygiene has never been undertaken in Belgium in an intensive fashion. The Red Cross of Belgium has, since the conference at Cannes in 1919, established its program of peace in putting at the base the protection of public health by popular edu- cation, and for the last year it has undertaken this action in an energetic fashion. 303 The medical committee believes that only a complete teaching, co-ordinated and homogeneous, can truly reach the population and convince the public. The program of its courses of twenty-five lessons given by doctors and nurses, has been mapped out with the great- est care and is inspired with a different principle from that which is applied ordinarily to this kind of teaching in Bel- gium. Our medical committee has judged that this instruc- tion should be essentially popular, that it should be under- stood by all, whatever the former instruction or lack of in- struction. The purely scientific notions have accordingly been suppressed as much as possible; the questions of hygiene are presented in a concrete and extremely simple fashion. Our teaching has for aim, not so much the acquirement of scientific knowledge as to draw attention to the impor- tance of hygiene; to the application of its principles; and to the means which each possesses of spreading the knowledge which he has gained, and of obtaining from all-individuals and public powers-co-operation in health protection. For the next courses there are already enrolled in our little country 6,000 students. The Red Cross dreams of creating in this country a hygiene atmosphere, a new mentality concerning these questions. Surrounded by a competent and devoted co- operation, it is certain to succeed. Education of the Children But we do not deny that the program that we have just explained to you interests almost exclusively the adults, and-let us speak frankly-almost nothing has been done in our country for the Health Education of the children. We do not hesitate even to say that our work can be truly effective only when it concerns itself with the children. The efforts made for the adults give only a relative result, while those for the children-if we indeed do our best- can yield complete results. We do not wish certainly to criticize our official instruc- tion, but let us say simply that the teaching of hygiene is outlined in the school programs in an insufficient manner, since we see in the primary instruction of each grade one hour, once a week, consigned to "hygiene, natural science and agriculture." 304 One can easily judge the time-nearly nil-in this group of studies reserved to the teaching of hygiene. And this teaching is entirely theoretic. This field of action is then wide opened and, because of this, for several months an effort has been made in our country to ameliorate this situation. The Junior Red Cross The Belgian Red Cross did not wish to be behindhand on this form of education so, several months ago, it created a Junior Department and inspired by the example of the American Junior Red Cross, has adopted en bloc its program. Commission for Relief in Belgium (Educational I^oanda- tion, Child Health Section) And we are particularly happy in terminating our ac- count by an account of a recent action in our country which should draw the attention of all. Again the United States brings to us an aid particularly precious, which is going to give a new understanding and enthusiasm to the move- ment for health undertaken in Belgium. The C. R. B. Educational Foundation, of which Mr. Hoover-the Providence of all Belgians-is the President, has until recently confined itself to higher education. Now, by the establishing of a Child Health Section, it is working through the primary schools for the health of our children. The teaching of hygiene will be radically transformed by the application of the new methods introduced by this section. These methods have taken as their model those of the American Child Health organizations. It is in the school and by the school that this new Health Education will operate. All teaching will be impregnated with hygiene through the active methods of education ap- propriate to this branch. We will not enlarge upon this program which you all know; but I am happy to let you know that this project, initiated with enthusiasm and competence by Miss Jean and Miss Harrison, has won the approbation of the academic authorities. The Minister of Science and Arts, the Minister of Hygiene, the National Organization for Children, the Belgian Red Cross, the medical and teaching bodies have recognized that it should be officially introduced into our school system. 305 Let us say, in order to present it concisely, that from next October both our official and Catholic instruction is going to undergo a fortunate transformation in the matter of Health Education. Courses for the training of the teach- ing personnel and for the inspectors are being organized during this vacation. In terminating this report, it is then to the United States that we have the pleasant duty to address the homage of our gratitude. The Belgian people have in them great reserves of energy, of intelligence and of good sense; but we ought not to be afraid to affirm that, in the matter of social education, without fear of belittling ourselves, we should draw in- spiration from the examples and methods which you have demonstrated to us. Confident in the results of these new efforts, entirely persuaded of the efficacy of these new methods, we await with joy the moment when all the Bel- gian children will understand what health means; hygiene will have the place which it should occupy in the school life. Miss Theodora George, of Paris, France, offered the fol- lowing presentation of the health program of the League of Red Cross Societies, interesting to hear in the wake of the Belgian program just described. The League of Red Cross Societies Miss George: In the spring of 1919 the Red Cross Societies of the five Allied powers-Great Britain, France, Italy, Japan and the United States-met in Cannes, France, on the initiative of Mr. Henry P. Davison, chairman of the American Red Cross War Council, and formed the League of Red Cross Societies, which had as its purpose "the improvement of health, the prevention of disease, the mitigation of suffering throughout the world, and to secure co-operation for these purposes." This League now consists of forty-four member societies, with a central secretariat in Paris. The League maintains close co-operative relations with the Health Section of the League of Nations, the Of- fice International d'Hygiene Publique, the International Labor Office, and the more important non-official interna- tional health organizations. 306 It also keeps in touch with the local problems of its mem- ber societies by means of regional conferences. A confer- ence of the Red Cross Societies of the Far East was held in Bangkok last December. The Central European Societies met at Warsaw in April of this year. There is to be a Pan- American conference in the spring, on the invitation of the South American Societies, and the Oriental conference has been invited to meet in Manila next year. Last year in August an informal Junior Red Cross conference was held in Paris, on the invitation of the French Red Cross, and there is to be another in Vienna in October, on the invitation of the Austrian Red Cross Society. The Public Health Division of the League receives and distributes health propaganda publications from all the member societies, as well as from other health organiza- tions, including the very popular material issued by the American Child Health Association. It also has a library of health propaganda films which may be borrowed by mem- ber societies. Our only difficulty is that we haven't enough of them. The Public Health Nursing Division of the League main- tains a public health nursing course given at Bedford Col- lege for Women, University of London. Forty-eight stu- dents from thirty-two different countries have been trained in this course. It also has the supervision of five nurses' training schools in Central European countries. Various translations of texts on nursing are being un- dertaken-among others the adaptation is being prepared in French and German of Miss Gardner's "Public Health Nursing." The General Council of the League, which is composed of delegates from all the member societies, at its meeting in March, 1922, determined to limit its program to: Public Health Instruction, Public Health Nursing and Junior Red Cross. It was at this meeting that the General Council passed a resolution, recommending that in the statement of Junior Red Cross principles in any country the following be incorporated: "The Junior Red Cross is organized for the purpose of inculcating in the children of the country the ideal and practice of service, espe- cially in relation to the care of their own health and that of others, the understanding and acceptance of civil responsibility and the culti- 307 vation and maintenance of a spirit of friendly helpfulness towards other children in all countries." The Junior Division of the League was instituted in January, 1921, and its first piece of work was the organiza- tion of the Junior Red Cross in Czecho-Slovakia, at the re- quest of Dr. Alice Masaryk, president of the Czecho-Slovak Red Cross. This work was done with the assistance of American Junior workers, who used the health game as the basis of their work. The membership now includes several million children. An interesting phase of the work in the Junior sections of fifteen national societies is the publication of magazines. This activity is carried on in New South Wales, Australia, in Austria, Belgium, Bulgaria, Canada, Czecho-Slovakia, Great Britain, Hungary, Italy, The Netherlands, Roumania, Siam, Sweden, United States and Yugo-Slavia. There is rarely a number which does not have something about health, though it is often concealed in an article about other things. It is very difficult to compress into so small a space of time an accurate idea of the extent of the League's activi- ties, and I have of necessity omitted many particulars. There is one point, however, which I wish to make in clos- ing, and that is that the League secretariat is fully aware that our hope is in the education of the children. I hope that this brief and rather dry outline has served to give you some idea of the scope and possibilities for Health Educa- tion of the work of the League of Red Cross Societies which was the great inspiration of a great American. At home, the health program of the Red Cross is as active as abroad. Its activities in relation to a possible school program were outlined by Mr. Carl Hunt, Manager, Pacific Division of Red Cross. The American Red Cross Mr. Hunt: For many years prior to the Great War the American Red Cross was active in the field of public health, but since the War this activity has been greatly quickened by de- mands growing up in rural chapters everywhere. Consid- erable question arose in the minds of some as to the le- 308 gitimacy of this work on the part of an organization like the Red Cross. For that reason a Health Advisory Committee of ten of the ablest men that could be secured in the medical and public health field, was appointed to give the subject the most thorough consideration possible. After months of painstaking investigation and thought, the committee unanimously adopted a report, which so well expressed the spirit and purpose of the Red Cross in performing its health functions that a number of excerpts are quoted from it as follows: "Education is the center and the essence of the Red Cross Health Program. "As important integral parts of this program based on health study and health demonstration, the following poli- cies of the Red Cross are at present formulated: 1. The organization of classes in Home Hygiene and Care of the Sick. 2. The organization of classes in Nutrition. 3. The organization of classes in First Aid and Life Saving. 4. The health phases of the Junior Red Cross program, such as: (a) The development of personal health habits; (b) Participation in a school health program; and (c) Participation in community health programs. 5. The enrolment of properly qualified nurses under the Depart- ment of Nursing Service. 6. The organized development of public health nursing in rural and semi-rural districts. 7. Assistance in the development and standardization of the train- ing of public health nurses through loans, scholarships, subsidies and the like." While all health work of the Red Cross is educational, not all of it is confined to individuals of school age. Some consideration is given to the pre-school and pre-natal child, while considerable effort is made to train adults into proper health habits and attitude. Home Hygiene and Care of the Sick The American Red Cross has contributed to Health Education by conducting classes in Home Hygiene and Care of the Sick for groups of adults and school children. Every type of school has embraced this opportunity to instruct its youth in the proper way to safeguard health and minimize epidemics. During the last eleven months the number of school students under instruction in Home Hygiene and Care of 309 the Sick was 35,000 plus. The number of non-school stu- dents under instruction was 30,000 plus, while the number of schools giving credit for this work was 244. When we stop to consider that the vast majority of those who are sick can never have the care of a trained nurse, but must take their chances for recovery with the kind of nurs- ing they receive in their homes, it is easily seen that the importance of a wide-spread knowledge of the simplified art of caring for the sick can scarcely be over-estimated. Nutrition The nutrition program of the Red Cross includes in- struction concerning pre-natal, pre-school, adult and ab- normal dietary requirements. This activity is conducted by qualified nutrition workers. During the past year, through Red Cross nutrition service the number of children receiving regular Red Cross nutritional instruction in the schools was 110,000, and regular instruction was given to 3,096 teachers. Nutrition classes conducted for the mal- nourished reached more than 10,000 children. There were 1,943 schools aided in introducing hot lunches. There are approximately 1,500 volunteers throughout the country as- sisting in this great work. First Aid In First Aid the Red Cross prepares text-books of in- struction, standard first-aid kits, boxes of appliances, etc. The course, which is conducted through local Red Cross chapters, consists of fifteen hours of instruction and prac- tical demonstration. All adult classes are taught by phy- sicians, while physicians, nurses or qualified laymen may be used as instructors for the Junior or school courses. Ap- proximately 14,000 students received instruction in Red Cross First Aid last year. Life Saving Red Cross Life Saving Service was formed to eliminate preventable loss of life by drowning. This work is con- ducted through chapters in co-operation with summer camps, universities, Boy Scouts, Girl Scouts, bathing beaches, etc. There are now some 27,000 members en- rolled as Red Cross life savers. 310 Junior Red Cross While the Junior Red Cross is not essentially a health organization, yet through the Junior News, the Calendar and pamphlets, the members are made acquainted with the need for the conservation of health and eradication of disease. Junior Auxiliaries often assist in financing nutrition classes and in establishing and managing hot school lunches and supplementary milk feedings. They frequently pro- mote adapted courses in Home Hygiene and Care of the Sick, First Aid and Life Saving. They are active in com- munity clean-up campaigns, poster-making contests, mak- ing health scrapbooks, writing compositions on health sub- jects, forming health clubs, conducting pageants, plays, ex- hibits and parades as well as carrying on anti-fly, mosquito, and rat campaigns. There are at present 24,000 Junior Auxiliaries with 123,000 teachers conducting Junior activi- ties, and a Junior Red Cross membership of approximately five million children. Public Health Nursing The Red Cross Public Health Nursing Service in many rural or remote districts has supplied and is supplying the first conception of the positive health ideal; has supplied and is supplying the leadership for an awakened health in- terest; has helped establish the feasibility of school nurs- ing; has helped establish a standard for rural public health nursing, and has, through national scholarships, aided in equipping efficient workers for this field. The nursing activities can be brought under three headings, namely, the school, the home, the community. If the instructions re- ceived at school are of value, it is important that the child be aided in carrying them out in his home. So with Health Education in the school must go Health Education in the home and subsequently in the community at large. The Boy Scouts were represented by Dr. G. H. Richard- son, sent by the Scout Executive of San Francisco, to de- liver the following message: The Boy Scouts of America Dr. Richardson: It may be interesting for you to know what the Scout program really is along health lines. There are three 311 grades of Scouts, the Tenderfoot, the Second Class and the First Class Scout. To become a Scout a boy must be at least twelve years of age. Upon demonstrating to the satisfaction of the Scoutmaster his ability to repeat the Scout oath and law in full and his thorough knowledge of their meaning, and upon passing prescribed tests, the boy formally subscribes to the oath and law and is registered as a Tenderfoot Scout, and is then entitled to wear the Tenderfoot badge and the official Scout uniform. (Dr. Richardson then outlined the tests the boys must pass in order to become progressively a Second Class Scout and a First Class Scout. These tests can be found in detail in the Boy Scout Manual. Dr. Richardson added:) The boy may never use the instruction he receives, but intuitively his mind is imbued with the ideal of service. He thinks, possibly for the first time in his life, in terms of others. It is only in an indirect way that the teaching of First Aid affects a boy's physical fitness. It does, however, teach him the principles of carefulness, cleanliness and asepsis. When he comes to pass his Merit Badge tests, more is expected of him. Just a word at this time about Merit Badges. There are sixty-two subjects which Scouts are able to take along this line. The three I am interested in are First Aid, Public Health and Personal Health. When he passes the test he is able to wear on his coat sleeve a badge showing his qualification. I have found that the winning of these badges is the primary incentive for the study of the subjects, and I have often asked myself whether there was not a broader, better incentive that we should use to stimulate his young mind. When the boy gives the Scout oath, which he does at every meeting of his troop, he promises to keep himself physically strong, mentally awake and morally straight. It is possible that we are not giving the proper guidance to these boys along these lines, being willing to listen to their lips, and then not give sufficient instructions to guide them correctly. I wish to submit to you today an idea which I feel the Scout movement is wonderfully adapted to organize and follow. The chapter on health and endurance in the Hand- 312 book is well written, but it gives no definite direction. Could not a plan something after this form be devised which would be of benefit to both the Boy and Girl Scouts. Let us divide the members of the troops into three grades ac- cording to their physical development: (a) Boys above average (b) Boys about the average (c) Boys below the average. Class (a) boys are apt to over-specialize in athletics and to become one-sided physically. They particularly need in- struction in all-round work, and watching in their training. The class (b) boy should be made to feel that only by con- stant effort can he retain his present good health and that by faithful attention and care he can attain the higher grade. Especial consideration should be given the class (c) boy, so as not to discourage him by drawing the lines of demarcation too closely. It would not be desirable for the boy to believe himself far below the physical condition of other boys, and this matter would require further consid- eration and study. He may, however, have some remedial physical defects that prevent his physical development but no means of determining this defect and no way of pro- curing relief. He may also have some bad habits that in- terfere with his growth-such as poor carriage, bad foot pronation, and undeveloped chest capacity, together with poor food conditions and unsanitary housing. A Scout- master could be trained to recognize these defects and, owing to the close relation he has with the boy, should be able to advise him and his parents in order to remedy them. I have also another suggestion which I think worth your consideration. Could we not follow the following plan: Give to every Boy Scout in the country on July Fourth, the nation's birthday, a card on which he could place his age, height, weight and chest measurements. Let him keep his card until the following year and then check his annual gain, expressed in figures which he can understand. This could be made a part of his Scout record and kept in the files of his individual troop. We should impress upon the boy the fact that the country may at any time need, for its protection, the service of its citizens, that it is his privilege to be so physically fit that he is able to perform his full duty. What the Girl Scouts do to earn their membership was described by Mrs. Herbert Hoover, the President of the 313 National Organization, and by Dr. Elizabeth Kemper Adams, the Secretary of the Education Department of the Girl Scouts. The Girl Scouts of America Mrs. Hoover: Girl Scouts are usually from twelve to sixteen years of age. In emergencies they get down to ten years, and in many, many cases they will not be turned out at eighteen, which is the age limit. But, as a rule, we have girls from twelve to sixteen years of age who voluntarily enter the ranks of the Girl Scouts. The girl goes in because she wants to. Before she becomes a Girl Scout, she reads the laws and the promises and discusses them with the leader of the troop which she wishes to join, so she knows what the duties of a Girl Scout are. She knows that a Girl Scout is loyal; that a Girl Scout is truthful; that every Girl Scout is a sister to every other Girl Scout; that a Girl Scout is clean in thought and in word and in deed; that a Girl Scout tries to do her duty to God and her country, and to help other people. And then after a month, at least, for the study of the Girl Scouts, she becomes one of them. She wants to try her wings in the world. She wants to do things herself; to expend that surging of initiative that a girl has at that age; to get into the group activities that she sees her elders interested in; she has a longing to do other things with the girls, as a boy has to do things with "the gang." At this age she especially wants to give service; she wants to do something for other people outside of the family circle. She wants to join other girls for the "service" that our civilization is demanding of us. She wants to strive to at- tain the ideals that are crystallizing in her consciousness. For these reasons she becomes a Girl Scout. And her problem is shared, however unobtrusively, by her "leaders." As you can see, the girl from the East Side of New York and the girl from a little village in California's mountains would each need something and want something very dif- ferent in her scouting from what the other is getting. We cannot have a cut and dried pattern and send it to a Scout Leader on the top of the Sierras and to a Scout Leader down on the East River in New York to work out with their girls, 314 because it would be impossible of accomplishment. The leader must have a pattern which she can adjust to the needs of the girls of her community; so we have a long list of possible activities, including a very good health program from which the leader and her troop can choose but a few activities. These leaders have to look very carefully over the needs of their girls and see how they can help them without ap- pearing to teach or to dictate. For an ideal leader to give an ideal scout everything that one would wish would re- quire a hundred years-or anyway a half century-and we realize this cannot be done. So, we push the activities that are most needed in our community, and only re-emphasize those which are already well taken care of. The result is that with some leaders, and with some girls, the health program of the Scouts needs very little stressing. If there were a Girl Scout troop amongst the residents of the district where the John Swett School is, for instance, of whose splendid health work we have j ust been hearing, that leader, I am sure, would stress health very, very little. She would realize that the health conditions of her troop were being well taken care of in the school. Consequently, when she passed a reflective eye over her girls and saw that some needed a little special attention, she might consult with the officials of the school, and stress, with one or two or three of the girls, certain phases of their health program; but it would be auxiliary to the school work. Girl Scouts may be asked by the State health authorities to emphasize certain features of the State program, as for instance, we have just been asked to help the Department of Health of Pennsylvania in its anti-diphtheria campaign. In another State, where there is no health program at all, the leader would feel that the program of the Girl Scouts needed special stressing and that it is imperative to attempt to further it. The way the problem is then met is usually the practical one of co-operating with some of the big asso- ciations. We have a little handbook worked out for us by the American Child Health Association that is given to every Girl Scout, in which, day by day and week by week, on the little pages she records how many times she brushes her teeth, what she has for breakfast and lunch and dinner, how many baths she has taken during the week, how many times during the day she washes her hands, and so on. 315 There are awards-stars and badges for those having com- pleted the three months' work as outlined in the book. Then there is the Health Guardian Badge, which is the one which has to do with the health of the community. A girl gets that after passing an examination showing that she knows how the health of her community can best be maintained, and what her community has accomplished, and what it should accomplish, in the protection of the health of its population. This knowledge, and co-operation in its furtherance, gains a Health Guardian Badge. So, we may divide Girl Scout health work into two or three different classes. It is little stressed in the community having other competent agencies engaged in a successful health program; and more stressed where less is being done otherwise; while in the community that is doing nothing practical to increase the standard of the healthful living of its children, the Girl Scouts try to push an energetic pro- gram of their own. But always, from our point of view, it is something for the girl who volunteers to do things-per- haps for the sake of adventure-whether it is in health, or in an overnight camp or in a canoe trip-something de- manding courage, perseverance, preparedness and self- reliance in meeting any emergency. Dr. Elizabeth Kemper Adams, Secretary of the Educa- tion Department of the Scouts, supplemented Mrs. Hoover's remarks by the following discussion of the making of girls into "Health Scouts." Dr. Adams: The visitor to a Girl Scout summer camp-or a winter one, for that matter-who sees a happy group of "teen-age" girls, the "very picture of health," living an active, free, and orderly life in the open, is likely to think that the en- tire Girl Scout program is a means of Health Education, and that no more specific instruction is needed. In a large sense, the visitor is right, for we are all recog- nizing more clearly each year that activities suited to the ages of groups and individuals and carried on in suitable surroundings give a "set" towards health for which no definite instruction failing to capture interest and imagina- tion and given under poor physical conditions, can ever be a substitute. 316 But under the general fun and freedom and creative in- terests of the "Scout Game," to use the phrase of Sir Robert Baden-Powell, the Girl Scout organization is laying a foundation of persistent attention to the specific health needs of girls of Scout age and persistent study of the pos- sibilities of Health Education through a leisure-time move- ment with voluntary membership and leaders who are them- selves volunteers. In addition to providing indirect Health Education through the positive suggestions of healthful surroundings and activities and the real health contagion of vigorous and intelligent adult leadership, we have as a major problem the provision of a type of direct Health Education which shall capture the girl's interest and im- agination, and shall make her into a true Health Scout and not merely a winner of health points and health badges, useful as these may be as a means to this end. In spite of the fact that the three basic ideas of the Girl Scout program are Home, Health, and Citizenship; in spite of the fact that each year our winners of Health proficiency badges vie with our winners of Home-making badges for a place at the top of the list, we are far from thinking that we have adequately or finally solved our problems of direct Health Education, or exhausted our possibilities of con- structive effort along these lines. We need-and we are receiving-the help of such great organizations as the American Child Health Association, the American Red Cross, the National Education Association. We need the inspiration and the exchange of ideas of such a splen- did gathering as this International Health Education Conference. Such an occasion lends itself to the asking of questions rather than to the giving of answers. Here are some which Girl Scouting has been asking itself, and which it cannot answer alone. 1. What can a supplementary junior program like Girl Scouting do for Health Education that cannot be done by the schools and the great health organizations, public and private? 2. What are the most effective modes of co-operation between such a recreational agency and the great agencies for education and health? 3. What are the characteristics and interests of the teen-age girl that may be actively enlisted in making her a Health Scout? 317 4. What are the great energizing health ideals, habits and atti- tudes that should be established in order to make the Health Scout a useful and happy human being, citizen, and member of a family? Within the limits of a brief paper, these aspects of Health Education through Girl Scouting can only be touched upon in passing. Those of us who are in the movement, as well as many outside of it, hold that its voluntary and leisure-time character is one of its greatest assets. It con- tains no element of coercion, it cannot duplicate the school, any more than it can duplicate the home or the church, al- though it may supplement all three. Recreational in method, although profoundly educational in intent, em- phasizing group activities and responsibility, initiative, and resourcefulness in the service of others, it enables the girl just passing out of childhood into youth to join an organiza- tion of her own free choice, and to satisfy her craving for novelty, her "club instinct," her desire to have a share of planning and making things and to try herself out in all sorts of ways. It affords desirable outlets for her restless energies and any number of "good times." Scouting emphasizes health as an adventure, requiring courage and steadfastness like other adventures, and it makes use of health games and health projects. Last winter the Girl Scouts of Atlanta took a prominent part in a project called "Following the Health Trail," devised by all the organizations working with girls and assisted by the school and various other community organizations. Surely agencies everywhere may find valuable reinforcement in the spirit of adventure and play, the spirit of independent choice, and the spirit of joyous co-operation which Scouting brings to Health Education. The most effective modes of co-operation between Girl Scouting and the great agencies for Health Education rep- resented here will have to be worked out in consultation after the agencies have come to see that Scouting is a useful ally. The American Red Cross has long been our good friend. Only this year it has issued a valuable little bulletin on Home Hygiene and Care of the Sick for Girl Scouts, and is holding classes for Scouts through its Teaching Service. In Syracuse, N. Y., the sixteen girls who have recently finished this course, have organized as a Girl Scout Hos- pital Unit. They meet regularly with their Red Cross nurse 318 instructor, teach and demonstrate first aid and home nurs- ing to Girl Scout troops, and are registered with the Red Cross in case of a civic emergency. The American Child Health Association has given expert advice with regard to the dietaries in Girl Scout camps and the methods of in- teresting Scouts in food groupings and food values. School superintendents in both cities and towns are showing an increasing interest in the Girl Scout program and are co- operating in many ways. The Girl Scout herself, who is for the most part between the ages of 12 and 16, is in the early stages of learning the difficult business of being a grown-up. She is no longer a child, and resents being treated as one, a habit which both her family and teachers find it hard to break, since her be- havior is at times still lamentably childish. In contrast to the period of later childhood, from 9 to 12, which is rela- tively stable physically and emotionally, the Girl Scout is growing rapidly and irregularly, which means that she fatigues more easily, although she has an abundant supply of energy, often undirected or ill-directed. She is also going through the novel experience of physical maturing. Intel- lectually, she rebels against routine, and is eager for new mental provender, as well as for something new and excit- ing in her own daily life. Her chief difficulties, however, are social and emotional. She is restless and hard to man- age at home, but is full of new admirations for older people outside of the home, trying to be like first one and then another. In fact, at this period, she is essentially a self- dramatizer, trying all sorts of attitudes and situations. Few people realize that her crude attempts at self-assertion are a necessary stage in her becoming an independent adult human being, fit to carry on the life of the race, nor that her bravado all too frequently conceals inward timidities and self-distrusts. About physical, and, above all, sex mat- ters she is often reticent and tongue-tied, even though she may be longing for explanation and wise counsel. Much more has been done in the way of Health Educa- tion for children than for either boys or girls of Scout age, and less for girls than for boys. Even our knowledge of the psychology of the adolescent girl has many gaps, and is too often in terms of boy psychology. If the sketch just given of the teen-age Girl Scout contains elements of truth, it indicates that her 319 Health Education should be carried on in concrete and ob- jective terms of people and events, teaching her indirectly about her own health problems so far as possible through the problems of others, younger brothers and sisters or other groups of girls and children, utilizing her dramatic and creative impulses and interests, her admirations and enthusiasms. It should always be understood that her physical maturing is as normal and healthy a process as learning to walk or the coming of second teeth, and that any indications to the contrary are a sign of wrong health con- ditions elsewhere. Personal health should be looked upon as a means to an end, one of the marks of a good Scout and a good citizen, as well as fulfilling the Greek ideal of the interrelations of bodily and spiritual health and beauty. Mental health and the right use and direction of the emo- tions should never be forgotten. These are the years in which control of the emotions through attaching them to the right objects and interests determine character and be- havior throughout life. Only by studying and using her characteristics at this age, we make the girl into a true Health Scout. The Girl Scout program lays down various health re- quirements, both personal and involving others, for its Second Class and First Class Scouts. Its proficiency tests and badges include those for Health Winner (personal health), Health Guardian (public health), First Aid, Home Nurse, and Child Nurse. Other tests and badges for Ath- lete, Dancer, Horsewoman, Pathfinder, Pioneer, Swimmer, Gardener, Cook, Canner, Homemaker show the close rela- tions between health, outdoor exercise and activities, play, and home-making in Girl Scouting. The fundamental problem of Health Education through Girl Scouting, however, is to make these various health requirements not a mere matter of information nor of routine practice for a limited time in order to win an award and sew a badge on a sleeve, but a permanent interest and attitude, affecting the Health Scout's character and conduct throughout her adult life. A considerable part of Girl Scout health teaching has had to do with the prompt and skillful meeting of emer- gencies, in accordance with the Scout motto, "Be Prepared." But a deeper preparation, which is also recognized, but which may be still further developed, relates to the conserv- 320 ing of human life in all its aspects, which is the great occu- pation of women as mothers, teachers, housekeepers, citi- zens, whatever else they may do. With from 60 to 80 per cent of retail buying in the hands of women, Girl Scouts may well center their work in health, child-care, and home- making around the great topic of food and nutrition, g/bout which our knowledge has been increasing by leaps and bounds. And who shall say that later, in dealing with their own children or with children in the school, or with "all the children of all the people," they will not bless Scouting for having given them the ability to play and the love of life in the open? The discussion of the Girl Scout program was closed by Miss Mary Hicks, of the Cincinnati Public Health Federa- tion, who said: Miss Hicks: Mrs. Hoover has spoken on the general health program of the Girl Scouts, telling oi the merit badge and of the keeping of the health record. In Cincinnati we have between 1500 and 1800 registered Girl Scouts. The health program for the Girl Scouts is tied up very closely with the child hygiene work. I am connected officially with the Public Health Federation, which is the body that fed- erates and co-ordinates the health work in Cincinnati. I have the privilege also of serving as chairman of the Educa- tion Committee on the Executive Board of the Girl Scouts. The work of the Girl Scouts is therefore very definitely tied up with the regular child hygiene work of the city. The greatest opportunity we have in the Girl Scout movement to put over a Health Education program, in addi- tion to the health merit badge contest, is the health ex- amination before entrance to camp. We have two camps, one for white girls, and one for colored girls. The camp for colored girls offers unlimited possibilities in the way of health work. Altogether we have health examination for between six and seven hundred girls during the season. These examinations are given from the educational point of view, and all of the girls are urged to bring their mothers to the clinic at the time the examinations are given. The girls are privileged to have their own physicians give these examinations. They must, however, take to their phy- 321 sicians the regular form which is used in the clinic. The physicians are recruited to the Child Hygiene Council of the Public Health Federation. They are women physicians and they give the complete examination, and with a view to in- cluding definite recommendations after the examination on diet, rest and exercise that the girls can indulge in at camp. A trained nurse is in charge of the camp for the entire season. The health rules are emphasized and the whole camp regime is built up on the program of providing whole- some diet and exercise and periods of relaxation for the girls, to profit by it physically as well as joyfully. This is the third year that the plan of health examination has been carried on, and this year we are planning to get more information than we did last on the gain of the girls in weight at camp. We thus hope to plan our regime for another season with greater wisdom and care. I think the one thing we have to guard against in any camp program is over-indulgence in sports and in games and in recreation and work. In these camps, girls have so much they want to do, in order to get all the Scout work that they can possibly crowd in within the short time. We are therefore trying to put before the people who are interested in Scout work, the need of more relaxation and more time for leisure. The Chairman at this point introduced Miss Marjorie Wise, of London, England, who told something about the Girl Guides in England. The Girl Guides of England Miss Wise: I want to say that I do not officially represent the Guides. I am only a Girl Guide leader. Our Guides are what you call Girl Scouts. We were very anxious not to call them Scouts, because at the beginning, when they were first in- augurated, all the girls rushed to be Scouts, and there was a great deal of talk of their mimicking and aping the boys. First, I would like to tell you that we have three or four grades or ages of Guides. The movement for the little ones was started on the basis of Mrs. Ewing's story of the Brownies. They have quite a little health work. We think that in the work of the Guides the camp offers the best opportunity for a health program 322 that we have. All the Guides go into a field, and for one week that field is their home, and they do everything for themselves. Their sanitary problem, their cooking, everything they manage themselves. Before they go, they plan all of their food and the things they must take with them so that that food can be properly kept for a week. The first day we get there very early, and the very essential sanitary arrangements are made-the tents put up and the larder made. The next day we provide for drain- ing-they trench the tents just as our soldiers do. Their arrangements are completed, and we try to make these so that the girls will naturally, without any teaching from us, do the things necessary for them to do. One thing that al- ways amuses us, is the way the old campers insist on the younger campers airing their beds, and we wonder if they do that at home. We have also Senior Guides, or Rangers. Those are the girls who, when they reach 18, still want to be Guides and are not suitable for leaders. Then, the women have ar- ranged very much the same kind of clubs as those inaugu- rated by your Department of Agriculture, and they do very similar work to that of the Guide, first aid and cooking and home nursing. The program for Health Education carried out by the Camp Fire Girls was described by their San Francisco leader, Miss Celia Davis. The Camp Fire Girls Miss Davis: Health has an important place in the Camp Fire pro- gram. It not only forms the center of the watchword "Wohelo"-made from the first two letters of the words "Work, Health and Love"-but "to hold on to health" is one of the seven Camp Fire laws. The purpose of our health program is to help each individual girl to establish perma- nent health habits that will give her added vigor, greater vitality and a wealth of reserve power, that she may develop to the highest degree her capacity for future duties as a mother in the home and a citizen of the community. Realizing that the program must be attractive and have an appeal to the imaginative mind of the adolescent girl, a plan 323 of elective health honors has been adopted. The long health tasks have been broken up into less difficult ones, and as each is completed, recognition of the achievement is given. For example, these are a few of the honors: 1. Abstain from chewing gum, candy, ice cream, sundaes, sodas and commercially manufactured beverages as well as from eating between meals, for two consecutive months. 2. Swim one hundred yards. 3. Sleep out of doors, or with wide open windows for two consecu- tive months between October and April, inclusive. 4. Play games out of doors for not less than twelve hours during one month. Then there are others that branch out and include the knowledge of first aid as well as problems of camp and general sanitation. The Camp Fire girl also keeps a health chart which con- tains a list of chores that she should do each day, pertain- ing to food, sleep, exercise, and cleanliness. If at the end of the month she has fulfilled 90 per cent of these require- ments she is entitled to wear the health symbol. For each succeeding month that she keeps up the record, a bar is added. Camping and hiking are emphasized in this pro- gram. Last year over 125,000 Camp Fire girls went camp- ing. Consider what it meant to instill within those girls the desire for that health that comes from living and play- ing out of doors! Although it is difficult to measure exactly what our program has achieved, we do know that the acquiring of good health habits is decidedly popular in the Camp Fire groups. Then, too, we feel encouraged when we see many of the girls beginning to feel within themselves the absolute necessity of health for success, and assuming the responsi- bility not only for the improvement of their own health but an interest in the betterment of health conditions around them as a result of playing the good health game. Dr. Anna L. Brown, of the Education and Research Division of the Young Women's Christian Association, thus outlined its important Health Education program: The Young Women's Christian Association Dr. Brown: The Young Women's Christian Association holds itself responsible for helping the young women of its own mem- 324 bership to accept health absolute and dynamic as a social obligation. In its health program the Young Women's Christian As- sociation aims to convince young women that it is their own individual responsibility to secure for themselves the high- est degree of physical, mental and emotional health possible. The Association can only invite co-operation and persuade to patient perseverance because it has no recourse to the disciplinary measures inherent in an educational system up- held by the State. It cannot enforce adherence or submis- sion to regime. Its appeal, its program, and its methods of promotion must be ethical, sound and demonstrable. What would you have? Perfection of face and form, of poise and carriage, of manners and behavior, of mental force and social qualities, in short accepted standards of human excellence? The road to this is health; health of body, of mind, of spirit-the health that means wholeness- nothing less. If training in health were for every child already a fact, first in the home, second in the school, third in society, most of our young people might reach maturity with the magnetism of personality, the qualities of mind and spirit which would make them adequate to their social opportunities. But if it really takes three generations to make a gentleman, then we are only now teaching the grandparents to be of those who will accept their place in society on the health basis of noblesse oblige. A health magazine comes to my desk on the wrapper of which is printed, "Public health is purchasable." I read it and say to myself: "Would that individual health were purchasable." But we in the Young Women's Christian As- sociation know that the individual who aspires to health of the kind that means freedom from illness, from preventable ailments, from removable imperfections of body or mind, has to work for it herself. For the person past childhood, Health Education is primarily education of the conscience. Because of the inadequate training received in childhood any young woman has a hard row to hoe when she seriously undertakes to attain to that particular brand of health which means both deliverance from the traditional attitude of women toward illness and the acquisition of a new free- dom and a new power. Therefore, the Young Women's Christian Association undertakes to reinforce all the re- sources which the individual girl brings to this task, and, 325 building from the point where she registers, it gives her every possible aid; first, to believe in herself; second, to believe in the goal; third, to believe in the process by which she is to reach it. In its health work the Y. W. C. A. places equal emphasis upon both the social and physical problems of youth. Hence, it designates its health program social education. In local Associations all available equipment, gym- nasium, swimming pool, camp, clubrooms and recreation grounds are used as a sort of health training center. In a good many Associations these facilities are being placed more and more at the service of all the young women in the community. With the assistance of the National Board staff members, both physicians and physical educators, different types of local associations are acquiring a definite Health Education technique and are developing a health program adapted to community type. A physician and a physical educator will specialize in city Association health work next year; one physician with occasional help from a physical educator will continue to work wholly in rural communities, training the rural Association secretaries in health technique and practice, and one physician will go on as before working altogether with Colored Associations in cities and colleges. Through the generous co-operation of the American Social Hygiene Association, the Girl Re- serve section of the Young Women's Christian Association membership, some 200,000 girls from twelve to eighteen years of age, have a physician giving full time to training for leadership. Dr. Snow and Dr. Exner, of the Social Hygiene Movement, believe in the possibility of obtaining practical results consistent with the objective of their own organization by working directly with the National Board of the Y. W. C. A. among these well organized groups of teen-age girls and their trained leaders. The department of physical education in a good many local Associations is coming to be called the Health Educa- tion department. The physical educator in charge is known as the Health Education secretary. The starting point in her work with the individual girl is the health examination. The medical part of the examination is made by a physician with a health point of view who seeks to discover how well the examinee is; the second part, by the Health Education 326 secretary, who examines feet and back, shoulders and hips, takes height, weight, lung capacity, strength tests, etc. The ideal examination seeks not only to discover the physical status but also to secure a clear insight into the examinee's mental attitudes and social problems. Note is made of her preferences, her ideas of a career, her atti- tude toward work and marriage, her views on social rela- tionships and the type of sex information she has acquired. All this helps in advising her on many matters related to her new enterprise of building health. She begins her con- structive work in company with others but their needs are not usually hers. Each one's needs are as individual as her personality. To all local Associations we in the National Board Division of Education and Research offer the following suggestions: 1. If you can arrange for it, let the examinations given for admis- sion to your gymnasium and swimming pool be health examinations, not merely protective. If you make health examinations available to every girl in your membership and then follow up every examination with opportunities for health building and re-examinations, you will have made an important contribution to health in your community. The difference between health examinations and protective exami- nations is partly the completeness, and partly the point of view. The purpose of a health examination is to put the girl examined in posses- sion of the facts about her own health, existing and possible, and to give her as full a realization as possible of the reasons for working for health and the ways by which she can accomplish most. Such examinations should be given by a physical education secre- tary and a physician who will give them with the health point of view. If you cannot have the physician's full time, probably you can have part. If you cannot get enough time from one physician, can you from several? 2. Bearing in mind that among the more than 600,000 members distributed among the Associations throughout the country those seek- ing educational opportunities of some sort are to be found in every kind of group formation consistent with prevailing social interests- business, professional and industrial women, high-school girls, Ameri- can and foreign-born, girls in the teens and young women from 17 to 35 and on-we urge that every department of the Association and every activity should be contributing to health. The Health Education department should be contributing to every other. Since health is a state of well being that depends upon and in turn affects social life, physical condition, spiritual richness, mental energy and satisfaction, artistic enjoyment and self-expressiveness, the more closely all depart- ments co-operate the more will be done for health, and the more worth having the health they are all working for will be. 327 3. The right kind of recreation is a health essential. The right kind gives a person an opportunity to do something, not merely to receive; and something that tends to develop power, not to interfere with development. The right kind of recreation may be doing some- thing with the muscles, or the intellectual faculties, or the voice, or the artistic instincts, or the spirit and its appreciations. No one kind of recreation is necessarily the best for all kinds of people, nor even for all kinds of times and moods. Everyone needs some recreation. The fuller the health, the more different kinds one will have the power to enjoy; and conversely, the more wholesome kinds of recreation one develops the power to enjoy, the higher the tide of health. 4. Exercises done every day do a great deal to keep up the lively sense of physical well being which is one of the joys of perfect health. To bring the body to its utmost beauty and grace, and to increase conscious pleasure in feeling the smooth, supple movement of one's own muscles, exercises can be chosen not haphazard but fitted to one's individual body and habits. Out of such a choice one gets the maxi- mum good. We frankly prescribe a health regime but we accept no authority on any part of it as final. We must know for our- selves the effect of diet, exercise, work, recreation, rest, dress, reading and amusements upon the individual at least to the extent of adaptation to type. Therefore, we are com- bining careful research along with the promotion of a program of activities intended to intrigue the interest and engage the attention and co-operation. For all the increasing numbers who are entering the ranks in our campaign for health we urge that the means shall not be mistaken for the end. We would deliver people from the necessity of counting calories or recording the number of glasses of water per day prescribed as part of a health regime, or registering as a matter of conscience the number of miles walked, or the performance of any given exercise a given number of times within a given period. We seek to aid the person concerned to discover the point at which she does not need to remember how many glasses of water she has already swallowed at the moment that she is thirsty. She does not have to say: "I walked two miles yesterday and must walk three today." Instead, she says: "I reached the waterfront yesterday, I would like to reach the Presidio today and perhaps the Twin Peaks next." These are the processes by which the girl in the Y. W. C. A. group may work her way slowly but surely towards that freedom, that joyous participation in life, that glorious sense of being one with the universe, of being identified with all the great cosmic forces, which we call Health. 328 The Chairman: In the absence of Dr. Linsly Williams, the Managing Director of the National Tuberculosis Asso- ciation, his presentation of the school program of the Mod- ern Health Crusade, will be read by Miss Edith Country- man, Health Crusade Director of Iowa. The Health Crusade of the National Tuberculosis Association Miss Countryman: The Modern Health Crusade, as its name implies, is an endeavor to arouse the interest of school children to carry- on a crusade for health. The program is planned for school children and the ultimate aim of the program is to teach children the principles of healthy living and also to train them to acquire healthy habits. The crusade consists of the following: 1. The carrying out by a school child of a certain number of health functions daily, known as health chores. 2. The keeping of a daily record by the child of the number of health chores carried out by him during a minimum period of 12 weeks during the school year. This record to be taken to the home and countersigned by the parent or guardian with the intent of arousing the interest of the parent in seeing that the child performs all of the health chores. 3. The granting of a chivalric title to a child upon the completion of the daily performance of the health chores for a minimum period of 12 weeks and the showing of a satisfactory record which has been countersigned by the parent or guardian. The awards given are simple buttons or pins granted with the title of squire, knight, knight banneret and knight banneret constant. Administering the Crusade The Crusade is administered by the Educational Depart- ments. It is usually commenced as a voluntary method of health instruction and the details of its operation are com- monly described to the school teachers after an agreement has been made between the local tuberculosis association, the state tuberculosis association and the superintendent of schools that this method will be tried in certain of or all of the schools. The teacher is advised by the representative of the tuberculosis association of the various steps to be taken to use the material. The first and most important piece of material needed is the chore folder, which contains a list of the chores. The chores are the rules of health, and 329 when the Crusade was first launched only one series of chores was given for children of all ages. This system has been improved upon so that now there is a system of graded chores for four grades. These graded chores are so well known that they are not quoted. The forms A, B, C, D, de- signed for third, fourth, fifth and sixth grades, can be obtained from National Headquarters in New York. The teacher is then advised that each child who becomes a Crusader will pledge himself to carry out these health rules and to check daily on the score card the chores which he conscientiously completed during that day. At the end of a six-week or twenty-four-week period, the chore record is countersigned by the guardian or parent and returned to the teacher by the child. The teacher then inspects the chore record and estimates the percentage of success ob- tained by the individual child. The child is supposed to con- tinue to follow out the chores for a minimum period of twelve weeks or up to a maximum of thirty weeks, and when the period is completed, the teacher goes over the complete record for the entire period in order to grade the children on a percentage basis and to see which children shall be given initial award of squire. As each grade is finished, an additional title is given and a suitable button or pin may be given to the child. All children who follow the Crusade are regularly weighed and measured. Contests Contests are not required as a part of the Crusade but seem to stimulate interest in the children and in the school by the group process of influencing children who are naturally backward in movements of this kind. The mere fact that a class or a school is engaged in a contest with another class or school urges the children to be more perse- vering in carrying out their chores. Award of Titles After the pupil has performed at least 54 (75 per cent) of the Crusade chores for a minimum period of twelve weeks in the school year from September to June, the title of "Squire" is conferred upon him; after the performance of at least 54 of the chores over a second similar period, the title of "Knight" is conferred; the title of "Knight Ban- neret" follows the completion of three similar consecutive 330 periods, and the title of "Knight Banneret Constant" is con- ferred after four years' (a minimum year is twelve weeks) faithful performance of the chores. This latter is known as the achievement title. The award of titles may be indicated by paper stars on the schoolroom chart, roll of health knighthood, and by badges or other insignia. The use of insignia, however, is optional. Results of the Crusade. It is difficult to give an accurate figure of the number of children who are carrying on the Health Crusade. From the amount of material distributed annually by the Na- tional Tuberculosis Association, it would appear that some- where between 6,000,000 and 8,000,000 children are Health Crusaders. The Modern Health Crusade or practice method of Health Education has been adopted as the official system of Health Education by the Departments of Education in 21 different states. This activity is fostered and aided by many of the 53 affiliated associations of the National Tuberculosis Association and by the majority of the 1,200 local associations. In hundreds of schools and among thousands of children, the Health Crusade has brought about a marked change in the appearance, cleanliness and habits of the children. This fact has been testified by children, teachers, and workers in the various tuberculosis associations, and it has stimulated amongst the children not only a group movement for cleanliness, but also a keen interest in many places in community hygiene. By means of the Health Crusade, children unaided by the teacher, have been able to secure pure water for the school, proper sanitary arrangements, better lighting and ventilation in the school, and various other improvements in the sanitation of the school building. It is believed by some that the Crusade is complicated because of its variety of accessories. Only two things, however, are required, namely, the performance of the chores and their recording. The materials and supplies for carrying out the funda- mental principles of the Crusade make it a very simple process for the teacher, and but little effort is left to the initiative of the teacher in applying methods of habit for- 331 mation, though the Crusade requires initiative on the part of the teacher to select material for instruction on hygiene and physiology and to choose various topics for the lessons as outlined in the syllabus. It is believed by the National Tuberculosis Association that a large proportion of school teachers have not had the training necessary to enable them always to apply sound pedagogical principles and that the method of teaching required by the Health Crusade is the same used in the teaching of many other subjects as evi- denced by the outlines and syllabi distributed to teachers by various state educational departments; and that many of the teachers in this country through no fault of their own are not yet prepared either to define or apply sound pedagogical principles. The Crusade develops the initiative of the child and assists parents in teaching the value of healthy habits in bringing up their children. It is also of value in teaching uninformed parents of the value of healthy living. It has promoted school attendance, scholastic standing, interest in school surroundings, class and school loyalty and has stimu- lated real community movements for improving sanitary conditions. It promotes general health and therefore better attendance, as shown by the following example: In Texas, for three years, pupils in a three-room rural school have won State and national honors in Crusade tournaments. During the epidemic of dengue fever last fall the attendance was 99.1 per cent. During that month only two pupils out of an enrollment of 150 were absent on account of dengue, while from 50 to 75 of the pupils in schools all around them, that were not using the Crusade, were sick. In Iowa, in the same school before and after taking Crusade: Defects 1919 1921 Teeth 60% 39% Tonsils and Adenoids 55% 29% Underweight 60% 32% Vision 12% + 12% Hearing 5% 4% By similar specific data, it can be shown how the Crusade promotes scholastic standing, promotes interest of children in cleaning up school surroundings, and promotes class and school loyalty. The community itself has shown the influence of the Crusade as shown by improve- ments in school buildings, as in Southold, L. L, where a new school was erected as result of the Crusade in interesting parents in school needs. Town clean-ups have been reported from Wyoming and Arkansas resulting from Crusaders' clean-up campaigns. 332 The Crusade for Younger Children and the Higher Grades A modified form of the Health Crusade has been adopted for kindergarten children, the details of which will not be gone into. In addition, a program has been prepared for children in the higher grades by which children who have success- fully finished the chores over a four-year period become eligible for the Round Table. In the Round Table course more advanced work is given, playground, Boy and Girl Scout activities recommended and community spirit aroused. Nutrition Chores For underweight children special nutrition chores are recommended under medical guidance. The Chairman: Mr. J. B. Nash, Superintendent of Recreation and Director of Physical Education of the Oak- land Public Schools, Oakland, Calif., will describe the work of the Playground and Recreation Association of America. The Playground and Recreation Association of America Mr. Nash: For your own health, I wish that you could get some play in connection with this Conference. I suppose there is no group of people that need real Health Education of the kind our fathers and mothers had when they were out in the open as much as does the group of people I am facing today. I am sure none of you take as much exercise as you advise in all of your classes, but I do not believe we are as nearly abnormal as the statisticians would have us think. If chil- dren learn to love the sound of running water and the wind in the trees and will get a new vision, their bodies, in the majority of cases, are going to grow strong. There is only one way to get human beings to take enough exercise and that is to give them the incentive of the play viewpoint. They will not take it in a moment; they will spend years inventing machinery to take away the need for work. They must be given the play incentive. It 333 will provide them with a joyous outlook that will affect their attitude on health. Play develops vital and functional strength, utilizes the neglected portions of the body, and brings about a co- ordinated use of the various sets of muscles. It promotes nervous stability. Play helps counteract the physical as well as the mental effects of highly specialized industrial work; it gives opportunity for self-expression, and keeps fresh the enjoyment of life so essential to health. The vigorous games of the playground carried on in the open air are making for health. The annual death toll from tuberculosis in the United States reaches a total of 107,000. The National Congress on Tuberculosis has declared that the playground constitutes one of the most successful meth- ods for the prevention of tuberculosis and should be put to the fore in the world-wide propaganda for the diminution of the unnecessary destruction of human life. I have spoken of the play incentive which takes men, women and children out into the open, giving them the joyous outlook on life which is one great source of good health. Nature-study classes leading out of doors, the de- velopment of municipal camps making it possible for groups of people, at their own expense, to spend healthful vacations in the open, folk dancing, and the many forms of playground activities are all features of the play program which are promoting health. The Playground and Recreation Association of America with headquarters at 315 Fourth Avenue, New York City, is helping cities through its field secretaries, Correspond- ence Bureau, and literature, to establish year-round recreation systems with playgrounds and play programs incorporating the activities I have mentioned. It is also publishing athletic badge tests designed to set minimum standards of physical efficiency with which all children may measure up, and it is working through its National Physical Education Service, created at the request of a number of groups, to help states pass physical education laws and to secure federal legislation. Thirty-two states now have such laws. Through all these channels the Association is working to promote health, believing that the provision of adequate public recreation facilities and activities under careful leadership will produce healthy, well-rounded citizens. 334 The Chairman: The Woman's Christian Temperance Union has sent Miss Cora Frances Stoddard, National Director of Scientific Temperance Instruction, to present its Health Education program. The Woman's Christian Temperance Union Miss Stoddard: The Woman's Christian Temperance Union in its first declaration of principles, now nearly fifty years ago, put into the very first paragraph its belief in the freedom re- sulting from obedience to the laws of health. It was par- ticularly concerned with the child, its health, welfare and training, its possibilities in the future as a citizen. Because alcoholic beverages menaced the child and youth, the or- ganization pledged itself "to education of the young, to form a better public sentiment." The Health Department has long served women as a medium of dissemination of health practices and informa- tion, especially as to the health of children. To this is now added the work of the Child Welfare Department. Four years ago an annual appropriation of $10,000 for five years was made to the Iowa Child Welfare Research Station, en- abling it to enlarge its work in some important respects. In practical operation, education to total abstinence and for health went hand in hand, and it was the laws secured by the Woman's Christian Temperance Union that opened the doors of the American school to training for health as well as for sobriety. Very many members of the organization have been or are teachers, and also mothers. This combined experience has caused them to realize that with the constant skillful training in the practice of ideals, the child or youth must be given definite facts to help him understand why these practices are desirable and necessary, and to enable him to face intelligently unexpected personal or public health prob- lems. With the subject of alcoholic beverages education has to deal not only with ignorance, but with positive mis- information and age-old traditional errors. This misin- formation still exists. For concrete misinformation, there is no adequate cor- rective or preventive except the concrete truth of facts, and it is the judgment of the women of the Woman's Christian 335 Temperance Union that it is the right of every youth when he leaves our schools to know the modern scientific facts as to the nature of alcohol and other narcotic drugs, and their dangers in relation to health, efficiency and complete human soundness. The organization stands actively ready, therefore, to assist the school in every possible way in giving this in- struction. It publishes every year hundreds of thousands of pages of up-to-date reliable information useful to the teacher, and supplied by local Unions. Suggestive graded outlines of facts about alcohol and other narcotics for school use are supplied superintendents. Constructive wall charts or posters have been made available for teaching, with accompanying pamphlets giving scientific facts, and sug- gesting practical applications of truths to every-day life. Several trained women, former public school or normal school teachers are doing very successful work in address- ing public and normal schools, supplementing the regular school instruction. Prize essay work on subjects concern- ing the nature and effects of alcoholic drinks and other narcotics is now done in colleges, normal schools, secondary and elementary schools, and several thousand dollars' worth of prizes in the form of money, books, or medals are awarded annually by the Woman's Christian Temperance Union to the contestants. Practically all of the States require systematic instruc- tion. In addition, the Woman's Christian Temperance Union has been instrumental in securing laws in over twenty States requiring one day each year to be observed as "Temperance Day." For this there are special programs, sometimes prepared by the State Superintendent of Public Instruction, sometimes by the local school management, availing itself of the material which the Woman's Christian Temperance Union compiles for such assistance. Carefully prepared lantern slides can also be obtained for school use and are the only educational films in the United States presenting scientific facts about alcohol. The necessity for scientific instruction concerning al- cohol and other narcotics has not ceased in the United States with the prohibition of the liquor traffic; indeed, the thoughtful educator will realize that more than ever the work should be carried on and incorporated in the courses of study. Millions of children and young parents are troop- 336 ing to the United States from countries where drinking customs and thoughts concerning drink are the antipodes of the scientific knowledge of this century. To such, total abstinence is strange, and prohibition, therefore; a violation of what they consider a natural right. There were over 5,000,000 foreign born children in the United States in 1920. The schools must help them quickly to understand America; what its laws mean; why sobriety is an advantage to health, and to getting on in the new world; that America has abol- ished alcohol because it wants its people strong, healthy, prosperous, self-reliant and self-controlled. The Woman's Christian Temperance Union has no wish to enter the schools to do work which the school itself should properly and competently do in this phase of work for public health. This instruction is, however, related to nearly every other vital feature of the health program. Alcoholism retards progress in dealing with tuberculosis; it undermines the self-restraint needed in meeting prob- lems of sex-control; it was formerly directly responsible for at least one in every ten of the unfortunates entering our insane hospitals whose number our mental hygiene move- ment aims to reduce. As our schools of the past half cen- tury have rightfully been honored for their part in increas- ing intelligent sobriety, it may be confidently expected that they will loyally "carry on" for completing the task. The motto forty years ago was, "If we save the children today, we shall have saved the nation's tomorrow." That vision has been in part fulfilled. The Woman's Christian Tem- perance Union stands ready with its resources, its experi- ence, and it far-flung organization in fifty nations to co-operate with all health programs having as their aim the building of sound bodies, sound minds and sound characters. The Narcotic Education Association Mr. H. R. Bonner, of the Narcotic Education Associa- tion, Los Angeles, Calif., desired to describe the studies made by his Association of methods for controlling the use of opium, morphine, heroin, cocaine-narcotic drugs. He said that his Association planned in every city of the United States to carry on the work they had begun in Los Angeles, where there is a committee of one hundred leading 337 citizens of all vocations, co-operating to put on a narcotic education campaign. He expressed his belief that the teachers of America were not fully aware yet of the importance of this narcotic question, indicated by the fact that in 1915 it was discov- ered that the United States was using more opium per capita than any other nation in the world. Despite the passage of the Harrison Narcotic Law, preventing the im- portation of opium except for medical purposes, there were about a million addicts in the United States five years after the law was passed. For this reason, the Narcotic Associa- tion stands for educating people regarding this great menace, particularly the rising generation of boys and girls. In conclusion, he described a bulletin prepared by the Narcotic Education Association, summarizing the facts about narcotic drugs, which he offered for the use of teachers everywhere as a supplement to texts in physiology and hygiene. Dr. William F. Snow next told of the work of the Ameri- can Social Hygiene Association, and also of the National Health Council. American Social Hygiene Association Dr. Snow said that he felt it unnecessary to present any- thing in detail about the Social Hygiene Association, inviting instead, those present who wished information to apply to the New York headquarters for literature. He stated that the American Social Hygiene Associa- tion believes its principal job, from a medical angle, to be that of trying to marshal the forces of society to reduce, and so far as possible to eradicate, syphillis and gono- coccus infection. He stated that with these is bound up the whole question of sex education, and that the Associa- tion, realizing this, had divided itself into divisions for handling the various angles of this work. The National Health Council Of the National Health Council, Dr. Snow said: "The National Health Council interests itself in what is going forward in the field of national health agencies in general. 338 Around the central idea of getting into one group and get- ting acquainted with each other, we have built up the Na- tional Health Council of ten or twelve affiliated agencies, each organization being independent. We have interested people with means to provide funds to try out this or that demonstration; and as rapidly as possible, when practical facts have been ascertained, these things have been turned over to local groups through cre- ating public opinion to support the local health authorities to carry these on. We have found that by getting together there are a good many things we can conduct in common, the library and various common services, shipping, etc., to the extent that each group desires to use them. There is something in that indefinable sense of teamwork that has grown up in these organizations. They feel that they are glad to be under this one roof and related to each other as they are. One significant thing has been the appointment of a com- mittee on budgets and programs, where each of these or- ganizations has laid before the executives of all the others its budget and its projected program for activity, and these have been thoroughly and carefully dissected and compared and studied out in relation to each other, so we can answer as to whether there are duplications. I think we are apply- ing a principle that is very worth while, and worth while presenting here for your consideration in connection with this general discussion of co-ordinating agencies working for Health Education. The Chairman: The National Parent-Teacher Associa- tion was invited to this Conference but no representative has appeared. The American Public Health Association was repre- sented by Professor C. E. Turner, of the Massachusetts Institute of Technology, who described it as follows: The American Public Health Association Professor Turner: I am glad to mention in connection with the other or- ganizations which are represented here the American Pub- lic Health Association. It is professional and includes not only health department workers, but any person who is en- 339 gaged professionally in public health, no matter what the particular specialty or training or degree the person holds. It is divided into various sections, including among them all, one on child health and one on methods of popular Health Education. It publishes a professional journal, the "American Journal of Public Health." Any person who is interested or working in any phase of public health is eligible to membership in this Association, which is about fifty years old. The Chairman: Health Centers as Institutions for Health Education, will be presented by Mrs. Gertrude Whitton Barrett, Secretary for Health Education, Public Health Center of Alameda County, Oakland, Calif. Health Centers Mrs. Barrett: To discuss the contribution of the health centers to Health Education would probably be to take up every indi- vidual health center in our country and discuss their po- tentialities and benefits, because no one, I believe, can definitely define a health center. It may be a clinic or a treatment center, or a center for early diagnosis or a center purely for advice, literature distribution, etc. So it is diffi- cult to take them all together and say something about the contribution of health centers to Health Education. But the health center that I am thinking about is one that is dedicated to the prevention of disease through an educa- tional program, through early diagnosis and through relief of disease and treatment where necessary. Before we pass on to the actual working of a program, I think the contribu- tion of a health center in initiating a program in a com- munity cannot be overlooked. The question of how best to enter the community is answered by the health center. It is an organization that can invite to its headquarters all the people in the community who would be distinctly in- terested in a real, live program, those people who start public opinion in a community. A perfectly delightful way, I think I Simply say, "We are all here to get what we can in inspiration and to work out problems as our local situa- tion dictates." A health center which has in its adminis- tration the educational institutions and the public health 340 officials can act as hosts to the interested leaders of the community and then actually start the administration of the desired program. Such an arrangement answers the question, "Which leaders in your school system shall lead the health program?" You can have a group which sits down together and says: "We have children which we want to lead to health, and we are all interested in it. Let's make a program. Then each of us will take the part we are most fitted to do and work it out." In starting the program, no question arises as to who shall lead, but all do it together. One of the first contributions of health centers to the development of Health Education in the community is co- operation, and co-ordination. But what that program shall be is definitely absorbed within the school system. In start- ing it as a general community program you have an or- ganization to bring together all of the forces that will make it a strongly functioning program. When you start it in the schools, you have approach through mothers' clubs, the press and other entities. You have your variety of com- munity organizations concerning the school, and in that way you can at the same time start your fires burning throughout the city and strengthen the school program. It is interesting to see how these community organizations react. When the proposal for a dental program is placed before a rotary club, we feel that it is very worth while in our educational program to have the community organiza- tions interested. And so, through the mothers' clubs, when they set aside a day a month to discuss the health problems of the child and call on the health center for a speaker, we find that the fire that is started burning there will make possible the condition in the home which will allow the health habits which the child is learning at school to func- tion to the very best possibilities. So, after a program is planned and started, I think a health center can surround it with inspiration and support. A teacher who is at a loss to know what to do may find in the health center some of the newest and latest ideas. It can bring together the fine things that various teachers are doing and make possible the circulation of the exhibit material, providing conferences from time to time. We have just had a series of sixteen such conferences, consti- tuting a course for teachers at the health center, making the teachers more strong by furnishing them material, literature, posters and the contributions of specialists. 341 Then, we do need more opportunities for girls and boys to get out into our communities and actually contribute to the program. There are numerous opportunities around a health center to really put to work the boys and girls of high school age. Putting them to such work often arouses their personal interest in themselves. Our girls help with the dressings in one of the departments; another group comes down and binds the material and literature. There are hundreds of opportunities to expose boys and girls to altruism and the possibilities of Health Education. We work with all the health organizations. You know the story of Ben Hur, where the unknown Jew rides to success. To do it he had to live with his horses, to stimulate and work with them. That is the way health centers con- tribute, mingling humbly day by day with the organizations in the community, stimulating effort where it is, co-operat- ing, and humbly losing themselves where co-operation is needed, and all working together for the success of any program that strengthens our common cause. Following Mrs. Barrett, Mr. Thomas Yuan, of Peking Teachers' College, Peking, China, spoke thus: Mr. Yuan: For the people in China whom I have the honor to repre- sent, I want to express a brief appreciation of the noble undertaking of the National Education Association of the United States in calling this international health session. I feel very deeply impressed by the lofty spirit, the thor- oughness, frankness and democracy in the way of giv- ing speeches and discussion. Let me extend my warmest thanks for the contributions that have been given in this conference. The Chairman: I want to express in behalf of our Con- ference its thanks to the local committee for the splendid and unselfish service that has been given. The Conference furthermore extends its thanks and warm appreciation of the contributions made by its many distinguished speakers. It hopes that the deep and widespread interest manifested by the group daily gathered here for listening and discus- sion will result in speedy and definite improvement in the welfare of the world's children. The International Health Education Conference is now adjourned. Resolutions Presented by the Health Education Con- ference to the Plenary Session of the World Conference on Education. Adopted Health Education. IntrodiLctory WHEREAS, The promotion of health is recognized as a funda- mental aim in the educational program of progressive nations, and Health Education in many instances is granted a prominent place in the courses of instruction, and WHEREAS, We believe that the advancement of health in educa- tion would be advantageously furthered by co-operation of and inter- communication between the various nations; therefore be it RESOLVED: 1. That the World Education Conference make provision for an International Health Education Section. 2. That the report of this International Health Education Con- ference and other significant pieces of health literature be translated and made available for the nations that make special request for such material. 3. That aid and encouragement be given as far as conditions and resources may permit for the improved professional training of teach- ers and leaders in Health Education, by the offering of scholarships for study and training in countries which may provide desirable facil- ities for such professional training. Status and Aims of Health Education WHEREAS, We believe that educators are now feeling the need of definite assistance from specialists in the preparation of courses of study, and that the public is ready to support the development of a broad and sound health program, and WHEREAS, We believe that the school health program must be built around the fundamental principles of positive health teaching- a training in action as well as the giving of facts, imbued with the spirit of joyous living; therefore be it RESOLVED: That the fullest co-operation be developed between all experts as well as official, voluntary and non-school agencies in the various fields of Health Education, and that the co-operation of parents, through associations of parents and teachers be secured. WHEREAS, We realize the importance of training children under five as well as those of school age in habits and attitudes, mental, physical and social, and are convinced of the value of experiments already conducted; therefore be it 342 343 RESOLVED: That further experimentation in this field should be encouraged in all countries in order to give us a sufficient knowledge upon which to base the fundamentals of a program that may be uni- versally adopted. That the removal of physical defects during this period be encouraged so that the child may enter school free from physical handicaps. WHEREAS, We recognize the value of growth records as a partial but simple and concrete index of health; therefore be it RESOLVED: That we hereby recommend the value of weighing and measuring school children as a teaching project, in addition to, and as distinct from, the use of weight standards as a clinical index. Nutrition and Health Education WHEREAS, We realize that food is the only source of energy- building material and vitamines; and WHEREAS, we are impressed by the disastrous physiological results that have been produced in experimental animals by defective diets; and WHEREAS, We know that foods differ fundamentally in their nutritive properties; and WHEREAS, We are convinced that there is an urgent need for the dissemination of information about the nutritive requirements and the nutritive properties of foods; therefore be it 1. That mothers be taught the importance of food, its selection and preparation, for the pre-natal period, the period of infancy, the pre- school and school periods and for adult life; that mothers be taught the relative values of food in terms of cost in order that the income may yield the largest nutritive returns to the family. 2. That lessons in nutrition be incorporated into the school cur- riculum. 3. That teachers in training and teachers in service be given instruction in nutrition by properly trained persons. 4. That anyone who is preparing to instruct either teachers or parents in the food requirement should study thoroughly the chemistry of food and nutrition and should have fundamental courses in physi- ology, psychology, sociology and allied subjects. RESOLVED: The Contribution of Physicians and Dentists to a School Health Program WHEREAS, We recognize that the contribution of the physician and the dentist to the school health program is of fundamental and vital importance in developing (a) Ideal medical and dental examination of pupils; (b) Frequent and effective inspections to prevent the spread of contagion; 344 (c) Suitable organization of the body of scientific knowledge upon which Health Education is based; and WHEREAS, We recognize the need for more careful and accurate physical examination of school children and for further scientific instruction in Health Education for public health workers; therefore be it RESOLVED: That there is a vital need of further training in the preventive phases of child health in both medical and dental schools and the further development in universities and schools of public health of specific instruction to train specialists and administrators in the field of school health work. The Contribution of Nurses to a School Health Program WHEREAS, We appreciate the opportunity afforded the nurses to participate in the development of the Health Education program; therefore be it RESOLVED: That we recommend that in all countries of the world there shall be a concerted effort to promote such a program of nursing education as will produce the type of nurse qualified to take her place with the other leaders in the field of Health Education in the schools of the world. That in all countries schools of higher education be encouraged to support university schools of nursing and to recognize the development of these schools as part of the program of general education. The Relation of Physical Education to Health Education WHEREAS, We believe that physical education in its play and athletic features should take a more vital place in the life of all nations and all communities; and, WHEREAS, We base this belief upon the character building, health giving, right behavior producing values, in skilfully applied physical education for all nations; therefore be it RESOLVED: 1. That there should be extensive use of athletics separately adapted to girls and boys as a means of developing the finer type of girls and boys, rather than the emphasis on intensive competition of the few with their exploitation. 2. That physical activities should be correlated with health exami- nations, the formation of health habits, and the promotion of a healthy nation, so that everywhere there shall be better boys and girls, finer men and women. 345 Preparation of Teachers WHEREAS, Successful Health Education must depend upon the following factors: 1. Knowledge of the various approaches to, and fundamentals of, health promotion and disease prevention and control; 2. Acquaintance with the modern machineries of public health which are indispensable to attaining positive health and physical efficiency; 3. Familiarity with and ability to utilize efficiency, sound peda- gogical methods for the purpose of teaching health and creating in the child an active and impelling desire for positive health and physical efficiency and for training him in lasting health habits; 4. Enthusiasm on the part of the teacher for Health Education as expressed by her knowledge of the subject and activities for health work and her own positive personal health attainments; Be it RESOLVED: That this Convention hereby recommend that agencies of all insti- tutions concerned with the training of teachers, establish courses in, and programs of study for, Health Education in order that these factors may be realized, and efficient teachers and supervisors of the schools' health interests and activities be trained. That it is the sense of this Convention that all prospective teachers in training be required to complete a well-balanced course in the fundamentals of health promotion and disease prevention and control, with particular reference to school hygiene, so that all teachers in the future will have some knowledge of and interest in the health of school children. / Be it further RESOLVED: Those serving on the six committees which prepared these resolutions are: Dr. Thomas D. Wood, Columbia University, General Chairman of all Committees. Miss Sally Lucas Jean, New York City, General Secretary of all Committees. Dr. Richard A. Bolt, Director of Medical Service, American Child Health Association. Miss Elizabeth Breeze, Director of School Nurses, Vancouver, B. C., Canada. Dr. William Burdick, Director Playground Athletic League, Balti- more, Md. M. L1SON de Paeuw, Director General of Normal Schools, Ministry of Science and Arts, Belgium. Miss Carolyn Gray, Department of Nursing Education, Western Re- serve University, Cleveland, Ohio. Mlle. Madeleine Kaiser, Director of the Colony for Debilitated Chil- dren, Brussels, Belgium. 346 Dr. William Palmer Lucas, Professor of Pediatrics, University of California. Miss Mary G. McCormick, Supervisor of Nutrition, State Depart- ment of Education, Albany, N. Y. Senor Guillermo Mendez, Professor of Pedagogy, National Institute, and Director of Preparatory School, Panama. Dr. Guy Millberry, Dean, Dental Department, University of Cali- fornia. Mr. Jay B. Nash, Superintendent of Recreation and Director of Phys- ical Education, Oakland Public Schools, Calif. Senor Jorge Orozco, Junior Red Cross, Costa Rica. Dr. Anna Rude, Director Maternal and Infant Hygiene, U. S. Chil- dren's Bureau, Washington, D. C. Miss Ryn Sato, Teacher in Friends' Girls School, Tokyo, Japan. Mr. Yoshizo Sano, Director of Japanese School, and Boy Scout Mas- ter, San Francisco. Dr. John Sundwall, Director Division of Hygiene and Public Health, University of Michigan. Miss Elnora Thomson, Associate Director, Portland School of Social Work, University of Oregon. Mr. C. E. Turner, Associate Professor of Biology and Public Health, Massachusetts Institute of Technology, Boston. Dr. Antonia Ursua, Representing Secretary of Education, Mexico. Miss Christina Stael von Holstein, Sweden. Miss Edna White, Director, Merrill-Palmer School, Detroit, Mich. Miss Marjorie Wise, England. Madame Tetsuko Yasui, Dean of Tokyo Union College for Women, Japan. Mr. Thomas Yuan, Peking Teachers' College, China. ©-1923-American Child Health Association 2000-12-23-WHCCo.