PITTSBURGH'S FOREGONE ASSET, THE PUBLIC HEALTH A RUNNING SUMMARY OF THE PRESENT ADMINISTRATIVE SITUATION

SAMUEL HOPKINS ADAMS

Starting at the lowest level, let us formulate our initial axiom in terms of dollars. A sound man can do more work than a sick man. Therefore he can make more money. A sound city can do more work than a sick city. Therefore, in the long run, it can accumulate more wealth. Public health is a public asset. This is a truth which, in her single-minded purpose of commercial and industrial expansion, Pittsburgh long ago forgot, if, indeed, she ever stopped to realize it. Consequently, at a time when all the other great American cities have organized their forces thoroughly and are waging battle, with greater or less scientific skill, against that most potent of all destroyers, the germ, this mighty aggregation of half a million human beings has only just declared war, and has barely established its outposts. After two years of preparation to meet conditions which have been half a century in forming and solidifying, Pittsburgh's little regular army of defence now faces the most complicated problem of municipal betterment to be found in American hygiene.

A health bureau performs a defensive and protective function. Its intelligence department must keep it apprised of every manifestation on the part of the enemy; and it must rally to the threatened point to check the advance before it be too late, whether the emergency be a school epidemic of diphtheria, or a localized onset of typhoid. It must maintain a jealous watchfulness over the food and water supplies that are brought into the city, lest with them shall come the invading diseases. And its statistics of death and disability must point out for repair, the breaches made in its walls by the never-ceasing onslaught. Such a sanitary garrison has little rest, and no respites, for the besieging germ never sleeps.

The date of Pittsburgh's last annual health report is 1899. That fact is crammed with meaning. Strategically it means that for nearly a decade the sentries have all been asleep at their posts. Politically it has meant that those responsible for the administration of the city were too lethargic, too ignorant, or too indifferent to disturb that profound Rip Van Winkleism. Civically it means "Who cares!", and that companion gem, "What's the use?". Between public indifference, private selfishness, and political inertia, the germ has pretty well had its own sweet way with Pittsburgh, and the city's annual waste of life from absolutely preventable disease has been a thing to make humanity shudder, had it been expressed in the lurid terms of battle, holocaust, or flood, instead of the dumbly accepted figures of tuberculosis, typhoid, and infant mortality.

Presumably, before this article gets into print, the Pittsburgh health report for the year 1907 will have been issued. What laborious exhumation of dilapidated statistical skeletons that report represents, I have not space to explain here. The important and significant point is that the authorities are at last at work, and energetically, under the leadership of a skilled sanitarian, Dr. James F. Edwards, superintendent of the Bureau of Health. It would be pleasant to add that Dr. Edwards goes into action with his hands free; pleasant, but quite untrue. On the contrary, he is bound and hampered to an extent that would devitalize the efforts of any but the most patient of enthusiasts. His forces are not under his own control, since under the Pennsylvania system he is at the head, not of a department, but of a bureau of the Department of Public Safety, administered by a layman. The law gives him no power to choose or discharge his own subordinates within the limits of the civil service; all that he can do is to train and educate such of them as most need it, when they come to him. He has no specific supervision or control over public or charitable institutions, those prolific culture-beds of contagion. Even the Municipal Hospital for Contagious Diseases has been taken out of his hands and put under other management. He cannot condemn a building inimical to the public safety, nor can he revoke a milk license. He cannot abate a nuisance without going to court for it. And, lest the powers of his bureau should wax too great and impinge upon individual privilege, old laws have been raked up and carefully interpreted to restrict the scope of its work. Yet in spite of all this, wonderful to say, the efforts of the bureau seem to have made an initial impress already on the death rate, and, even more important, to have gathered to its support some tangible force of public opinion.

"Seem to have made," I say, because figures in this connection are largely a matter of conjecture. Basis for any detailed comparison between present and past, is lacking. What is certain, however, is that the sanitary forces are doing work which must inevitably have its effect in life-saving in the future; and the efficacy, if not the qualitative result, of that work is hopefully apparent. The first attack was made on a condition of affairs which would have disgraced a country village, the prevalence of unprotected outhouses, scattered over the length and breadth of the landscape; not only lurking in the slums, but peering from the proud eminence of hilltops down upon the homes of wealth and elegance below.

Through the agency of flies in summer and of wind or heavy rains in winter, these relics of communal barbarity spread filth and contagion through the city. How many of them existed at their maximum will never be known. There are still six thousand survivors, but the number is being reduced daily. Proceeding under an ordinance which declares them illegal, Dr. Edwards began his campaign modestly. Opposition he foresaw, but he waited to keep it, as far as might be, sporadic, and to prevent it from concentrating. In the year 1905 only forty-six of these nuisances had been abolished. In 1906, six hundred of them fell. Thereupon the sensitive nerve of property rights thrilled the alarm throughout the commercial body. Reform was threatening rental profits; was becoming "radical," and "destructive." People with pulls, real or imagined, rushed to councils with demands for the repeal of the ordinance. But here an unexpected ally appeared. Destruction of the old meant construction of the new and modern, with much accruing increment to the plumbing trade. Therefore these shrewd business sanitarians hastened before the committee with lawyers and arguments, and so effectually backed up the case of the Health Bureau, that the repeal project was killed then and there. In the enthusiasm of well-won victory plumbers' supplies soared heavenward, with the result of bringing the unfortunate property owners down upon the Bureau of Health in agonized droves, begging for protection from the masters of the situation. Thereupon the bureau quietly allowed an extension of time, until the enthusiastic plumbers, somewhat chastened, saw the point and came nearer to earth in their prices; after which the process continued, and has been continuing, with accelerated progress. For the issue had now been decided. The proprietors of noisome property had lost the first skirmish. In 1907, 7,755 notices were served on recalcitrants, and 3,590 privies were abolished. By the end of 1910, Dr. Edwards hopes to have relegated these nuisances to a purely historical status.

Encouraged, the Bureau of Health sought from the Legislature the power to condemn unsanitary dwellings. At present, in order to destroy property prejudicial to the public health, the bureau must go to court and prove the conditions unsanitary,—a cumbrous, expensive, and uncertain process. It is not long since a presumably upright and intelligent occupant of the bench held that a house which leaked so badly that the floors were rotted and the plaster peeled from the walls could not, on that account, be adjudged unsanitary. The bill passed the Legislature, prescribing condemnatory powers, with a proviso for court review and damages to the owner if the condemnation should be found unjustified. Governor Stuart vetoed the bill on the ground that it was too sweeping. If the local undertakers haven't passed a vote of thanks to the governor, they have missed a gracious opportunity. What would have been the one most effectual check upon the city's mortality, the wiping out of those death-in-life conditions of housing which make for tuberculosis, the active contagions, and above all the undermined vitality represented in Pittsburgh statistics under every division from general debility to suicide,—that the gubernatorial veto has effectually blocked. So certain large and small owners of slum property have an extension of immunity for their rentals drawn, at the worst, from premises where they wouldn't house their pigs,—particularly if they designed to eat the pigs afterward.

Evil housing conditions are almost invariably reflected in the mortality figures of tuberculosis. Yet Pittsburgh's given death rate from tuberculosis is low; hardly half the normal rate for American cities, in general: so low, indeed, that I doubt whether any sanitarian would give implicit credence to it. Similarly, the death rate from pneumonia and bronchitis is suspiciously high. For example, in 1907 there were a quarter as many deaths attributed to bronchitis, as to consumption, an incredible assumption. Dr. Matson, who is in charge of the bureau's statistics, has decided, with a wisdom born of experience, to regard fatal cases of bronchitis as belonging, statistically, in the pneumonia column; so I shall lump the two diseases. In the first eight months of last year (which is as far as the monthly figures have been supplied to me) there were but 565 deaths set down to tuberculosis in all forms, whereas the pneumonia and bronchitis totals aggregated upwards of 1,100. This is a condition which, so far as I know, has never been paralleled in any American city. The inference is inevitable that deaths, which should properly be ascribed to the great white plague, are reported by physicians under other heads. This is due, usually, to the influence of the decedent's family, who fear to lose their places if it be known that there is "consumption in the house," or who will perhaps, forfeit the insurance money if the true cause of death appear on the records. Very wisely Dr. Edwards is proceeding, not upon local certificates, which may lie, but upon universally recognized facts, which cannot; and is planning an exhaustive tuberculosis campaign. In this campaign will be concentrated the local official health force, the Pittsburgh Tuberculosis League, and the local dispensary of the State Board of Health, all working in conjunction with a special Tuberculosis Commission now in process of organization by the city government.

At present the consumptive poor of Pittsburgh have a small, practically a negligible chance of life. The great, rich, busy city that slowly kills them, has no means to care for them while they are dying. There is no municipal tuberculosis hospital. To be sure, Marshalsea, outside the city, can care for some thirty victims; but they are taken there, usually, only when they are too weak to resist effectually. For Marshalsea is the Poor House. And there is inbred in the American an indestructible, illogical, pathetically self-respecting something which makes the term "Poor House" a poison to his soul. Live he might, within those walls. He prefers to stay outside and die. The late Dr. Charles Harrington of the Massachusetts department, wisest and most human of health officials, said to me once in one of his characteristic bursts of impatience with the stupidity of Things as they Are:

"If I had the choice to make between naming a refuge for the helpless sick 'Poor-house' or 'Sure-Death,' I'd choose 'Sure-Death' every time. You could get more people to go to it."

Marshalsea doesn't save many of the consumptives who come to its gates. Non-consumptives it does save, indirectly, since it removes from a susceptible environment, a certain number of spreaders of infection. Private effort does its altruistic but minute best in Pittsburgh; the Tuberculosis League has a hospital in which it can take care of fifty to sixty patients. And the State Board of Health relieves the situation a little by maintaining one of its admirable tuberculosis dispensaries in the city, with a staff of visiting nurses; and sends a few hopeful cases to its sanatoriums. Perhaps 100 victims of the plague can be cared for in proper institutions. There are to-day in the city probably 3,000 sufferers in a sufficiently advanced stage to be a peril to all with whom they come into contact. At a very moderate estimate three-fifths of this number are unable to afford proper home care, and of this three-fifths (all of whom will die, barring the few that can be accommodated in the hospitals) probably one-third,—again my estimate is conservative,—could be saved under proper conditions. That is, Pittsburgh of the mighty mills, Pittsburgh of the heaped-up millions, Pittsburgh of the rampant industrialism which has spread its influence to the far corners of the world, stands by helpless while six hundred lives are going out needlessly, not because they might not be saved, but because there is no place in which to save them. Nor is this the worst; since, in the slow process of dying, these victims will radiate the poison to hundreds, directly; indirectly to thousands, who are now well, strong, and unsuspecting the inevitable doom. What can the Health Bureau, the officially constituted army of defence, do to remedy this condition? Nothing. That is the answer which goes over the telephone wires, once, twice, half a dozen times a day, to people who ask for advice for helpless cases of consumption. I suppose that the sorriest duty of a health official, is to deny the application of some man upon whose life depends the support of other lives, for a fighting chance to get well and do his work in the world. Ask Dr. Edwards, oh comfortable resident Pittsburgher, how often he has had to do the very thing in the last year. It may give you new light on your civic responsibilities.

Not so often will that hopeless response be made in the future. The united forces, drawn together by the forming Tuberculosis Commission, will make it their first business to provide some refuge of increasing adequacy, for those who are now distributing the infection. Meantime, though there is little to be done for those already stricken, the city is being covered, district by district, by the visiting nurses of the league, of the State Dispensary and of the Health Bureau, soon to be re-enforced by five special nurses from the commission, and all training and instructing the consumptive in those measures of prevention which safeguard the people about him from contracting the disease.

One-third of all who die in Pittsburgh, die without having anything to say about it. That is, they die under five years of age. One-fourth of all who die, die without having anything to say about anything. That is, they die under one year of age. Most of these deaths are preventable, being the outcome of conditions which, humanly speaking, have no right to exist. Chief among the causes is bad milk. Pittsburgh uses 40,000 gallons of milk per day, coming from a wide radius in both Pennsylvania and Ohio. Before the present administration, this vitally important merchandise received rather less attention than the corner-stand vending of collar buttons. At the beginning of 1906 the Bureau of Health had one lone milk inspector. He collected samples, and, if one may judge by the brief records of analyses, he didn't imperil his own health by over-assiduity in the job. Dairy inspection was an unthought-of phase of activity. In August, 1906, two more inspectors were acquired and began, by prosecutions, to do some work in the matter of discouraging the use of formaldehyde. There was even some inspection of stores and adjacent dairies. Now the bureau has six men in the milk division, two of whom are dairy inspectors and one a veterinarian, and all of whom do conscientiously the work the city pays them to do. Two more have been arranged for, with which addition Dr. Edwards believes he will have a sufficient force to inaugurate a higher standard of supply. Unfortunately there is no official standard, though an ordinance is being prepared establishing bacterial and temperature requirements. Unfortunately, too, the law has been interpreted to mean that the Bureau of Health must issue licenses on demand; and that it cannot revoke these licenses. What has been done thus far is chiefly in the line of educating the dairymen and dealers. Dr. Edwards admits frankly that, while he regards pasteurization as a make-shift only, he believes that it will be necessary for a time to accept the deteriorated quality of milk consequent upon pasteurization, for the sake of destroying the pathogenic bacteria with which the supply swarms. Analyses made last summer showed an average of a million bacteria per cubic centimetre. The limit of reasonable safety is usually set at half that number.

As for conditions as they existed at that time in certain local dairies, I can do no better than quote from the report of Dr. Goler, the health officer of Rochester and an international authority on milk supply:

Dairy inspection, it is fair to say, has recently ameliorated the worst of these conditions. Increasingly careful supervision of the retail milk dealers, and constant inspection of the less cleanly stores, which has discouraged many of them out of existence, tend to minimize the danger of contamination of milk at the other end of the line. There is, however, an additional peril in the well-water supply often used to wash cans and bottles.

The milk-inspection force faces a situation outlined in the latest complete figures (not yet in print); those for 1907, which show a total infant mortality of more than a thousand from diseases inferentially due to bad milk. The poorer quarters of the city where prices rule at six or seven cents a quart, exhibit the heaviest figures, and there is the typical rising curve of the mortality line in hot weather. Last summer that curve, while still unpleasantly in evidence, was noticeably modified. Education of mothers of the slums was largely responsible. The Bureau of Health put a corps of six special nurses in the field who went about from house to house, instructing mothers in the hygienic care of their children, and working in conjunction with the Pittsburgh and Allegheny Milk and Ice Association, one of the most efficient charitable enterprises in the city. Probably the infant mortality for the whole year of 1908 would have been low but for the winter epidemic of measles, which killed more victims than scarlet fever, diphtheria, smallpox, chickenpox, and all the other active contagions put together. Now the city, having learned a costly lesson in the seriousness of this too commonly disregarded disease, quarantines for it. It is perhaps, hardly ingenuous to include smallpox in the foregoing comparison, as that disease is now a practically negligible quantity. Since the epidemic of 1903 Pittsburgh has been the best vaccinated of American cities. Wherefrom depends a corollary for the consideration of the anti-vaccinationists, that for two years there has not been a death from this loathsome and unnecessary infection in the city, nor has a single original case developed.

We are prone, in this country, to study the public health too much in terms of death rates, and too little in the character of the survivors. Applying this latter test to the children of Pittsburgh's slums, we shall find cause to wonder whether, in a sense, the deaths are not too few rather than too many. Would it not be better for the unfortunate and innocent victims themselves, and certainly for the community at large, that this puny, helpless breed of hunger, filth, and misery which creeps about the city's man-made jungles, should succumb in infancy to the conditions that bred but cannot support them? For there are certain phases of existence in which a high death rate is less to be feared than a high birth rate. Anti-race-suicide has a fine, rotund ring, as it issues from the presidential lips. But President Roosevelt has never, I take it, been in Mulberry Alley, or Our Alley, or a certain unnamed court off Washington street that wafts its stenches into the boulevard below, or any one of a score of other hopeless thoroughfares which might give him pause in the promulgation of his doctrine.

Nor are conditions of life here in the city's choked up center greatly worse than in the "runs" which diversify the landscape of the newer parts of the city; damp, heavy-aired, steaming canyons, into which the poorest classes have been pushed; over the rim, and "off the earth," as it were. There they live, pasty women and weazened children, in the heavy air, polluted, as like as not, by the stenches from the creeks which are little else but open sewers. One such little isolated population I found, in a huddle of houses, under a towering steel bridge, faithfully reproducing, in what was practically open country, the deadliest living conditions of the crowded center of population.

To return to the central slums, there are whole districts which might well (were it of any avail) be placarded, as are certain New York flats:

Settlement workers know the truth about this matter. Here are the words of one of them:

"Not one child in ten comes to us from the river-bottom section without a blood or skin disease, usually of long standing. Not one out of ten comes to us physically up to the normal for his or her age. Worse than that, few of them are up to the mental standard, and an increasing percentage are imbecile."

What can a Bureau of Health do to

alleviate such a status? Nothing: the problem is too big for official solution. Either a sense of responsibility on the part of the mill owner toward his employes who must live near the mills will start a housing movement that will do away with the present outrageous rentals for disgraceful accommodations, or an aroused public conscience will, by one means or another, make a clean sweep of these pest holes. Or, a third, and ugly alternative. London's East End is open for the inspection of travelling Pittsburghers. There they may see in its fullness the crop of pauperism, dependence, and degeneracy which is bred in the third and fourth generations, of conditions no worse than their own average, and not so bad as their own worst.

As an escape from the slum there is the school. Here again Pittsburgh is in the dark ages of hygiene. Every public school is a law unto itself. The principal, always a layman, and not unusually an ignorant one in health matters, decides when a pupil shall be isolated for a contagious or suspicious ailment. Is it surprising that a short time ago a certain skin disease infected an entire institution, or that eye and scalp ailments are often widely diffused among the scholars? From an inspection of buildings and pupils Dr. Goler draws these conclusions:

In no manner of justice, can the Bureau of Health be held to account in this matter. In co-operation with the Civic Club, settlements, physicians and school principals, Dr. Edwards sought to establish a medical inspection of public schools, such an inspection as would, for example, undoubtedly have checked almost at its inception the disastrous onset of measles of last year. But the measure never got past the legal department of the city administration. In view of the present conditions in the schools, Dr. Goler's closing and pregnant suggestion has a special force:

Semi-public institutions in Pittsburgh are quite independent of hygienic control or inspection. This seems to me one of the crying evils of the present status. Let me give a few examples: An inmate of an institution for children was infected by another child who had virulent skin disease and soon afterward he became totally blind. This was a repetition of a past experience of the same institution in which a child contracted trachoma within the institution walls, is totally blind in consequence and a charge upon the state.

Last spring an institution was found in charge of a matron whose special qualification for her care of very young children was experience. She had had ten of her own, all of whom died of intestinal disease and rickets in early childhood. She was feeding the little ones in her care on coffee and other food suited only to robust grownups. Every child in a certain charitable institution, a short time ago, was suffering from skin and scalp disease. Lack of arrangements for effective isolation, in case of contagious disease, is more common than provision for isolation. A refuge for fallen women has, naturally, a large percentage of inmates suffering from venereal disease. The women of one refuge work in the laundry which gets a certain amount of outside trade. Among other things it washes towels for a hotel. Contraction of gonorrhea or syphilis from infected towels or garments is a well-recognized medical fact. A laundry with infected women on its working force cannot but be a public peril.

Grim facts are piling up on the records of the Pittsburgh Tuberculosis Dispensary as to advanced cases of tuberculosis among the little charges of charitable institutions.

Instances such as these might be multiplied. As in the case of the public schools the authorities are helpless. Even over the city's own institution, the Municipal Hospital, the Bureau of Health has no control. It has been transferred to the Bureau of Charities within the last year. It receives only contagious diseases, and is too small for the requirements in time of epidemic, having proper accommodation for only eighty, with a crowded capacity of 125. Dr. Booth of the Bureau of Health, who acts as visiting physician by special appointment to the Bureau of Charities, tells me that up to 1905 the plant was housed in buildings erected in the seventies. The furnishings were beds and bedding from the fire and police departments, regarded as being no longer fit for use by the city's paid servants, and therefore proper charity for the city's helpless sick. Two years ago, Dr. Booth put an end to this system by burning the last consignment of furnishings (for reasons principally entomological); and announcing that he would admit to the hospital no more equipment, discarded as unfit by the police and fire forces. Now the plant has its own furnishings. The building is modern but of an obsolete and unsatisfactory type, and has not sufficient grounds for its convalescents. All the other hospitals in the city are private institutions. There is no co-ordination of hospital work among them, and their distribution is such that localities where there are the most ambulance calls are without easily available hospital plants.

To sum up, these are some few of Pittsburgh's immediate needs, if it is to fight its battle successfully for fewer deaths and a better living product:

Autonomy of the official health authorities (preferably a department of health, not a bureau) under the executive and administrative control of a physician or sanitarian.

A tuberculosis hospital for advanced cases which are now spreading infection throughout the city. More visiting nurses and more sanitary inspectors. Eventually a hospital for the incipient cases that can be saved.

Municipal collection and disposal of the rubbish which accumulates everywhere, seriously hampering efforts to make the city hygienically clean and which must now be removed at private expense.

A general hospital of sufficient size, proper equipment, and adequate surroundings.

Some reasonable division and co-ordination of effort on the part of the private hospitals.

Authority to condemn and destroy unsanitary buildings.

Authority to condemn and destroy, upon its entrance to the city, or upon discovery within the city limits, unclean, infected, or adulterated milk, and to refuse and revoke milk licenses. Establishment of a standard for milk.

Medical inspection of schools and school children.

Medical and sanitary inspection of hospitals, and of all public or semi-public chartered institutions.

These authorizations to be embodied in a city code. At present the health officials work almost wholly under the state law.

---

What is Pittsburgh going to do about it? Though the foregoing rather general survey may suggest pessimistically "the little done, the undone vast," yet there is not lacking, in the view, definite promise as well as progress. Many and diverse agencies are helping the cause. The monthly reports of the bureau keep a public, which has for years been in a state of Egyptian darkness as to the how and wherefore of its mortality, fully informed. A Civic Improvement Commission has been appointed by Mayor Guthrie, one of the sub-committees of which will deal with needed hygienic reforms. The Chamber of Commerce has appointed a special committee to co-operate with the Health Bureau for the betterment of housing conditions, and another to aid in improving the milk supply. For the protection of the communities downstream, a sewage disposal plant has been voted; and badly needed it is, as is shown by the fact that, at the present writing, two thousand people are ill in the suburb of Bellevue, from drinking water polluted by Pittsburgh's sewage. The Allegheny County Medical Society has constituted a committee on public instruction in health matters; also a milk commission. The Tuberculosis Commission will soon be in the field with its broad campaign. Municipally there has been an important step forward in the establishment of a disinfection corps which sterilizes and makes safe, at the public expense if necessary, the premises from which a consumptive has been removed. Anti-tuberculosis education by the various corps of visiting nurses is extending into every corner of the city that harbors a dangerous consumptive. The state school commission has recommended medical inspection of schools. City ordinances providing for milk standards, and rubbish disposal, are in prospect. The Bureau of Health, only a short time ago a rusted and ineffectual machine fed by incompetents from other departments, has, under its new head, developed an esprit de corps, and is now welded into a compact, dependable organization. And this organization will constantly have a supply of better trained men to draw upon, since the University of Pittsburgh and the Carnegie Technical Schools have, at Dr. Edwards's suggestion, arranged for special courses in sanitary engineering and practical hygiene.

Yes; Pittsburgh is awake to the needs of the situation. But the true test is yet to come. Thus far it has been but the laying out of the lines of battle and a few preliminary, and, on the whole, victorious skirmishes. For when hygienic and sanitary reform impinges, in its advance, as it needs must, upon the private purse of some, the political purposes of others, and the industrial and commercial license of the whole, then will come the tug of war. Then, according as shortsighted selfishness shall prevail over, or succumb to, civic pride and patriotism, the victory will be to the germ or to the city.

A SLUM IN THE OPEN.