Fifth Report of the Committee on Municipal Health Department Practice. i

The objectives and policies of the pastes on Municipal Health ppetinent
Practice have been sufficiently cuhlined in the four previous veneers which |
have been made to the American Public Health Association.~ It need only be
repeated here that its ideal is to realize the primary aim of the Association
as a whole, "the preparation, study, standardization and presentation of
scientific public health procedures, by the eckisstion of information in re-
gard to current administrative health practice, the analysis of the material
obtained to derive standards of organization and achievement and the transla-

tion of these standards into terms of concrete achievement through an informa-

tion bureau and field service placed at the disposition of all members of the |
Association,"

During the past year the Committee, at its own request, was reorganized
and enlarged so as to make it more fully representative of the practising
health officers of the country. As at present constituted it includes six
city health officers, two state health officers, one representative of the
‘United States Public Health Service, three professors of health administration
and three representatives of voluntary health agencies. Hight states, in is
dition to the District of Columbia and the Dominion of Canada, are represented
in its membership. : i

The funds for the support of the work of the Committee during the first
four years of its existence were generously contributed by the Metropolitan

Life Insurance Company. During 1925 the cost has been borne equally by the

i. Presented at the Fifty-fourth annual meeting, 5t. Louis, Mo., before the
General Session, October 21, 1925,

&. American Journal of Public Health, 1922, 12, 7, 138; 1924, 14, 184;
1925, iD, <2,

 
OT

Milbank Fund and the Metropolitan Life Insurance Company. Both these organi-
zations have consented to contime their aid to the Committee during the
coming year; but it is felt by all concerned that the work of the © mittee
is in essence a primary, and indeed a fundamental, activity of the /iserican
Public Health Association itself and that the Association should next year
begin to take a substantial share in its support,- with a view to assuming,
as soon as possible thereafter, complete financial responsibility for what
is logically a bureau of its administrative office.

Surveys of Health Practice.

Three general surveys of municipal health practice in the United States
have now been conducted; the first in 1921 (covering 83 cities of over 100,000

population) by the Committee itself with the cooperation of the United States
3 : oe
Public Health Service and other agencies;’ the second in 1924 (of 100 cities

of 70,000 population and over) by the United States Public Health Service;

and the third, also in 1924 (of 86 cities between 40,000 and 70,000 population)

by the American Child Health Association. The United States Public Health

Service has asked the Committee on Municipal Health Department Practice to

take charge of the analysis for publication of the data collected in its 1924
survey; a the full report based on this study will appear during the coming
winter.* The report. of the A.C.H.A, on the smaller cities has just been is-
—s The Committee does not plan in the immediate future to undertake on

its ow initiative any further comprehensive and detailed surveys of munici-

pal health practice in the cities of the country as a whole. It believes

that this type of service, whose value has now been completely demonstrated,

can most logically be carried on by the office of Administrative Health Prac~

tice, created in 1923, in the United States Public Health Service. :

3. Published as Bulletin 136, U.S.P.H.5., 1923.

4. Several chapters of this report are already in print; see American Journal
of Public Health.

 
aS

The Committee will, of course, feel free to conduct surveys of indi-
vidual cities when called upon to do so; and for this purpose the Committee
is preparing a revised survey schedule suitable for such studies,

The Committee feels that by the use of the Appraisal Form for City
Health Work (to be diseased in a succeeding paragraph) it should be possible
to secure from the city health officers themselves annual reports of the more
Significant phases of health department achievnsst. which could be analyzed
and published promptly so as to furnish year by year a timely picture of cur-

rent progress,

The Committee has peceived urgent requests to undertake a comprehensive
preliminary study of county health service like that which it initiated for
city health departments in 1921. If the Association desires us to undertake
this task, and if Surgeon-General Cuming's approval and cooperation can be
secured, we shall be glad to do so, If, however, this enlargement in the
scope of our labors is authorized, the name of the Committee should be
changed a eatnsitne Eapetjoe of tg tnartons Public Health
Association; Without the qualifying word "Municipal",

A second problem in the field of health practice which has been brought
forcibly to our attention is the nsed for the most convenient and exa.t
records and in their dealings with the public. At the request of the secre-
tary of the Association a special eukeoomrbttes on Health Department Forms,
including several co-opted members not members of the general committee,

has been created to deal with this subject and much valuable material in
the files of the Association office has been placed at the disposal of

this sub-committee,

ge ay
oe

Standardization of Health Practice.

The major work of the Committee during the past year has been devoted to
the perfecting of the Aepenneai Form for City Health Work, whose history was
discussed at some length in our report a year ago.

The aim that me have had oe has been to devise a brief Appraisal
Form which would sicid a reasonably accurate picture of the health services
actually performed in a city as evidenced by certain typical sample activi-
ties, It was to be based not on money expended or personnel employed, which
indicate resources rather than performance. Nor was it to be saece om mor-
tality rates, which are affected by so many racial and industrial factors
as to make comparisons between various cities so frequently misleading. It

Was our idea rather to measure the immediate results attained,- such as
statistics properly obtained and analyzed, vaccinations performed, infants
in attendance at instructive clinics, physical defects of school children
discovered and corrected, tuberculosis cases hospitalized, laboratory tests
performed; with the confidence that such immediate results would inevitably
lead on to the ultimate end of all public health work,- the conservation of
human life and efficiency.

The preparation of such an Appraisal Form involves, first of all, the
selection of such typical activities in the various fields of Gosdie <oue
vice as are susceptible of definite and quantitative measurement; secondly,
the establishment of standard values for a maximum score, based on the ac-
tual performance of those cities which have attained outstanding results
in the various fields in question; and, thirdly, the weighting of the
various rated activities so as to give a reasonably clear picture of a bal-
anced health program.

As stated in our report of a year ago, "We are convinced that an Ap-
praisal Form, if it can be arrived at by the procedure here outlined,

would prove of real value to the individual health officer in helping him
, to develop a baianced departmental program based upon relative values; to
check up on the performance of his own bureaus and thus maintain the depart-
ment at the highest point of efficiency; to defend himself when wnjustly at-
tacked, by showing that his department is organized in accord with the views
of his professional colleagues; to secure funds for expansion by indicating
where his organization falls short of that generally accepted as ideul; and
to secure the cooperation of local voluntary health organizations along the
most effective lines. "'

The task of preparing an Appraisal Form is, however, one of the great-
est difficulty and delicacy and we have felt it necessary to proceed with
the highest degree of caution in our — As pointed out in our last re-
port the Committee began its consideration of the Appraisal Form problem
in the spring of 1923 when Dr. C, V. Chapin prepared the first draft of such
a form for its consideration. In the fall and winter of 1923-24 Dr, W, 5.
Rankin, then Field Director of the Committee, devoted himself with the
greatest energy and enthusiasm to the development of the appraisal plan
and brought into consultation in regard to it a large mumber of health offi-
cers and representatives of voluntary agencies. In particular, the American
Child Health Association, in connection with its comparative studies of
health work in eighty-six cities (referred to above) and in the planving of
its subsequent field service with these cities, came to the same viewooint
held by our iendt tos: that it would be desirable to express its finding
in the form of a definite schedule of performance and values. After two
separate Appraisal Forms, those of our Field Director 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
forms should, if possible, be reconciled and consolidated. In conference
between representatives of the two organizations, which lasted well over a

week, the two tentative forms of appraisal were reduced to one. Subsequently,

 

 
« G «=

representatives of several of the other large voluntary organizations, such
as the National Tuberculosis Association, the American Social Hygiene Asso-
aiation and the National Organization for Public Health Nursing and other
members of the National Health Council were invited to submit criticisms
and suggestions.

Finally, in August 1924 a committee of nine ay health officers,
representing groups of city health ict who had been enlisted in the
ee study of the Sceaiaedl Fort in Ohio, and Michigan, and in New England,
were called together in New York for a four-day conference, at which the
Appraisal Form was again revised in a form later printed and issued: by. the
American Public Health Association for experimental use for one year.

After these lengthy preliminary sonterengia, after one full year of
trial use by a group of nearly fifty cooperating city health offiners and
after the sstd cation of the Appraisal Form to the study of the data for
186 cities collected by the U.S.P.B.5, and A.C, HA. surveys, a second gen-
eral conference was held in New York last month in which the Committee on

‘Municipal Health Department Practice, the group of nine health officeu.j,s
representing cooperating officials in New England, Ohio, and Michigan and
the American Child Health Assosterion and other national voluntary health
agencies all took part. On the basis of recommendations made by this con-
ference your Committee has once more revised the ieprasaal Form and believes
that it is now in sufficiently satisfactory shape to be issued with the ap-
proval of the Committee as a basis for the appraisal of city health work.

This revised Acpoasaal Form is therefore wanenied as an appendix to
our report. It will naturally require further oe in the future as
knowledge advances and practices progress; but we delieve that in its
present form it should be given trial for a period of at least three years.
in order to secure data which shail have comparative value. We purpose to

make a continuing study of the Appraisal Form by careful analysis of the

 
scores actually obtained by the cities of the United States during the next
year, by activities and items and in relation to budgets, personael and
disease rates, in order to be in position, with the aid of sther eae
interested, %~O recommend whatever changes may be necessary in the form in
1928,

We celieve that the general ability of the Appraisal Form idea has been
abundantly demonstrated by its first year of trial use. In a publication
issued by the American Child Health Association there were reported the fol-
lowing specific uses, as demonstrated by its experience with the cities of
40,000-70,000 population; and our own field agents report exactly simi iar
reactions among the larger cities. The term "rating schedule" as used in
‘the following quotation refers to the tentative Appraisal Form described above, -

"As a brief Sor carat appropriations of the Department of Health.

- Ts several cities the ratine schedule has been used to show in a comparative
objective manner certain deficiencies in the department of health, and the
expenditures which would be required bo secure a full credit in place of
these deficiencies. When peanented in this manner to the appropriating body
of the city, as a vart of the health officer's budgetary request, the health
department Was, in one instance, the only department of the city goverment
to receive an increase (amounting to 14%) for the coming year. Jn another
instance in the face of a strong movement for retrenchment throughout the

_ eidy goverment, ihe health budget, presented in the light of the rating
schedule, was the only departmental budget to remain uncut.

"As a basis for a health program. The value of the aiteae sche iuie -
as an outline of a well-balanced health program has ennenked to several health
officers to such an extent that their future programs are definitely based up-
‘on achieving the standards set in the schedule. * * * * oe te eee eS
NAs a iets for an Anal Report. It has occurred to one health officer

to incorporate in the annual report of his health department the detailed

2 gee ae oa rn fer Re ET
—

rating of his city, for the 83 items included in the schedule, and to publish
the score attained, with full discussion of many of the items, Another health
officer has largely improved the character of his annual report in the light
of the Appraisal Form,

"As_a means of interesting a Mayor or Chamber of Commerce, In a city
which had recently scored itself the health officer was studying the ating
when the mayor of the city happened to enter the office of the health depart-
ment. Upon being shown the low rating of the city in eoputherss prevention
the mayor inquired what could be done to improve the situation. When the
health officer explained that he could secure a full score (30 points) if he
had $175 with which to buy toxin-antitoxin, the mayor promised to make the
sum available from special funds. Other health officers have taken the rating
of their city to the mayor or the chamber of commerce and by comparing the lo-
cal rating with other cities have awakened a new interest in the city's health
record.

"As_a means of arousing and cementing the interests of the Departments
of Health and Fducation and of the private agencies in each other, A striking
outgrowth of the use of the rating schedule in one city where the findings
were reported in a special meeting, was the development of a new sense of the

interdependence of all health agencies on each other and the formation of a

joint health committee on which all agencies were represented under the leader-

ship of the health officer. In another instance the rating schedule brought
to the heaith officer for the first time the realization that he shou.d co-
operate with the department of education in its health work if his city was

to secure the fullest return from its health activities. school medical

inspection was promptly started."

Such evidence as this has materially strengthened our conviction that
the A, praisal Form is likely to fill a large and important place in the
history of public health development. Cn the other hand we realize very

fully the hazards involved in any such plan. In a problem so complex and

 
= |
so diversified as public health administration, so materially affected by
climatic and social factors, and in which the relationships between public
and private agencies are so vattous: no mumerical appraisal plan can fail
at times to yield an unscientific and inaccurate picture. If the Appraisal
Form were to be used by outside lay agencies for the arbitrary comparative
rating of cities, gross injustice might result. The primary safeguard of the
scheme must lie, however, in its application: It has oe prepared and
issued by a comnittee representing the professioral health workers of the
ee for the use of the minicipal health officer in he self ooprasadt

of his work. We believe that there should be no appraisal of the health

-

work of a city on this plan anoepe 5ate the approval of the health eificers
concerned; and that in no event should there ty any publication of the
appraisement of the ann ieee of a city except with the consent of the
health officer. |

The Committee has approved the official publication of an. Appraisal
Form only after long consideration and much discussion. Certain nembers of
the Caranetas seriously doubt the advisability at this time of setting up
any formal standard eee health service. Certain others have
felt that there is at present no adequate scientific basis for an attempt
to formulate ay numerical expression of the relative value of various
health activities. A majority of the Committee, however, have felt that
ic SeGeeE utility of the method more than outweighs its inherent inaccur-
acies and disadvantages, and have approved the schedule with the hope that
in tis next. three years experience and study will permit the further p< cfec-
tion of the schedule and the establishment of methods of evaluation which
will obviate the objections which have been offered he the present plan.

In the field of stagierdatéen, as distinct from fact finding, the
ee represents in a sense a primary step. It indicates a general

i
~ 10.
balance of activities and it measures actual service as indicated by typical
items, susceptible of quantitative statement. Ultimately, however, we fe6l
that the work of our Committee mist logically and necessarily lead to the
preparation of more detailed standards for appropriations, personnel, |

ea SS elie
equipment, policies and SEPERRUEES for each major division of the benkee

spss

ers

 

Se nomic: a none oreenen

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department, - in fact a picture of a model and well-balanced om depart

 

 

 

ment such a5 Wa" attempted in our 1923 report, but on @ much more extended scale.
The three surveys now seine should make it possible to approach this task
with greater success than has been possible before. With the aid of men-
bers co-opted on the sections representing the special fields concerned
we plan to procaed as rapidly as possible with this important task.

Field Service of the Committee. |

Finally, there remains for consideration what is perhaps the most
important of all the functions of the Committee, the bringing to the
individual health officer of such direct aid in the conduct of his daily
‘work as may be furnished by a properly organized field service. Our plan
-for this service received a heavy blow when early in 1925 Dr. W. S. Rankin,

our Field Director, resigned to undertake the direction of the medical work

of the newly organized Duke Foundation. On the first of May, however, we
were fortunate in securing the services as Acting Field Director of Dr.
C.st Clair Drake, whose past administrative experience as Director of the
Illinois State Health Department weil fitted hin for this task.

The outstanding items of the summer's work are as follows:

Twenty-seven cities were appraised on he basis of inf ormration
gathered through personal visits.

Thirty-two cities were appraised from inforration secured from
the survey, supplemented by information furnished by the
local health officer.

One hundred survey schedules were prepared in duplicate.
One copy was sent to the local health officer with the request for

 
i

insertion of supplementary data. One was retained as
permanent office record.

The health officers of practically all the larger cities have
deen addressed twice by letter for the purpose of

a. Advising them of the aims, purpose and policies of the
Committee.

b. Securing supplementary information for the appraisal.

Permission was received from 21 cities to use their local city

graph on the cover design of a special city health number of
the Survey Graphic.

Copies of the tentative appraisals of 37 cities have been made,
preparatory to sending to the local health officer for correc-
tion and the supply of supplementary information.

Although the summer has been largely given over to the appli-
cation of the appraisal form to specific cities, a service
call was made to Manchester, New Hampshire, and invitations
are at hand to visit:

Knoxvilie, Tenn.
Toledo, Ohio
Portland, Oregon

Trenton, Nd.

Waco, Texas
Houston, Texas

San Antonio, Texas
Dallas, Texas
Forth Worth, Texas.

On September 8th, Dr. W, F. Walker, who had long experience in health ad-
ministrative methods as a member of the city health department of Detroit and
who had in addition unusual experience in the survey and appraisal of cities
as Research Associate of the Arerican Child Health Association was appointed

ield Director and will give his special attention to the cities of the east-
erm and central states. Or. Drake, as Associate Director, will for the present
work in the southern states and provision will be made as soon as resources per-

mit for special service to the West coast. Its field officers will be prepared

to offer detailed information as to this or that administrative practice,
such as the length of time to isolate a particular disease, the simplest of-

fice practice in filing reports of nuisance inspections, the exact status

 
= if =

of the serum treatment of scarlet fever, the accepted ratio of staff numses
to surervisors; general counsel as to the development of a rounded and con~
plete health progran for their communities, counsel based on a knowledge of
what is being done by other health officers throughout the country; or the
effective support of an organized nation-wide professional opinion in se-
curing needed appropriations or facilities fron city authorities or in
mobilizing public support for their policies. As pointed cut last year,
"This Committee is your Committee, directly responsible to this Association
of professional health workers. The upbuilding of the public health service
of this country along the lines of sound and enlightened progress is pri-
marily the probleu of the professional public health workers themsel: 2s."
It is to aid in the realization of such an ideal that the Committee on
Health Department Practice stands ready to be of aid.

In view of the enlarged staff and facilities of the Committee it will
be possible during the coming year te offer te the health officers of the
country a larger measure of consultative and advisory service than has

heretofore been vossible.