THE TYPHOID TOLL
Certain cardinal facts stand forth in opening a discussion of the significance of typhoid fever. First of all, let is be clearly understood that there is no question of its being an entirely preventable disease. Second, that all typhoid is caused by taking the typhoid germ into the mouth. And, third, that typhoid fever in America is the chief disease conveyed by impure food and drink. Since the disease cannot be contracted naturally without taking the specific germ into the mouth* and since the manner in which this act is commonly performed can be said to be associated almost exclusively with the consumption of typhoid infected food and drink, it follows that to eradicate the disease involves only the exercise of really simple measures of precaution, which, in the concrete, are to see to it that the food and drink be pure, or made pure, and kept pure until consumed. Public understanding of this need is, of course, in the ideal sense, imperative, but when once the typhoid scourge has been placed under control, it is possible for public health authorities to prevent the re-establishment of its sinister influences on the public health, in spite of the ignorance, selfishness, or almost unbelievably complacent tolerance of the public itself. It is not for a moment denied that to effect this idealistic result is an undertaking beset with tremendous difficulties. Education must be forced upon the public by those qualified to teach; public health officials must be given wider power through more exact and far-reaching laws aimed at the destruction of the roots of this filth-sustained plant; and ample funds must be appropriated to carrythrough the work. The vital capital needlesslydissipated by the typhoid scourge in this country amounts each year to not less *han $150,000,000, yet the combined annual appropriations for all the health departments of the cities of the United States amount to less than 30 cents per capita, or not more than $15,000,000. This fund is made to cover the expenses of work on infant morbidity, inspection of school children, laboratory and dispensary service, tuberculosis, and for educational and publicity work, and this sum is clearly inadequate for the efficient prosecution of tuberculosis work alone. In New York City a very large share of the expense of such work is borne by the Department of Charities. Probably not 10 per cent, of the health department funds are devoted to holding typhoid fever in check; the prevention fund, if you like. Such an amount would be equal to 1 per cent, of the loss suffered through failure to exercise adequate and efficient measures of prevention. Public health officials realize this unsatisfactory state of affairs, but if insufficient power is given them under the law, and if they are hampered by lack of funds and competent helpers to do the things they know are necessary, who is to blame? The annual budgets, with very few exceptions, are made up by officials who sense but dimly the responsibility they shoulder when they cut the health department appropriations to the very quick. Ignorance on their part of the reasons why heavy expenditures for disease prevention are justified is large responsible for this; and the average health official realizes only too clearly how wellnigh impossible it is to obtain for his work even a reasonable approximation of what his department could make very good use of. The soundest argument for larger appropriations to place before the arbiter of state and municipal financial expenditures is a statement of what preventable disease actually costs in dissipated vital capital. A city of 100,000 people, with an annual typhoid fever death rate of twenty, suffers an annual loss of vital capital from this disease alone amounting to $150,000. In view of the indisputable fact that typhoid fever is preventable, the actual loss of this amount of vital capital through failure to provide sufficient means to effect such prevention, is mighty poor financial management. And yet dozens of cities do experience as great, or an even greater proportional loss in this way each year. The present day typhoid toll of New York City, expressed in lost vital capital, amounts to $4,000,000 annually. The general public, eliminating, of course, those individuals who have learned by sad experience, rarely gives a thought to the possible disease bearing properties of the two essentials to human existence, drink and food, unless these commodities actually are repulsive to the senses. There is tacit knowledge that such matters are controlled by some mysterious, yet real, authority, hence blind confidence impels the public to take things as they come. Twenty millions of people in the United States are now being furnished with filtered water at a cost not exceeding $8,000,000, or 40 cents per capita, per year, and in these cities having filtered supplies the water borne typhoid fever has been practically eliminated, as reliable statistics abundantly prove. Inexpensive as water puritication is these people are spending more money for that alone than they appropriate for the work of prevention and public treatment of all diseases, whether water borne or not, and it is not to be forgotten that out of the public health fund comes a considerable expenditure for work in the line of the conservation of purity of public water supplies. The results of water purification always show a big balance on the right side of the ledger. Where one dollar is spent for pure water many dollars are saved in the form of vital capital through the prevention of sickness and death. If a community of 19,000 people spends each year 40 cents per capita for filtered water, and thus each year prevents a single death and the attendant cases of illness from typhoid fever, it will come out even financially, and increase its self-respect into the bargain. In Pittsburgh, to cite a well known example, the adoption of water filtration has saved over 600 lives, 9,000 cases of typhoid illness, and $4,500,000 in vital capital annually. Three hundred thousand persons suffer annually from typhoid fever in this country, and 20,000 die of it. This means that in the course of a decade one person in every 33 contracts typhoid fever by taking into the mouth germs. Of those who recover a substantial number die later from other causes leading out of a depleted vitality. Still others never completely recover from its effects, and, although they may live to old age, their usefulness has been materially curtailed. To give for each human life lost through typhoid fever an average value of $3,fi00, and for lost wages and medical attendance $200 per case, the present day annual typhoid toll in the United States amounts to $130,000,000. It would seem that the influence of depicted vitality in the case of typhoid convalescents resulting in earlier deaths from other causes, and depreciation of usefulness through the years ot remaining life, should be given some expression of money value, and if for this even $’j is allowed for each typhoid convalescent the final result is $150,000,000, as representing, in terms of dissipated vital capital, the annual typhoid toll paid by the citizens of the United States each year. Whose is the responsibility? Who can be blamed for permitting typhoid fever to exist and thrive in this enlightened age? Is it the national government, the state governments. the municipal governments, or the people themselves? There is no law prohibiting the consumption of impure water or food unless the consumer deliberately contemplates suicide. The average state cannot, or, to say the least, has not thus far been signally successful in so doing, force a city within its boundaries to cease allowing impure water and food to be furnished to its citizens. The national government has no control over health matters in any individual state. Each state is a power within itself, in this regard, and in a very large measure each city also, and each individual citizen as well. The national government has a certain sort of control over boundary water, but here its effect on the public health is virtually neglible, and otherwise, at the most, it exercises but a paternal influence in questions of pure food and drink. The state health departments, with their limited funds and power, do much good in encouraging the purification of polluted water supplies, the sanitary disposal of sewage and refuse, the prohibition of adulteration of foods, and, largely by moral suasion through the admirable medium of education, exert a generally benign influence in other lines of disease prevention. The city health departments, having a narrower field to cover, probably accomplish more visible good, and when such departments are in the hands of competent officials, and when the available funds are an appreciable fraction of what they should be, and where the local officials have the sympathetic co-operation of the state authorities, the results accomplished have been all that reasonably could be expected. In the last analysis, education respecting health matters is the light which eventually will lead us out of the insanitary wilderness. Almost every year sees an improvement, but except in the field of water purification, where in the past fifteen years have seen stupendous advances, other lines of disease prevention work, allied to impure foods, with some exceptions in the case of milk, have not advanced a fractional part of what they should; and lack of public realization of the controlling conditions is chiefly rc-ponsible for this deplorable state of affairs A significant fact disclosed by a study of the mortality statistics of the United States is that in rural districts, that is, where the population of communities is less than 2,500, typhoid fever is more prevalent than in urban districts, although the combined mortality from all causes is greater in cities. Occasionally this rule may not hold, as perhaps in the case of New York for last year, when the rural combined death rate of New York State was in excess of that of New’ York City; but generally it docs. Vhat, then, are the reasons wdiy typhoid fever is more prevalent in rural districts than in urban districts? To the sanitarian this is no mystery. In rural districts the individual is a plenary power unto himself. In small communities the appropriations made for disease prevention work are trifling, and to attempt by innocuous persuasion the observance of regulations looking to more sanitary modes of living, and thereby summarily alter the practice of customs observed for generations, is sometimes sufficient to arouse antagonism on the part of the individuals affected pronounced enough in itself to preclude the establishment of different, and better, practices, the acceptance of wdiich, with sympathetic co-operation on the part of the individuals, would do untold good. The farmer, living isolated from his fellows, usually considers that he is sufficient unto himself. He obtains his drinking water from the most convenient source, which usually is a shadow well often located nearby his barnyard or privy, and thus open to dangerous contamination. The ruralite is not particularly concerned if hi* sink, privy or barnyard drainage discharges into a brook from which his lower down neighbor takes his water supply. For some reason, which patently has no good financial foundation, the amount of health department appropriations generally varies as the size of the city, that is, the larger the city the higher the per capita appropriation. The budget adjusters evidently conclude that the smaller the city the less need there is for disease prevention. It is difficult for the heads of health departments to obtain appropriations of sufficient size. Practically their only statistical argument may be based on the records in their own cities for several years back. It cannot be denied, in the face of indisputable statistical facts, that public health service has raised the health tone of the world in a very material measure.
Campaigns for Pure Water Supplies.
No one can gainsay that in progressive states the majority of the movements looking to the improvement of public water supplies originate in the health department. It can be stated unqualifiedly that no community, whatever its size, is too poor to have a pure water supply. It is better to have bad streets, grade crossings, and inadequate public buildings, than to tolerate a public water supply of questionable purity. State health officials, realizing the necessity better than anyone else, order that purification works be built. The cost thereof being estimated, the matter of a bond issue to carry the expense is put up to the people, and very often is defeated. Many cities have endured an excessively high typhoid fever death rate for years, and withheld the financial support necessary for the furtherance of measures of prevention, even when it was plain that the public health of the community would be immensely benefitted thereby. Laws have been enacted giving to the state the power to force the purification of public water supplies within their boundaries. The so-called Bense Act of Ohio is one of these. There is need of more legislation of this kind, which leads to the protection of the public against itself. The author believes that an important and controlling amendnict to all existig public health laws should be made particularly those surrounding the contemplated purification of public water supplies. To promote the health and comfort of such a community the law should require that the water as delivered to the consumer comply at all times with reasonable standards of purity, essentially as regards its bacterial content and physical characteristics. Furthermore, that any method of purification, tangibly guaranteed continuously to furnish a water at all times complying with the law, shall be acceptable. The physical features of such purification plants thus would not be subject to approval by the health department, it being the duty of that department, proper, to see to it that the guarantees under which the plant was constructed, are fully complied with. Most public health laws governing water purification projects specify that plans and specifications of the contemplated works shall be submitted to the health department, and that construction work shall not be begun until the health department has indicated its approval thereof. No time limit U set for such action by the health department, and this is needed to preclude unnecessary inaction, provided the law delegating to the health department the power to approve or reject a project on the plans and specifications is allowed to stand.
What the Common Purification of Public Water Supplies Would Do.
If all the urban population of the United States were supplied with filtered water or water of equal purity, the average urban typhoid fever death rate would be fourteen per 100,000. In making this important statement it is well to explain that this figure was obtained by estimating, on a basis of proportions, an average typhoid fever death rate of forty-three per 100,000 among the total urban population of the United States in 1900. or about the time when filtration began to show its effects on the public health of the country. A reduction of 67 per cent, in the typhoid rate immediately following filtration has been amply demonstrated. Hence a residual rate of fourteen per 100,000 results. It has just been shown that the average typhoid fever death rate among the total urban population of the United States in 1913 was twenty per 100,000, a fair figure for present day conditions. Purer filtered water supplies, or supplies of equal purity, would lower this rate to fourteen, representing among the urban population a saving of 3,000 lives annually, and forty-five thousand cases of typhoid fever. This represents an amount of vital capital equal to $22,300,000 annually, or, at 6 per cent., the interest on an investment of $375,000,000. Of the 50,000,000 people representing the urban population of the United States, 20,000,000 are now supplied with filtered water. To build filtration works having a total daily capacity of 4,000 million gallons daily, easily sufficient to provide pure water for the remaining 30,000,000 people, would not cost $100,000,000. To operate these works and pay all charges, including interest and sinking fund, would not cost more than $12,000,000 per year, or about one-half the present annual loss in vital capital. The remaining $10,500,000 per year in saved vital capital would make a substantial nucleus for a public health fund to be expended in general disease prevention work. It would represent 21 cents per capita per year for the entire urban population of the United States, and if expended solely for typhoid prevention would go a long way toward effecting the elimination of this plague. In addition it must not be forgotten that the filtration of the water supplies of all the urban population of the country would reflect favorably on the health tone of the rural population, or such of it as comes in touch with the larger communities through periodical visits. If laws were enforced making it an imprisonable offense on the part of the officials for a city to allow the use of a contaminated water, or the existence of privies and cesspools, or slack garbage collection and disposal, or unclean streets and gutters, the health tone of the country at large would be immeasurably improved.