Fourth Report of the Committee on Municipa} Health Department Practice

Presented to the Public Health Administration Section
~ of the AgPeHeAs at the Fifty=third Annual Meeting at

Detroit, Oct. aly 19 24,

General Objectives

Your Comnittee on Municipes Health Department Practice was created four
years ago with the conviction that the time had come for a concerted advance
in the field of American municipal health service. The fundamental scientific
and snciaigeesl bases of health department practice had become reasonably well
established in their broader lines; and in almost Te special
contributions of real, and sometimes of unique, value were being made to
the technique of administrative method, Yet there was no central clearing
house to facilitate the prompt interchange of information in regard to
such pioneering efforts; there was ok eseeen standard for evaluating
either the program or the performance of a health department as a whole; and
there was no source £5 which the individual health ofeesr could turn for
counsel and for practical support in the execution of his vbese.

Your committee was created to fulfill this need, Its functions,
were obviously threefold. It was necessary to establish machinery for
(a) The collection and filing ef current and up <ss information
in regard to public health practices and procedurese
(pb) The critical anelysis and interpretation of the data ee
(a) The bringing to ths individual health officer of the eBonits of
such analysis in the way most Likely to be of immediate practical assistance

to him in his official work...

 

 

{
i
|

 
‘Sie

= 2 =

In other words, the task of the Committee was to apply in its special
field, that of municipal health practice, the primary objectives of the
American Public Health Association as a whole, as stated in the report of
the Committee on Reorganization two years ago, “the preparation, study,
standardization and presentation of scientific public weRith pracedures.*

The Collection of Information in Reeard to Health
Department Practice .

The first definite step along this line was taken by your committee
when in 1921 it developed a carefully prepared schedule of information

covering every phase of municipal health work and through the generous

financial assistance of the Metropolitan Life Insurance Company and the

invaluable cooperation of the United States Public Health Service, set about
ei the satemuet inn called for in the schedule for eightyathree
cities - the United States which had a population of approximately 100,000
or more, The information, thus obtained was systematically analyzed, and
in 1923 was published by the Public Health Service as Bulletin 136. Copies
of eae Bulletin were presented to the members of the Association last year
at our meeting in Boston,

The United States Public Health Service seemed the logical body to

continue in the future this task of collecting and keeping up to dete current

information in regard to public health procedures, We had the pleasure a year

ago, in Boston, of reporting that on the instance of your committee Surgeon
General Cumming had agreed to establish in the Public Health Service an office
of Administrative Health Practice under the able direction of Dr,Paul Preble
for the fulfillment of this function. During the current year Dr.Preble pre»
pared a new and more elesexens schedule for the study of municipal health
practice which was applied under his direction by officers of the Publie Health

Service to a second survey of public health procedures in one hundred

cities of 70,000 population and over,
— Sos

These surveys are all now in the hands of Surgeon Preble and are being carefully
analyzed, and their important data tabulated and classified, This material will
be published in a second bulletin dealing with city health practices as soon as the
preparation of the information contained aS schedules has been completede
The Committee is under heavy obligations to the Public Health Service for the work
which Surgeon Preble is doing in keeping the studies of city health practices
CUrrente

: In this connection, mention should be made of the fact that the American
Child Health Association, having become interested in a similar study of municipal
health activities, agreed, after — with representatives of this Committee,
+o include within their studies only cities with populations under 70,000 $0 that
there would be no overlapping in work and no duplication of surveys of city health
departments. The Child dealth Association has made a study of some sig hty-six
: cities in the United States with peneietions ranging between 40,000 and 70,000
during the last year and is now engaged in preparing its material for publication
at an early date. : |

it #2 tna be seen that the collection of data — to city health

procedures or practices has been developed to a highly satisfactory degree and
that 4hrough the creation of a special office within the United States Public
Health Service ideal machinery has been created for ie carrying out of such work

on a permanent basis in the futures

The Evaluation of Public Health Procedures.
fhe basis for any sound public health program must necessarily be sought
in a study of none bicel experience, The collection of raw data as to current
practice is however only a first step. The data must be analyzed and critically
evaluated if they are to prove of the maximun practical value.

It is sometimes of course the case that a health officer desires simply a

 
= Ane

piece of concrete information, such ae ths number of cities practicing terminal
funigation or the srattics of New York or Detroit in regard to the isolation

of whooping cough. More often however the problemswhich come to us require: the
expression of some degree of critical judgment, as to the relative value of this
or that procedure and its relative importance in the general public health
field. i is inevitable that any group or committee in a comparative study of
city health work, must set up in their own minds, if not on paper, certain
standards of service and standards of values as bateeua different classes of
service. The advantegs of committing these impressions to paper is that they
may be reviewed, criticised and improved by the many who may be interested in
the subject.

Such standards of health practice, immature and eeutediee thoug n they may be,
not only constitute a natural evolution of comparative studies, but they become
almost a matter of necessity in the development of a helpful field service by
this Committee. The field representatives of this Committee, in conference with
city health officers, in advising city health officers with reference to such
important matters as their budgets, personnel allotment, program and reasonable
objectives with reference to the more important problems acs in city
health work, must give either their individual judgment on these important
matters or must express a group judgment which is in reality noth ing more nor
less than a standard. It is a standard however which is binding on no one but
the committee itself and binding on the committee only until it is modified in
the light of future experience,

It is from this point of view that your committee presented in Bulletin 136
a tentative plan for An Ideal Health Department for a City of 100,000 Papaiattets
and it is tu — point of view that it hopes during the coming year on the

basis of the material collected by the United States Public Health Service, and

 
we Fue

by the American Ciild Health Assoc ia tion, to prepare special monographic studies
of what Soeus at the moment to be the best current practice in various special
lines of administrative health work.
Above all, your Committee, in its contact with the health officers who

have called upon it for service, has been impressed by the need for a concise
and clear form of evaluation for the activities of a municipal health department
as awmle. In our report of a year ago we suggested that it might be helpful
to award medals to certain cities of outstanding merit in community health
service as evidenced by their showing on a searing plan to be devised by
Dr. Rank ins This plan of awards was criticized in the subsequent discussion
at the Boston meeting and after obtaining by letter as asinies of the health
officers of the 83 large cities the proposal was definitely abandoned, The
preparation of an appraisal form to be used, not for publication or for the
comparative grading of cities, but for the use of the health officers and of
our field agents in their service to the health officers has so far as we
are aware met with universal approval.

| The aim in this appraisal form was to provide in the first place for an
evaluation of the relative importance of various lines of public health
activity and in the second place for an estimate of the results attained along
each line of activity as measured by the service actually rendered. The
: Committee began the formulation of such an appraisal form in April, 1923
when it requested Dr. Charles V. Chapin, one of its members, to evopare for it
a draft of a schedule which could pe used for this purpose. Dr. Chapin complied
: with this request and, in the fall of 1923, the Field Director of the
Committee, Dr. Rankin, after making certain minor alterations in the tentative
foc that had been prepared, brought the statement vefordine Committee for its
senidien., The Field Director; taking the Committee's revised statement into the
field, where he had opportunity to confer with a number of individual health

officers in regard to it, received from themmny helpful criticisms and

 
— Gme

suggestions, some of which were adopted tentatively for still further
revisionss

In his field conferences, the Field Director of the Committee had the
opportunity of oeveubites the subject of standards iu eue eel health depart
ment practice to two separate representative groups of city health officials.
One was a group of health officials of New England cities with which contact
was made through their attendance upon the New England ipalth Institute which
met in Boston early in May of this year. A second group contact was made
possible through the ee of the State Health Commissioner of Ohio were,
on account of a considerable number of large cities closely related
ae it was sonvonpent. at the time and place of the meeting of the |
Ohio State Wedical Society in Cleveland the latter part of May, to discuss 3
with a group of Ohio city health officers the question of the appraisal of city
healthwork. <A third group contact was effected through the interest of
Dre S. J. Crumbine, Director of Public Health Relations of the American Child
Health Association who interested the State Commissioner of Health of Michigan
and, tirough Dr. Olin's cooperation, was able to present the matter to a
con twelve city health officers in that State. With all three groups

a temporary organization was effected for the purpose of considering standards

and, if possible, revising the tentative appraisal form of the Committee to

meet their own group judgment and needs.

At this juncture, tae Committee, in its initial efforts looking toward
a statement of standards for city health department practices, found a most
helpful ally in the American Child Health Association. That Association,
in travelling the same road over which the Committee had previously passed,

came, through the comparative studies of the health work in the eighty-six

cities which it had surveyed and in the planning of its subsequent field

service with these cities, to the same necessity encountered by our Committee,

that of crystallizing its impressions of practices and values into a definite

 
re

schedules of values and attainment. aries two separate statements of standards,
those of our Committee and those of the American Child Health Association, had
thus been independently formulated, it was realized by the representatives
of both organizations that the two statements should if pocecis be reconciled
and consolidated. in conference between representatives of the two organ-
izations, which lasted well over a week, tne two tentative forms of appraisal
for city health department practice were reduced to one. Subsequently
representatives of goyotnl of the other large voluntary organizations, such
68 the National Tuberculosis Association, the American Social Hygiene Association
and the National Organization of Public Health Nursing, were conferred with
and their criticisms and su est tame incorporated, so that the statement came
to be, at least for the time, an expression of the group rudenent of representatives |
of four of the large national voluntary health organizations, as well as of the
representatives of the American Public Health Association.

It was clear to us all, however, that even this widely based group judgment
as to appraisal standards for values and attainments in city health work would
be of Little service unless it incorporated the practical viewpoint and experience
of a larger group of city health officers than were directly represented on your
committee, As a result of this conviction, a committee of three members from
each of the groups of city health officers that had been formed, one in New
Bngland, onein Ohio and one in Michigan, were called in to review the tentative
statement of standards of values end attainments which had been prepared and
were paced to criticise it and amend it in such a way as to make it conform to
their composite judgment and to meet their practical needs. An agreeme nit was
reached between the repranentatives of the voluntary organizations present
that in this conference with the nine city health officers representing the
three temporary organizations of a total of thirty-six city health officers,
the voting, the settlement of all differences at judemont, should rest entirely

with the city health officers. The conference with the representatives from

 
a Om

the three groups of city health officers continued for four days, August i8th,
19th, 20th and 21st, and passed upon both the principles and the minutest
details that had entered into the development of the tentative standards. A
number of changes were made and out of the conference came the only expression
that we have of vrofessional group judgment as to what should constitute standards
of service and relative values in municipal health work. It was understood on
the adjournment of the conferences of city health officers that the representatives
would present the statement to their respective groups with a request that
these thirty-six health ertueers accept it as it is until next August; that they
apply it to an appraisal of the work of their own departments; that, after full
epaescereises and trial, they name their representative to meet with represen
Lotives from the other groups, now temporarily organized, and with those of several
other groups that will be organized for revising the statement next yeare

The general lines along which the appraisal form is being developed are
indicated in an address delivered by Dr. Rankin, Field Director of the Committee,
in an address delivered before Conference of State and Provincial Health
Authorities and printed in the American Journal of Public Health for October.
Copies of the appraisal schedules in its present form can be obtained by any
member of the American Public Health Association on application to the New
York office. It involves, as tr, Rankin points oat in the address in question,
an evaluation of each stangn “ivlavity of municipal health departments upon a
basis of so many points on a total of 1000, with additional credits for special
acitivities, such as malaria and plague control, industrial and mental hygiene
not now universally undertaken by city health departments; while under each
activity the value to be set down is dependent upon service actually rendered

as determined by specific quantitative standardse

 
= Que
It would be fruitless to debate sue details of this appraisal form upon
the floor of this meeting; but your committee urgently invites individual
criticisms and suggestions in regard to it. The clearest light on its merits
and demerits will come from its application by health officers to their owm
organizations. The group of health officers from Ohie, Massacmsetts, and

Michigan now studying the schedule in this way is no close corporation. We

urge all of those here present who are servingas city health officers to take

part in the work, and to indicate their willingness to try out the schedule
and attend next year's conference for its revision. We desire to broaden the
basis of group judgment behind this appraisal form until it represents the

direct experience and the considered judgment of the entire membership of the

Health Administration Section.

We are convinced that an scoraieni form arrived at by the procedure here
outlined will prove of very real value to the individual health officer in
enabling him +0 develop a balanced departmental program becad upon the
bedrock principle of relative values and safeguarded against the undue
influence of this or that special group eoteed to some particular interest;
to check up on the performance of his own bureaus and thus maintain is-depertment
at the highest point of efficiency; to defend himself when unjustly attacked
by showing that his department meets the objective standards of nic of opetcunl
colleagues; to secure funds for expansion by indicating where his organization
falls short of that generally accepted as ideal; and to secure the cooperation
of local voluntary health organization along the most effective lines.

Presentation of Studies and Standards to Halth ‘A
Officers or Field Service | S

The first phase in the work of this Committee was necessarily the collection

of information in regard to city health department practices, the second phase the

organization of group judgment for evaluating the information obtained, and

 
- 10

the third phase, which has now been approached and already begun, is that of
field service, that is making the results of its studied directly applicable
to city health work, During the first three years of the Committee's work»
he weliect ic of information, naturally dominated the picture; during the last
year the organization of group judgment in form of tentative standards was the
outstanding feature and, following this, the development of a practical, helpful
field service will take the ascendancy se |

Even during the past year, howevér, the Field Director of the Committee |
vic ibed and conferred with the city health officials and others in nineteen
cities, spending an average of shres days in cach city; vy invitation ne
conferred with the health officers of two states with reference to their state
problems and on one occasion was called to advise a group of interested citizens
and physicians with = to the development of a county health department};
he eadeeased nine national and state organizations of health officers in regard
to the sina and work of the Committee, spoke to nine local medical eScisties
in regard to che relation of the medical profession and the public in health work,
andalso addressed ten luncheon clubs on the subject of public health, a total
of twenty=five addresses

Your —— has felt that the continuance and extension of its field ser
vice was of primary and tastano importance and therefore set itself very
early in the present year to seek for the financial support necessary to carry
out this plan. Since 1920 the funds at our disposal have been entirely
contributed by the generosity of the Metropolitan Lite Insurance Company.
We felt it manifestly unfair to approach this company for further aid unless it
could be shown that the tasks we had undertaken were of sufficient importance
to appeal to other friends of the cause of public health, We are happy to.
report that the interest of the Milbank Memorial Fund has been enlisted in
this activity of the Amorkaau Public Health Association and with its support

secured we again approached the Metropolitan Life Insurance Company which

 
=] Le
fas eatend <6 appropriate 910,000 for our work during the year 1925, a similar
sum being contributed — the Milbank Funds

With this financial support it will be possible during the coming year
not only to retain the services of Dr. Renkin as Field Director but to provide
him with competent assistance sufficient to enlarge materially the scope and
volume of his work, Furthermore the service which can be rendered to members
of the American Public Health Association along this line will be further
extended by an agreement which hes been reached with certain of the great
sectional voluntary health agencies represented in the National Health Council
under which field representatives of these obenaatioe Wiki be available as
consultants i so phases of health eduinistepil such as tuberculosis
or child hygiene or public health nursing for those health officers who may
desire their aid,- in exchange for similar services rendered by Dr. Renkin
and his staff to the organizations in question,

Your committee believes that the posgibilities of this field service under
such direction as that of Dr. Rankin are almost unlimited. The extent +0 which
it develops will depend on the extent to which the individual members of this
section call upon it in a futuree Your Sxcities is reasonably confident
thet if your demands exceed the capacity of the staff available more baste eas
be found for expansion when they are needed, If you desire to ‘chow wheat other
health officers are doing and how that knowledge can be applied to your local
conditions Cell upon Drs Rankine If you want the effective support of professional
opinion in securing support for needed local developments call upon Dr. Rankin.
this committee is your ponmit ses directly responsible to this association of
efefosaicucl workerc. The members of the Field Staff sre your employees
organized for your pereee The upbuilding of the public health service of
this country along the lines of sound and. enlightened progress is primarily

the problem of the professional public health workers themselves, It is a

 
legitimate source of pride and setisfaction that the lead in the solution of this
problem has been undertaken by the body to which it logically belongs - the

w

American Public Health Association.