RA 
 
 UC-NRLF 
 
 B 3 bS3 7bfl 
 
 September, 1916 
 
 RELATIVE VALUES IN PUBLIC 
 HEALTH WORK 
 
 BY 
 
 FRANZ SCHNEIDER. JR. 
 
 SANITARIAN 
 
 DEPARTMENT OF SURVEYS AND EXHIBITS 
 RUSSELL SAGE FOUNDATION 
 
 READ BEl ^RE THE MASSACHUSETTS ASSOCIATION OF BOARDS OF HEALTH. 
 
 PROVlOtNCE. R. I.. JULY 27. 1916. REPRINTED FROM AMERICAN JOURNAL 
 
 OF PUBUC HEALTH. VOL. VI, NO. 9. SEPTEMBER, 1916 
 
 Department of Surveys an'd Exhibits 
 
 Russell Sage Foundation 
 130 East Twentv'-second Street, New York City 
 
 Price 10 C. t» 
 
XS^i^ 
 
3^ 
 
 RELATIVE VALUES IN PUBLIC HEALTH WORK. 
 
 Franz Schneider, Jr., 
 Department of Surveys and Exhibits, Russell Sage Foundation, New York City. 
 
 ABOUT 1,400,000 persons die in 
 continental United States each 
 year. Probably a fourth or 
 a third of these die from preventable 
 causes. In addition, it is asserted, 
 and recent sickness surveys seem to 
 support the claim, that two or three 
 per cent. 6i our population are, at any 
 one time, disabled through sickness. 
 Then there is the larger number of 
 persons afflicted with illnesses not 
 serious enough to disable but which 
 cause loss of comfort and efficiency. 
 
 The task of preventing these vast 
 amounts of sickness and death, so far 
 as is possible, is delegated by the public 
 to its health authorities. The latter 
 nuist decide what parts of the losses 
 are preventable, and must determine 
 how the greatest return in prevention 
 can Ik? obtained with the money avail- 
 able. This is the problem of relative 
 values in j)ublic health work. 
 
 If unlimited funds were at the dis- 
 posal of health depa. ments the prob- 
 lem of relative values would be one of 
 merely theoretical interest. The ad- 
 ministrator would need only to insti- 
 tute all the activities that seemed 
 likely to e.xert a beneficial effect, and 
 at the close of the year prepare a table 
 of expenditures with regard to the 
 several activities. This list would 
 indicate the relative value attached to 
 different activities when no stone is 
 
 left unturned, but would be a tabula- 
 tion of purely academic interest. 
 
 Quite different is the situation actu- 
 ally confronting health officials. With 
 the scanty funds now at their disposal, 
 and the great variation in effectiveness 
 of different activities, the most careful 
 discrimination must be exercised in 
 making up the department's program. 
 A bad distribution of funds means 
 lives lost, and the responsibility, a 
 heavy one, falls on the administrative 
 official. The problem is rendered the 
 more difficult by the lack of accurate 
 data as to costs and results. The 
 practical importance of an accurate 
 appreciation of relative values can 
 hardly be overemphasized. Professor 
 Whipple, in discussing the subject 
 says, "This is one of the greatest ques- 
 tions that a sanitarian can consider. 
 It is today the most important of all 
 hygienic problems because it compre- 
 hends all others."* 
 
 The Field of Prevention. 
 
 In attempting to determine values 
 it seems reasonable to take vital statis- 
 tics as the point of departure. Our 
 death and sickness records suggest the 
 opportunities that lie before us, and it 
 is by these figures that we must judge 
 the efficacy of our endeavors. Our 
 
 ♦Whipple, G. C: "How to Determine Relative 
 Values in Sanitation"; American City, X, 5, p. 427. 
 
.•Uel4iiv.e.t^a1iio.s in rul)lic Health Work 
 
 TABLE 1. 
 PREVENTABLE DEATHS IN ALL REGLSTRATION CITIES, 1913. 
 
 Cause of death. 
 
 Number of deaths. 
 
 Per cent, of pre- 
 ventable <leaths. 
 
 Infectious Di.seases 
 
 Tuberculosis — all forms: 
 
 Lmigs 
 
 Meiiiniiptis 
 
 Other forms 
 
 Diarrhea and enteritis (under i) 
 
 Bronchopneumonia 
 
 Common contagious diseases 
 
 Measles 
 
 Scarlet fever 
 
 Whoopinp-cough 
 
 Diphtheria and croup 
 
 Typhoid fever 
 
 SjTJhilis — total 
 
 Syphilis 
 
 Locomotor ataxia 
 
 Softening of the brain 
 
 Influenza 
 
 Puerperal fever 
 
 Gonococcus infection 
 
 Other infectious diseases 
 
 Erysipelas 
 
 Dysentery 
 
 Tetanus 
 
 Cereljrospinal fever 
 
 Malaria 
 
 Infantile paralysis 
 
 ( Iiolera nostras 
 
 "Otlier epidemic diseases" 
 
 Rabies. . ." 
 
 Smallpox 
 
 Intestinal parasites 
 
 Mycoces 
 
 Hyatid tumor of liver 
 
 Anthrax 
 
 Ankylostomiasis 
 
 (ilanders ... 
 
 Ix"i)rosy 
 
 Typhus fever 
 
 Relapsing fever 
 
 Plague 
 
 Nutritional Diseases 
 
 Pellagra 
 
 Rickets 
 
 Scurvy 
 
 Beriberi 
 
 Poisoning by Food 
 
 Industrial Poisonings 
 
 Lead poisoning 
 
 Other chronic occupational poisonings. 
 
 Total — preventable deaths 
 
 48,733 
 3,8G1 
 4,030 
 
 1,599 
 
 1,4H 
 
 876 
 
 834 
 
 644 
 
 39:2 
 
 140 
 
 124 
 
 67 
 
 44 
 
 30 
 
 24 
 
 13 
 
 12 
 
 10 
 
 7 
 
 4 
 
 3 
 
 2 
 
 1 
 
 702 
 
 335 
 
 53 
 
 7 
 
 120 
 4 
 
 149,600 
 56,624 
 
 30,244 
 21,091 
 19,058 
 
 5,627 
 4,902 
 
 3,000 
 
 2,825 
 
 191 
 
 6,038 
 
 1,097 
 
 329 
 124 
 
 151,150 
 
 99 
 37 5 
 
 20.0 
 14.0 
 12.6 
 
 3.2 
 
 2.0 
 1.9 
 0.1 
 4.0 
 
 0.7 
 
 0.2 
 0.1 
 
 100.00 
 
Relative Values in Public Health Work 
 
 sickness records are, unfortunately, 
 so fragmentary as to be of little prac- 
 tical value, while our death records 
 are reliable for only two thirds of the 
 country. Let us turn, however, to 
 the mortality statistics for 1913, and 
 seek to discover the opportunities for 
 prevention. 
 
 The registration cities of the country 
 represented in 1913 a population of 
 34,230,583, or 35 per cent, of the total. 
 In Table 1 an attempt is made to show 
 the preventable deaths occurring in 
 these cities. This table is intended 
 to include all infectious diseases; cer- 
 tain nutritional diseases, such as beri- 
 beri and pellagra; industrial poisonings; 
 and food poisonings. Certain of the 
 infectious diseases included, such as 
 puerperal fever, will seem novel in 
 connection with, health department 
 activities. They are included on the 
 theory that being infectious, they are 
 preventable; that ultimately we may 
 come to prevent them; and that the 
 health department is the only govern- 
 mental agency whose business it is to 
 prevent them. The numbers of deaths 
 from these diseases are, furthermore, 
 relatively small. 
 
 There are conspicuous omissions 
 from the list. Cancer is a striking 
 example. No one doubts that many 
 deaths from cancer may be avoided 
 through early operation, and allowance 
 must be made for this disease in making 
 up relative values; however, it has 
 seemed better to omit cancer from this 
 list, and to lump it in with the degener- 
 ative diseases of middle age. Allow- 
 ance will be made for this group of 
 diseases under the heading of health 
 education. Again, the list disregards 
 
 the great group, Diseases of Early 
 Infancy, from which something cer- 
 tainly can be saved. In addition, 
 bronchopneumonia is included entire 
 and placed in the infant group, while 
 all other forms of pneumonia are 
 omitted. Finally, the list seriously 
 understates the losses caused by the 
 venereal diseases, making no effort 
 to include the deaths that may be due 
 to syphilis but that are registered 
 under diseases of the arteries and other 
 organs, although it does include deaths 
 from locomotor ataxia and softening 
 of the brain. The list also disregards 
 deaths from such causes as salpingitis — 
 deaths in which gonorrhea may play 
 a part. An attempt to make due 
 allowance for these inclusions and 
 omissions will be made later in the 
 paper. 
 
 It is worthy of note that this list 
 of preventable deaths, although con- 
 servative, totals 151,150, or 29 per 
 cent, of the deaths from all causes. 
 
 Damage Done as a Criterion. 
 
 When we come to compare the 
 different diseases in the list it becomes 
 evident that relative importance can- 
 not be tested adequately by any 
 single criterion, but that several of 
 fairly eciual importance must be con- 
 sidered. One of the most obvious 
 tests is the number of deaths caused 
 by each disease. On this basis tuber- 
 culosis, responsible for 56,624, or 37.5 
 per cent, of the whole preventable list, 
 is the most important. Second in 
 importance comes diarrhea and en- 
 teritis among children under two, 
 resj)onsible for 30,244, or 20.0 per cent. 
 Next comes bronchopneumonia, with 
 
 .S89219 
 
Kehitive Values in Public Health Work 
 
 14.0 per cent.; followed closely by the 
 four common contapous diseases of 
 children— dij)litlieria, scarlet fever, 
 whooi)ing-cou<.'h, and measles, respon- 
 sible as a group for li2.0 j)er cent, of 
 the deaths. 
 
 But the number of deaths is not 
 an adeciuate measure of the damage 
 done. For one thing, it fails to take 
 account of non-fatal illness. Perhaps 
 the extreme example of this failure 
 is gonorrhea. In the table this disease 
 is rejjresented l)y only 191 deaths, 
 about 0.1 of one per cent, of the total; 
 yet we know that gonorrhea is one of 
 the commonest of communicable dis- 
 eases, and that its public health im- 
 portance is far in excess of the figure 
 just given. Other examples of diseases 
 with low fatality rales, and whose 
 importance is inadequately represented 
 by the death test are hookworm and 
 malaria. In measuring the loss due 
 to any preventable disease we must 
 consider not only the number of deaths 
 but the number of cases of non-fatal 
 sickness, the duration of attack, and 
 the seriousness of secondary effects 
 or imj)airments. Unfortunately, our 
 knowledge of these things is imperfect. 
 
 Another factor c-omes into the esti- 
 mate of damage done — the relative 
 value of the lives lost or temporarily 
 disabled. The econolnic value of an 
 infant is of course not as great as that 
 of a wage-earner. On the other hand, 
 we realize that economic value is an 
 unsatisfactory measure of the value 
 of life, and is one the public is inclined 
 not to accept. Afost of us would put 
 the humanitarian side — the anguish 
 caused those near and dear — abo\-e 
 economic value; and on this basis the 
 
 loss of an infant may be as important 
 as that of an older person. The argu- 
 ment that the loss of a wage-earner 
 nuiy have a serious effect on a greater 
 number of persons is one deserving 
 more consideration. 
 
 Preventability as a Criterion. 
 
 Passing from damage done,we come 
 to another criterion of the first im- 
 portance — preventability. Certain of 
 our "preventable" diseases are much 
 more preventable than others. Small- 
 pox is, by vaccination, almost abso- 
 lutely preventable. Typhoid fever is 
 another disease we are prepared to 
 attack with great confidence if the 
 necessary funds and powers are at our 
 disposal. Infantile paralysis, on the 
 other hand, is much more difficult to 
 curb; and measles, with its period of 
 infecti\ity principally before the ap- 
 pearance of symptoms, is largely in- 
 dependent of our efforts. Similarly, 
 we expect quicker and more sharply 
 defined results from infant hygiene 
 work than from that directed against 
 tuberculosis. 
 
 Attention must be given not only 
 to the general preventability of the 
 disease, but to the degree of prevalence. 
 It is generally easier to secure results 
 in a virgin field. After a death-rate 
 has been forced down to a certain 
 level, each new unit of reduction is 
 successivelj' more difficult. This is 
 the problem of residuals, and must be 
 considered with reference to local 
 conditions. 
 
 Cost of Prevention as a Criterion. 
 
 A third major criterion is cost of 
 
 prevention. The great importance of 
 
 this factor is enforced by the meagre- 
 
Relative Values in Public Health Work 
 
 ness of the funds at our disposal. In 
 some respects cost is the most im- 
 portant criterion of all. It can be 
 arjiued that in considering activities 
 we should determine what line of effort 
 will save a unit of life or health for the 
 least money, and then prosecute that 
 activity alone until the law of diminish- 
 ing return brings the activity to a par 
 with its nearest rival. 
 
 Such a one-sided program is of course 
 impracticable. Even if theoreticallj^ 
 desirable, which is questionable, such a 
 course would not be tolerated by public 
 opinion. Great weight must, however, 
 be given to the factor of cost. The 
 figure used should include only that 
 to the health department, and not 
 that to society as a whole. Otherwise 
 we shall become entangled in questions 
 of other standards of value, such as 
 comfort, convenience, and aesthetics; 
 and these seem to be matters to be 
 interpreted by the demographer, and 
 evaluated by the people themselves. 
 
 COMMUNICABILITY AS A CRITERION. 
 
 Another factor that seems to de- 
 serve consideration is the communica- 
 bility or contagiousness of a disease; 
 in other words, its tendency to become 
 epidemic. On account of this prop- 
 erty, certain diseases, such as smallpox, 
 must be suppressed immediately upon 
 appearance, almost without regard to 
 cost and, it may be, quite without re- 
 gard to the amount of damage they 
 may have done in the community 
 during the last year, or the last ten 
 years. Such diseases, if neglected, 
 may quickly cause extremely abnormal 
 damage. Communicability appears 
 
 not to be correlated with the other 
 three factors. Infant mortality, for 
 example, which receives high ratings 
 with regard to damage done, preventa- 
 bility, and cost, receives a relatively 
 low rating for communicability. Ac- 
 cordingly this factor seems to qualify 
 as a separate criterion. 
 
 Solution for Relative Values. 
 
 in general, then, the relative value 
 of a disease, or of an activity to pre- 
 vent a disease or diseases, would seem 
 to depend on four prime factors: first, 
 amount of damage done; second, pre- 
 ventability; third, cost of prevention; 
 fourth, tendency to become epidemic. 
 As a formula this might be expressed: 
 
 Value = Damage X Preventability X 
 Cost X Communicability. 
 
 Certainly these seem to be the main 
 criteria. Perhaps weights should be 
 assigned to the four factors, but thi^ is 
 a refinement one hesitates to attempt. 
 It should be noted that in the for- 
 mula, cost is in the nature of an inverse 
 factor. 
 
 One other point deserves attention. 
 Certain activities are indispensable to 
 a health department. For example, 
 nothing is more important than the 
 registration of vital statistics, yet it 
 is obviously difficult to assign any 
 number of deaths prevented by this 
 work. Similarly it is difficult to 
 measure the results of health educa- 
 tion, although we feel sure it is an 
 important part of the program. Per- 
 haps activities of this kind should be 
 regarded as in the nature of "over- 
 head" charges. At all events, they 
 should be assigned a liberal value. 
 
Relative Values in Public Health Work 
 
 Relatht: Value of Different 
 Causes of Death. 
 
 The task of applying these criteria 
 and of deri\ing a set of values is a 
 difficult one. In ofTcring the following 
 values no claim is made for a high 
 degree of accuracy. It is believed, 
 however, that tlie values derived per- 
 mit a considorahle margin for difference 
 of opinion without altering the gene^^ 
 conclusions which the figures suggest. 
 The method may, moreover, suggest 
 ways in which more accurate values 
 eventually will be derived. The cal- 
 culations involved appear in Tables 2 
 and 3. 
 
 Starting with tlie original hst of 
 preventable deaths (Table 1), an 
 estimate has been made of the damage 
 done by the different causes. This 
 estimate is intended to give due weight 
 to non-fatal illness, and the other 
 
 damage factors already mentioned. 
 The proportions of damage done as- 
 signed to the diseases are, arranged in 
 order of magnitude, as follows: tuber- 
 culosis, 25 per cent.; infants' diseases, 
 25 per cent.; venereal diseases, 20 per 
 cent.; the four common contagious 
 diseases of children, 15 per cent.; 
 typhoid fever, 5 per cent.; other in- 
 fectious diseases, 8 per cent.; nutri- 
 tional diseases, 1 per cent. ; and poison- 
 ing by food, 1 per cent. 
 
 These values have been multiplied 
 by what seem appropriate factors rep- 
 resenting preventability, cost of pre- 
 vention, and tendency to become 
 epidemic, the various steps of the 
 computation appearing in Table 2. 
 The resulting values, which relate to 
 causes of death and not to lines of 
 activity are, when reduced to per cents 
 and arranged in order of magnitude, 
 as follows. 
 
 TABLE 2. 
 
 CALCULATION OF VALUES FOR DIFFERENT CAUSES OF PREVENTABLE DEATH— AND ADJUSTMENT TO 
 INCLUDE VALUES ARBITRARILY ASSIGNED.* 
 
 
 I. 
 
 II. 
 
 III. 
 
 IV. 
 
 V. 
 
 VI. 
 
 VII. 
 
 VIII. 
 
 IX. 
 
 X. 
 
 XI. 
 
 Cause of death. 
 
 Per 
 
 cent. 
 
 of 
 
 deaths. 
 
 Estimate 
 
 of 
 
 damage 
 
 done. 
 
 Factor«> 
 
 for 
 preventa- 
 bility. 
 
 II 
 
 times 
 III. 
 
 Factor 
 
 for 
 cost." 
 
 rv 
 
 times 
 V. 
 
 Per 
 cent. 
 
 Factor 
 
 for 
 
 communi- 
 
 cability. 
 
 VI 
 times 
 VIII. 
 
 Per 
 
 cent. 
 
 X 
 
 times 
 0.73. 
 
 Ttiborculosis 
 
 37.5 
 
 34.0 
 
 (20 0) 
 
 (14.0) 
 
 12.0 
 
 3 3 
 
 3.7 
 
 7 9 
 
 7 
 
 2 
 
 0.1 
 
 25.0 
 25.0 
 
 15 
 20 
 5 
 8.0 
 1.0 
 10 
 
 d 
 
 6 
 8 
 
 6 
 5 
 
 g 
 
 5 
 6 
 
 1 
 d 
 
 150 
 200 
 
 90 
 100 
 45 
 40 
 
 6 
 
 1 
 d 
 
 4 
 10 
 
 6 
 4 
 8 
 5 
 6 
 1 
 
 600 
 2,000 
 
 540 
 400 
 360 
 200 
 30 
 1 
 
 14.5 
 48.4 
 
 13.1 
 9.7 
 8.7 
 4.9 
 0.7 
 0.0 
 
 5 
 3 
 
 10 
 4 
 3 
 3 
 
 3.000 
 6,000 
 
 5,400 
 
 1,600 
 
 1,080 
 
 600 
 
 •30 
 
 •1 
 
 16.9 
 33.9 
 
 30.5 
 9.0 
 6.1 
 3.4 
 0.2 
 0.0 
 
 12.3 
 
 
 24.7 
 
 Dinrrhra and enteritis 
 
 Bronchopneumonia 
 
 
 Conta«ioii!<ilis<>aac8 of children. . 
 
 22.3 
 6.6 
 
 Tv|)hoii| fever 
 
 4.5 
 
 Other infectious diseaaea 
 
 2.5 
 0.1 
 
 
 0.0 
 
 Iniluatrial poisonings 
 
 
 
 
 ToUl 
 
 100 
 
 100 
 
 
 
 4,131 
 
 100.0 
 
 
 17,711 
 
 100.0 
 
 73.0 
 
 
 
 * BasrtI on mortality in all retcistrations cities, 1913. 
 
 *< Fartors on a scale of 10; that number being most favorable rating, one being the 
 least favorable. 
 
 * Cost — to health department. 
 "* Disregarded. 
 
 * Factor for communicability not applied in these cases. 
 
 Values arbitrarily assigned: 
 
 Inspection of school children 7.0 
 
 Education 5.0 
 
 Vital statistics. 5.0 
 
 Dispensar;,' and clinics 5.0 
 
 Laboratory 5.0 
 
 ToUl 100.0 
 
Relative Values in Public Health Work 
 
 First: infants' diseases, 33.9 per 
 cent. The two causes included under 
 this heading, diarrhea and enteritis 
 under two and bronchopneumonia, are 
 responsible for 34 per cent, of the 
 deaths in the preventable list. Bron- 
 chopneumonia, responsible for 14 per 
 cent., includes deaths of other than 
 infants; but the median age of the 
 deceased is 1 .5 years, and 68 per cent, 
 of the deaths occur among children 
 under five. To compensate for the 
 deaths improperly included, there are 
 the deaths of infants from several 
 other causes which I have disregarded, 
 — such causes as pneumonia, and the 
 group Diseases of Early Infancy. 
 Deaths of infants under two amount to 
 over one fifth of all the deaths that 
 occur, and in our list of preventable 
 deaths this group of infants accounts 
 for over a third of the total. In an 
 unworked field, infant mortality offers 
 a high degree of preventability at a 
 low cost ; if it were not for a low rating 
 on communicability it would attain 
 even a higher value than it does. 
 
 Second : the four contagious diseases 
 of children, 30.5 per cent. These 
 diseases are responsible for 13 per cent, 
 of the preventable deaths, and are 
 estimated to be responsible for 15 per 
 cent, of the damage done. They are 
 the most likely to become epidemic, 
 a fact that contributes largely to their 
 high final rating. 
 
 Third: tuberculosis, 16.0 per cent. 
 Although responsi})le for 37.5 per cent, 
 of the |)reventablc deaths, its value 
 is reduced l)y high cost of prevention, 
 moderate preventability, and absence 
 of the acute tendency to become 
 
 epidemic that characterizes some of 
 the other communicable diseases. 
 
 The fourth value falls to the venereal 
 diseases, 9 per cent. Although only 
 3.3 per cent, of the preventable deaths 
 can be definitely ascribed to these 
 diseases it is certain that they cause 
 many deaths that are registered under 
 other titles. In addition, there is a 
 tremendous number of non-fatal cases, 
 and the indirect results of these are 
 frequently grave. Conservative esti- 
 mates have placed the number of cases 
 in the country at tAvo or three million. 
 This field is almost untouched, and 
 health department effort in the way of 
 education, diagnosis, and treatment, 
 should accomplish great good. 
 
 The fifth place goes to typhoid fever, 
 with a value of 6.1 per cent. Then 
 follow other infectious diseases, 3.4 
 per cent.; and nutritional diseases, 0.2 
 per cent. Poisoning by food registers 
 less than 0.1 per cent. 
 
 These are values calculated for the 
 different causes in our list of prevent- 
 able deaths. It is necessary now to 
 make allowance for certain diseases, 
 such as cancer and the degenerative 
 diseases of middle age, which were not 
 included in that list; to make allowance 
 for certain activities that are indisj)en- 
 sable to a health department; and to 
 express the result in terms of health 
 department organization. 
 
 Values According to Lines 
 OF Activity. 
 
 To health education an arbitrary 
 value of 5 per cent, in the final scale is 
 assigned. This item will cover activi- 
 ties in behalf of the semi-preventable 
 diseases just mentioned. Similarly, a 
 
Uelatiw Values in Piihlic- Ilealtli Work 
 
 \alue 
 cxjimi 
 \ aliic 
 ti\ itii 
 
 of 7 is assigned to the physical 
 nation of school chiUiron, and a 
 of ') to each of the foHowiiif^ ac- 
 s: \if;il statistics, dispensary 
 
 
 iit 
 
 J 
 
 H Q_ . 
 
 > 
 
 ■^2.1 
 
 d 
 
 So'B 
 
 
 n 
 
 1 
 
 a 
 
 3 
 
 » a 
 
 e> 
 
 •0.2 
 
 > 
 
 «S 
 
 g 
 
 f.^ 
 
 1 
 
 
 
 82 
 
 2g 
 
 SSS 
 
 SSS 
 
 
 SS2^gx2g 
 
 CO 00 CO to to >c o 
 
 23 Jj'O'i^esb 
 
 8- 
 u. c 
 
 : X 
 
 and clinics, and laboratory. As these 
 arbitrarily assigned items aggregate '27 
 per cent., it is necessary to reduce 
 propcjrtionally the previously deter- 
 mined disease values to make them 
 total 73 per cent. Table 3 exhibits 
 the distribution of what seem ap- 
 propriate parts of these reduced 
 values among the following activ- 
 ities: milk control, privy and well 
 sanitation, fly and mosquito suppres- 
 sion, and food sanitation. The result 
 is the following hst of final values, 
 expressed according to lines of health 
 department activity. 
 
 TABLE 4. 
 
 Final valiios* as applied to actiWlies directly 
 concerned with: 
 
 Control of Communicable Diseases — 
 
 Tui)erculosis HI 
 
 Ve iiereai diseases G . 6 
 
 All others i5 S 
 
 Infant hypiene iO S 
 
 I'riv\ and well sanitation 3 .5 
 
 Milk control 4.7 
 
 I'ly and mosquito suppression •i A 
 
 Food sanitation 1 
 
 Inspection of school children 7.0 
 
 Vital statistics 5 
 
 Education 5 
 
 Dispensary and clinics 5.0 
 
 Laboratory 5.0 
 
 Total 100.0 
 
 * For a more detailed sutniivision of values see, 
 Chapin, C. V.: "Effective Lines of Healtti Work," The 
 Providence Medical Journal, Januarj-, 1916. Persons 
 ■"sted in relative values should consult also, "How 
 ^. ..- "^ijend the Health Appropriation," by the 
 
 same auth<v, -American Journ.^l of Public He.m.th, 
 Vol III, No. 3, page 202. 
 
 The A alue '2.).3 for communicable 
 di.sea.ses other than tuberculosis and 
 the venereal di.seases may .seem high as 
 compared with the values for those 
 specific di.sea.ses and that for infant 
 hygiene. On the other hand, this 
 25.3 per cent, must cover the work 
 against the common contagions of 
 
Relative Values in Public Health Work 
 
 9 
 
 children, as well as that against ty- 
 phoid fever, smallpox, and others of 
 the more unusual diseases. It must 
 take care also of the possibilities in 
 connection with pneumonia. In addi- 
 tion, infant hygiene is represented by 
 4.5 per cent, in the allowances for milk 
 control, privy and well sanitation, and 
 fly suppression. It is assumed that 
 control of communicable diseases will 
 be carried on with modern epidemiolog- 
 ical methods, public health nurses, and 
 emphasis on bedside disinfection of 
 discharges. 
 
 The list of final values does not con- 
 sider industrial hygiene; not because 
 the work is unimportant, but on the 
 theory that state authorities will meet 
 the need. Plumbing inspection does 
 not appear, partly because of lack of 
 evidence to justify its insertion, and 
 partly because this is considered work 
 for the building department. Nuisance 
 abatement is intentionally omitted; 
 it is realized, however, that health 
 departments commonly must carry 
 this largely police function. The privy, 
 well, fly, and mosquito work, for 
 which allowance has been made, cover 
 the important sanitary parts of what 
 is generally understood by nuisance 
 abatement.* 
 
 Before leaving these values it seems 
 wise to utter a few words of warning. 
 The values are based on the rates of 
 mortality existing in registration cities 
 
 ♦ For a vigorous exposition of existine inconsistencies 
 see, Armstrong. D. B., "Public Health Values— A 
 Few Modern Fallacies," Proc<-eding9 of the Fifth 
 Annual Conference of Mayors of New York State: 
 25 Washington Ave., Albany, 1914. For an excellent 
 critical discussion of the relative value of different 
 branches of his own work by a practi.sing health officer 
 see, Terry, C. E , .Annual Keport of the Board of Health 
 for 1915, Jacksonville, Fla., page 47. 
 
 as a whole in 1913, and thus represent 
 certain average conditions. Local con- 
 ditions will of course modify any 
 values, as will the passage of time and 
 the development of sanitary science. 
 Similarly, the importance of different 
 health measures in any one city will be 
 different at different times. It must 
 be confessed that the existing data for 
 the determination of relative values is 
 seriously inadequate. What we need 
 for better values is better vital statis- 
 tics and better cost-keeping. Probably 
 nothing would be a greater help to the 
 progress of this subject, and perhaps of 
 sanitary science in general, than for 
 our health officers to form the habit 
 of keeping careful records regarding 
 new procedures, together with state- 
 ments of the results and the costs. 
 These could be published in the de- 
 partments' annual reports; and thus 
 there would be accumulated a mass of 
 data comparable to that in the hand- 
 books now existing in the fields of civil 
 and mechanical engineering. 
 
 Some health officers, of course, do 
 this already; none more admirably 
 than Doctor Chapin of Providence. 
 On this occasion one is tempted to ex- 
 press one's admiration of Doctor 
 Chapin's reports and other writings, 
 and say what models of scientific work 
 they are, and say how much we all owe 
 to him. But one hesitates to do so, 
 from fear that he would dislike it. At 
 all events, when we ha^•e more reports 
 like Doctor Chapin's we shall be in a 
 fair way to get our judgments of 
 relative values onto a definite quan- 
 titative basis. 
 
 Making liberal allowance for in- 
 accuracies in the values here presented. 
 
10 
 
 Relative Values in Public Health Work 
 
 and for possible diflVrenres that may 
 1)0 occasioned hy local conditions, the 
 followiiifi conclusions seem fully justi- 
 fied: 'I'he prevention of infant mortal- 
 ity is a fundamental activity, and one 
 of the most valuahle a health depart- 
 ment can pursue. \'ery exceptional 
 is the city in which this work can he 
 iji;nored without convicting the health 
 authorities of gross neglect. Anti- 
 
 tuberculosis work and that involved 
 in the control of the common conta- 
 gious diseases, are other activities of 
 I)rime importance. In addition, it 
 seems time to admit the venereal 
 (lisea.ses to the group of larger oppor- 
 tunities. In most cities the value of 
 the al)ove mentioned lines of activity 
 is considerably greater than that of the 
 various forms of sanitary inspection. 
 
I 
 
II- 
 
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