Civilian Health in Wartime [Reprint 2014 ed.] 9780674492264, 9780674187306

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CIVILIAN HEALTH IN WARTIME

LONDON : HUMPHREY MILFORD OXFORD UNIVERSITY PRESS

CIVILIAN HEALTH IN WARTIME BY

FRANCIS R. DIEUAIDE, M.D. Associate Professor of Medicine,

Harvard Medical

Massachusetts General

CAMBRIDGE,

School

Hospital

MASSACHUSETTS

HARVARD UNIVERSITY 1942

PRESS

C O P Y R I G H T , 1942 BY T H E P R E S I D E N T A N D F E L L O W S O F HARVARD C O L L E G E

P R I N T E D A T T H E HARVARD U N I V E R S I T Y P R I N T I N G O F F I C E CAMBRIDGE, MASSACHUSETTS,

U.S.A.

PREFACE EALTH grows in significance in proportion with the duration of the war in which most of the peoples of the world are now engaged. Few among us have an adequate conception of the sacrifices which may be necessary before victory is won. The preservation, even the improvement, of health should be one of our foremost aims during the war. This book represents an attempt to provide the general reader with a statement, in broad but definite outline, of the varied aspects of health in the United States in relation to the war. The point of view is that of positive health. Hence diseases are not described; nor are methods of treatment presented. Obviously, in such a compass, details can be given only by way of illustration, here and there. The health of a people at war is a development of their previous condition. For this reason, it is necessary to discuss American health in recent years. We think much of physical health, but not enough of mental health. We rightly pay great attention to the care of children, but slight the elderly and aged. Occupational hygiene has gained but little general consideration among us. We are only dimly aware of the tremendous differences of health between the social groups and geographic regions of America. The aim of our enemies is to

H

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PREFACE

destroy our health; but through our health we shall defeat them. The last chapter in the book (which is called an epilogue, not by way of pretension, but in recognition of the heterogeneous aspects of morale) goes somewhat beyond the accepted confines of health; but if morale is not a mental state, can anyone say what it is? The sources of the material which has been used in writing the book are too numerous to mention, and it has not been judged desirable to indicate them, except in a few instances. It is hoped that the statements of fact are such as not to be subject to controversy. Most of the numbers which are mentioned relate to matters in which accuracy of a high order is out of die question. It is with gratitude and pleasure that I acknowledge the untiring assistance of my secretary, Miss Joan Wilkinson. F. R. D. May 18, 1942

CONTENTS PAGE

I. HEALTH AND THE IMPACT OF WAR UPON IT

3

II. THE NUTRITIONAL BACKGROUND .

.

.

25

III. INCREASED STRENGTH THROUGH BETTER DIETS

45

IV. SAFETY FROM INFECTIOUS DISEASES .

.

V. SHELTER AND RAIMENT

118

VI. MOTHER AND CHILD VII. THE AGING AND THE AGED

146 .

.

VIII. OCCUPATION AND RECREATION

.

.

.

.

IX. ABOUT OUR DOCTORS AND NURSES

.

X. MENTAL CALM AND VIGOR

.

.

.

EPILOGUE - MORALE AND THE SECOND WORLD WAR SUGGESTIONS FOR FURTHER READING . INDEX

83

177 .199 .

228 .262 289

.

.307 313

CIVILIAN HEALTH IN WARTIME

CHAPTER I H E A L T H AND THE IMPACT OF W A R UPON I T

HE ultimate strength of nations is measured by the qualities and numbers of their peoples, and by their available resources. This land is endowed by nature with almost unparalleled riches. Its people now number one hundred and thirty-two million. Their abilities and their accomplishments, apart from inheritance and training, depend upon their health. Perfect health for the individual is perhaps life's greatest gift. For a nation a high level of health is its most valuable asset; indeed, upon the state of its health may depend its survival or eclipse. Destiny has marked this age as one of trial for the nation. Only a short span of years separates us from one great world convulsion. The "War to End Wars" has become "World War I." The nation has been compelled, for self-defense as well as for the welfare of mankind, to enter another great international struggle. This war is incomparably more significant than any other in our history since the War of Independence. The world is the battlefield — neutrality in fact is non-existent. The outcome will determine whether or not America will continue to develop as a democracy. The ultimate goal is the

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preservation of our ideals; it should mean the enriching of life for all. Side by side with other peoples who share these ideals, we must win this contest. It is not necessary to labor the difficulties of victory. The aggressors are powerful and use all their might. On our side we need not only to muster all our present resources and to put forth every effort, but also to increase our strength to the utmost. War is an international test of health, numbers, equipment, and supplies. Its immediate aim is to destroy health, in any or all of its aspects. War has always acted powerfully to damage health and retard its enhancement. It is perhaps only in modern times that warring nations have been acutely aware of the direct significance of general health in the outcome of their strife. In any event, the realization is now fully upon those who direct nations at war. In offense, no effort is left untried to undo the strength of the enemy. The possession and preservation of health are potent factors in winning victory. In modern times war has acquired a totalitarian quality. Mercenary troops, and even civilian armies, alone can no longer gain the final victory. The decisive influence of man-made machines, and the utter dependence of armies and navies upon constant support by their home populations, mean that no citizen can escape the effects of war. Our enemies can only be defeated if every able-bodied man and woman finds some part to play in the gigantic

HEALTH AND THE IMPACT OF WAR

5

struggle in which America is now engaged. It is not the democratic way of life to place all of the responsibility upon organized government. Every citizen, man and woman alike, must ask himself what his contribution is to be. The normal selfinterest in being healthy and the normal social duty to be healthy should be greatly enhanced by a state of war. The successful maintenance of good health against such an additional strain depends upon close and intelligent cooperation of state and citizen. Men and women who achieve or preserve health make a signal contribution to their nation's success. The word "health" is in frequent use; we should know what it means. But in spite of much study and an extensive literature, this basic human and social quality is of an elusive nature. We have to consider both national and individual health. The frequent metaphorical use of the term, especially with reference to economic and political affairs, is confusing. The difficulty in defining individual health — upon which national health is dependent — arises partly because health is an aspect of all the parts and functions of the body and mind taken together. The interaction of these various parts and functions is so intimate that only in brief and trivial disturbances can they be properly considered apart from the whole. The absence of disease, at least as disease is usually understood, is not an adequate description of health. Health has a positive meaning. In health not only are particular diseases, pneu-

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monia, fracture of a bone, hysteria, and the like, absent; but, beyond that, the organs are in good condition and carry out their functions at a high level. Furthermore, the numerous mental and bodily activities are integrated so that the individual can make highly effective use of his endowment by inheritance and education. The outward signs of health are familiar, but often misleading. Rosy cheeks, bright eyes, lustrous hair, clear skin, and a spirited carriage may be significant, but a deeper knowledge of mind and body is necessary before judgment can safely be made. In comparing individuals, health is in a measure a relative quality. This is one of the reasons why it has been difficult to set up well-defined and acceptable standards for the classification of populations. As with all qualities of living beings, health is a function of time. The state of health today depends in part upon the age attained and upon the condition in previous years. The future state is uncertain unless the pertinent intervening events can be controlled. It follows as a general rule that, while there is life, there is hope of better health. The healthy individual manifests strength with muscular control and coordination suitable to his particular activities. He has endurance, which means resistance to fatigue and hunger, to irritation and worry, as well as to disease whether arising primarily from without or from within. In health there is latent energy, that is, readiness to act, physi-

HEALTH AND THE IMPACT OF WAR

7

cally or mentally. There is a lively interest in the surroundings, human and inanimate. Above all, there is adaptability to new developments. During a few brief years healthy men beget and healthy women bear sons and daughters. The condition of health implies extensive physical and mental reserves. These reserves can be drawn upon before bad health or disease appears (note how well the common use of the word "exhausted" applies). When health is considered from a national point of view, it is obvious to begin with that the state of health is determined largely by the condition of the citizens taken collectively. There is no contrast between personal hygiene and public health: they are mutually complementary. There are various purely social aspects, however, which must be taken into account. An increasing population has always been considered to be an important element in national health. Apart from migration, which is not significant anywhere in the world today, the birth rate and the death rate determine whether or not the population increases. In particular, the death rate among infants under one year of age is taken to be an index of national health. Another item that might be considered is the proportion of pregnancies that fail, that is, the abortions and still-births. Statistics of sickness are gathered for only a few specific diseases — for the most part communicable infections; they give a very incomplete account of the amount of illness. Behind these representative

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or inclusive indices lie the laws and regulations with the machinery for their enforcement, and the administrative program which the state provides to guard the health of its people. Side by side with these agencies stand doctors and nurses, whose professional knowledge and skill are devoted to the common welfare. The attainment and maintenance of health under modern circumstances imply certain resources, including intelligence and effort. Some of the problems which are presented have not yet been analyzed, to say nothing of their solution. Particularly is this true when health is considered as a positive quality. It is still necessary to speak of many measures that increase health in very general terms. With respect to the individual, it is a happy circumstance that nature endows both mind and body with a strong tendency toward health. From ancient times doctors have spoken of the "curative power of nature" (vis medicatrix naturae). This power is more than curative, however, for in proportion to the favoring elements about the individual, nature creates good health. The problem, therefore, is to discover and provide the circumstances in which health flourishes. For practical reasons the predominant approach in the past has been the prevention of this or that disease or deficiency. Great success has been achieved. Creative health has made a good start, but it is much less highly developed than preventive medicine. In

HEALTH AND THE IMPACT OF WAR

9

health, as in military, campaigns, the offensive position is stronger than the defensive. The elements in life which militate against health are numerous and varied. Their pattern differs from time to time and place to place. Dr. Η. M. Vernon has grouped them as hereditary, occupational, and environmental (including nutritional defects and infectious agents). He estimates the role of these categories in the production of disease in ordinary times as follows:

Source of disease Hereditary Occupational Environmental

Share, assuming average intelligence 10 per cent 20-30 60-70

Share, including indirect effects of intelligence 40 per cent 10-20 40-50

The major threats to health have always included poor nutrition, which may be due to bad diet, to disease, or to a combination of both. The diet may be excessive, with the result that the organs are deformed and handicapped by the accumulation of fat, or it may be inadequate, so that the body simply lacks either the total supply or the particular materials necessary to create or preserve health. Infections and poisons, which are destructive invasions of the body from without, until recent years have been the chief direct cause of ill health, as of death. (Cancer, the nature of which is still obscure, needs

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mention, but will not be referred to again.) Modern developments, chiefly industrialization and the growth of mammoth cities, have added occupational hazards and a complexity of life which strains man's powers of adjustment. Overwork, physical and mental, without serious damage to health, is only possible for limited periods. Ignorance, maladjustment, and fear are potent enemies of good health. In all times of stress these dangers are increased. Flood and drought, tempest and earthquake, in addition to immediate injuries and loss of life, in the past have always been followed by ill health and disease. In modern times cooperative effort greatly restricts the after-effects of these disastrous natural phenomena. War, man's self-inflicted scourge, has been called the best friend of disease. The oldest records bearing on the problem, as well as the voluminous reports of the course and aftermath of the war of 1914-18, lead to the conclusion that this is a fair statement. One of the earliest and most celebrated literary descriptions of wartime plague was written by Thucydides in his account of the Peloponnesian War. The disease came over Athens in two great waves (beginning in 429 B.C.) and carried off thousands of civilians and soldiers. The city was crowded with refugees (it is said that there were 400,000 persons then in Athens, which later centuries were to see reduced to a few thousands).

HEALTH AND THE IMPACT OF WAR

11

Food was scarce, doubtless especially the fresh sources of some of the essential ingredients of a good diet. It is enlightening, as well as amusing, that Aristophanes brings on the stage a countryman, who smuggles into his make-believe market pigs, salt, and leeks ( T h e Acharnians, 425 B . C . ) . This obscure and remote instance at once brings to attention some of the potent evil elements in warfare, confused population movements, overcrowding, and malnutrition. Every great war since those far-off days has been accompanied and followed by vast damage to civilian health. In the Thirty Years' War (1618-48) the German states lost half their population by the ravages of various forms of pestilence and starvation. This overwhelming loss of life is an index of the wretched state of those who survived. Our Civil War, only two generations behind us, brought widespread suffering from typhoid fever, dysentery, and smallpox. It is not necessary to follow in detail the miserable tale of woe.1 The question is sometimes asked, "Are not these terrible epidemics really independent of the wars they seem to accompany?" While it is true that these diseases arise from independent agents, their extensive spread and the degree of sickness and the death rate they cause cannot be dissociated from the 1 Anyone who is interested can read the story (as to epidemics up to 1914) in Prinzing's Epidemics Resulting from Wars (1916).

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CIVILIAN HEALTH IN WARTIME

circumstances of war. At the time of the Thirty Years' War the control of epidemics was in an embryonic state. Yet as soon as local governments were able to exercise their authority, controlling the migrations of people and arranging a normal supply of food and drink, the diseases rapidly began to subside. In many instances the analysis of reliable statistics of well-known diseases leaves no doubt that war opens the door to these epidemics. The progress of medical science and public health administration has restricted many of the diseases that constituted the great historical epidemics to the more backward parts of the world. Some of them, even such as were not long ago common in this country, are mere shadows. The war of 1914-18 was fought less than a generation ago, when medical science was in an advanced state. Its effects on health, therefore, are much more significant for us than those of older conflicts. It was the first great war in which the casualties due to military action approached in magnitude those caused by accompanying evils. In Western Europe there were no great epidemics of the historical type, except the pandemic of influenza, the origin of which cannot be ascribed to the war. Apart from influenza, soldiers in active service particularly were protected against epidemics. In Central and Eastern Europe, however, the story was very different. With the exception of the plague and cholera, all forms of infectious disease were rampant at one time or an-

HEALTH AND THE IMPACT OF WAR

13

other. Western Europe was not immune, and it may be assumed for all the countries which were deeply involved in the war that there was increased suffering from the whole gamut of infectious disease. In regard to other important forms of disease, our knowledge of the effects of the war of 1914-18 is much less precise. Nutritional deficiencies are well known to have been both serious and numerous. From the spring of 1917 onward, the Allies' blockade was effective, and the whole continent of Europe, with the exception of France, suffered greatly. By the end of the war, the urban population of Germany and Austria was reduced to a state of physical exhaustion. Because peace returned slowly, the supply of food continued to be deficient for several years. Widespread weakness and suffering were the results. In a biometric study, the effects of war are stated in terms of population changes. Although this approach does not afford direct information about the whole state of health, it is an index of the final outcome of alterations in health. In round numbers, some of the results of careful estimates are given in the table on page 14. The numbers represent losses of population over those which were normally expected for 1914-18. The outstanding civilian loss was in unborn babies (the natural decline in birth rate has been taken into account). If deaths due to influenza are omitted, the slow downward trend in pre-war death rates in

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CIVILIAN HEALTH IN WARTIME

England and France was interrupted by only a slight increase (of the order of 1-2 per 1000 population). In Germany the increase was about half as much Losses During 1914-18

United Kingdom

Excess of civilian deaths (not 200,000 including influenza) 100,000 Civilian deaths from influenza 600,000 Deficit of births Deaths of soldiers & sailors. .. 1,000,000

France

Germany

200,000 550,000 150,000 100,000 1,000,000 2,900,000 1,400,000 1,800,000

again. Austria-Hungary, Italy, and the other warring nations of Europe suffered more than Germany. There was no significant change in the American rate. The general effect of the war on population trends is seen on comparing the ratios of deaths to births as shown in the table below (after Raymond Pearl; if the ratio is less than 100, the population is increasing). Year

Bavaria

France (Non-occupied)

England & Wales

1914 1915 1916 1917 1918

74 98 131 127 146

110 169 193 179 196

59 69 65 75 92

The unfavorable position of Germany and France is obvious. In 1916 and 1918 nearly twice as many people in France died as were bora. At the end of the war there were two million fewer inhabitants

HEALTH AND THE IMPACT OF WAR

15

of France than at its start (not counting the population of Alsace-Lorraine). The advantage enjoyed by England is equally clear. In the interval between the war of 1914-18 and the new world war, which had its overt beginning in 1939, many advances were made in the organization of war and in its death-dealing machinery. During that period, dire predictions were made of the devastation which any new world war would cause, including the wiping out of whole populations and the complete destruction of cities. Civilian injuries and loss of life in China under the stress of Japanese attacks, and in the European countries which German forces have occupied, have been heart-rending. The damage done to London and other European cities by bombing has been appalling. Nevertheless, the destruction of health and life has been only a tithe of that which was forecast. The death rate in England for 1940 was higher than that for 1939, but only by 15 per cent. The second World War, however, is producing a somewhat different pattern of effects on health than that of 1914-18. Among civilians, injury and death as the direct result of military action — the toll of shell and bomb — are much more frequent. In 1914-18 about 1,400 civilians in England were killed and 3,400 injured in air raids; whereas, in the nine months from September 1940 through June 1941 — the period of London's greatest trial by bombing — 40,077 persons lost their lives and 50,992 were injured in this

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way.2 In the United States nearly as many citizens were killed by automobiles in the year 1941. The blackout of large areas produces special problems. Automobile fatalities in England increased by 38 per cent in 1939-40, largely on account of driving in the dark. A "war of nerves" is being waged, which makes great demands upon the mental stamina of populations. In some parts of Europe, the dreaded age-old infectious scourges, which are prone to accompany war, have flared up. Practically all of Europe is living on rations, which, over much of the continent, are greatly deficient. A few misguided propagandists have claimed for war a mythical uplifting effect on man. History tells us that this is nonsense. No evidence exists that war causes any elevation of the level of health, physical, mental, or moral, of the peoples engaged. There is no survival of the fittest, but rather a depletion of the fittest. The major processes by which war acts on health may be grouped under seven headings, if we bear in mind that the interaction between all these forces is both constant and complex: (1) Withdrawal of the fittest citizens for military service. (2) Decrease in births. (3) Direct military damage, threatening not only maiming or death, but also disruption or destruction of office, factory, and home, leading a

The high proportion of deaths (about 44 per cent) in the total casualties is notable. It far exceeds that of previous wars. In 1914-18 the ratio of deaths to injuries was about one to four.

HEALTH AND THE IMPACT OF WAR

17

toward an unemployed, homeless, wandering, and starving population. (4) Requirement of harder and more hazardous work with fewer and less expert workers, while better food and better play are needed. (5) Interference with the supply and distribution of food and clothing, both local and imported; disturbance of the cost of these essentials in relation to wages. (6) Demand for mental adjustment to new conditions, and conquest of anxiety, fear, greed, and license. (7) Increase in disease, both in incidence and in severity, from malnutrition, crowding, and migration of people, with the risk of collapse of sanitary and medical systems. Certain aspects of modern society and modern warfare render civilian life particularly vulnerable. Large areas are densely populated. Urban agglomerations of from half a million to ten million people are numerous. Industries of all kinds are similarly crowded together without the slightest reference to the risks of war. Occupations and factories are specialized so highly that replacements are difficult and trying. Society is entirely dependent upon an intricate and delicate network of communications, and an equally complex sanitary system. The decline in the size of the family has greatly weakened the position of the individual in times of stress, and correspondingly increased his dependence upon public agencies. The automobile has made large numbers of people highly mobile — a dangerous characteristic in wartime. The radio has habituated

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everyone to continuous "up-to-the-minute" news from all over the world, as well as to constant distracting entertainment; its potentialities for evil are quite as great as those for good. Modern armies are completely dependent upon civilian industry for their creation and support. The pace of labor can never be allowed to flag; rather it must be constantly quickened. The industrial worker is as essential to victory as the soldier. The airplane and the mechanized army with breathtaking speed bring war into the very midst of the civilian population. Both of these developments bring soldier and civilian into a new and high degree of mutual dependence and intercourse. This relationship needs to be understood, fostered, and utilized for the common good. If modern society is highly vulnerable, and modern warfare potentially overwhelming, there are also elements of social strength which may ward off disaster. It seems now as if scientific knowledge of nutrition had been in its infancy in 1915. Great progress has been made in the control of infectious diseases, as also in the understanding and treatment of mental disturbances. Industrial hygiene is far more highly developed than it was a generation ago. Numerous agencies for social welfare have been developed, which contribute to the cause of health. The discovery has been made that work must be limited. Food for the mind must be provided, as well as for the body. Recreation is a necessity, not

HEALTH AND THE IMPACT OF WAR

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a luxury. New methods of treatment, medical and surgical, for war injuries save many lives. An outstanding example is the use of the blood bank. Man's ingenuity can find ways to avoid destruction, if only time permits. The means of defense may lag behind, but they tend to catch up with the forces of destruction. Americans can take courage from the experience of Britain, for the strength and determination of her people have held off the would-be invader without overwhelming human losses. Furthermore, it is reported that British health in the unusually severe winter of 1940-41 was better than that of many ordinary peace-time winters. In certain respects the health of Americans has undergone continuous improvement. The expectation of life at birth has risen from fifty-one years in 1920 to over sixty years in 1940. The death rate has fallen from 14.1 per 1,000 in 1915 to 10.6 in 1940. Infant mortality has declined from about 100 deaths per 1,000 living births in 1915 to 47 in 1940 (the rate in New Zealand, however, is about 31). Deaths of mothers in childbirth were unduly high in 1920, 8 per 1,000 live babies born (about twice the rate of England), but by 1940 they were reduced by more than half; even so, the rate in Sweden and Denmark before 1939 was 25 per cent lower. On the other hand, it is well known that the birth rate fell. The excess of births over deaths in 1915 was 11 per 1,000 population; but it was only 7.1 in 1940. Mother and child are vulnerable elements in the

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population and, at the same time, its only means of survival. The general statistical data which are quoted above cover a multitude of variations in different geographic sections and social groups of the United States. It is not easy to evaluate the physical and mental health of the "average citizen." In 1917-18 the draft boards and army examiners found 52 per cent of the young men who registered to be defective. They rejected completely 21 per cent and accepted 10 per cent for limited service only, so that one in three was not suitable for full military duty. As a result of the examinations for selective service in 1940-41, about 45 per cent of those called were rejected. The significance of the increase in rejections is the subject of controversy. The examinations were made when the country was at peace. It seems hardly likely that the standards in use were the same as those of 1917—18. Certainly it would be hazardous to draw any conclusion from a comparison. A large number of the defects which are listed are not ordinarily considered to be serious, because apparently they do not interfere with a normal life. We may expect, indeed, to see many of the young men who were at first refused ultimately taken into the service. Among the defects in this group are poor teeth, poor eyesight, "diseased" tonsils, and flat feet. A great many defects were found which can be made good. Poor nutrition and bad living conditions have been blamed for much

HEALTH AND THE IMPACT OF WAR

21

of the ill health of "selectees." Health surveys have not been altogether reassuring. In the winter of 1935-36 about six million people were incapacitated each day by illness or accident. We know that industry loses a much larger amount of labor through sickness than it does from accidents. In spite of these considerations, there is no ground for describing the picture of American health as black. It is more to the point to indicate the deficiencies and the means to repair them. The danger spots and the methods of protecting them imperatively call for study and action. The contribution of health toward victory in modern warfare cannot be exaggerated, for good health is the human stuff of which victory is made. We are not concerned here with the health of soldiers and sailors; it has long been realized that every effort must be made to keep combatants in the best of health. The general population, however, is the source of the country's fighters, so the latter's basic health cannot be entirely independent of the general health. The armed forces must be constantly replenished as the struggle proceeds. National health means a steady, and with time, an increasing number of men to draw upon. Furthermore, it takes a healthy people to know that machines and munitions are needed to win a war in the 1940s, and to turn them out at an adequate rate. The qualities of health will play a dominant role in meeting the demand for increased work, which is necessary in

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every important industry; harder work and longer hours are inevitable. Wartime programs cause dislocations and confusion which call for adaptability of a high order. Of a higher order than even this last quality, is the calm, determined spirit of cooperation, which may be the decisive element in the outcome. For large groups of people this spirit must have a foundation in good health. Much has already been done toward planning and organizing the maintenance and improvement of America's health in this critical period. Civilian defense, in the broadest sense, includes the whole problem of the maintenance of health. For practical purposes, however, it is necessary to limit organizations for civilian defense to the narrower field of protection of life and property. The immediate defense of civilians is a civilian task, for the army has other work to do. The need for such defense is something new in the annals of war, for never before have non-combatants been so subjected to attack. The example of Rotterdam, where nearly as many citizens lost their lives in a few days as did in England's nine months of heavy bombing, shows the danger of failure to organize civilian defense. Unhappily, it must be admitted that the line between the fighting forces and non-combatant citizens, including women and children, is disappearing. The vital work of organizing citizens for self-defense is going on under the supervision of the national Office of Civilian Defense (a subdivision of the

HEALTH AND THE IMPACT OF WAR

23

Office of Emergency Management). This office works through state and local defense councils, which are largely made up of state and local officials. Under them is proceeding the necessary training of personnel for all the numerous duties which are required to ward off the attacks of the enemy upon civilians and civil institutions. The organization of hospitals and other medical facilities is one of the essential features of this program. Another national coordinating body, the Office of Defense Health and Welfare Services, has been established under the Federal Security Agency to care for the broader aspects of health. Thus, there are two national bodies to which is committed the general supervision of the nation's health for the duration of the war.3 The Office of Defense Health and Welfare Services is concerned with general problems of health, including nutrition, and related matters of education, recreation, and family security. It is working with and through established agencies, such as the United States Public Health Service and the Children's Bureau in Washington, and private organizations all over the country, instead of setting up an elaborate new organization. Under the National Research Council, numerous committees plan and supervise important research work which must These two national agencies face a difficult problem in the adjustment of centralization and dispersion of authority and facilities, especially in civilian defense. The comment of those familiar with British organization for the same purpose is all to the effect that there is too much centralization in this country. 3

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be done in order to solve pressing practical problems in the field of health. The Department of Agriculture and related agencies are planning and helping American farmers to carry out a program of food production which is designed to prevent any serious shortage. The new National Housing Agency is striving to bring order out of chaos, especially in the housing of defense workers. The war is not the occasion for the curtailment of any of America's social services. No petty economy in the midst of lavish spending for armament and munitions should be allowed to tempt us to risk the success of the whole undertaking by undermining our health or by omitting any possible measure to improve it. On the contrary, wise spending, even of increased amounts, for better health is our cue. In our planning, we should bear in mind the peace that is to come after the war, so that what we do for health in time of war may lead to permanent benefits. Meanwhile, our highest purpose is the improvement of national health to the end that we may be able to preserve and ultimately enjoy to the fullest our national heritage.

CHAPTER I I THE NUTRITIONAL BACKGROUND

F

OOD takes high rank among the munitions of war. The United Nations will not win this war through the starvation of Axis peoples alone. Nevertheless, an adequate food supply is a necessary element in victory. Although food alone cannot win a war, the lack of it may entail defeat. Lack of food was a contributing cause of the failure of the Central Powers in 1918, even though the diet of German soldiers was still adequate in the last year of the first World War. An army of citizens whose families are on the edge of starvation will not continue indefinitely to fight. The winter and spring of 1917-18 were for Germans "turnip time." That time has not been forgotten by those who passed through it without benefit of special privileges. In December 1918 the German Board of Public Health presented a memorial to the Peace Conference, which described the nutritional state of the German population in terms which indicated that great damage had occurred during the war. The existence of the conditions described in this memorial was amply confirmed by the studies of a British Committee under the leadership of Professor Ε. H. Starling, whose report was published in 1919. There can be

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little doubt that bad food, lack of food, and malnutrition were important elements in the internal collapse of Germany in the latter part of 1918. The definition of good nutrition is still the occasion of discussion, and, partly on this account, there are differences of opinion concerning the prevalence of poor nutrition in the United States. One of the reasons for the lack of agreement in this matter is that the work of one observer or group of observers tends to be confined to a limited section of the population or to a particular region of the country. It is well known, however, that nutrition varies greatly from group to group and region to region. Another consideration is that poor nutrition is often thought of as necessarily expressing itself in commonly recognized forms of manifest disease, whereas students in this field are just beginning to know the minor evidence of inadequate nutrition. Furthermore, the importance of bodily reserves of certain nutrients, the estimation of which requires very special studies, is only now dawning upon us. Yet such reserves may play a vital role when foods are suddenly restricted, and in the face of extra stress, disease, or accident. The effects of prolonged or severe undernutrition are beyond controversy. Many careful studies were made by scientifically trained observers during the war of 1914—18 and in the years immediately afterward. According to the German physiologist Rubner, one of the earliest results of an insufficient diet

THE NUTRITIONAL BACKGROUND

27

is a decrease in the efficiency of workers, including not only the hired laborer, but everyone with any physical task. Vigor is lost and with it the desire for sport. Economy of muscular activity insidiously increases. Two advantageous changes were noted in Germany: obesity tended to disappear; and diabetes decreased greatly in frequency and severity. But in addition to the loss of fat, there came shrinkage of muscles and other vital tissues. The German scientist Loewy saw his body weight fall from 143 to 112 pounds from 1914 to 1917 (a loss of 22 per cent). A similar loss of mental vigor and capacity was described. Graham Lusk relates that a distinguished German mathematician kept to his bed in order to make the most of the available food and continue his mental work. The particular so-called deficiency diseases, to which reference is made later in this chapter, in both severe and mild forms were widespread at the end of World War I. For reasons that will be made clear in a later chapter, children especially suffered from the effects of both general and specific defects in their diets. Sir John Orr, whose work in the field of nutrition has meant much for the welfare of the British people, has defined perfect health as a state of wellbeing that cannot be improved by a change in the diet. Since an adequate supply of food is of such fundamental importance for national success, some idea of what constitutes a proper diet and how we may all enjoy its benefits is essential.

28

CIVILIAN HEALTH IN WARTIME

Man has obtained food (when he could) and eaten it without much thought until recently. The social and economic changes of the last century have greatly altered the foods and food habits of Americans and Europeans.1 Two generations alone have seen the creation of a great science of nutrition, which teems with information about the significance of our foods and with practical suggestions for our better nourishment. Much of the most enlightening portion of this knowledge has developed in the past twenty-five years. Today, when the expert in nutrition looks at our diets, he finds that all is by no means well. Since the early nineteenth century, great urban populations, which make almost no contribution to their supplies of raw foods, have come into being. Extensive farm lands have been devoted to one or two crops, or to grazing for dairy or meat products, all for sale to huge processing industries or central distributing agents. Large tracts have been dependent for their profitable working upon the export trade; as, for example, cotton, tobacco, and wheat. The growth of industry and the development of mechanized farming have both contributed to the existence of a population with low purchasing power. The fluctuations of trade and employment have caused their purchasing power to vary enorTwo fascinating books describe these changes: The American and His Food (1940), by R. O. Cummings, and The Englishman's Food (1939), by J. C. Drummond and A. Wilbraham. 1

THE NUTRITIONAL BACKGROUND

29

mously from time to time. Furthermore, we have not yet learned to control harvests so as to avoid alternating surpluses and shortages. On the other hand, a vast food industry has been built up, which in a measure has centralized and standardized food supplies. One of the results of these changes is obviously a complicated and costly distributive system. The necessity of storing staple foods led to their "purification," because they were found to keep much better.2 In the case of flour and sugar this process was carried to a high degree. It happened that as they were chemically purified they became white, a quality sometimes taken to stand for purity in a wider sense. Hence in the case of flour the process is completed by bleaching. In this and other matters the food industry doubtless both led and followed popular demand. Supply and cost, custom and taste, control the consumption of foods. Advertising, fashion, and education continually play upon established custom, which, however, alters slowly in a given generation. Taste, which is the result of habit, is a powerful influence. Mass taste, or what is interpreted to be the taste of the masses, leads to mass production of food and drink, cast in a well-defined mould. Such mass production then inevitably reinforces and 2 The quotation marks signify that the materials removed in such processes are not, in general, impurities. Wheat-germ, for example, is a valuable food, although it is removed in "purification."

30

CIVILIAN HEALTH IN WARTIME

tends to perpetuate the taste on which it was built. Taste even constitutes a professional hazard for the scientist who offers practical dietary advice.3 Our ancestors, not having much sugar available, for the most part made shift to do without it. In 1941 the annual per capita use of sugar in the United States was 114 pounds, of which about 74 pounds were used in homes. The total consumption was well over five times the amount for the decade 1840-49. About 17 pounds per capita of candy were eaten by Americans in 1941. Sugar is found today not only in sweets, but in all our bread, most of our tinned goods including soups and vegetables, and most of our drinks. Since 1890 the use of wheat and meats has declined by about 30 per cent. The consumption of butter has increased somewhat; that of milk to a greater extent (at least in cities). A most important change is the growth in our use of vegetables and fruits, which was made possible by rapid transportation, refrigeration, and canning. Man as a living organism needs a nearly constant supply of food to maintain optimal vigor. The various nourishing substances into which the foods are changed by digestion and cellular action intimately interact with the living material of which the cells of the body are composed. (The old image of food * Only by a special effort can a nutritionist divorce himself from his own liking for, or dislike of, whole-wheat or white bread, cow's milk, or sugar (as in the choice of sugar or corn as a source of extra alcohol for war use).

THE NUTRITIONAL BACKGROUND

31

burning in a fire is altogether unsatisfactory and has been abandoned.) Life and all its activities seem to parallel these interactions. The particular nutrients which the body requires are many; doubtless the known list is incomplete. The tissues can store some of these substances in varying amounts, but in every case interruption of the supply contained in food is followed sooner or later by lowered vitality. Physiologists understand fairly well the special functions of some of the nutrients; others await further study. An incomplete list, giving only the more important nutrients, follows ("certain" means definite chemical compounds): Oxygen (from food and drink as well as air). Water (from all food and drink). Certain amino acids (from certain proteins). Certain fatty acids (from various fats). Glucose (from carbohydrates and proteins). Minerals, for example: Calcium, chlorine, iodine, iron, phosphorus, potassium, sodium, sulphur. Vitamins, for example: Vitamin A, certain sterols (D), certain naphthaquinones (Κ), tocopherol (E) — all fat-soluble; ascorbic acid (C), thiamin (Bi), riboflavin (B2 or G), niacin, pyridoxine, pantothenic acid — all water-soluble. To do its best work continuously the body needs certain optimal amounts of each nutrient, which in some cases are not yet known. The essential nutrients are found in varying amounts in natural foods,

32

CIVILIAN HEALTH IN WARTIME

which frequently give no outward indication as to whether their value in this regard is great or small. Meat proteins and the proteins of dairy products are adequate sources of the amino acids needed, whereas proteins from a single vegetable source are not. Moreover, the amount of a given nutrient in a natural food as eaten is subject to a great variation. The value of milk depends upon whether the cows have been out to pasture or fed in the stall; if cows are stall-fed, it depends upon the composition of their fodder. The vitamin content of vegetables and fruits is influenced by the nature of the soil, and even by the season in which they are grown. In some cases the age and method of handling affects the vitamin and mineral content. Drying destroys a large part of the vitamin content of fruits and vegetables. The canning industry has made great and, on the whole, successful efforts to conserve a high vitamin value in its products. Refrigeration and rapid freezing not only prevent foods from spoiling in the usual sense, but generally prevent the loss of essential nutrients. Long cooking destroys some vitamins. Valuable minerals and vitamins are commonly wasted by extensive peeling and by discarding the water in which vegetables are boiled. Some of the special functions of the ultimate foodstuffs are of great interest. Parts of the story of the vitamins are familiar.4 The war of 1914-18 brought For a readable and reliable account, see Vitamins: What They Are and How They Benefit You (1940), by Henry Borsook. 4

THE NUTRITIONAL BACKGROUND

33

to light some of the less well known results of specific nutritional deficiencies. Xerophthalmia is a disease of the eyes which leads to blindness, and in the very young is associated with a high mortality. In neutral Denmark this condition steadily increased in frequency during the war years until the winter of 1917-18, when it suddenly almost ceased to appear. But in 1920, more than a year after the end of the war, 25 cases occurred, whereas in 1919 there were only four. The study of these events led to their explanation. Up to the end of 1917, as the price of butter rose, Denmark exported more and more of this commodity, and her people increasingly used margarine, containing no Vitamin A, as a substitute. On December 21, 1917, butter was rationed at a reasonable price, each person getting nearly nine ounces a week. In ignorance of the situation, the government stopped this ration on May 1,1919, and the manufacture of margarine was resumed. It soon became clear that xerophthalmia is caused by severe deprivation of Vitamin A, of which butter is one of the richest sources. In Germany, by contrast, it is said that xerophthalmia tended to disappear during the war. This unexpected phenomenon is attributed to the successful encouragement of mothers to nurse their infants and to the special diets provided for mothers. It is now known that a definite amount of Vitamin A is necessary for the maintenance of good vision. When food is deficient in this essential, ability to see properly in dim light is impaired long

34

CIVILIAN HEALTH IN WARTIME

before there is any obvious disturbance (which may, indeed, never develop). The significance of this function for performing the increased amount of work at night which has to be done in time of war is obvious. Mild Vitamin A deficiency is considered to be common in the United States. Dr. Norman Jolliffe has found evidence of it in 60 per cent of the patients in one of the divisions of Bellevue Hospital in New York. The history of scurvy and rickets (which are caused by severe deprivation of Vitamins C and D respectively) has often been told. Both of these diseases were widespread in Europe in the later years of the first World War, and for two or three years after it. Except in mild forms, neither condition is now common in America. It is now possible to measure reliably the nutritional status of a person with reference to Vitamin C. The results show that deficiencies in this nutrient are common among Americans (the proportion runs as high as threequarters in some groups), although plain signs of scurvy are lacking. A marked and prolonged dietary lack of minerals in Central Europe toward the end of the war was associated with a rickets-like disease of adults, called osteomalacia, in which the bones are softened and liable to distortion. This condition is almost unknown to doctors in America. Hunger edema, or war edema, was another affliction of Europe during the war of 1914-18 (nearly

THE NUTRITIONAL BACKGROUND

35

23,000 cases were reported in Bohemia alone). In this state the tissues accumulate water and become bloated, so that the soft parts of the body finally become visibly swollen. This form of edema is due to a deficiency of proteins in the circulating blood, which are built by the body from amino acids derived from the dietary protein. There are some twenty-odd amino acids known to exist in varying combinations and amounts in food proteins. Some of these can be synthesized by the body; and some, perhaps, are not needed by man. About ten amino acids, however, are required in the human diet, and food must be chosen so as to supply these needs in the right amounts. The body proteins, of course, have other functions than the prevention of edema. They are essential constituents of all cells and, therefore, are particularly needed during the period of growth. The vital activity of cells also entails a constant minimal destruction of body protein, which must be made good by the formation of new human protein from the materials of the diet. Apart from lack of growth and hunger edema, no specific disease is known to result from inadequate protein intake. The effects are lost in the general picture of malnutrition. The proteins of the blood, however, can be accurately measured, and deficiencies are known to be very common in America. One of the results of extreme deprivation of vitamins of the Β group is beriberi, a disease which in

36

CIVILIAN HEALTH IN WARTIME

its full development is rare both in Europe and America, even in wartime. A portion of the picture of beriberi, which consists of pain, tenderness, and malfunction of the nerves, is common among Americans, especially in association with alcoholism, digestive diseases, queer diets, and pregnancy. Recent studies have shown that milder lack of the Β vitamins is widespread. Doctors of the Mayo Foundation, and others, have demonstrated that the early signs of lack of thiamin (B x ) resemble those of neurasthenia, including: loss of appetite (followed by further dietary deficiencies), inefficiency in work, loss of interest, irritability, depression, anxiety, uncoöperativeness, and slovenliness. As Dr. Russell Wilder has pointed out, such a state readily lends itself to defeatism. Pellagra, which involves extensive disturbances of the skin, digestive system, and mental functions, is another manifestation of deficiencies in the Β group of vitamins. It constitutes one of the more serious health problems in the United States, since it is common and severe in the Southern States. Two independent observers estimated that there were one hundred thousand cases of pellagra in America in 1938. The two vitamins the lack of which is principally responsible for the appearance of pellagra are niacin (formerly known as nicotinic acid) and riboflavin. A deficiency of riboflavin, which shows itself in relatively minor changes in the eyes, skin, lips, mouth, and tongue, is perhaps the

THE NUTRITIONAL BACKGROUND

37

commonest of all our nutritional inadequacies. It is of special interest that Dr. C. P. Rhoads has shown in animal experimentation that certain cancer-producing chemical agents operate only when animals are deficient in riboflavin.5 Iron and protein form hemoglobin, which is a vital physiological compound, since it is essential for the transport of oxygen from the lungs to the tissues. Anemia, which is hemoglobin deficiency, is associated with only vague and unimpressive symptoms. Hence, although iron deficiency is common, it is often unrecognized. Another mineral element which must be present in the diet or drink in minute quantities is iodine. An inadequate intake of this nutrient is followed by the development of goitre and failure of the thyroid gland. Not all of the nutrients have been considered, but only outstanding examples. It is sometimes forgotten that oxygen and water are essential nutrients. Inadequacies in their intake, however, rapidly make themselves felt. It is important to note that the nutrients are numerous and, as has already been pointed out, there are probably more awaiting discovery. The vitamins in certain ways are losing their special position as a group, since they have turned out to have no particular relation to one another in either structure or function. It would be 8

These results should not be considered to apply to the problem of the cause of human cancer, unless studies in man demonstrate their applicability.

38

CIVILIAN HEALTH IN WARTIME

difficult, if not meaningless, to arrange the nutrients in order of importance, for they are all essential. The particular illnesses caused by the lack of the essential nutrients are known as deficiency diseases. In every case they represent severe deprivation and signify starvation in one or another form. Modern studies have proved that most of these conditions have a complex origin and are not due to the simple lack of one nutrient. As common sense would suggest, dietary deficiencies are seldom single. Furthermore, the various basic nutrients have involved interrelations. For example, the ability to use certain minerals at a given level of intake depends upon the availability of Vitamin D. We are slowly learning about the slight and insidious signs of minor deficiencies in the nutrients, as in the case of Vitamin Bj cited above. Still more important is the realization that there is an optimum requirement of each basic food material for positive good health, which proceeds from our knowledge that the nutrients enter into the general life of the cells of the body. The physiological ideal now is not so much the prevention of the deficiency diseases, which should soon pass into the limbo of things "of historical interest," but rather of maintaining robust good health. In addition to the numerous specific needs which must be supplied in food, the total heat-producing capacity of the diet, or its caloric value, must be considered. The caloric value determines how much

THE NUTRITIONAL BACKGROUND

39

energy the body can develop without using up its own stores, and how much energy can be stored up against an hour of want. Most Americans meet this requirement predominantly by sugar and starch, and then by fats, with protein in a minor role (in this regard, sugar, starch, and proteins have about the same value by weight, and fats two and a half times as great a value) .6 In energy production, the body does well over a wide range of variation in the relative amounts of these foodstuffs, provided a great shift is not made too rapidly. Both the total fuel value and the amounts of the various nutrients required are determined by the size and activity of the individual. If deficiencies exist in any of the normal body stores, they should be made good by increased consumption of appropriate foods. Many diseases interfere with the absorption of nutrients, or cause the body to use abnormally large amounts, so that the patient needs greater than normal supplies of such nutrients. The harder the work a man does and the longer his hours of labor, the greater his needs. Women in most circumstances require smaller supplies than men of the same size. Growth and old age, pregnancy and nursing, introduce special requirements, which will be described elsewhere (see Chapters VI and VII). Nutritionists find it useful to consider the requireEach gram of sugar, starch, etc., and of protein, yields about four large calories; each gram of fat about 9.3 large calories. The exact value varies with different compounds. 6

40

CIVILIAN HEALTH IN WARTIME

ment of a normal adult man engaged in moderate work as a unit, and to state those of other individuals as fractions of that unit. A general idea of the daily caloric requirement can be obtained from the table on pages 50-51. When the diets of Americans of today are scrutinized in the light of modern nutritional science, we can better appreciate the significance of the great changes in our dietary regime during the last two or three generations. Extensive purification of foods removed many valuable nutrients before their value was realized. White flour has lost two-thirds or more of the mineral content and practically all of the rich supply of vitamins of the Β group, which are natively inherent in whole-wheat. Since flour (mostly in the form of bread) bulks large in all American diets, this is a serious loss. The enormous increase in the consumption of sugar, which supplies only one nutrient, must jeopardize the supply of other nutrients, unless some other dietary change counteracts the tendency. Fortunately, most valuable additions to our food were made in the shape of vegetables and fruits. These foods, with some exceptions, are low in caloric value, but high in vitamin and mineral content. Milk and butter, which are important sources of essential nutrients, have been low in the diets of our industrial populations, but have recently shown moderate increases. In spite of these improvements, American diets all too often are found to be deficient, or to have a danger-

THE NUTRITIONAL BACKGROUND

41

ously narrow margin of safety, in adequate proteins (those which furnish the necessary amino acids), Vitamin A, the vitamins of the Β group, and the minerals, especially calcium. The outstanding result of studies of popular diets is the wide variation in their content and nutritional value at different levels of income and in different sections of the country. A high expenditure for food does not necessarily ensure a good diet, since doctors not infrequently encounter well-to-do individuals who suffer from a particular deficiency or deficiencies. Such dietary inadequacies are usually due to idiosyncrasies or fads. In general, the value of diets tends to parallel the income, and deficiencies are commonly found only at lower economic levels. Two extensive studies of American diets were reported in 1939 by the Bureau of Home Economics of the United States Department of Agriculture. The first dealt with the food of families of employed city workers in the major industrial regions of the country. Families receiving relief and those with incomes of less than five hundred dollars per annum were excluded. Of all the diets which were studied, 40-60 per cent were in need of improvement. About 10 per cent of the diets were deficient in caloric value (all at the lowest level of expenditure for food). Some other inadequacies, stated without reference to the region or the expenditure for food, in approximate percentages of the diets which were studied, are shown in the table on page 42.

42

CIVILIAN HEALTH IN WARTIME

Deficiencies in pellagra-preventive vitamins were found extensively only in certain southern states, where 60-70 per cent of white persons in the lowest income level were receiving less than desirable amounts of these nutrients (this would amount to Dietary Value Protein Calcium Iron Vitamin A Vitamin Βχ Riboflavin Vitamin C

Sub-minimal 2 per cent 17 5 25 25 1 10

Sub-optimal 25 per cent 50 25 75 75 25 50

about 20 per cent of the families studied in this region). Differences in the foods habitually used resulted in the negroes' faring much better in this regard than the whites at the same income level (2 per cent subminimal, against 12 per cent for the whites). Important differences in the nutritional value of diets result from choices of foods as well as from local prices. In this study of the diets of urban workers, at the same level of per capita expenditure for food ($2.50 per week), only 37 per cent of white families in Alabama and Tennessee had poor diets; on the Pacific coast, 47 per cent of families in this group had poor diets; while in Ohio, Indiana, Michigan, Pennsylvania, New York, and New England about 70 per cent of the diets .were poor. It is remarkable that the diets of families at this single level

THE NUTRITIONAL BACKGROUND

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of expenditure in Alabama and Tennessee were almost equally divided into the good, fair, and poor categories of nutritional value. These differences are related to local costs of particular foods, especially meat, milk, fruit, and vegetables, and also to the individual selection of foods. A somewhat similar survey of the diets of farm families brought out the fact that, while many farm dwellers were better off nutritionally than urban workers with comparable expenditures for food, the value of farm diets is much influenced by the season, and varies greatly in different regions. If it were not for their consumption of home products, which consist chiefly of milk, vegetables, and fruit, farmers would, of course, be much worse off than city workers. Even with these advantages, the proportion of inadequate diets on farms was not greatly different from that in city homes. In summary, the words of the Department of Agriculture Yearbook for 1939 may be quoted: "All too many families in the United States have poor diets; some have fair or passable diets; and only relatively few have really good diets." A group of experts, reporting in the spring of 1942 for the Food and Nutrition Board of the National Research Council, concluded that the nutritional status of an appreciable part of the American population could be distinctly improved; and added that, if optimal nutrition was sought, not mere adequacy, widespread improvement was possible. Let us be clear

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that there is no ground for believing that "diseases" caused by nutritional deficiencies are rife in the United States. The point is that we know many ways in which the nation's diets can be improved, and, thereby, the health of its citizens. We like to think of our country as a land of plenty; and such it is indeed. Except at the lower income levels, the waste of food is great. The urban survey of the Bureau of Home Economics showed purchases of food with per capita fuel values of 4,000 to 5,000 calories a day, much more than could have been utilized. Far worse than this household waste is the actual destruction of certain foods, which has taken place from time to time, "in order to protect the producer" (and the distributor, let us add). The past decade has seen a series of "surpluses" of various staple foods. We have not used even the whole supply of milk produced, but have discarded large quantities of it after it is skimmed. Now that we have entered a great international trial of our strength, the problem of providing our people as a whole with adequate diets insistently demands solution. Clearly, some more adequate form of statesmanship than that we have been practicing is necessary.

CHAPTER III INCREASED STRENGTH THROUGH B E T T E R

DIETS

HE German armed forces consist of young men in unusually excellent physical condition. So runs the testimony of all observers. There can be no doubt that this state is the result of careful planning, in which every consideration was given to the dietary basis of health. The German program of nutritional upbuilding began in the middle 'twenties, long before Hitler came into power. Great advances were made in the preparation of dehydrated food rations for military forces. The manufacture of vitamins was developed to a high point, so that large supplies are now available at low cost. Less is known about the nutritional state of the German civil population, but it is likely that the general diet is not far above the margin of adequacy. It is noteworthy, however, that workers in heavy industries receive special rations, perhaps double those of ordinary citizens. The German government has made far-reaching attempts to prevent the blockade from reducing its people to the straits they reached in 1917 and 1918. Great Britain and, especially, France have been slow to attack the problem of general improvement of popular diets. It may well be that the sudden

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collapse of France in 1940 had some of its deeper roots in malnutrition. English diets have been even more defective than those in America. Neutral correspondents in 1939^40 made many unfavorable comparisons of the physiques of French and British with those of German soldiers. Since 1939, the British government has striven valiantly with the great difficulties which confront it in its nutritional problem.1 In ordinary times Great Britain has to import 60-70 per cent of all her foods. The loss of supplies from Denmark and the Channel Islands, and especially the shortage of shipping, threatened to cause the collapse of British food economy. The outcome, however, has been quite otherwise. Harvested acreage was increased in 1941 by 45 per cent over the pre-war area. It proved possible to raise significantly the number of milch cows. By December 1941, British stocks of food were double those of September 1939. Above all, the government has gradually achieved a reasonably satisfactory and fair control, not only of agriculture, the manufacture and importation of foods, but especially of their distribution. After more than two years of war, the diets of many British workmen and children are better than they were in 1939. Britain, of course, is still dependent upon imports of food materials. Although Canada, other parts of the Empire, and the Argentine are able to furnish 1 See Feeding the People in War-Time (1940), by Sir John Orr and David Lubbock.

BETTER DIETS - INCREASED STRENGTH

47

much of the needed supply, the United States must aid Britain by sending her food as well as by helping in its transportation across the ocean. America's contribution constitutes about 5-6 per cent of British total consumption, and about 3 per cent of our supplies. The items which are included, however, are of very special value. As a result of German occupation of the Ukraine and other parts of the Soviet Republic, the possibility exists that Russia, the greatest wheat-consuming country in the world, may have to seek foreign supplies of wheat, which could best come from America. In time, sheer humanity will undoubtedly compel America to give food to the peoples of the war-stricken Continent of Europe. These external calls upon the American larder must be borne in mind in planning our wartime food economy. We have seen that diets here in America are greatly in need of improvement, and that nutritional deficiencies are reflected in various weaknesses among large groups of Americans. The demands of war forcefully call attention to the need for widespread improvement in our food supplies and diets. The increased employment furnished by the armament program will not alone solve these problems. Warlike conditions will assuredly intensify the difficulties in food supplies, distribution, and costs, which prevent so many Americans from having good diets, unless wise and energetic steps are early taken to avoid such an event. We must also strive to make

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good existing deficiencies. The strain of war must be anticipated by every possible effort to bring a maximum number of citizens to perfect health. Good nutrition is the foundation of health. Many agencies in the United States, national and local, public and private, are concerned with American food supply and diet. The Department of Agriculture is, of course, the most important single organization in the field. Citizens who are not acquainted with its excellent work would do well to put themselves in a position to give the Department their understanding support. An important guiding body is the Committee on Food and Nutrition of the National Research Council, which is composed of scientists who specialize in nutrition. The Council also has a Committee on Food Habits. For immediate purposes, all national nutritional activities are coordinated under the Advisory Commission to the Council on National Defense. Plans have been made for the closer cooperation of regional and local agencies with federal bodies. In May 1941, a National Nutrition Conference was held in Washington at the call of the President. Work on the many problems which demand solution is now under way. One of the most pressing questions has been that of standards for adequate diets. The Committee on Food and Nutrition in 1941 adopted a statement of recommended daily allowances for specific nutrients. In individual instances there is difference of

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49

opinion concerning the amounts which are necessary to provide optimal health. In some cases adequate data pertaining to human needs are not available. It must be admitted that there is a tendency to assume certainty where none exists, and to jack the allowances up in order to provide a margin of safety, the need of which is not clear. Nevertheless, the recommendations of this committee represent the best advice we have. Simply to give some idea of the complexity of the problem and of the care which is being exercised at each step in its solution, a table is reproduced which shows these allowances — as yet tentative (see pages 50-51). It may seem that food science has wandered a long way from everyday life. The query, "How did our forebears manage to survive without all this modern knowledge?" is a natural one. But the answer is not difficult to find. On the one hand, the men of old did not all survive; nor were they necessarily as healthy as we are wont to think.2 Only those who intuitively, or through special advantages, secured a good diet enjoyed health or survived. On the other hand, their foods were not highly processed or simplified, and much more meat (which always contains many nutrients) was consumed, especially by the well-to-do. There is also a tradition that a variety of foods ensures an adequate diet. This idea does not stand 2

Hunger and History (1939), by E. Parmalee Prentice, tells the story of how food has been produced through the ages.

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CIVILIAN H E A L T H IN

WARTIME

RECOMMENDED DAILY ALLOWANCES COMMITTEE ON FOOD AND NUTRITION,

Calories

Protein, Gm.

Calcium, Gm.

Man (70 Kg.) Moderately active 3,000 70 70 Very active 4,500 Sedentary 2,500 70 Woman (56 Kg.) Moderately active 2,500 60 Very active 3,000 60 Sedentary 2,100 60 85 Pregnancy (latter half) 2,500 Lactation 3,000 100 Children up to 12 years Under 1 year § 100 per Kg. 3 - 4 per Kg. 1,200 1 - 3 years 40 4 - 6 years f 1,600 50 2,000 60 7 - 9 years 70 2,500 10-12 years Children over 12 years 80 2,800 Girls — 13-15 years 16-20 years 2,400 75 3,200 85 Boys —13-15 years 100 3,800 16-20 years

Iron, Mg.

0.8 0.8 0.8

12 12 12

0.8 0.8 0.8 1.5 2.0

12 12 12 15 15

1.0 1.0 1.0 1.0 1.2

6 7 8 10 12

1.3 1.0 1.4 1.4

15 15 15 15

* Journal of the American Medical Association, CXVI, 2601 (June 7, 1941). Reproduced by permission. These are tentative allowances toward which to aim in planning practical dietaries. These allowances can be met by a good diet of natural foods; this will also provide other minerals and vitamins, the requirements for which are less well known. ° " Requirements may be less than these amounts if provided as vitamin A, greater if chiefly as the provitamin carotene. f One mg. of thiamine equals 333 international units; 1 mg. of ascorbic acid equals 20 international units (1 international unit equals 1 U. S. P. unit).

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51

FOR SPECIFIC NUTRIENTS * NATIONAL RESEARCH

COUNCIL

A," International Units

Ascorbic Acid Nicotinic Riboflavin, Acid,° (C),f Mg. Mg. Mg.

Thiamine ( I M

Mg.

5,000 5,000 5,000

1.8 2.3 1.5

75 75 75

2.7 3.3 2.2

18 23 15

5,000 5,000 5,000 6,000 8,000

1.5 1.8 1.2 1.8 2.3

70 70 70 100 150

2.2 2.7 1.8 2.5 3.0

15 18 12 18 23

1,500 2,000 2,500 3,500 4,500

0.4 0.6 0.8 1.0 1.2

30 35 50 60 75

0.6 0.9 1.2 1.5 1.8

4 6 8 10 12

5,000 5,000 5,000 6,000

1.4 1.2 1.6 2.0

80 80 90 100

2.0 1.8 2.4 3.0

14 12 16 20

D, International Units

X X 400-800 400-800 400-800

X X X

° Now known as "niacin." X Vitamin D is undoubtedly necessary for older children and adults. When not available from sunshine, it should be provided probably up to the minimal amounts recommended for infants. § Needs of infants increase from month to month. The amounts given are for approximately 6 to 8 months. The amounts of protein and calcium needed are less if from breast milk. I Allowances are based on the middle age for each group (as 2-5, 8 and so on) and for moderate activity.

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critical examination. A varied diet may be quite unsatisfactory. Often it is merely unnecessarily expensive. The results of the scientific study of foods and nutrition must be used in our daily life; that is where they find their significance. Now, no one wants to dine on calories, amino acids, minerals, or even vitamins. Nor do physiologists desire any such revolution in our habits. Our natural appetites and satisfactions from eating are much too valuable to be sacrificed to any pedantic dietary system. It is entirely possible to translate the basic physiologic needs into the everyday language of the market and kitchen. It is the job of practicing dietitians to know what foods contain the needed nutrients and how much of each is required to supply optimal amounts of the nutrients. There are few instances in which we eat the basic nutrients as such. In general we should not endeavor to do so. Doctors know that a physiological revolution will have to occur in the human body before the basic nutrients alone can make a satisfactory steady diet. The nutrients are relatively simple substances, whereas our foods, for the most part, are highly complex and bulky. We cannot make proper food of the already numerous known nutrients. Furthermore, nutrients which are not yet known would assuredly be omitted from such a "synthetic" diet. Lastly, the vitamins, as such, are expensive. The money paid in recent years by the public for these chemicals, which ought to

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be in our food, is well-nigh incredible (in 1937, twenty-one million dollars for self-medication, and another twenty-six million dollars on prescription). The supplies of some vitamins, especially of riboflavin (one of the Β group), are limited. The government has already found it desirable to restrict the Vitamin A content of preparations which are sold directly to the public, chiefly because in their enthusiasm many people purchase far more than they can use. There is a great waste in attempting to give the body a current over-supply of most nutrients, for they are simply not absorbed. Vitamins, as such, are not necessary for approximately normal people who can get a proper diet. They should be saved to make good temporary known deficiencies, for sick people, and for emergencies. We should use the money spent on vitamins for food. In regard to concentrated diets, such as those upon which the German armies are reputed to flourish, they are, so far, only suited to very special purposes, and probably only satisfactory for limited periods. It is notable that German soldiers immediately ransack the restaurants and larders of newly occupied territory with an avidity which has greatly impressed American correspondents. The table on page 54 shows the outstanding general sources of the more important nutrients in our familiar foods. Further details may be found in any book on practical dietetics.

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Proteins (Amino acids and glucose) Meat, poultry, fish Milk, cheese, eggs Potatoes, sweet potatoes Mature dry beans, peas Cereals Carbohydrates (Glucose) Cereals. Milk Sugar Potatoes, sweet potatoes Other vegetables, fruits

β

Iron Potatoes, sweet potatoes Mature dry beans, peas Leafy green, yellow vegetables Fruit (except citrus) Eggs. Cereals Vitamin A (Or precursors) Butter, cheese, milk, eggs Sweet potatoes. Tomatoes Leafy green, yellow vegetables Liver

Fats Butter, cheese, milk, eggs Meat, poultry, fish Extracted vegetable oils Nuts Chocolate

Vitamins of Β Group Whole grains. Milk, eggs Potatoes, sweet potatoes Mature dry beans, peas Pork, ham, liver Peanuts

Calcium Milk, cheese Potatoes, sweet potatoes Mature dry beans, peas Leafy green vegetables

Vitamin C Tomatoes, citrus fruit Potatoes, sweet potatoes Leafy green, yellow vegetables Other vegetables, fruit

° Based on a table given by Hazel K. Stiebeling and Faith Clark, "Planning for Good Nutrition," Food and Life, U. S. Department of Agriculture Yearbook, 1939 (Washington: Government Printing Office, n. d.), p. 324.

Nutritive value varies with the precise food, with its condition and its preparation. The relative costs of different sources of die same nutrient vary widely. Vitamin D is almost entirely obtained by the action of sunlight on the skin; hence its absence from the table.

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When the defects in modern American diets are traced to our daily foods, the points at which improvements are needed are readily discernible. An outstanding defect is the loss, through fine milling, of the vitamins of the Β group and of minerals. In the last chapter it was pointed out that the use of breadstuffs in the United States has declined by at least 20 per cent. The proportion of the total caloric value of American diets which is derived from grain products like bread now varies from 19 to 54 per cent, largely according to economic status. The general average is about one-third. The breadstuffs are still, and must remain, a basic dietary item. Professor H. C. Sherman believes that they should furnish 40 per cent of our calories, provided the rest of the diet is properly constituted. This is the equivalent of a pound of bread per day (including all forms of breakfast cereals, and so forth). Whether such an increase is desirable or not depends much upon how good the breadstuff is. American production of wheat is said to be ample, both for our own use and for the share that our Allies have to secure from us; but the loss of minerals and vitamins as a result of modern methods of milling flour is serious. Dr. Norman Jolliffe calculated that the replacement of thiamin (Vitamin Bi) to the value of the bread of one hundred years ago would require the daily consumption of 1.5 pounds of fruit, 1.3 pounds of potatoes, 2 pounds of other vegetables, and 1.3 quarts of milk — a quite impossible undertaking. It has been proposed,

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therefore, that flour be restored to its natural nutritional value. The British faced a similar situation. In 1941, provision was made for a "national wheatmeal" which consists of 85 per cent of the grain, instead of the usual 73 per cent. It was thought that this change would result in bread of satisfactory nutritive value, but there is some uncertainty as to whether too much of value is not still milled away. Bread made of British national wheatmeal has a light brown color. It has received much praise, but apparently has not achieved widespread use. White flour, reinforced with thiamin and calcium, continues to be sold at the same price as national wheatmeal, and seems to hold its own easily. The addition of calcium and neglect of the remaining deficiencies have received much adverse criticism from the British medical profession. In the United States, opinion has differed sharply as to whether an effort should be made to mill wheat so that the vitamin- and mineral-containing portions of the grain are retained in the flour, or whether the lost nutrients should be added to milled flour. Many nutritionists consider it undesirable to "doctor" a natural food of such basic importance as flour. It is no easy matter to replace the nutrients in the proportions in which they are naturally present (which may well be very significant). Furthermore, not all of the nutrients present in whole-wheat are known. It is impossible, therefore, to reproduce a complete

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equivalent of the natural grain. Lastly, one might well ask why we should willingly discard for human use the valuable specific nutrients which are removed by modern milling, thereby making necessary their artificial synthesis. On the other hand, the great milling industry is only equipped to make white flour, and naturally looks with distaste upon proposals to make drastic changes (which in all probability could not be made quickly). Wholewheat flour and bread as made by processes so far available have poor keeping qualities. Hence, distribution and storage are difficult, which makes the product expensive. The increased amount of bran (of which white flour is now practically free) causes some individuals to suffer from intestinal disturbances. How frequent and how severe such illnesses are is not known; they seem to speak for an interesting adaptation to the blandness of modern diets, which must have occurred in the last century. Whole-wheat breadstuffs, according to many observers, are unpopular at the present time, though no doubt they could become favorites. As has just been mentioned, such products are expensive; if they were extensively used, however, they would be much cheaper. Whole-wheat products are not now generally available, and this accounts in part for the fact that they are not widely consumed.3 3 What in the past has been called whole-wheat bread has always been made of a mixture of whole-wheat flour and ordinary white flour, with relatively small additional value. Begin-

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Those who have a taste for the intermediate "wholewheat" bread, which so far has been purchasable, are sometimes regarded as faddists. It is unfair to ridicule them because the brown bread they like is not truly whole-wheat, since they are helpless in the matter. Public interest in this problem is not commensurate with the dependence of public welfare upon its solution. The plan of adding to flour the lost nutrients (and perhaps others that were never present) has immediate appeal. Some of our bread is already made with flour which contains 6 per cent by weight of skimmed-milk solids and thereby has its nutritional value moderately improved. Reinforced flour could be prepared and put on the market with little delay; whereas the satisfactory use of whole-wheat would require time for further technical studies, as well as for an educational program — which would be quite necessary for the widespread acceptance of real whole-wheat. Minimum standards for the content of reinforced flour are relatively easy to enforce. Some, but not all, of the missing desirable nutrients are available for this purpose. On the balance of these considerations the Committee on Food and Nutrition in 1941 approved a plan of "fortification" of white flour and bread. The terms "Enriched Flour" and "Enriched Bread" were adopted. The ning in 1941, by regulation of the Federal Food and Drug Administration, the term "whole-wheat" cannot be used when such bread is sold in interstate commerce.

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Food and Drug Administration and the American Medical Association adopted tentative standards for acceptable enriched flour and bread, which are shown in the table (the amounts are in milligrams per pound, except those for Vitamin D, which are in units of the United States Pharmacopeia). Calcium

Iron

Thia- RiboVitamin flavin Niacin min D

Whole-wheat flour 240 72 White flour Enriched flour, min. 500 max. 2,000

18 4.5 6 24

2.04 0.23 1.66 2.5

1.13 0.18 1.2 1.8

12.3 0 3.7 0 6 250 9 1,000

So far, only these standards have been announced; official regulations have not yet been issued. It is understood that riboflavin, as such, is not now available for this use. Fortification with Vitamin D and calcium was announced as optional for the time being (if calcium is added, phosphorus will also be present in increased amount). Beginning in the summer of 1941, many large mills and bakeries provided enriched flour and bread, which contained thiamin, niacin, and iron, in amounts within the tolerances of these standards, besides the usual ingredients. Enriched flour and bread, therefore, are on trial. Unfortunately, nutritionists are not unanimous in their support of the plan; many who feel that technical problems of producing and marketing satisfactory unfortified flour are not insurmountable favor this method of improving American bread-

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stuffs. Popular acceptance of either enriched or whole-wheat bread depends largely upon the manner in which the innovation is presented to the public. Vegetables and fruits, as important sources of Vitamin C (and other vitamins) and minerals, present a problem in distribution. They are expensive in cities and are very unevenly available in country districts. It is estimated that our consumption of tomatoes and citrus fruits should be increased by about 50 per cent, while the amount of leafy green and yellow vegetables should be doubled. Home gardens, about which there was much ado in the first World War, may help some families, but they are not likely to be of great importance in raising the nutritional status of the huge urban population. The Secretary of Agriculture has asked for an increase of 20 per cent in the number of farm gardens for 1942 over that of 1939. The expected increases in vegetable production for 1942 range from 10 to 30 per cent. Since large amounts of certain vegetables, and some quantities of fruits, have to be exported for the use of American forces abroad and our Allies (especially dried beans and fruits and canned tomatoes to England), it is clear that further increases will be necessary. The natural supply of this vitamin in Britain is so limited that there has been some agitation for the preparation of Vitamin C for general distribution as an emergency measure; this is actually being done in Germany. The

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bulk of the increases in our fruit and vegetable production will have to come from farms, but community and school gardens which are already helpful can be developed with great advantage. Subsidies may have to be granted to certain crops in some parts of the country. The government is already underwriting higher prices for fruits. Urban prices should be kept low. So far we have a "ceiling" only on the prices of canned goods. A more even consumption of fruits and vegetables on farms throughout the country should be assured by an appropriate educational campaign. It is possible that public regulation of distribution will be necessary in order to achieve the desired increase in the use of fruits and vegetables in our diets, which, together with milk and milk products, Professor H. C. Sherman thinks might well contribute 50 per cent of the caloric value. There are two important vegetables which have attracted little notice in popular discussions of the American dietary. We consume a moderate amount of one of these, the potato; the other is hardly used at all as a food in this country, although a large crop is now grown, the soybean. Potatoes are the mainstay of the people of Central Europe, where the annual per capita consumption runs up to over 400 pounds. The average Englishman eats a little more than 200 pounds of potatoes a year. American consumption runs from 100 to 150 pounds. Potatoes are rich in energy value, and, properly prepared, are

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good sources of Vitamin C and minerals, particularly iron. Sweet potatoes in some ways are more valuable than white potatoes. Neither variety of potato is now an extremely cheap food. If the need arises, both white and sweet potatoes can be grown more extensively and sold more cheaply to general advantage. The soybean is remarkable among vegetables in that it is a completely adequate source of protein, which we are accustomed to look for in meat and milk. A large section of the vast Chinese population derives its most important supply of protein from soybeans, with good results. Soybeans, if necessary, can take the place of some of the meat or milk which otherwise should be in our diets. Milk has been called the most nearly perfect food, since it contains some amounts of practically all the known essential nutrients (many, however, in dilute and variable concentrations). For the last generation, nutritionists have been urging that every child have a quart of milk a day and every adult a pint (which would provide the adult with about 20 per cent of his calories). It is remarkable that, apart from infant feeding, milk has not long been of any widespread importance among human foods, and that whole sections of the world's population, at least in historical times, have never known cow's milk as a regular constituent of their diet.4 The The Chinese are an example of a people with a successful culture who have never used cow's milk. Though it may be granted that the use of this food would improve their health, 4

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large water content is a disadvantage. Nevertheless, the great value of milk is undeniable, especially for young children and nursing mothers (see Chapter VI). It is estimated that the use of milk and milk products in this country should be increased by 10-20 per cent in order to bring consumption up to the desired level (milk production in 1942 is expected to top that of 1941 by 7 per cent). The additional amount, of course, is needed by different sections of the population in varying degrees. A disturbing fact about the milk industry has been the discarding, or using for animal food, of large quantities of skimmed milk. The improvements in the American cheese industry, and the increasing national consumption, are favorable tendencies. For the duration of the war, the United States will be sending large amounts of cheese to Great Britain, where it holds a relatively larger place in the diet than it does in this country. Modern dairy development has resulted in extensive stall-feeding of cattle; as a result, the vitamin content of milk, butter, and cheese needs closer scrutiny than was necessary when cows fed principally by grazing. This change is nutritionally significant with regard to butter, which is our most important single source of Vitamin A. Moreover, it is estimated that our national use of butter is deficient by 10-25 per cent. The problem of an adesuch a development is out of the question. They can, and will, find other equally satisfactory sources of the necessary nutrients.

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quate supply of satisfactory butter is intensified by its high cost, which is causing a progressively greater use of oleomargarine. We may expect to see still larger amounts of margarine and other butter substitutes in American diets. These foods for the most part, in the past, have contained no vitamins, but certain vitamins are gradually being added. In 1940, about a quarter of the margarine manufactured in the United States was "fortified." The social standing of margarine has been low, justifiably so, so long as it is not nutritionally an acceptable substitute for butter. There is no reason why all edible fats, including butter, should not be brought up to a minimum standard content of Vitamins A and D (which are fat-soluble substances).5 In that case, margarine might be thoroughly acceptable. The question turns upon whether or not there are yet unknown nutrients in butter. Great Britain is consuming large quantities of margarine which contains Vitamin A and D up to the standard of butter. The result may indicate the acceptability of such a product. In any event, steps should be taken to be sure of an adequate intake of the vitamins in question, either by adding them to margarine, or by controlling the price of butter, so that all may have enough. The ordinary allowance is about four ounces a day (which furnishes something like 15-16 6 If this is done, and if Vitamin D is added to the new enriched flour, our general adult diets for the first time will carry a significant amount of Vitamin D.

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per cent of the day's calories). Nothing like this amount, however, is absolutely necessary. The British ration consists of about one-sixth of this amount, and is limited to one- to two-thirds in the form of butter. Meats, fish, poultry, and eggs are aristocrats among foods. Nutritionally, they are all excellent sources of protein, minerals, and in some cases, vitamins (but rarely an important source of the latter). In time of war, these foods are the first to become scarcer and dearer. Their production and distribution are costly and troublesome. Yet there is a natural human craving for these foods. A great portion of the world's population, however, does very well with a small fraction of the well-to-do American's supply, which is half a pound or more a day. British rations allow about two-thirds of a pound of meat a week (depending on the price), with a quarter of a pound of ham or bacon; eggs, about one a week; fish and poultry are not rationed (but may be hard to come by). Modern nutritional science assigns a lower rank in importance to these foods than they had a generation ago. With the proper substitutions, the average American would be just as well off with less meat. Scarcity in time will force our hand in this matter. The amazing growth in the use of sugar by Americans in the last century has deformed our diets beyond recognition. The weekly per capita consumption of sugar is about three-quarters of a pound

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in "made" foods, confections, and drinks (sugar added by industry), and one and three-quarters of a pound in the home. About a quarter, or more, of the daily supply of energy-yielding food in the prevalent American diet comes from sugar, which is cheap and popular. It is unfortunate that so large a proportion of our diet yields only a single nutrient, glucose, which can just as well be secured in combination with other nutrients, and perhaps better (at least to a large extent) in the form of starch. It has been calculated that a diet containing 3,000 calories (a common male allowance), with the usual amount of 500 calories from fats, must contain vitamin-carrying foods to the value of 2,200 calories. This leaves only 300 calories to come from sugar, which is only three-fifths of the prevalent amount. Furthermore, the constant consumption of so much of a concentrated substance seems undesirable. Among other disadvantages may be mentioned the softness and small bulk of our food, which interfere with the normal functions of the gums, teeth, and intestines. Every dietary that has been recommended since the war of 1914-18, as well as during it, has implicitly called for the reduction of American consumption of sugar, though often without pointing the issue. Of the sugar used in this country, about 60 per cent has been brought from the Philippines, Hawaii, Puerto Rico, and Cuba. The loss of the Philippine crop as a result of Japanese seizure of the Islands, and uncertainty about the

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safety or practicability of shipments from our other sources of sugar, have forced the government to ration this food. The amount allowed for home use, one-half pound per week (which may be increased), together with the allotment for industrial use in foods, candy, and drinks (apparently two-thirds of the present consumption), leaves Americans more sugar than they should have for their health. From the point of view of good nutrition, it is to be hoped that the American public will recognize the desirability of a permanent cut in their use of sugar. Rationing would then be welcome. The government would not be driven to employ at great risk, for the transportation of sugar, too many ships which are sorely needed to carry munitions and food to the armed forces abroad. Perhaps we can recover tastes for other flavors than sweetness, and discover how good sugarless bread, soups, sauces, vegetables, and fruits can be. Dr. Russell Wilder of the Mayo Foundation has made an interesting suggestion for the improvement of sugar. He proposes to add to sugar the solids of skimmed milk which is now discarded, in the proportion of 22 per cent. By this means sugar would carry with it significant amounts of good protein and calcium (and variable amounts of other nutrients). The proposal deserves a trial. Food based on the principles which have been outlined will give Americans much more generally satisfactory diets than those that now prevail. Nu-

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merous special problems remain which cannot be discussed. Among others, is the local need for enrichment of the natural content of iodine in some diets, especially in the Great Lakes region and in the Pacific Northwest. This is easily done by the careful addition of an iodine salt to table salt. The combination of good foods into satisfactory and appetizing meals that will make an adequate diet is one of the most important arts of the housewife at all times. Under the restricted and varying conditions of war, it becomes a vital necessity that the housewife be knowing and ingenious in the management of her kitchen. Purchasing power, knowledge, and taste are the limiting factors in this skill. The different results which different individuals achieve in apparently similar circumstances are amazing. There are many oddities about the nutritional value of foods. Some of the most important nutrients, particularly the vitamins of the Β group, are not to be obtained in adequate amounts by the consumption of one or two foods, but by picking up a little here and a little there, in this or that food. How many people realize that peanuts are a good source of the Β vitamins? 6 Or that the humble cabbage, properly prepared and eaten with its cooking water, is one of the best sources of Vitamin C? The details of dietetics may be gleaned from one of the many excellent books which have been pre' The thin reddish skin is the richest known source.

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pared for the housewife and cook.7 The war will not change American supplies enough to invalidate any of the sound advice in standard manuals. It is, however, just the occasion for getting down to essentials in nutrition. By way of showing how adequate nutrition can be secured with pocketbooks of varying dimensions, the Bureau of Home Economics has described four types of diets to fit various income levels: (1) a good diet at low cost, which was available at the time of the study, for families of not more than two adults and one or two children, with annual incomes of $1,000; (2) a good diet at moderate cost, available to all families disposing of $2,000 a year; (3) a fair diet of very low cost, which is the best available to any family with only $750 a year; and (4) a good diet which is relatively expensive.8 Communal feeding, at least for the mid-day meal, has had a great development in large cities during the last fifty years. In Great Britain, the war has led to wide expansion of the provision for communal feeding in schools and factories, as well as the establishment of eating facilities in air-raid shelters. Communal feeding is economical and good for morale. It should be encouraged. The success of a wartime economy, as well as of 7 One of the most helpful general books in this field is Feeding the Family (1940), by Mary D. Swartz Rose. 'Hazel K. Stiebeling and Faith Clark, "Planning for Good Nutrition," Food and Life, U. S. Department of Agriculture for 1939 (Washington: Government Printing Office, n. d.), 321-340.

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plans for improvement in our national nutrition, depends upon widespread understanding of the subject. Americans are already far more aware of the spectacular aspect of the vitamins than any other people. This knowledge, however, is thinly diffused and suffers from misplaced emphasis. In short, an intensified educational program which will reach into the homes of industrial as well as farm workers is essential. The Committee on Food Habits is excellently constituted to serve as an expert planning body for this purpose. The Office of Defense Health and Welfare Services, in cooperation with scientific bodies, has planned an experimental campaign of nutritional education among the defense workers of the Baltimore region and their families. In addition to more general methods of spreading knowledge, the cooperation of our vast restaurant industry should be sought. All of the numerous forms of community feeding offer opportunities for the wise and gradual change of food habits. The Oslo cold meal, which is of unusual value from nutritional, educational, and economic points of view, merits an investigation as to its adaptability and acceptability in this country.9 Although tastes and food habits must be studied and taken into account, they should not be considered immutable. 9 In its original form, the Oslo meal consisted of whole milk, whole-wheat bread, margarine, cheese, and orange, apple, or raw carrot. It was planned for school children, but has been adapted to factory workers. It is remarkable for its high "protective" value.

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Habits of eating have undoubtedly been changed by advertising for commercial purposes — witness the taste for cold prepared cereals, which was unknown until about a generation ago. The right program can just as well bring popular diets into accord with nutritional principles. The existence of a national emergency is favorable to such a movement. The United States is fortunate, indeed, in producing, or being able easily to produce, within her own borders adequate supplies of practically all foodstuffs for its present population. This could still be true if all of us had good diets. Sugar is the only food that has to be brought into the country in large quantity. Our only other food imports of any consequence are fish, coffee, cocoa, tea, and certain condiments. Other importations are unessential or readily replaceable. The improvement which is desirable in American diets, as well as the need for sending food to Great Britain and other allies, calls for readjustments in agricultural programs which are now in process of development. The total harvested farm land of the United States averaged about 365 million acres from 1928 to 1932. In 1939 the harvested acreage was approximately 312 million acres. The prevailing consumption level required 280 to 285 million acres, the balance being exported. In 1939 it was estimated that an additional 10 million acres, together with the requisite rearrangements of lands for particular crops, would provide the increases in milk,

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vegetables, and fruits which are needed to supply adequate diets selected according to income levels, as planned by the Bureau of Home Economics. In the meantime, exports have risen greatly. Harvested farm land in 1940 amounted to 333 million acres. The circumstances have been such as to prevent the achievement as yet of an adequate supply of the "protective" foods for the whole population, but this is still within the bounds of possibility. The Department of Agriculture looks forward to an increase in farm produce of 19 per cent over that of 1935-39 (25 per cent for human foods, excluding wheat). Unfortunately, we have to bear in mind for the future two troublesome matters: first, that the reduction in crop acreage following 1932 was necessary in part for soil conservation; and second, that in normal times the import-export balance of foodstuffs can no longer be in favor of the United States. It is apparent that steps must be taken to keep available sufficient labor to man the country's farms. It is reported in April 1942 that shortages of 25-40 per cent exist in various regions. Nothing has been done so far to prevent the continued draining away of farm hands into the armed forces or defense factories. Either farm labor must stay at its work or new hands must be trained, for the need of food is second to none. The greatest difficulty in raising a large proportion of unsatisfactory diets to an adequate level lies in lack of purchasing power on the part of the con-

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sumer. One-third of our people need better diets. One-third (not entirely the same group) of our families and single individuals dispose of annual incomes of less than $750 (they receive 10 per cent of the national income). Some idea of the burden of the cost of food may be gained from the fact that city families whp enjoy annual incomes up to $2,000 spend 30 per cent of their income on food. In the lower brackets this item amounts to 40-45 per cent, depending on the number of persons in the family. At the level of wages and costs of 1935-36 it was estimated that the addition of a little more than $2 billion to the national income, provided it went entirely to the families receiving the lowest incomes (those below $750), would enable the most deficient group to enjoy the "economical fair diet" which was suggested by Dr. Stiebeling. Since that time a much larger sum has been added to our national income. There is no reason to believe, however, that the most deficient group has been taken care of by the change. Certainly, if no further steps are taken, the old problem will arise again at the conclusion of the war. Furthermore, the rising prices of food jeopardize the position of the middle economic group who live on fixed wages and salaries and receive little or no increase in income during the war. The rationing of foods is an emergency measure, which is set up to secure fair distribution in the face of shortages and difficulties in transportation and wholesale marketing. It is also caused by fear of

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shortages and by hoarding, elements which have played a prominent role in rapidly bringing the United States to a sugar ration. Hoarding indicates lack of confidence, and therefore is a sign of low morale. It assumes the right to take advantage of one's fellows and therein is unmoral. Few hoarders have any chance of success in covering their needs for the duration of the war, so that the plan is unintelligent. In short, hoarding is to be denounced without reservation. Great Britain and all the Continental countries of Europe are living on rationed and controlled foods. The system is irksome because it necessarily interferes with tastes and habits. In 1941-42 the British weekly ration includes bacon or ham (4 ounces), sugar (8 ounces), tea (2 ounces), preserves (4 ounces), cheese (2 ounces), edible fats (6 ounces, with only 2 of butter in winter and 4 in summer), cooking fats (2 ounces). Milk, eggs, and meats are rationed by more elaborate plans, and only small quantities are available for most citizens. Unrationed foods are poultry, fish, liver, kidney, heart, tripe, bread, flour, fresh vegetables, fruit, coffee, and some other items. Many of the unrationed foods are difficult to get at a given time or place. An egg a week is more than some people are able to find. Cereals, however, are amply available. The British people have taken these great restrictions manfully and made a rather good job of it. Special care is given to the food supplies of mothers and children

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(especially milk) and of agricultural and other laborers. The diets of some groups in the population are better than before the war. There has been practically no loss of weight, which was common in the war of 1914-18. The prospect for rationing in the United States depends partly upon the reaction of our people. Our food supply has already suffered some losses, and there are indications of more to come. The sugar loss is not necessarily of the slightest significance, and could be turned to our advantage. Fats, including olive, palm, and coconut oils and chocolate, have been lost, but these can be replaced by peanut, soybean, and cottonseed oils. Other foods, such as pork, will be available in smaller quantities than usual, but suitable substitutes will always be at hand. Coffee, tea, and condiments, which from the nutritional point of view are pure luxuries, may become scarce. Canned goods will be less abundantly available, because of the huge amount which the armed forces require. The elaborate system of packaging which has grown up in the past thirty years will undoubtedly be very greatly curtailed, but that does not mean that food will be any the less adequate. There is no indication in the spring of 1942 of a shortage of any essential food in the United States (if we deny that status to sugar). If we manage our affairs properly, it is unlikely that the war will produce any such shortage. Granted we all had adequate understanding of food supplies,

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of our nutritional needs, and of the nutritional value of foods, and if we all reacted patriotically and fairly to the situation, rationing might well be unnecessary. The practical difficulties of fair distribution, however, are likely to lead to extensive rationing before the war is over. When it comes, the special needs of mothers and children, of heavy workers, and of the sick must be carefully met. Even a system of rationing depends for its success on the intelligent and loyal cooperation of citizens. Overeating, which is an important cause of obesity, should disappear; it is as much a cause of malnutrition as inadequate feeding. Food fads are an example of unintelligent attention to nutrition. At any time they are a serious nuisance to everybody. In their place we should put sound knowledge of nutrition. We must all learn how to make necessary substitutions and adaptations in our foods and maintain or achieve a satisfactory diet. The control of prices of foods is necessary in some degree, whether or not there is extensive rationing. The problem of the relation between food prices and wages is not new, but as old as civilization. Price control of some of our most important foods has long been with us. Such as it has been, the control of prices has done little to ensure proper food for everybody. Cost of production plus profit, plus cost of distribution plus profit, is a thoroughly unsatisfactory basis for the price of food to the consumer. We must come to the realization that the

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purpose of the whole food industry, including most of our farming, is to provide a good diet for the whole people. The demand for basic foods should be well defined in terms of consumer needs, and not alone in terms of past purchases. The welfare of our farmers and other producers of foods must not be overlooked. But it cannot in general be safeguarded solely by high prices. In time of peace, raising prices restricts sales. Then, the basic aim should be a large and steady consumption; the larger the market, the lower the price can be. In wartime, the excessive demand for foodstuffs has always caused prices to soar, to the great detriment of the war effort. Under these conditions, it is unwise to try to avoid price control. Moreover, control must be exercised in such a way that fundamental foods are kept within the reach of people with small incomes. In other words, the consumer's power to purchase food must be controlled, as well as the price of food. There are many possibilities, at least in peace time, of lowering prices. Both production and distribution can be done far more efficiently than heretofore. Marketing, in particular, is in its infancy. The margin between cost to producer and cost to consumer should be greatly narrowed (in general, farmers receive 40 per cent of the city price of their produce). When the government finds itself compelled to fix prices for a longer list of basic foods, it will also exercise greater control of marketing. No matter what arrangements are made in

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the near future, many Americans will be unable to afford adequate food. The deficiency should be made good by continuing and extending the food stamp plan of the Surplus Marketing Administration. The regulation of the production and distribution of the food of the nation is one of the most fundamental aspects of good statesmanship. In our moments of irritation at the confused congeries of laws provided for our guidance we should remember that economy implies regulation. Our difficulty lies in unwillingness, or inability at this stage in our development, to attack such problems on a sufficiently grand scale. Our need is not for more laws, but for more wisdom expressed in fewer laws. The determination of the necessary total and relative production of crops and animals (having in mind both the need for meat and dairy products and the consumption of food by animals) is not a matter of great difficulty. The achievement of the policy is another story. During the war, there will be no surpluses such as those of the early 'thirties, but the memory of those years haunts many a farmer. Those surpluses, however, were not truly excessive food production, when so many Americans were in need of more and better food. What the farmer wants to know is how we are going to manage after the war. The nutritionist's answer is that Americans will need pretty much what American farms can produce, provided it is properly assorted. The statesman and

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the economist must furnish the rest of the answer. Wise planning and management during the war will go a long way toward putting American agriculture on a sounder basis than it has had. The size of the modern food industry is matched by its complexity. At least one person in four, of those gainfully employed, is concerned with the production or distribution of food. In addition to farmers and workers in food factories, there are workers in industries which supply farm and factory machinery and materials, and distributors, wholesale and retail. Transportation workers play an essential role. The path taken by our food from its place of production to our tables is now highly complex. The coordination of the work of various groups of producers and distributors cannot be left to chance. Desirable in time of peace, under the conditions of war, cooperation is essential. We should gladly reconcile ourselves to increased regulation of our food supply. The development of public control of this basic service has been slow and somewhat patchy. Perhaps this is partly because of our democratic methods, but it is only partly so. We prefer these methods and believe in them. We are convinced that the end-results will be better than those that might be more rapidly secured by other means. We intend to preserve the democratic approach to this, as to other problems of government, even while waging war. Science, unfettered by law, never stands still, is

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never finished. We do not know how much remains to be learned of nutrition. We are syre that we do not know all of the essential nutrients, even vaguely; nor do we know all about the significance of the known nutrients. The scientific planning and conduct of food production and distribution for the nation is in an embryonic state. One of the most damaging results a long war could bring in its train would be stagnation in progressive scientific work. Hence, generous provision in funds, men, and materials must be made for the continued analysis of unsolved problems and for the experimentation which is necessary for their solution. The immediate nutritional goal is to survive in an international struggle by making ourselves fit. The need for improvement in our diets, however, is by no means only temporary, but a vital necessity, war or no war. Professor H. C. Sherman, of Columbia University, has pointed out that in experiments with animals a good diet not only increases the length of life, but also (and this may be more significant) prolongs the period of fullest functioning. Neither Professor Sherman nor any other scientist has in mind the development of a race of supermen by the adjustment of human diets. Such notions belong to other ideologies. Each individual has inherent limits of good health. A satisfactory food supply can only bring him up to those limits. Hence, a superabundance, or excess over the optimal amount, is sheer waste. In the case of some

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nutrients at least, it is harmful. We have seen, however, that a large proportion of Americans have been brought up on, and are currently consuming, inadequate supplies of essential foods. This is not to say that nutritional diseases are rife among Americans, for that is not the case. It is true, however, that the health of many Americans, even in the advantageous period of youth, is poor. A writer on the editorial page of the New York Times of March 8, 1942, mentioned pessimistically the apparent fact that our health has not improved since 1917, in spite of much social progress in that period. The truth is that, with the exception of the food of infants and young children, American diets are not significantly better today than they were in 1917; they are much the same, although some adult groups have more milk, fruit, and vegetables. The observations in England by Dr. G. C. M. M'Gonigle on the relation between better housing and health, as contrasted with that between better diets and health, help toward understanding the failure of some forms of social amelioration to produce physically fitter men and women (see Chapter V). Nutrition is closer to the root of health than housing. There is a long way to go before Americans as a whole approach their optimal nutritional state. The most effective approach to the solution of the manifold problems which are involved in the improvement of American diets is through the diffusion of understanding of the elements of food supply and

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nutrition. In a democracy, governmental leadership must rest upon popular support for the steps which are required to raise nutritional standards, as well as to enforce the rationing system which a world war forces upon the nation. Confident that food supplies are adequate for their needs and understanding that food control is indispensable to victory, Americans will respond intelligently and wholeheartedly.

CHAPTER

IV

SAFETY FROM INFECTIOUS DISEASES

N past centuries, both in war and in peace, infectious diseases have been the greatest cause of human illness and untimely death. Man slowly and painstakingly sought to gain the upper hand over the agents and conditions which determine this constant threat to his welfare, but these efforts only began to show signs of success in civil life in the latter part of the nineteenth century. Not until the first World War was the campaign against infection able to protect armies in the field so that disease wrought less havoc than the weapons of war. Even in 1914-18, civilian populations and soldiers, especially in less highly developed European countries, suffered terribly from epidemics. What the effect of the second World War on the incidence of infectious diseases will be is a question of the greatest importance. Communicable diseases (a term preferred to "infectious diseases" for its straightforward implication that these maladies may be passed by various means from subject to subject — sometimes by devious paths) are caused by biologic agents that range from readily visible worms to particles that cannot be seen through any ordinary microscope.1 A con-

I

1

Among the many books devoted to the subject, reference

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tagious disease is merely one which characteristically spreads directly and with ease from patient to patient. An unusual number of cases of a communicable disease in a limited population and in a limited period constitutes an epidemic. The causative agents of communicable diseases continuously exist in some natural reservoir, or host, which may be specific to a given agent. In some cases, apparently the human body alone will serve (as with the common form of meningitis and with syphilis). In the long list of hosts we should see that cattle harbor one form of the tuberculosis germ; rats are hosts to a number of serious diseases, including the plague; dogs are chiefly responsible for the continued existence of rabies; and so on. A few years ago there were several human epidemics of psittacosis, a disease which is indigenous to parrots. Some agents of disease may exist independently in nature at large, at least in inactive forms, like the spores of tetanus bacilli; but this independent existence of diseaseproducing germs is probably not as extensive as most of us have thought. The transmission of communicable disease is sometimes direct from patient to patient (as in smallpox, gonorrhea, and syphilis), or from other natural host to patient (as in rabies). The patient's excreta (as in typhoid fevers and dysenteries) and sputum (as in tuberculosis and pneumonia) may may be made to those of F. Sherwood Taylor, The Conquest of Bacteria (1942), and Geddes Smith, Plague on Us (1941).

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contain myriads of germs. Food and drink when infected are dangerous sources of various diseases; contamination may not affect the appearance in the slightest degree. The objects used by, or close to, patients or infected animals sometimes spread disease by conveying the germs with which they have been contaminated (this is possible in many, but by no means all, infectious diseases). In other instances, animals, especially insects, carry the germs from the natural reservoir to patients: such animals are called "vectors" (as mosquitoes for malaria, yellow fever, and some forms of encephalitis; and lice, fleas, and ticks for the groups of typhus and relapsing fevers). It is clear that many elements combine to make up the total risk of spreading infectious diseases. There are the human patients themselves and, sometimes, their excreta and their immediate environment. In addition, there are animal reservoirs and vectors. Death may "lie in the pot," or in the cup, because of contamination. Sewage which carries the germs of disease may find its way to unsuspecting human consumers. Individuals vary in their susceptibility to infectious disease. Some diseases confer immunity from a second attack. Immunity may be found in some cases even though the individual apparently has never had the disease in question; this phenomenon is probably to be explained by mild or symptomless attacks. In the absence of definite information,

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however, it is never safe to take immunity to any disease for granted. The discovery of methods for artificial immunization against certain infections is a triumph of medical science. The list of such diseases is not long, but it comprises several of man's greatest scourges. In the short span of little more than half a century, many infections which previously were formidable risks have become uncommon or rare. The change represents an increase in human welfare which is singularly clear-cut. It came about through two sorts of human achievement. In the first place, scientific knowledge of communicable diseases advanced from dim impressions to clear understanding. Secondly, the general standard of living improved to such a degree that, however deficient from our present point of view, the cities, towns, and many of the farms of today could hardly be recognized by their inhabitants of two generations ago. Utilizing this expanded knowledge of disease and these growing resources, the medical profession and governmental agencies have cooperated in securing ever-increasing control of infectious diseases. This social advance was interrupted, or disturbed, all over the world, though to a lesser degree in America than elsewhere, by the war of 1914-18 and the confusion which followed it, but rapid progress has been made ever since the early 'twenties. Typhoid fever is a striking example of the decline in certain well-defined infections. Until twenty-five

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years ago it was common all over the United States. In 1898-99 an epidemic occurred in Philadelphia in which there were over 14,000 cases of typhoid — half as many again as were reported for the whole country in 1940. The fatality rate for seventy-eight of our largest cities in 1910 was 20.54 per 100,000 inhabitants (4,637 deaths). In 1939 the rate for the same cities was 0.65 (239 deaths), representing a reduction of over 95 per cent in thirty years. Typhoid fever was brought under control even more rapidly in some countries of Western Europe. Of the other intestinal infections, the dysenteries were brought within bounds at the same time; cholera was kept out of America; Europe was practically freed of it long before 1914. In the second year of World War I, however, cholera attacked 30,000 people in Galicia (then Austrian). Throughout the war, and for three or four years after it, cholera was epidemic in southern Russia. Typhoid fever and dysentery were rife in Central and Eastern Europe. Dysentery reached epidemic proportions even in Austria and Germany. Typhus and relapsing fevers, usually spread by the humble louse, perhaps have been man's greatest scourge in modern times of war and famine.2 Good hygienic conditions had made them rare by 1914 in peaceful civilized countries. But in 1915, following the defeat of their armies and the complete disorganization of their country, 2

Read for its gripping interest, as well as for its informative value, Hans Zinsser's Rats, Lice, and History (1935).

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half a million Serbians had typhus. Over 150,000 died. Even in Austria there were more than 13,000 cases in that year of apparent victory. Later, this disease spread over the whole of Russia and Poland. It is estimated that there were 5,000,000 cases in Russia in 1919-20. In Poland there were 200,000 cases. Relapsing fever also spread throughout Russia and Poland. These two diseases, acting in combination with starvation, took an appalling toll of lives in these countries. Much effort and money were required to suppress both the intestinal and the louse-borne diseases and to restore peacetime security from them. For many years before the war of 1914-18 civilized nations had made special efforts to suppress the "white plague," tuberculosis. These efforts were largely associated with signal declines in the disease, which year by year steadily carried off fewer victims. The effects which war might have could only be indirect. They are so clear and so significant that a few comparative data are given in a table. By 1918 in Prussia (which is representative of Germany as a whole) the increase in deaths was 68 per cent, which means a rate comparable to that found about a generation before. Only five years after the end of the war did the Prussian rate fall to its previous low level. England suffered a smaller setback (maximum 23 per cent in 1918); and recovered as soon as the war ceased. The neutral Netherlands saw their death rate from tuberculosis

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rise by 45 per cent. Across the ocean, in the United States, the steady fall in tuberculosis mortality was interrupted by slight increases during the two years 1917 and 1918. (These elevated death rates, of course, indicate proportionately greater increases in MORTALITY FROM

TUBERCULOSIS

PER CENT OF LOWEST PRE-WAR RATE

Year

Prussia

1913 1915 1916 1917 1918 1919 1920 1924

100 107 115 150 168 160 115 100

England & Wales Netherlands U. S. Α.* 100 113 113 119 123 95 84 86

lOlf 104 120 131 145 125 105 91

104 103 100 103 106 89 81 71

* The "Registration Area." t Lowest rate for the Netherlands was in 1914.

the number of cases.) As the table shows, the downward trend in America was resumed in 1919. By 1940, the tuberculosis death rate per 100,000 population, which in 1910 had been 160, was just under 45, less than 30 per cent of the earlier rate. In the last two or three years the decline has been slighter than in previous years. A weakness in the national situation is shown by the fact that nearly three times as many colored people die of tuberculosis as do white persons. It is notable that the decline of these diseases

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which have been cited as examples, as well as many others, has come about, not as the result of methods of immunization or treatment which are specific to the diseases in question, but through the application of general hygienic measures.3 Smallpox and diphtheria are outstanding instances in which control has been gained by specific immunization in conjunction with the isolation of patients. Diphtheria, which is a disease of infancy and childhood, is further referred to in Chapter VI. Before the days of vaccination, probably two-thirds of the population contracted smallpox, usually in childhood. Until recent years death claimed from 25 to 50 per cent of those who contracted smallpox. With the exception of Russia, all the chief countries of Europe had achieved low rates of incidence by 1914. Soon after the first World War began, cases of smallpox multiplied, and, before it was over, epidemics occurred everywhere in Europe. The increase was smallest in England and France. As early as 1915-16, however, 50,000 cases occurred in northern Austria-Hungary. In 1919, over 34,000 Italians had smallpox. The disease invaded neutral nations, including the Netherlands, Sweden, and even Norway. The United States has been relatively backward in the suppression of smallpox. The annual incidence for 1909-14 averaged 31,000 cases, * Although preventive immunization against typhoid fever, typhus, and cholera is possible, it has not yet played a role in the protection of general populations.

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far more than was justified, but this number was doubled in 1919, and tripled in 1920 and 1921. This disgraceful increase was undoubtedly caused in part by the confusion which was associated with America's participation in World War I. After 1921, the number of cases greatly decreased, and in 1940 there were somewhat less than 3,000 smallpox patients in America. Yet as recently as 1938 we had nearly 15,000 cases. The struggle against this disease is hampered, strange as it may seem, by the fact that in recent years it has been mild and has caused few deaths. In summary, the status of infectious diseases among the causes of death in America today is indicated by the estimate that they are not responsible for more than 15 per cent of our mortality.4 Only two infectious diseases, tuberculosis and pneumonia, cause more deaths each year than automobiles. The story of how medical knowledge and community effort have brought infectious diseases under control has been repeatedly told in recent years, often with not a little dramatic embellishment.5 The achievement is truly one which may evoke social pride. There is some danger, however, of misinterpretation of the present situation. Some writers refer to the eradication of disease, although it would 4 In 1940, the death rate for 41 states was approximately 1,050 per 100,000. The combined rates of twelve important infections totalled 119.7. 5 Reliable accounts may be found in Sir George Newman's Rise of Preventive Medicine (1933).

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be difficult, if not impossible, to find an example of communicable disease which the efforts of man have exterminated. Not even leprosy fills the bill. It is doubtful whether the hope, or even the conception of eradication, is justifiable in the light of our present knowledge. The control of disease is another matter; and the difference is of more than academic significance. This view should not be regarded as pessimistic, since adequate control fulfills our social needs. Control of communicable disease implies constant vigilance. As long as an infectious disease continues in existence, relaxation of measures of control will be followed sooner or later by an outburst of cases, few or many. The distribution of such diseases as typhoid fever, dysentery, smallpox, and diphtheria is very uneven in the United States. Examples are not wanting of regional epidemics, even in recent years. It has already been pointed out that as late as 1920 there were over 110,000 cases of smallpox in this country, when there should have been practically none. In 1936 there was an important epidemic of typhoid fever in England, when 518 cases occurred in Bournemouth; there were 51 deaths. A combination of (1) carriers of amebic dysentery, (2) congestion due to over eight million visitors to a fair, and (3) a defect in hotel water and sewerage systems produced an epidemic in Chicago in 1933. In a period of about six months there were 1,409 cases of amebic dysentery with 98 deaths; patients

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scattered to forty-three states, Hawaii, and three Canadian provinces. Amebic dysentery is commonly regarded as an exotic infection peculiar to other and less civilized peoples. The price of freedom from such attacks is constant watchfulness. Much remains to be accomplished in the fight to suppress infectious diseases, not only in backward parts of the world, but right here in the United States. The war challenges us to maintain our present control. The challenge must be met, and every effort must be made to gain still greater dominance over these diseases. The job is by no means completed for smallpox, tuberculosis, and diphtheria. Malaria, once common all along the Atlantic seaboard as far north as Connecticut, is now restricted to the southeastern states and the Mississippi Valley. It has so far proved beyond our ability, or our will, to suppress in those parts of the country (over eighty thousand cases were reported in 1939, which, however, represented but a fraction of the total). In times past, this mosquito-borne infection has defeated armies and crippled civilian populations. Before the war of 1914—18, it had become a rarity in Europe, save in Mediterranean lands; but, soon after the war began, it increased rapidly in Russia, and later reappeared in Germany after an absence of many years. Sanitary engineering offers the means of coping with this menace, though at considerable pains and expense. The infections which are commonly hidden under

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the term "social diseases" (as if there were some disease which is not social!) are the outstanding instances in which America has failed to apply adequately measures of control that are at hand. The venereal diseases, to which this euphemism refers, include some half dozen infections, the most important of which are syphilis and gonorrhea. Accurate knowledge of the incidence of these diseases is hard to secure, because of the prevalent demand that they be kept under cover. The indications are that a decrease in the number of new cases of syphilis has taken place since World War I, especially in the last five years. However, the disease is still not under control. On the basis of the examinations of the first million "selectees" for the new civilian army, it is estimated that about 2.5 per cent of Americans have syphilis.6 In some sections of the country and in some social groups, one person in five is infected. The disease is from two to ten times as common among negroes in various parts of the United States as it is in white people. Gonorrhea afflicts at least three times as many people as syphilis; unlike syphilis, it may be repeatedly incurred. Some smaller and more homogeneous countries have achieved much greater success in the control of venereal diseases than the United States. Sweden, with a population of six and a third million, had only 343 new " The general rate among "selectees" was 4.5 per cent. Unhappily, it must be realized that some of these young men who were free from the disease when examined will later be infected.

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cases of syphilis in 1938, a rate of incidence which is a fifteenth or less of the present American rate. Twenty years ago the incidence in Sweden was about what it is in the United States today. The difference is due to education of the public and application of control measures which Sweden introduced in 1920. A campaign against syphilis has also reduced the number of cases in England and Wales, though not to the same degree as in Sweden (in 1939 the incidence was estimated to be onethird of that in 1920). The decrease of the last five years in the United States, which is due in good part to the program for federal aid in the control of venereal diseases, is gratifying, but only represents the beginning of a huge task. The emotional disturbances, confusion, and uncertainties of war are all too likely to be associated with increases in venereal disease; it has always been so in the past since 1492. This is not the place to discuss the crippling and unhappy results of venereal disease. Every citizen, however, should be acquainted with the general nature of these infections.7 Some infectious diseases have so far eluded the efforts of scientists and hygienists to find a specific means of controlling their spread. Prominent in this group are cerebrospinal meningitis, encephalitis, poliomyelitis, rheumatic fever, the common cold, influenza, and pneumonia. Many of these diseases 7

A dignified and constructive presentation will be found in Thomas Parran's Shadow on the Land (1937).

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are important, not so much for their direct share in the death rate, as for the sickness and disability which they cause. They represent unfinished professional business, while the previous groups bespeak inadequate statecraft. The epidemics of influenza, pneumonia, and encephalitis which swept around the world in the later years of World War I and for about five years afterward are still fresh in popular memory. The guess has been made that over twenty million people died of influenza. The ravages of these diseases are clearly not entirely attributable to the war. Nevertheless, the poor general state of health, and especially the unusual movements of large numbers of people, played an important role. It is presumably a part of biologic evolution that infectious diseases change their nature and that new diseases arise from time to time. At all events, diseases which were previously unimportant or unnoted have become in our time serious menaces. Diseases like pneumonia and influenza wax and wane in virulence. In some cases there seems to be a permanent regression in virulence, or a permanent decrease in man's susceptibility. There is evidence that this has happened in the history of tuberculosis, syphilis, and typhus fever. Since all communicable diseases are social phenomena, their occurrence and distribution at all times is influenced by changes in other social spheres. Our huge cities are only possible because of the success of modern sanitation.

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The great speed and frequency of travel at the present time facilitate the ever-widening spread of diseases, which without it would remain localized. The results of these two forces, biologic evolution and social development, are often mingled in such a fashion as to be inseparable. Animal hosts and vectors play an important role in the appearance and spread of communicable diseases which have acquired importance in recent years. In many cases, animals once infected, how we know not, serve as growing reservoirs. Among these diseases are: undulent fever, tularemia, ratbite fever, new forms of typhus fever, and several varieties of encephalitis. Undulant fever was hardly known in this country fifteen years ago, yet in 1939 over 3,000 cases were reported. It spreads from cows, pigs, and goats; hence dairy products may be dangerous. Tularemia was first described in 1911; in 1939 over 2,000 cases were reported (258 deaths). It is acquired by man through handling infected rabbits, which are probably spreading it all over the country. A sporadic form of typhus fever, of which the brown rat is the natural host, and his flea the chief vector, was first found in 1928. This disease is now widely scattered across the southern belt of states. There has been an irregular but marked increase in the number of human cases. Plague, which is an old human scourge, has never seated itself in the United States as a human disease; but it is being discovered with increasing

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frequency in rats, squirrels, and other rodents, apparently spreading from California eastward across the country. The natural center of plague seems to be in Central Asia. The indications are that it was introduced through the ports of the West Coast from ships engaged in the Far Eastern trade. One case of human bubonic plague was reported in Utah in 1939. There is not the slightest reason for public concern over the presence of plague in American rodents — it is not a new discovery — but it is one of the problems to which public health officers have to give careful attention. Few citizens are aware that epidemic typhus, cholera, and yellow fever have ever been serious menaces in the United States. Nevertheless, at various times throughout the nineteenth century all of these dread diseases took many American lives. The reason for our general ignorance of the potential importance of these infections is that for many years there have been only a few sporadic cases, most of which were imported from abroad. Indeed, there has been no native case of cholera since 1911, or of yellow fever since 1924. Cholera continues to exist in India and China. Two different varieties of yellow fever, transmitted by separate groups of mosquitoes, are at home in Africa and Brazil. Epidemic typhus is always present in many parts of Eastern and Southeastern Europe. Kala-azar ("black death") is a general infection of children and young adults which is native to China, Burma, and India,

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but in recent years has spread widely in the Near East and Mediterranean basin.8 This disease has its reservoir in the dog; its vector is the sandfly. Kala-azar is so far entirely unknown in America, but since both of the animals concerned in its existence and transmission are common here, its introduction is not out of the question. Both biologic and social changes constantly furnish us with new problems to solve in order to hold in check communicable diseases. Worldwide travel, especially by airplane, requires careful scrutiny to prevent the spread of localized infections, particularly those carried by insects and other small animals.9 Medical science and health administration must be always on the alert to keep up with those developments which call for revision of old methods or creation of new measures for the control of communicable diseases. War, as a social phenomenon of the greatest magnitude, has never yet failed to interact with the forces which give rise to infectious disease in such a way as to cause disastrous increases in suffering and death. The program for the control of communicable diseases has as its broad base our widespread municipal, county, state, and national sanitary agencies, with the whole medical profession cooperating in 8 There is a related disease, "Espundia," in certain parts of South America, about which little is known. 9 Man has a veritable struggle for existence against insects, not only as factors in disease, but also as competitors for food.

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the course of daily practice. One of the earliest duties of public health agencies was the proper disposal of sewage, garbage, and other wastes. This is now an engineering problem. An ideal solution for the country at large has not yet been reached. Large numbers of our streams are still polluted too far from the sea, with the result that while the town upstream is cared for, the countryside below is exposed to potential danger. In general our cities are well guarded, but many country and village homes are backward. Both education and financial assistance are needed to improve unsatisfactory conditions where they exist. Another duty of sanitary agencies is constant watch over the public supplies of much of our food, and all of our milk and drinking water. Although the standards for acceptable milk and water vary in different communities, the United States has attained a high level in this matter. These two types of sanitary activity are especially directed at the control of intestinal infections, such as the typhoid fevers, dysentery, and, when necessary, cholera. In time of war there is a risk that these fundamental sanitary services may be interrupted or broken down by enemy action. An extra guard must be set over great municipal reservoirs and aqueducts. London has successfully safeguarded its vast population against the possibly devastating results of breaks in sewer and water lines due to bombing by heavy chlorination of the water supply.

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There are three precautions which are now not usually necessary in this country, but which are of the greatest importance under certain circumstances. If the water supply of a community should become contaminated, or if water from a new or strange source has to be used, all water used for drinking should be boiled and carefully kept clean until it is used. Similarly, if it is necessary to use unpasteurized (or uncertified) milk, it should not be consumed raw. In the second place, in case of even a small epidemic of one of the intestinal infections, no raw fresh food (especially milk, cream, vegetables, and sea food) should be eaten, and no natural ice should be used. It is always necessary to remember that food and drink which was originally clean may be contaminated by subsequent handling. Thirdly, if normal means of sewage disposal should be interrupted, all material containing feces should be treated with a disinfectant, such as a 2 per cent dilution of compound solution of Cresol (equal volumes of feces and disinfectant). Public health officers will give ample notice of the need for such measures. The control of disease among animals, both domestic and wild, has continually developed in the last generation or so, both in importance and in successful application. We may be sure that this development, expensive as it is, will have to be carried much farther in the future. Rats and mosquitoes alone present a huge problem. The elimina-

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tion of such pests is called disinfestation. Delousing is a particular example which applies to man. When the population of animal hosts and vectors is large, we must be on guard against the diseases they harbor or transmit. The case of malaria has already been mentioned; the problem will not be soon solved. Widespread screening of homes, factories, and shops, which so many of us now take for granted, must be accounted a great asset. Yet its cost has so far prevented its universal adoption. Other methods of control, including drainage of stagnant water and distribution of larvicidal chemicals, can hardly have more than limited local extension in wartime. Proper housing is partly a problem in sanitation, which is closely linked with the provision of safe supplies of water and food and safe disposal of sewage. Overcrowding is responsible for the spread of many important infections, especially those whose causative agents are scattered in the spray which more or less constantly surrounds the human head. Included in this group of diseases are: tuberculosis, diphtheria, poliomyelitis, meningitis, common colds, influenza, pneumonia, streptococcal sore throats, and, perhaps, rheumatic fever. Adequate space per person and proper ventilation in dwellings, factories, theaters, subways, and wherever men and women congregate are important measures in the restriction of these respiratory diseases. The sudden growth of new communities of war-workers creates a special

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problem in sanitary housing. Further discussion of this topic will be found in Chapter V. If we take a broad view of sanitation, it is apparent that adequate nutrition is a fundamental need. A commonplace among physicians is that when infectious disease invades a patient the outlook depends in good part upon his general condition. This is the doctor's way of referring to the patient's state of preparedness to resist the disturbing and destructive effects of the invader. It has not been shown that any special diet or nutrient has a specific effect in the prevention of any particular infectious disease. Yet one of the most potent influences in the determination of the general condition at any given time is the diet of preceding months or years. Even though highly virulent diseases strike a large proportion of an exposed populace (it never happens that all exposed persons are infected), the length and degree of illness vary extremely. Herein lies a secondary but cogent reason for public as well as individual interest in reaching and preserving a satisfactory national standard of nutrition in accordance with the principles which have been outlined in Chapter III. Specific immunization against disease is one of the expanding activities of medical science and public health practice. The years to come will see the number of successful applications slowly but surely grow longer. The list of diseases against which specific means of immunization are available

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includes smallpox, diphtheria, and typhoid fever; and, with certain limitations and difficulties in their applicability, whooping cough, scarlet fever, measles, tetanus, yellow fever, cholera, plague, and typhus. Immunity is produced by the injection into the body of specific materials (prepared in a variety of ways), which cause bodily changes such that the corresponding agents of disease cannot set up their characteristic disturbance, i.e., the disease in question. Properly prepared immunizing materials are unquestionably effective in the cases just mentioned, although the duration of immunity is variable. In practically every case the manufacture of such material is safeguarded by governmental regulation. When immunization is done by a trained doctor, or under his supervision, it is safe. Each immunization in general is a separate process. The duration of immunity is unfortunately limited, in some cases to a relatively short time. Obviously it is both undesirable and unnecessary for everyone in the country to receive all the available immunizations. Such a program has never been advocated. The great majority of Americans will never be exposed to many of these dreaded plagues. Adequate protection is more satisfactorily provided in a good many instances by other means. Immunizations, however, are of incalculable value to the armed forces, which are protected against smallpox, the typhoid fevers, tetanus, and, when indicated, typhus, cholera, and plague. Moreover, in the face

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of the hardships, turmoil, and unknown possibilities of war, the availability of reliable specific means of controlling these diseases is a great source of comfort and confidence to civilians. Only in the case of smallpox is immunization extensively required by law and regulation; even in this case the requirement is not universal in the United States, though it should be. It is apparent that smallpox hangs on in communities where no compulsion is exerted, or where regulations are too often honored in the breach. Laws of this type are frequently not enforced for lack of popular support. In some areas popular sentiment has caused the specific exception of what might be termed conscientious objectors, who, in spite of salving their consciences, thereby remain a potential source of danger to everyone else. Everyone, without exception, should be vaccinated against smallpox at least three times in childhood and youth. All infants should be immunized to diphtheria. Popular understanding must rise to such a level as to demand this general protection, even though a backward minority remains indifferent. After one hundred and fifty years of preventability of smallpox, and fifty years for diphtheria, shall we not decide to have none of them? Apart from smallpox and diphtheria, the desirability of immunization varies with the degree of exposure, actual and potential, and other circumstances. To be taken into account are the occur-

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rence of the disease in question; the place of residence, and the probability of travel in certain areas; the age, occupation, and general condition of the individual. The problem is highly technical, and decision should be left to the doctor, whose advice should by all means be followed. There should be no room in the minds of intelligent Americans for opposition to well-advised immunization. In order to scotch a rattlesnake, one has to know where it is. Similarly, in order to control communicable diseases, public health officers must know when and where they exist. Hence all forty-eight states require prompt reports of cases of some thirty to forty infections (the lists vary, but all contain the more important diseases). Reports are known to be incomplete in various degrees for different diseases and different communities, with the result that the absolute numbers are often unreliable, and comparisons must be made with caution. Nevertheless, the system of reporting has long since proved its value. We should look forward to improvement in its accuracy. The reporting of cases of infectious disease makes it possible to be sure that patients are properly treated when that is a matter of general importance, as well as prevented from infecting others. In some cases treatment of the patient constitutes a particularly valuable means of controlling the spread of disease. This is notably true of syphilis and gonor-

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rhea. In these cases, the interests of the individual, as well as those of the community, are served. It is, therefore, of particular importance to find and place under treatment patients infected with venereal disease. Since syphilis often continues for years without causing even inconvenience, many persons are quite unaware that they are infected. For this reason, blood tests for syphilis, which are reliable when they are confirmed and interpreted by a physician, are urged for everyone as a part of all medical examinations. In many states such tests are required by law of applicants for marriage licenses and of pregnant women (for the special protection of their offspring). Such laws are valuable for their educational effect. If they are reasonably framed, there is little ground for objection to them (they have met much less popular opposition than was anticipated). It is said that more than half the large industrial plants of the United States require blood tests before giving employment. When blood tests for syphilis are universally performed, there is no reason for any individual to feel that he is singled out for investigation. In the case of the venereal diseases, reports are especially deficient because of a common feeling against the procedure, which is a part of our generally unsound attitude toward these afflictions. The venereal disease problem, above all others at the moment, will be eased by throwing the clear light of the general facts upon it. Reports can be made without the sacrifice of privacy, as has

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been demonstrated by the experience of Massachusetts for many years. It is convenient to note here the close relation between the incidence of venereal disease in the armed forces and that in the civilian population. Even before the United States entered the war, the great increase in the size of the army was accompanied by a rise in the venereal disease rate (42.5 per 1,000 in 1940 against 29.6 in 1939). We owe it to the nation's citizen-soldiers especially to make their environment safe. Few experienced students of the problem now believe in segregation or regulation of organized prostitution; suppression, however, is undoubtedly beneficial. A special section, the Division of Social Protection, has been created in the Office of Defense Health and Welfare Services to coordinate measures for the protection of the armed forces and industrial workers. Quarantine (from the Italian quaranta, forty, because in the Middle Ages the period involved was often forty days) is the restriction of movements of groups of people or animals infected with or exposed to dangerous disease. For a great many years the Public Health Service and its predecessors have given the United States splendid protection against the importation of disease by inspecting all ships that enter our harbors and, when necessary, trains, automobiles, and airplanes. Quarantine in ordinary times has come to be less and less necessary, except for a few diseases, but under the conditions of war

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today, with worldwide mass movements of troops, evacuees, and refugees, it is a measure of vital importance. The isolation of individuals who suffer from, or have been exposed to, certain infectious diseases, or the regulation of some of the activities of such individuals, in many instances is an important control measure. We now know that occasional persons who are not in any way ill may continuously carry in their bodies the causative agents of certain important infections. Such people are called "carriers." Typhoid fever is the best known example of this insidious parasitism, but carriers of many other diseases have been recognized. The state is sometimes temporary, sometimes apparently permanent. In 1941 an Illinois woman of ninety-seven was found to be a typhoid carrier. Such individuals are dangerous as potential sources of infection for others. In the case of serious diseases, it may be necessary, therefore, to place certain limitations upon the activities of such unfortunate citizens. The basic procedure of isolation, like that of quarantine, descended to us from the later Middle Ages, when a frightened populace, or an enlightened government, confined sufferers from leprosy, the plague, and other infections. Modern science has supplied a firm and reasonable basis for the technical measures which are now used, which vary a good deal from disease to disease. The degree of confinement and the type of regulation which are

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required to prevent the spread of various infections vary from the strictest isolation to careful disposition of sputum, or frequent handwashing alone. The duration of such restrictions may be a few days or possibly the remainder of a lifetime. The general principle is the same in all cases: the confinement of the infecting agent to the individual patient or his immediate surroundings, and its destruction before it reaches susceptible members of his family, or circle of friends, or associates, or even passers-by. Disinfection is the process by which such germs are destroyed so that articles which have been contaminated by them are rendered safe. Many methods, suitable for the varied resistance of different germs, are in use. Heat and chemicals, including certain gases, are the common disinfecting agents. Soap and hot water kill or remove many germs. We are all used to the idea of isolation, when it is applied to well-known diseases of epidemic nature, such as smallpox. We are not so well prepared for it in other instances. It is worth noting that the grouping in sanatoriums of sufferers from pulmonary tuberculosis has played a role in the decline of the "white plague," along with the decrease in the habit of promiscuous spitting. No one enjoys limitation of his activities, even in slight degree, so long as regulation is felt to be chiefly restriction. One begins by learning the value of self-limitation for the benefit of others. Finally the restriction should assume a matter-of-fact place in life, so that the

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advice and instructions of doctors and public health officers are readily followed. As the old saw puts it, an ounce of prevention is worth a pound of cure, but when it comes to the care of patients suffering from infectious diseases, the medical profession is composed of a highly trained personnel and commands great resources. Specific drug or serum medication is available for a number of diseases, including syphilis, malaria, amebic dysentery, and kala-azar. In the last few years a group of chemicals, which are known as the sulfonamides, have been found to exert a powerful curative effect in several infections. Pneumonia has been called the Captain of the Men of Death (Sir William Osier, paraphrasing John Bunyan). In 1940, of the 119.7 deaths per 100,000 population which were credited to twelve major infectious diseases, 53.5 were due to pneumonia. So far, we have no specific preventive measure to use against pneumonia. Until recently there has been only limited specific serum treatment to give. It is comforting, therefore, to know that pneumonia stands high among the diseases which are mitigated, shortened, or cured by the sulfonamide drugs. Other diseases against which they are effective include important common forms of meningitis, streptococcal ("septic") infections, and gonorrhea. The case of gonorrhea is of special importance, since it puts into the hands of doctors the means to cure a common infection which has hitherto been for the most part

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intractable. There is good reason to believe that chemical and medical research will produce further new drugs which can be safely and effectively employed against the invaders that cause communicable diseases. Large quantities of the special medicines and sera which are essential for the treatment of communicable diseases will be needed during the war. The great anti-malarial, quinine, has been lost for the most part (90 per cent) with the Netherlands East Indies. The production of certain important drugs is hampered by patent restrictions, some of which are due to control by German ownership or agency. Patents covering atebrin, the chief substitute for quinine, and neostibosan, which is used in the treatment of kala-azar, are among those under German control. War is war, and this war is more war than any previous war has been. No patent should be allowed to stand in the way of adequate production of any essential drug. Prudence dictates the forehanded accumulation of a stockpile of sera for immunization as well as treatment, and of drugs and chemicals of proved value for the treatment of disease and for disinfection. Military and naval authorities have long been gathering such reserves for the forces. It should also be done for civilians, but not by individuals. Personal hygiene makes a valuable contribution to our efforts to minimize the incidence and severity of infectious disease. Miscellaneous advice to keep

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the feet dry, to keep out of drafts, and so forth, is all very well as far as it goes. Few people attend to such admonitions. It is more important to give attention to diet, work, play, and sleep, so as to maintain good general health. The American Public Health Association concisely summarizes personal protection by urging the necessity of: " ( 1 ) keeping the body clean by sufficiently frequent soap and water baths; (2) washing the hands after voiding bowels or bladder, and before eating; (3) keeping hands and unclean articles, or articles which have been used for toilet purposes by others, away from mouth, nose, eyes, ears, and genitalia; (4) avoiding the use of common or unclean eating, drinking, or toilet articles of any kind, such as towels, handkerchiefs, hairbrushes, drinking cups, pipes, etc.; (5) avoiding close exposure of persons to spray from nose and mouth, as in coughing, sneezing, laughing, or talking." 10 It might be added that promiscuous sexual intercourse, including kissing, should be avoided. All of the habits that make up good personal hygiene, however, may be counted as assets in the fight against communicable disease. Confronted with the host of injunctions which can be marshalled against apparently innocuous human activities, and with the array of possible sources of disease, the citizen at first may feel like 10 The Control of Communicable Diseases, Report of a Committee of the American Public Health Association, Public Health Reports, Reprint No. 1697 (revised 1940).

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abandoning the effort and submitting to his fate. Or, like some visitors to countries reputedly teeming with germs, he may be overwhelmed by worry and ritualistic precautions, so that he is powerless to work or enjoy himself. There is no reason, however, for the problem to preoccupy us. Each of us should learn the fundamentals of good hygiene, learn what further may be pertinent to our circumstances in relation to infectious disease, learn to comply promptly and readily with hygienic advice and instructions, forget the rest of the problem and go about his own business. The second World War will follow the general pattern of previous wars by raising the incidence of infectious diseases, except in so far as man successfully exercises control over them. Assuredly, some of the dread plagues of the past will somewhere take a terrible toll before the war is over. Presumably the vanquished will pay the heaviest share of this awful penalty; there may well be a relation between such epidemics and defeat, as has often been the case in the past. There is a story that Hitler and the Nazis have contemplated "bacteriological warfare" — spreading disease among their enemies by sowing germs among them. There is no proof of such a plan, but it would accord with the theory of total war, if it were worth while. No evidence of such action has appeared in Europe, but it is claimed that the Japanese took this diabolical step on two occasions, once in 1940, and again in 1941, when

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plague bacilli enmeshed in cotton pledgets were dropped in Chinese cities. Cases of plague (where none had occurred for many years) are said to have followed this action, but no epidemic started. The Japanese may well have attempted this new form of warfare. If so, it failed in their hands. There are many reasons for doubting the possibility of signal success in "bacteriological warfare." The accumulation of huge numbers of such germs is a formidable task, in some cases quite impossible. Moreover, the existence and spread of disease-causing germs depend upon many complicated conditions, including the infection of animal hosts and vectors, which the germ-scatterer can hardly hope to provide. Nor could the control of "planted" germs by the intended victims be discounted. The rise of typhus fever in Eastern Europe is more significant than the abortive Japanese effort to spread plague. There was a tenfold increase in Poland in 1940, and still more in 1941, when large numbers of cases developed on the German side of the Russian front. Bulgaria, Rumania, and parts of Czechoslovakia have already seen epidemics of typhus. In 1940-41, there were something like ten thousand cases in Spain, where the disease had long been absent. It has even spread to North Africa. On the home front in America, we should note the slowing up of the decrease in tuberculosis, which has already been mentioned. In New York City the incidence of tuberculosis in 1941 was not

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less than that of 1940, but more. In England the tuberculosis rate for 1940 advanced 13 per cent for males and 7 per cent for females over that for 1939. It is gratifying, however, to know that, in spite of fears and previously unheard-of trials, with overwork, limited food, mass evacuations, and mass sheltering from air-raids, no epidemic of any kind has visited England during the fateful years 193942. Indeed, British rates for infectious diseases in general have been remarkably low — an indication of the great practical achievements and magnificent morale of the British people. It is notable, and a cause for special tribute to her people, that China has suffered no serious epidemic in the turmoil of the last five years. Americans have every reason to expect to escape any such terrible visitation as is all too likely to come upon parts of Europe and Asia, but a serious increase in sporadic infections is to be anticipated, unless our defenses are strengthened. Before this second World War is over, large numbers of Americans, both in and out of the armed forces, will have seen service in the southwestern Pacific region, Asia, the West Indies, South America, Africa, Europe — in short, all over the world. We must be prepared, therefore, not only to protect these men, but also to keep the United States free from tropical or exotic diseases which have been unknown here. It is no flight of fancy to say that morale contributes to our safety from infections, especially

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those of epidemic nature. Significant at all times, this relationship is particularly close in time of war. Wise and farsighted planning is needed to carry us through the coming years without grave advances on the part of the biologic agents of disease. We cannot abate any of the sums spent on the services that protect us — though grudgingly provided, these amounts are relatively small; for this vital work we should rather increase our appropriations. If we use our knowledge and our resources wisely and efficiently, we need not fear the outcome. With increased popular understanding and support, we might indeed lower the incidence of infectious diseases, even during the war.

CHAPTER V S H E L T E R AND R A I M E N T

HE role of housing and clothing in the determination of health must be considered, because war creates new needs and restricts repairs and replacements. Huge munition and armament industries are rapidly being created, often in places where the facilities for living are quite inadequate. Vastly increased employment is stimulating a widespread demand for better homes, while many families who have lived with others are seeking separate quarters. Numerous houses which have been unoccupied for some years are desperately in need of reconstruction or demolition. Some of these dwellings are being reoccupied and many more will be sought for occupancy as a result of war activities. It is alleged that much inadequate remodeling is in progress, and that former rooming houses and empty dwellings are being rapidly turned into workers' homes. Housing authorities should be on guard against the use of such buildings before they are put into proper shape for human use. It is reported that some large war factories are surrounded by huge trailer camps in which workers and their families are crowded; only the most primitive sanitary facilities are provided. In addition to immediate war needs, it must be borne in mind that the population will continue

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to increase, and that buildings and their appurtenances will continue to deteriorate. As a result of the war, material and labor for maintenance and repairs, as well as for the construction of new homes, are scarcer with each month that passes. The material and labor that can be spared for clothing are also restricted, and may have to be greatly curtailed. Under the conditions of total war, housing and clothing necessarily come within the scope of national planning and regulation. Although the individual is dependent upon organized agencies in meeting these fundamental needs, every citizen can contribute to the war effort by ready and willing adjustment to unavoidable deficiencies and restrictions. Housing and clothing have a complex relation to health, which is difficult to assay, since other elements in the maintenance of health can rarely be excluded. In the case of clothing, there is almost no knowledge that can be called exact. Reliable statistics that bear on the hygienic aspects of housing in America are scanty. The National Health Survey of 1935-36 provides valuable information as to the frequency of certain illnesses and accidents in homes of various types. R. H. Britten and Isidore Altman, of the United States Public Health Service, have analyzed the data for the urban white population.1 These authors point out that the degree of 1

Rollo Η. Britten and Isidore Altman, "Illness and Accidents among Persons Living under Different Housing Conditions,"

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crowding is an index of the quality of housing in other respects. They note that it closely parallels the family income, which is, therefore, taken into account in making comparisons. The illnesses which are recorded in this connection were those which kept a person from his habitual occupation for seven or more consecutive days in a year. Such disabling diseases were more frequent in relatively crowded houses (see the table). THE RELATION OF DISABLING ILLNESS TO CROWDING IN THE HOME * (Ratio of frequencies relative to overcrowding) Persons per room All illnesses f Pneumonia Tuberculosis Rheumatism Diphtheria % Diphtheria §

One or less 100 100 100 100 100 100

More than one and less than More than one one and a half and a half 105 134 122 120 178 126

118 168 191 143 272 187

* Compiled from data given by Britten and Altman (reference in footnote 1, this chapter), f As defined in the text. % In children under five years of age. § In children from five to nine.

In the case of the respiratory diseases pneumonia and tuberculosis, the increase in frequency with greater crowding was striking. The same study data based on the National Health Survey, Public Health Reports, LVI (1941), 609-640 (March 28, 1941).

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showed that the lack of a flush toilet for use by only one family was associated with excesses of 38 per cent in diarrheal diseases, and 128 per cent in the typhoid-paratyphoid fevers. Household accidents were correlated with the rental value of homes, and were found to be as much as 69 per cent more frequent in the lowest group than in the upper brackets. Burns occurred four times more often in families occupying homes of the lowest rental value. Accidents in the home merit special attention, for they cause about as many fatalities as do automobiles. The National Health Survey, which took account of a total of over two and a half million persons, showed that the home was the scene of 31 per cent of all accidents of sufficient severity to cause a week's disability. Falls were responsible for the majority of the injuries, with burns a distant second. It is clear that differences in the incidence of disease and accidents, such as those which were demonstrated in this study, are by no means solely related to variations in housing. Under natural circumstances housing always varies with income, which inevitably influences many other hygienic elements in living conditions. Among the forces which play upon health and cannot now be well separated from housing are intelligence, efficiency in management, and occupation. Britten and Altman point out, however, that their study demonstrates that low-income, poorly housed populations suffer from an excessive burden of disease. One may

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safely go further and say that certain features of our homes can do much to enhance or injure health, so that housing is, in important degree, a problem in hygiene. Good housing is universally accepted as essential on the farm for livestock. The Department of Agriculture in its numerous farmers' bulletins has no hesitation in stating the matter bluntly. As Dr. Edith Elmer Wood said in an unpublished address in 1940: "The Bureau of Animal Industry . . . comes out roundly with delightfully dogmatic statements, such as: 'Dryness, good ventilation, and freedom from drafts are the first requisites of buildings for sheep.' If little pigs are to get the right kind of a start in life, they must have plenty of sunshine.' 'Growing chicks and laying hens need comfortable homes that are dry and roomy with plenty of fresh air and sunlight. It never pays to overcrowd them.' Fortunate farm animals! No one writes doctors' theses to prove that there is no causal relation between their health and their housing." Modern dwellings have evolved from the simple protection which primitive man sought against the elements. They have to serve many more subtle functions than mere shelter. In spite of the fact that a variety of public regulations exist which control many aspects of housing, the individual citizen should be acquainted with the essentials of hygienic

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homes. A statement in concise and concrete terms of the principles of housing for health has been published by the American Public Health Association.2 In this report thirty principles are presented under four headings: (1) Fundamental Physiologic Needs, (2) Fundamental Psychologic Needs, (3) Protection against Contagion, and (4) Protection against Accidents. Building codes are largely concerned with requirements which are designed to prevent houses from falling down or burning up too readily. This form of regulation is elaborately developed in cities, but hardly extends to villages or farms. In spite of it, many American dwellings are in a wretched structural state.3 Our worst dwellings give only incomplete shelter from the weather. In a larger number, poorly lighted halls and stairways, and defective floors and stairs, are a menace to life and limb. Every winter in all large cities loss of life from fire shows that sufficiently easy means of escape from burning homes is not yet universally provided. Accident prevention requires not only the correction of such glaring shortcomings, but also protection against gas poisoning and electric shock. 2 See Housing for Health (papers presented under the auspices of the Committee on the Hygiene of Housing of the American Public Health Association, 1941). This brochure, to which the author acknowledges a special indebtedness, contains twelve papers of interest to all who are concerned with good housing. "According to the 1940 Census, 18 per cent of American dwellings were in need of major repairs, including one-third of all farm homes.

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The general principles in accordance with which infectious diseases may be avoided have been discussed in Chapter IV. With this background, we may review here the special needs which must be met in houses in order to avoid contagion. This subject is included in municipal sanitary codes. Again it must be noted that urban homes in general are better provided for than rural dwellings. An ample supply of safe water, with rigorous separation of sewage, is essential. A minimal allowance is said to be twenty gallons per person per day. Unprotected wells in close proximity to open privies or barnyards are still to be found on many American farms. Anyone who is using or contemplating the use of a country well or spring should assure himself that it is a safe source to employ.4 Provision should be made against the contamination of water within the building. Toilet facilities of approved design take equal rank with a safe water supply as sanitary needs of the first order. While it is well known that insanitary privies are common in rural districts, it is not so widely realized that a sizable fraction of urban homes is without modern toilet facilities. Although the United States Census for 4

For the conditions necessary for safety, see the Progress Report of the Committee on Ground Water Supplies of the Conference of State Sanitary Engineers for 1936, Public Health Reports, Supplement No. 124 (Washington: Government Printing Office, 1937). For practical information see George M. Warren, Farmstead Water Supply, Farmers Bulletin, No. 1448 (Washington: Government Printing Office, 1925).

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1940 showed that more than half of all the homes in the country have private baths, a survey made by the Bureau of Foreign and Domestic Commerce in 1934 found that 17 per cent of over two and a half million urban dwelling units had no indoor water closet (23 per cent had no bath). A flush toilet with water carriage of sewage is the ideal. The toilet room should be so constructed and lighted that it can easily be kept scrupulously clean. Good ventilation, preferably by an outside window, is necessary. The toilet should be restricted to the use of one household (see data given above from the National Health Survey on the incidence of typhoid fever). Sewer and water supply lines need to be kept rigorously apart. Back-drainage, or siphonage, and leakage should be guarded against, as well as contamination of the cellar or soil about the dwelling. In large buildings plumbing becomes so complicated that special attention must be given to pipe lines in order to keep the two systems isolated from one another (it will be recalled that the Chicago epidemic of amebic dysentery in 1933 was traced to incomplete separation of water supply and sewage). Where sewer systems do not exist, careful plans must be made for the disposition of excreta.5 In addition to protection of the water supply and soil, 5 The following publications of the United States Public Health Service are useful: Sewage Disposal for Suburban and Country Homes, Public Health Reports, Supplement No. 58 ( 1 9 2 6 ) ; and The Sanitary Privy, Public Health Reports, Supplement No. 108 (1933).

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provision should be made so that insects and other animals cannot spread infection from sewage. The proper construction of a dwelling provides safeguards against invasion by certain animal carriers of disease, including mosquitoes, flies, fleas, and rats. Screening, which cannot be regarded as a luxury, should cover all windows and doors. Cellar windows and ventilators ought to be covered by strong screens or gratings. Foundation walls, ground floors, and joints between pipes and floors should be rat-proof. In some cases the introduction of bedbugs or lice may have to be prevented by fumigation of clothing and furniture before new tenants take possession of a dwelling. In the greater part of the United States, at least in summer, facilities have to be provided to prevent the contamination and decomposition of perishable food, including especially milk, which should be kept at a temperature of 50° F. or less. Expensive mechanical refrigerators are not essential for this purpose, so that their disappearance from the market in wartime should not dismay anyone. A properly built icebox is quite satisfactory. It must be remembered, however, that some germs, such as the typhoid bacillus, survive in natural ice. Refrigerator drains need to be separated by an air gap from sewer and waste lines. Crowding, especially in sleeping rooms, should be minimal. A room per person is the standard America ought to meet. In sleeping quarters, beds

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should be at least three feet apart, and fifty square feet of floor space per person ought to be provided. Double-deck beds are undesirable. In point of fact, the housing survey of sixty-eight American cities by the Bureau of Foreign and Domestic Commerce in 1933-34 showed that 17.1 per cent of the dwellings had an average of more than one person per room. In 1940 the Census found that 9 per cent of occupied dwelling units were housing more than one and a half persons per room (which may be taken to indicate actual overcrowding). Included in this classification were nearly 17 per cent of farm homes. Overcrowding is found in small cities and on farms, as well as in metropolitan centers. The war has already caused an increase in crowding which is a serious menace to health, particularly because of the danger of epidemics of respiratory diseases. The nation's capital sets a shockingly bad example. A final basic principle of home protection against contagion is that the immediate vicinity of dwellings should be sanitary. Sewage and garbage must not be exposed. Piles of waste and refuse quickly become breeding and feeding places for flies and rats. Stagnant water breeds mosquitoes. Small ponds soon become foul. The avoidance of such accumulations is a hygienic as well as an esthetic good. In cities this work is done for the most part by public services, so much so that individual citizens rarely feel any responsibility in the matter, which sometimes rests very lightly on the shoulders

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of householders who live beyond the limits of municipal services. The public removal of refuse in large cities is a colossal and expensive task. The volume of wastes can be greatly reduced by destruction or compression in the home. Furthermore, in time of need, much that is ordinarily discarded can be reclaimed. During the war, the need to economize in these ways will make itself acutely felt, and the individual householder can render signal service in this direction. The simple basic sanitary requirements of good housing must be considered to apply to public airraid shelters, especially if shelters are in use over a long period of time. The citizens of London who spent so many of their nights for nine months of 1940-41 in shelters escaped epidemics, perhaps partly by good management, and partly by good luck. The principles of good housing which have been reviewed so far relate to elementary safety from accidents and contagion. They are those which early received detailed consideration after the modern industrial era began. Satisfactory homes, however, should meet fundamental physiologic and psychologic human needs, as well as giving protection from external harm. From a logical point of view, one would prefer to place these considerations in the front rank. We say that houses were developed to keep out the weather. The need arises because man is physiologically unable to adapt him-

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self continuously to extremes of environmental conditions. Moreover, mind and body in the long run function best within certain limits of external variation, which in some respects are rather narrow. Heat and cold, wind (or drafts, as we say in this connection), and changes in the composition of the air we breathe are physiologically important aspects of our surroundings. Although the human body has a remarkable ability to maintain a constant temperature, the mechanism by which this is accomplished is strained, especially when the body is relatively inactive, if the environment tends either to permit too much heat loss or to cause too great retention of heat. The effective temperature about the body depends upon both air and wall temperature. It usually varies much from floor to ceiling, often 10° to 20° F. For winter heating a temperature of 65° to 70° F. at knee-height, depending upon age and vigor, is recommended. Indoor humidity is generally low in winter. Although it is often said that low humidity is harmful, a scientific basis for the statement is lacking. In any case, observations, as well as calculations, show that the casual evaporation of kettles of water does not materially raise the humidity. There appears to be something in the common charge that too many American homes are overheated in winter. If so, we should learn how to keep our houses at a reasonable temperature. While die war lasts, fuel of all kinds will become progressively scarcer and more

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expensive. Hence, economy in the use of fuel will serve both patriotic and physiologic ends. It may help to remember that with increased activity the body makes more heat and, therefore, within limits, more successfully endures a low temperature. The role of clothing in the maintenance of body temperature is discussed later on in this chapter. Significant economies in fuel, without serious loss, can be made by not heating unused rooms and not opening windows and doors for unnecessary ventilation. The merits of various methods of heating, and the benefits of insulation, weather-stripping, double windows, and tight floors, are outside our scope. For summer, an indoor temperature of 75° F. or less is recommended. The relative humidity, which is often high, has a marked effect on the readiness with which the body loses heat. At high temperatures, a high humidity is said to depress various physiologic functions. A breeze, even though very slight, causes rapid loss of heat from the body. In ordinary circumstances it is difficult to control summer conditions beyond a light degree. Cross ventilation, particularly in a direction adapted to the prevailing wind, should be sought in all dwellings. The hotter air, of course, is at the ceiling, so that the tops, as well as the bottoms, of windows should be open. Electric fans give much relief, but, when played directly on the body, they are injurious to some persons. In very trying circumstances, the old, but perhaps not widely known, trick of blowing

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an electric fan on a cake of ice or a wet blanket may be used to secure some hours of comfort. The air we breathe should be free of unusual gases, dust, and odors. Home circumstances, and even conditions in churches, auditoriums, and theaters, are unlikely to give rise to a decrease in oxygen or an increase in carbon dioxide of any physiologic significance. It is worth noting that there is no basis for the advertised statement that "ozone" is beneficial. The only foreign gas which is likely to accumulate is carbon monoxide, from stoves and refrigerators in houses, and in garages, from automobiles. The precautions which should be taken against poisoning by this gas should now be well known, but it cannot be too often repeated that there may be no warning smell, and that the first symptoms are usually only drowsiness and headache. Fainting without warning is not unusual. Anyone with a coal-burning fireplace will do well to remember that it may be dangerous in this respect. At present the individual householder has no way to keep out dust and soot-laden oil droplets which have become troublesome from oil-burning furnaces. Odors in the home come mostly from cooking, heating appliances, and the human body. It is recommended that four hundred cubic feet of space per person be provided in any occupied room, and that there should be an air change of ten cubic feet per person per minute. In nearly all houses, an air change of this extent takes place in winter

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through normal leaks in outside walls and in windows. In summer, windows must be open. Control of temperature, humidity, and ventilation has been developed in recent years as "air-conditioning," equipment for which is extensively installed in public buildings. Whatever hope was entertained of widespread application of these methods to private dwellings is gone for the duration of the war, and probably a long period thereafter. Since we have many more pressing needs, we can afford to forget about air-conditioning until the time is ripe to reconsider it. The human eye functions best with good lighting; yet glaring light strains the eye. The intensity of light which is needed varies with the use to which rooms or parts of rooms are put. Light should be carefully arranged for all important household tasks, for reading, writing, sewing, and the like. A home in which artificial illumination has to be used regularly during the day cannot be regarded as satisfactory. Hence, adequate lighting without glare must be provided from both artificial and natural sources. Furthermore, it is desirable to have direct sunlight come into some parts of the house. The arrangements which must be made to secure these ends are not often achieved with complete success, since they depend in large measure upon the orientation, surroundings, and construction of the dwelling. Nevertheless, the householder can do much to improve defective conditions. He can make maximal use of

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window space, use proper shades, place furniture to the greatest advantage, and provide suitable artificial illumination for his needs. Darkening our homes for protection during enemy air-raids is a new but vital duty which too many American householders have not taken realistically. Merely putting out all lights serves in an emergency, but is quite unsuitable if raids are frequent or prolonged; for, in that case, everyone should be busily engaged in planned activities, which require light. In some parts of the house, illumination is necessary to prevent accidents. Light, with the activities which it permits, keeps up good morale. It helps, therefore, to defeat the purpose of air-raids, which is to make work impossible and life miserable. Carefully selected portions of every house should be scrupulously protected so that adequate illumination of it does not permit the faintest ray to be seen outside. Though we must be fully prepared for a "blackout" on the outside, there should be light and activity within. Good housing ought to protect the ear as well as the eye. Prolonged or frequently repeated excessive noise is harmful through its interference with efficiency in general, and particularly with sleep. Many individuals are mentally highly susceptible to the exciting and exhausting effects of noise (the divebomber in part is a means of making an astute attack with fiendish purpose on this human frailty). Partly because of the cost, and partly from short-

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sightedness, most American homes are constructed so that they keep out or restrict from apartment to apartment only a fraction of the noise which it is possible to control. Anti-noise campaigns in large cities have been flat failures because of public indifference. It is a fair conclusion that relatively few Americans are conscious of an unfavorable reaction to noise. Housekeeping is a job. It is said that sixty hours of work per week are done in running the average household. Efficient facilities are as much a hygienic need in the home as they are in shop or factory. We are proud of the fact that for thirty years or more conveniences have been progressively added to American homes, which are today the best equipped in the world. Nevertheless, large numbers of houses are in use which were not planned for convenient management, and poorer families have had only a small share of all the gadgets that go into a well-equipped house. Through its tremendous demands for labor, much of which must be contributed by women, the war puts an extra premium on efficient housekeeping. Servants will almost, if not entirely, disappear. Those who take up housework as an unaccustomed task may find satisfaction in it as a job with many techniques, which is worth doing well.8 A dwelling place meets many psychologic needs, " A straightforward and detailed description of techniques is given in Americas Housekeeping Book, compiled by the New

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in the satisfaction of which it may succeed or fail. Some of these needs are intricately bound up with the aspects of housing which have been already considered. The outstanding purely psychologic need is that for privacy, both for the family and for the individual. A separate room for each older child as well as each adult is a reasonable ideal, but we are far from attaining it now or in the near future. In England, housing legislation limits occupancy of a sleeping-room to two persons, and requires two rooms for three persons, and so on; separation of the sexes, except in the case of married couples, is required from the age of ten years. As a complement to the need for privacy, the family requires facilities for its social life. The pattern of family life naturally varies greatly from household to household. Yet it has to conform in important respects to the framework of its living quarters. It is not enough, therefore, to provide dwelling units of so and so many rooms. Intelligently planned houses or apartments should meet a variety of functional needs. Furthermore, the building which becomes a home, and its immediate surroundings, should be capable of satisfying in some measure the natural desire of its occupants for beauty. The formation of slums is an economic and social process which spreads as if an organic rot were at work. A single house which becomes a slum home York Herald Tribune Home Institute (New York: Charles Scribner's Sons, 1941).

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serves as a center about which an ever-increasing area deteriorates, even though individual householders struggle to halt the downward progress. The rot which makes slums can only be prevented by vigorous community or public action which is designed to create and preserve a healthy residential area. When the replacement of slums by decent houses is undertaken, opposition is sometimes met from the tenants themselves, an apparent paradox, which is explained by the fear of increased rents. Housing costs a considerable fraction of the family income, amounting to 20-25 per cent. Under the conditions of 1935-36, 31 per cent of American families and single individuals disposed of an annual income of less than $750. Except for some single individuals, and with the possible exception of a very few localities, none of these incomes was sufficient to provide an adequate dwelling without community subsidy in some form. A further 15 per cent had incomes between $750 and $1,000 a year, many of which were insufficient to provide proper housing. The abundant evidence that large numbers of American families are housed in unhygienic fashion will not be presented here. Cities still have slums, and country houses in some districts are often as bad or worse. Colored people are under special disabilities in this matter. The problem long antedates the depression of the 'thirties. It will not be solved by wartime increases in earnings, since proper dwellings simply do not exist in sufficient

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numbers.7 Our own housing history, as well as the experience of Europe, teaches us that public interest and community or governmental aid are necessary for progress in satisfactory rehousing. Progressive European countries, particularly those of Scandinavia, and even pre-Hitler Germany, long ago made improvements which we had only begun to institute when the war commenced.8 In the last decade before the war, however, American interest in this great problem was rapidly rising and spreading. Improved plans and governmental aid were beginning to add substantially to the number of healthy dwelling places. In 1940, housing construction was more than twice the average annual amount for the decade 193CM0. As of June 30, 1941, the United States Housing Authority had made loan contracts in thirty-four states and territories, which totaled over $700 million. These contracts provided for 230 public housing projects with over 190,000 dwelling units. Nearly 70,000 new dwellings financed by the Authority, or its predecessors, had been occupied by low-income families. The criticism has been made that too large a share of these new tenements * According to the Census for 1940, the number of occupied dwelling units was about 34.9 million, of which 20.6 million were rural. There were only 2.5 million unoccupied dwellings. In the decade 1930-40, the number of new units provided in 257 cities was only one-third of that for 1920-30. β An illustrated account of one of the most successful of modern developments is given in Chapter IV, "Low Cost Housing," of Sweden: The Middle Way, by Marquis W. Childs (New Haven: Yale University Press, 1936), pp. 51-65.

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was beyond the reach of those in the lowest income brackets. The war imposes such a strain on our resources of material and man-power that the program for better housing must be abandoned, at least as far as replacement of existing dwellings is concerned. This is a great loss, but its present importance depends largely upon our estimate of the significance of housing for health. Among the studies which bear on this question is an interesting observation which was made in England a number of years ago. A fair-sized slum population which had been well studied by public health officials was divided by rehousing some of the families in a model community. The other families continued to live under the old conditions. After five years, it was something of a shock to observers to find that, although the crude death rate had fallen definitely in the remainder of the old slum, it had risen by more than 40 per cent among the families in the model houses. The matter was carefully investigated. Nothing in the nature of an epidemic had occurred. The two groups were shown to be comparable as to income, which was generally very low in both. It happened, however, that the rents and other housing costs in the model community were higher than those in the old dwellings. At the low level of income which prevailed, the difference was perforce chiefly made up by economies in the purchase of food. After a thorough dietary survey, it was concluded that

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dietary deficiencies (mainly in proteins and vitamins) in all likelihood were responsible for the greater death rate in the model community. This observation strongly suggests that under the circumstances good housing was not so important as a good diet.9 It is safe to say that the more modern refinements of housing, though contributing to health, play only a secondary role. In any event, since there is more important work at hand, we must give up extensive plans for rehousing without hesitation. This is far from saying that the principles of housing for health can be safely forgotten, for that would be to court disaster. The immediate needs of war workers, at least, must be satisfied. It is well to remember that their health (and that of their families) is reflected in the output of essential factories. Bad housing was considered to be a serious cause of labor unrest in England in 1914-18. Although American workmen can be counted upon to endure with fortitude the demands for hard work and great sacrifices which the war will impose, there is a minimum standard of housing comfort below which their morale will suffer. In the spring of 1942, reports indicate occupancy of 95 per cent of dwelling units in war industry areas, while only a small part of those which remain are fit for occupancy. To ac" This study is described with fullness and clarity by George C. M. M'Gonigle and John Kirby, in Poverty and Public Health (London: Gollancz, 1936).

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commodate the additional workers who will be drawn into these areas, many new dwellings must be built. Nearly all wartime construction of homes is for war workers, as it should be. To consolidate its activities in this field, the federal government in April 1942 united sixteen agencies for planning, financing, and building houses into one organization, the National Housing Agency. During the war, some modification of building standards is inevitable, but changes should be made with due regard for the health and safety of occupants. We ought not to be led to build many thousands of flimsy dwellings with inadequate sanitation and space because the need for this new construction is temporary. New houses must continue to be planned for health, with greater emphasis than ever on simplicity and ease of management, so that a minimum of service is necessary. Convenience, not expensive gadgets, is what is needed. Multiple-family houses and grouped individual homes should be provided with more community housekeeping services than have usually been available heretofore. A wide extension of community services for household functions in wartime, such as has been undertaken in England, will prove efficient and economical. After the war is over, the housing problem will be more urgent than ever before. It is estimated that in 1945 about 30 per cent of American houses will be fifty years old, an age at which few ordinary dwellings are fully suitable for occupancy. It is to

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be expected that many of the houses built for war workers will be useless. During the war, careful plans on a large scale should be prepared in anticipation of huge housing needs after it is over. Arrangements can be made for the allocation of funds as soon as the war is over to vast rehousing schemes all over the country; then, these projects should be quickly put into operation, both for their own sake and for the employment they will provide. Clothing serves many varied functions. Colored shirts, beginning with Mussolini's black variety, have made a large share of the history of the last twenty years. Almost immediately on entering the second World War, Americans find that total war restricts their costumes —men are to have cuffless trousers, shorter coats, and no patch-pockets; women's skirts are to be shorter and narrower, and their silhouettes "frozen." From the hygienic point of view, clothing has three functions. That of covering our shame, or guarding against weaknesses in sexual relations, need not concern us here. Nor will we consider the far-reaching and varied psychologic significance which clothes have for many persons. The most important of these functions of clothing is that of aiding the body to maintain an even temperature by protecting it against undue effects of wind, cold, wet, and sunlight. The skin with its hair and the underlying layer of fat are man's natural

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protection against the elements. The English physiologist Leonard Hill has remarked that ornaments such as colors and beads were applied to the body before clothes were put on for protection. But perhaps that was largely in warm climates. European civilization has spread a heavy mantle over us. In the last thirty years, American women have shed a large portion of the burden of clothes which custom dictated at the end of the nineteenth century. Yet the death rate has rapidly declined, and there is no evidence of increased ill health among American women. Indeed, a case can be made out for the view that their health is the better for their scantier costume. Men have not made a comparable reform in their clothes, which remain much what they were fifty years ago. Masculine dress has an English origin; it is said to descend directly from a whimsical notion of Charles II. It is not adapted to the prevalent American summer, or to well-heated houses. In winter a man may carry 10 per cent of his weight in clothing, whereas a woman wears only one half or less of this amount; a dog has only 2 per cent of his weight in fur. But the thickness of clothing which the "well-dressed" American man wears in summer is a striking demonstration of the power of fashion. That everyday clothing, and not only Palm Beach finery, should be adapted to climate and season, may seem obvious to some readers. Yet many Americans who may have to work in tropical or subtropical regions need to be

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warned to provide themselves with simple clothing of very light weight. Few studies of clothing from a physiological point of view have been made in America. The subject is one of the many fields in which the Germans have worked. We need some exact investigations of the hygiene of clothing in different parts of this country and in various occupations. Clothes generally should be light in weight and readily permeable to air; they should allow free evaporation and absorb moisture to a minimal degree. An insulating layer of air between body and clothes is most desirable, so that clothes ought not to cling too closely. At low temperatures, however, the loss of heat through air movement is great. It is minimized by the use of impermeable materials, such as leather, rubber, and paper. Color is important only in regard to the reflection and absorption of heat, white reflecting about twice as much as black, with dark colors intermediate. Even a single layer of cotton cuts down the transmission of light and ultra-violet rays by 50 per cent or more. The qualities of textiles vary with preparation of the raw material and with the manner of weaving, but certain generalizations are possible. All textiles absorb a good deal of moisture (flannel takes up 40 per cent of its weight). The heat conductivity of cotton is increased threefold when it is wet, while that of flannel is only doubled. Wet wool still leaves an air layer about the body and retains some air

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spaces in itself, whereas cotton quickly becomes soaked and clings to the body. Dyed material takes up less water than undyed. As to thickness, woolens are necessarily relatively thick. Cotton goods can be made extremely fine, though this is rarely done. Silk and similar materials are highly impermeable, and the slightest moisture makes them cling. They form the sheerest tissues, but have then little durability. In spite of frequent use for the purpose, silk and rayon are poor materials to wear next to the body, except perhaps in stockings which are only worn for appearances. Linen has become purely an article of luxury. No single fabric fulfills in the highest degree all the various demands made of clothing. Silk we shall not have for a long time. We should not try to make rayon for civilian use. Wool will be scarce because of smaller importations and great military needs for it. Cotton we have in plenty. Cotton, which can be made up in many different ways, comes closest at present to an ideal material. It has the great hygienic advantage of being most easily cleaned. Few persons are allergic to cotton cloth. The substitute materials of the Germans, which to Americans have been ridiculous, have no advantage over cotton. Cotton, in fact, is one of the items for which the Germans are fighting. Let us make every possible use of our great supply of this raw material. The cost of clothing, except at minimal levels, bears little relation to the practical service which

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it renders. A good deal of material and labor can be saved by the elimination of frills and unnecessary variety. The war, with its demands for harder work, greater simplicity and economy, and less servicing, is a suitable occasion for a reform in clothing habits. In Great Britain, clothes are strictly rationed and the allowance is small — no more than a man or woman will wear at one time in winter — so that replacements are made with great care. The government encourages the use of standard fabrics which are cheap but of reliable quality. American regulations in the spring of 1942 have only trivial effects from the individual's point of view; they call for economy and for the elimination of fads, both masculine and feminine. Yet the saving in materials for women's clothes is estimated at one hundred million yards a year. The need of soldiers and sailors for all the protection that clothing can give them far outweighs that of civilians. Whether rationing will be necessary in America or not depends partly on the degree of cooperation which the public accords to the government's present program. None of the restrictions could be thought by the greatest stretch of the imagination to affect adversely die health of normal people.

CHAPTER VI MOTHER AND CHILD

HE health of mothers and children is naturally close to our hearts. Within the limits of their resources of money and knowledge, the individual family strives to secure for mother and child the best of health. For a generation there has been a slow popular awakening to their needs and to the possibilities of improving their condition. At the same time, America, chiefly through local agencies, but with substantial aid from federal sources, has been gradually developing measures for the protection and enhancement of the health of mothers and children. Yet we have not progressed far in this vitally important social field, and the advent of war is certain to intensify the problems which await solution. The fundamental significance of mothers and children for the welfare of the nation should transcend all other considerations. The only possible exceptions to this generalization are brief emergencies which may threaten to overwhelm the country. A long war is not an exception. Children are our future citizens. Their number and their quality will determine the wealth or poverty of the nation. In spite of these facts, in common with most other

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peoples, we have so far failed to face squarely the planning and action to which the situation challenges us. The fertility of a people which adds live, healthy babies to the population is measured by their birth rate, while the death rate indicates losses to the population from human frailty. The balance between births and deaths in the long run determines the growth or decline of populations. In Chapter I the effect of long wars, especially that of 1914-18, on belligerent populations was noticed. In the cases of France and Germany, the fall in the birth rate was catastrophic and, although these nations suffered very heavily from war deaths, their greatest loss was in unborn babies. War deaths caused a serious depletion of men of marrying age in the post-bellum years, as shown in the table below.1 WOMEN PER 1000 MALES Age Group in Post-war Census 20-24 25-29 30-34

France 1911 1921 987 1001 1022

1169 1261 1206

United Kingdom 1911 1921 1022 1016 1114

1176 1209 1186

Germany 1910 1925 995 999

1150 1259

Fear of a declining birth rate led Germany, both republican and Hitlerite, as well as Italy, to attempt to augment the number of babies born by offering 1 Data from "Post-War Depletion of Men at Marrying Ages," Statistical Bulletin, Metropolitan Life Insurance Company, XXI ( 1 9 4 0 ) , 1-A (February 1940).

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state rewards for larger families. The loss of population which France suffered in and after the war of 1914-18 was grievously felt when the second World War broke out. In 1940 the English birth rate was 2 per cent below that for 1939, the last year of peace. During, or immediately after, certain wars, it has been observed that more boy babies than usual are born in proportion to girls. The relative increase is not great (perhaps of the order of 3 per cent) and only occurs in association with long wars. It did not accompany the Franco-Prussian War, nor did it appear in the United States during the years 1914-18 or later. The phenomenon was seen in Germany during the first World War, rather than after it. Some neutral peoples in Europe, as well as belligerents, were affected. Various explanations of the higher proportion of male offspring have been suggested, none of which is acceptable. It has been thought that a higher rate of fetal death for females must take place during or after the wars in question, but there is no evidence that this is the case. Poor nutrition during pregnancy has been blamed. During the depression of the 'thirties, however, the ratio of male to female babies in the United States was unchanged. An increase in the proportion of first births in the total might be the explanation, since the number of male babies regularly decreases as the mother's age advances, but this hypothesis cannot be proved. The matter remains a mystery.

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It is well known that the American birth rate has been falling since about 1900; also that the decrease has a peculiar distribution in that it affects especially families which are relatively well provided with economic and educational resources. Since the number of births is profoundly influenced by economic and social, as well as by biological, forces, it fluctuates over short periods of years.2 The provisional birth rate for 1941 (18.8 per 1,000 population) is the highest since 1930; it is approximately 14 per cent above the lowest rate this country has yet seen (that for 1933). Since the death rate for 1941 is estimated to be one of the lowest on record, the net increase in the American population for 1941 is greater rather than less than that for recent previous years. In spite of this reversal, statisticians believe that the long-term tendency is downward, and that the prospect after another generation passes is that our population will be stationary or declining. During the depression of the ten years previous to the second World War, the suggestion was made that many economic troubles would be relieved by a smaller population. This is an assumption that rests on no sure foundation. Indeed, there is more to commend the view that America, or any country, would be in a better state with an increas2 In the Birth Registration Area of the United States, the rate declined steadily from 25.1 births per 1,000 population in 1915 to 16.5 in 1933; from 1934 to 1937 it fluctuated about the value 17, and from 1938 to 1940 about 17.5. The German birth rate for 1940 is given as 20 per 1,000 population.

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ing or even a stationary population. A nation can hardly hope to reverse a declining birth rate, but there are steps which can be taken toward a stable population and a population of higher quality.3 An intelligent and understanding attitude toward birth control is essential to progress in the solution of these problems. The accidental birth of children cannot possibly be justified in modern society on moral grounds. Children who are wanted, and children whose parents are reasonably well fitted to beget them and to bring them up, have the best chance of becoming worthy citizens. Children who have been separated from their families for various reasons are cared for in our institutions to the number of 250,000. No matter how good we may make these asylums, we cannot make them into real homes. Each year there are in the United States 60,000 to 70,000 illegitimate births, or something like 3 per cent of all live births. No one can doubt that illegitimacy is a very special handicap. Surely a nation alive to its future welfare must take adequate steps to reduce the number of these unwanted and neglected children. The huge armies and navies of wartime are associated with large numbers of both postponed and precipitate marriages, as well as with an increase in promiscuous sexual relations. War is a severe test of the upbringing and educa8 A presentation of the general subject, largely on the basis of the experience of Sweden, is given in Population, a Problem for Democracy (1940), by Gunnar Myrdal.

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tion of the nation's young people with regard to the responsibilities of marriage and parenthood. In such a time, the nation has a duty which is greater than usual to provide facilities of adequate quantity and quality for the care of unmarried mothers and their babies, as well as for those whose incomes are insufficient to secure proper medical attention. Birth control, from the point of view of the nation, should imply not only restriction of the number of children born in some families, but also increase in births in other cases. Dr. Gunnar Myrdal's analysis leads to the conclusion that families who have any offspring must average four children in order to keep the population stable. The totalitarian method of giving bonuses for numerous children is a crude and unsatisfactory approach, which does not accord with American ways. Deliberately to urge young men and women to produce offspring, regardless of their past and future relations (as has allegedly been done in Germany), is intensely repugnant to Americans. In this country, larger families for those relatively well fitted to have them should be encouraged by educational programs and by indirect economic means. Prudery keeps some potential parents from securing the medical aid which might prevent them from being childless. Economic assistance for mothers and children in the lower income groups is imperatively needed; it should consist, not of money, but of increased public services both for mothers and for children. We have long accepted

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nationwide education as a public duty. Adequate nutrition and good medical and dental care must be made generally available to children. We are far from this today. If such services reach a satisfactory standard, families who now protect their level of living by remaining small may be replaced by larger groups. A large number of pregnancies for various reasons fail to result in living babies. The total loss to America from miscarriages and stillbirths is unknown, but in 1937 there were 73,000 stillbirths recorded, or 33 per 1,000 living babies born. Death of both mother and infant is relatively frequent when a child is prematurely born. The most important causes of miscarriages and stillbirths are the poor health and inadequate medical care of mothers. Medical and nursing supervision of pregnancy and delivery has been greatly extended in the United States in the last generation, but their availability and quality vary extremely with economic status, urban and rural residence, and region of the country. Even in cities, 5 per cent of white mothers have no medical attendant and about 50 per cent are under supervision only during the second half of pregnancy. The National Health Survey showed that in 1934-36 one-third of the white mothers in urban centers were delivered at home (including nearly half of the mothers in families "on relief"), and only 40 per cent of these mothers had nursing care. In cities of less than 100,000 population in

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the South, half of the colored mothers, and in the country districts of the South a still larger proportion, are delivered by midwives. The maternal death rate in the American Registration Area before 1929 varied from 6.5 to 7 per 1,000 living babies, but since 1929 it has fallen to 4. One maternal death in three is still due to septic infection. The other outstanding cause is "toxemia." The war of 191418, and especially the confusion immediately after it, was associated with a rise in the number of abortions and maternal deaths in Germany. On the other hand, even during the stressful year of 1940, the maternal death rate of England did not rise, but fell slightly. Syphilis in the mother has been a prolific cause in the past of stillbirths and of deformities and crippling damage, especially blindness, to the children who acquire this disease before they are born. Congenital syphilis is rapidly decreasing and can be wiped out by finding mothers who need treatment and giving it to them in good season. It is estimated, however, that there are still 60,000 babies born with syphilis every year in the United States and that there are over 20,000 stillbirths which are due to syphilis. In 1940, over a third of the babies born to mothers with syphilis had contracted the disease before birth, a tragedy which need never occur. The possibility of suppressing pre-natal infection is demonstrated by the experience of Denmark, where in 1939 there were thirty-one cases of

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congenital syphilis, an incidence which is about 2 per cent of the estimated rate for the United States. Of newborn infants, over one hundred thousand die annually before reaching the age of one year (nearly 50 per 1,000 living babies). These infant deaths constitute over 8 per cent of all deaths; a quarter of them occur on the first day of life and nearly 60 per cent within the first month. The total infant death rate has been halved in the last twentyfive years, but there has been little reduction in deaths in the first month and almost none in those of the first day of life. The most important causes of early infant death are prematurity, birth injuries, and congenital malformations. Some of the smaller progressive countries, where the problem is simpler than it is in the United States, have achieved better records. The lowest infant death rate is that of New Zealand (31 per 1,000 live births in 1936). The loss of life in early childhood, though now only a small fraction of what it used to be, is still great, for nearly a third of all deaths in America occur in the 12 per cent of our population which is below six years of age. Americans can justifiably take pride in the improvements which have occurred in maternal and infant death rates. We should also realize, however, that all of these losses can be further reduced by earlier and better medical care and by better nutrition. The decreases which seem possible amount to 20 to 30 per cent. The grave risk of losing ground

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during the war is shown by the 10 per cent rise in the infant death rate which England suffered in 1940. The health of the future population is even more significant for the welfare of the nation than its numbers. After early infancy, sickness is more important in childhood and youth than death (the death rate is lowest at the age of ten years, when only one in eight hundred dies). A large portion of the illness and impairment of adult life is foreshadowed in childhood. The latest extensive survey of disease among children is that of the National Health Survey of 1935-36. The available results relate to 500,000 children in 83 cities of all sizes. The greatest annual frequency of illness lasting at least seven days was observed in the age group of 5-9 years, in which it was 305 illnesses per 1,000 children. This rate is higher than even that for persons 65 and over (276 per 1,000 persons). For all children below 15, except infants under one year, the rate was 225 illnesses a year per 1,000 children. Communicable and respiratory diseases (excluding tuberculosis) make up 80 per cent of the total. Accidents account for 5 per cent of these illnesses (and cause about one-fifth of the deaths at ages from 1 to 15). Of every 1,000 children under 15 years of age, 5 were found to have permanent orthopedic impairments. Poliomyelitis, accidents, and rheumatic disease (with its consequent crippling of the heart) are serious causes of lasting incapacitation.

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Fortunately, the duration of the average illness of childhood is short and the recovery rate high. It is difficult to estimate the general status of the children of the nation in terms of their approach to optimal health. School surveys are not reassuring, for they suggest a distressingly low level in comparison with a standard which seems to be reasonably within the bounds of possibility. The White House Conference on Child Health estimated that at least ten million children of all ages were handicapped in various ways. The types of handicap have been grouped, in descending order of frequency, as follows: (1) malnutrition, (2) mental deficiency, (3) nervous and behavior disorders, (4) hearing defect, (5) speech defect, (6) tuberculosis and pre-tuberculosis, (7) heart disease, (8) motor disability, (9) epilepsy, and (10) visual defect. It has been stated that half the children in the country are being raised on inadequate food.4 The overwhelming prevalence of bad teeth by the end of adolescence strongly suggests that some defect, known or unknown, exists in most of our diets.5 Such is a brief and incomplete survey of the state of our future citizens. Those who live in comfort*The evidence for such a statement is certainly incomplete, but it represents the belief of trained observers with wide experience. 5 A recent study by the Elizabeth McCormick Memorial Fund in Chicago showed that 58 per cent of the children examined were in need of dental care. Defective teeth were the commonest cause of rejection for military service in 1940—41.

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able and protected circumstances should bear in mind the extremely uneven distribution of defects in health. Obviously all statistical data for the country as a whole cover far higher rates of morbidity and mortality for certain regions and certain groups of citizens. Many of the illnesses of childhood are preventable. All of the nutritional defects must be considered preventable. There is little hope of improving housing and other environmental conditions of children during the war, but attention to these needs should stand high on the list of agenda for the post-war period. It is noteworthy that adequate hygienic and medical attention to the needs of mothers and children rapidly and certainly gives good results beyond those achieved in other fields. In many ways it is the most satisfying and most valuable of all health activities. Pregnancy is rightly looked upon not as an illness but as a physiological state. Yet it makes unusual demands upon the health of the expectant mother. The fetus is nourished and grows on nutrients furnished entirely by the mother. In the years following the first World War, there was a discussion of the important question as to whether the height and weight of babies born during the war were affected by the mothers' malnutrition. According to German authors, who made much of the bad condition of "war infants," in some cases the height and, to a greater degree, the weight of newborn babies were reduced, but these were apparently unusual in-

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stances of extreme deprivation. In general, the fetus is nourished at the expense of the mother, and, up to a certain point, it abstracts nutrients even though the mother is receiving an inadequate supply, an illustration of the so-called law of preservation of the species. In comparison with the expectant mother, the nursing mother furnishes at a much more rapid rate all the nutrients necessary for the growth of her child, so that her need for energyyielding foods is increased by about one fifth; that is to say, the caloric value of her daily food should be 20 per cent greater than is usually necessary. A greater increase in certain specific nutrients is needed, especially during lactation. Both pregnant women and nursing mothers are prone to develop deficiencies in proteins, the Β vitamins, and iron. The supply of proteins, minerals (in particular calcium, phosphorus, and iron), and all vitamins should be raised by amounts varying from 50 to 100 per cent. The diet does not yield Vitamin D; hence some special source, such as cod liver oil, must be used. Since milk is an excellent source of protein, calcium, and phosphorus, expectant and nursing mothers are urged to have at least a quart a day. The rest of the diet can be made up according to the usual general principles. Deficiencies in the food soon show themselves. The pregnant woman whose diet is inadequate must become malnourished herself, even though the fetus is not. During the period of lactation, if the food is insufficient, the nursing infant

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ceases to grow properly and the secretion of milk eventually ceases entirely. In modern times, particularly in urban communities, pregnancy is frequently a strain on the whole health of women. The symptoms are many and varied, perhaps most often summed up as nervousness and irritability. The explanation in a great many cases no doubt lies in economic or social difficulties. In other cases ignorance and misunderstanding are the causes. Work and other activities are apparently not stressful, but, up to a certain point, even ameliorative. The cure for these troubles as a whole is not easy. A good diet will help. Enlightening education will do a great deal. Assurance that mothers will be cared for and that their children will have their fundamental needs supplied will do more. In general the pregnant woman should be protected by all possible means against further strains. Women play an increasingly important role in office and factory. Although our usual tendency is to resist this enlargement of the sphere of women, in this war America will call upon them to take over much of the work of men. For the protection of our future population, not only adequate but liberal arrangements should be made to encourage women with jobs to bear children. The essential requirement, of course, is leave of absence with pay, for a period of about two months, if all goes well. Under such a plan it is imperative that the pregnant

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woman and her child continuously receive proper medical care and that suitable day nurseries be available. Medical supervision of the pregnant woman and of her delivery should be of good quality, intelligent, understanding, and forebearing. It should begin early in pregnancy and be continued by periodic examinations, culminating but not ending in the delivery. For the millions who cannot afford a private physician, public clinics of satisfactory standing should be everywhere available. This service is so important that all stigma from attendance at such clinics should be eliminated. In most of our large cities and towns good but limited facilities exist. Large areas of the country, however, have none. In view of the great demands the national emergency puts upon the medical profession, as a possibly temporary measure, properly trained midwives, under supervision, could be utilized to provide care for the thousands of mothers who now go without any, or receive only the help of unqualified mid wives. Such a plan, however, would call for a new program to train midwives. As early as possible in pregnancy every woman should have her medical and nutritional history taken and a thorough physical examination, including measurements of the pelvis, done by a competent practitioner. Her blood should be examined for anemia and tested for syphilis. Blood pressure measurements and tests of the urine for albumin

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and sugar should be made at intervals during the pregnancy. The immature members of the population, or children in the broad sense, constitute about 35 per cent of the total, with pre-school children, under six years of age, making up approximately 12 per cent of the population. As the number of children diminishes (relatively because of the lengthening average duration of life, and absolutely because of the fall in birth rates), we recognize with increasing clarity their significance. Growth is the outstanding quality of healthy children. Growth, while not steady throughout childhood, naturally proceeds day in and day out. Losses and deficiencies in early childhood are seldom completely made good later on. In addition to biological limitations, social and economic factors usually make restitution impracticable. Growth occurs in all human aspects — physical, mental, and spiritual, as our fathers put it; we may add explicitly the social sphere. The various aspects of growth are so intimately interrelated that its necessarily piecemeal consideration loses something of the whole. Taking a broad view of immaturity, Dr. Arnold Gesell, of Yale University, extends the period of childhood into the middle twenties.8 He divides it into four stages of six years each: (1) the pre-school years, (2) the elementary years, (3) the secondary β The First Five Years of Life (1940), from the Yale Clinic of Child Development, by Arnold Gesell and others.

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school years, and (4) the pre-adult years. Although we usually consider birth the beginning of life, the absolute zero is really at the inception of pregnancy. Of the four stages of immaturity, the pre-school period is in many ways the most important. The physical side of growth has been very thoroughly studied. Standards for height, weight, and other measurements for the two sexes at various ages are well known. It would be a mistake, however, to consider these standards as necessarily permanent, just as it is an error to apply them too rigorously to the individual. The nutrition of children is too often thought of mainly in relation to physical growth. The whole development of a child must be considered to depend in a fundamental fashion upon his diet from day to day and week to week. In comparison with an adult, on the basis of weight, or on any similar unitary basis, the child has a relatively great need of both calories and specific nutrients, since he is constantly building new living tissues of which the nutrients are the raw materials. The Table of Recommended Daily Allowances in Chapter III gives a summary idea of the amounts which are progressively needed. The adolescent youth actually requires a larger allowance than the adult, a fact which has only recently become clear. From both the general biological and the special human point of view, the mother's milk is the most satisfactory and the most economic food of the

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young infant. A proper supply of maternal milk furnishes adequately all the nutrients necessary for the young of her species. In modern times maternal nursing, especially in cities, has gradually become greatly limited in frequency or duration. Not a few infants are never nursed, and a great many more are nursed for only two to five months. Artificial feeding, when carried out according to the best principles, is now highly successful. This success is made possible, first by a safe supply of cow's milk (i.e., fresh milk of good quality, free from infective bacteria), and second by adequate supplementary vitamin feedings, particularly A, D, and C. The vitamin additions have removed the feeding difficulties and digestive disturbances which formerly were common. In spite of the success of artificial feeding, an increase in the frequency of nursing and its prolongation to eight or nine months are desirable. Wartime disturbances in the supply of food and the need for maximum economy render such a change highly advisable. After infants are weaned, it is essential that they receive the necessary amounts of proper proteins, minerals, and vitamins. Although severe nutritional deficiencies are not common in American children today, rickets can be detected by X-ray examination, and lack of Vitamin C and iron can be demonstrated by blood studies in 20-30 per cent of school children in the poorer districts of large cities. According to the Chicago survey which was referred

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to in footnote 5 of this chapter, 39 per cent of the children who were examined were in need of more vegetables and fruit. The tendency is to allow children to have too large a portion of their diets in carbohydrates in the form of breakfast foods, bread, crackers, and cakes of various kinds, and sugar. Even the reinforcement of flour with minerals and vitamins will not entirely eliminate the need for restricting the use of these foods. Milk is the best basis for the diet. It is recommended that all children have at least a quart a day. Vegetables, eggs, and meat should soon take a prominent place. Milk furnishes calcium, phosphorus, and Vitamin B, among other nutrients. Iron comes from vegetables and eggs. To ensure an adequate supply of Vitamins A and D, cod liver or other fish oil should be given at least to the age of two years and perhaps longer. The need for Vitamin C, which is not met by milk (even human milk kept overnight loses this nutrient), must be specifically met by the use of appropriate vegetables or citrus fruit juice. In this country, orange juice is used almost exclusively, although many other sources are suitable. No attempt whatever is made here to give instructions on the feeding of infants and children. The family doctor or the children's clinic is the proper source of such instructions. Books that discuss the subject are legion.7 Careful studies have demonstrated that the war 7

See the list of Books for Further Reading in the Appendix.

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of 1914-18 had a harmful effect upon growing children, apart from the incidence of particular diseases. In England and Wales, children who were born just before the war had, up to the age of nineteen, a higher mortality from all causes (excluding influenza) than had proper control groups. In 1919 and even as late as 1924, school children in Germany were lighter and shorter than in 1913. The handicap to which this stunting might lead in another war was early recognized by German statesmen and physicians, who soon set on foot special efforts to give German children the best of care. The results were remarkably good. Studies in Berlin showed that children entering school in 1926-28 (born in 1921-22) had gained average increases in height and weight of 5 cm. (2 inches) and 1.6 kg. (3/2 pounds) over children who entered school in 192426 (born in 1917-20). By 1933 these increases were still greater and had carried the average height and weight of such children above pre-war standards. There is no suggestion that such increments could be continued at will. These observations, however, show plainly both the effect of the war on nutrition and the result of careful attention to growth-needs after the war was over. The successful campaign of the late 'twenties and early 'thirties to strengthen German children, which was extended to the same group — as youths — after Hitler's coming to power, had much to do with the splendid physique of German armies in 1939. In time of war, one of the first duties of the food

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administration is to make sure that the supplies of children and nursing mothers do not fail, for their food must be available in steady and reliable supplies. The growing organism cannot draw upon stores in the body as can adults in some respects. Indeed, the opportunity of a national emergency should be used to improve the distribution of foods for our future citizens. Sweden not long ago provided by law for the free supply of "protective" substances to supplement dietary deficiencies of all mothers and children. In wartime England, codliver oil and fruit juice (largely from black currants in 1941^12) are being distributed, without charge when necessary, to children born after January 1, 1940. The distribution of milk is strictly controlled, mothers and children up to the age of five having priority over others, with the assurance of a pint a day apiece. School children are also assured of approximately a pint of milk a day. In these cases, milk is either free or extremely cheap (about one cent a portion). Rationing in America must provide milk, other dairy products, vegetables, and fruit juices in sufficient quantities for the needs of all American children. If necessary, our policy should be to allow adults to grow lean, while our children continue to receive their proper daily allowance. Furthermore, we must choose between the distribution of these essentials free or at a reduced price and ensuring an income which is adequate for their purchase. The valuable system of free or semi-free

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school lunches, which is highly developed in England, should be greatly extended in this country. Sunlight must be reckoned among the basic needs of children. Under the influence of its ultra-violet rays the skin converts substances at hand into Vitamin D. After the fish oils are omitted from the child's diet, he is dependent upon this mechanism. For good health, it is, therefore, necessary that definite steps be taken to ensure the adequate exposure of city children to sunlight throughout the year. Children are especially exposed to infectious diseases. As infants they carry from their mothers only brief transitory immunity to certain diseases and have gained no immunity in their own right. They have frequent intimate contact in their play with one another and at school. It is not surprising that there is a group of "children's diseases." Many of these infections are preventable or subject to control. The story of smallpox, which in former days was one of the most dreaded diseases of childhood, has been referred to in Chapter IV. The campaign for the prevention of diphtheria, another of the most serious illnesses of infancy and childhood, is of rather recent origin, but in the fight against this infection a specific antitoxin, or curative medicine, has been available for nearly fifty years. Before specific treatment was used, the fatality rate varied from 35 to 90 per cent of those afflicted, according to the type of case. With antitoxin, only 5-15 per cent of patients die. For twenty years increasing

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efforts have been made in the United States to prevent diphtheria, rather than cure it. In the last few years before America's entry into the new World War, the campaign gained great momentum. As a result, incidence of diphtheria has decreased by well over 80 per cent (about 150,000 cases were reported in 41 states in 1920, and 24,000 in 48 states in 1939). In spite of progress during the past generation, there is room for much improvement in the application of preventive measures, especially in rural districts. Of the children who were included in the National Health Survey, 21 per cent were in need of smallpox vaccination and 34 per cent had not been immunized to diphtheria. The British have made the war an occasion for an intensive campaign against diphtheria, and in 1941 two and a half million children received immunization. By the age of nine months every child should be immunized to smallpox and diphtheria. Smallpox vaccination needs to be repeated on entrance to school and immediately whenever exposure to the disease occurs. Only a rare American child should contract either of these diseases. Inoculation against whooping cough is now considered advisable during the second six months, and immunization to tetanus (which may be combined with that for diphtheria) is also recommended. Specific preventive measures in other cases are not generally desirable. Inoculation against typhoid and paratyphoid fevers should be done in circumstances in which

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exposure is unavoidable. Measles may be prevented or lightened, and scarlet fever prevented, in special cases in which the family doctor advises this course. Against other communicable diseases the best protection is good health, in conjunction with isolation of the sick and other hygienic measures. There is no doubt of the beneficial effect of good health and healthy surroundings upon the incidence and course of many infections. Rheumatic fever, which is always a serious illness and often causes great damage to the heart, is an example of the diseases which especially afflict undernourished and povertystricken children. The efficacy of isolation in many communicable diseases is so clear that parents should eagerly and whole-heartedly cooperate with their doctors and public health officers in measures to restrict such diseases. Furthermore, parents, who are naturally anxious about their children, should have confidence in these guardians of the people's health. If war or the natural course of events brings the threat or the start of an epidemic, there must be no panic or panicky tendency. In all likelihood any such threat will soon be brought under control. A calm and confident attitude will be the best help which citizens at large can contribute. Childhood is the period in life, not only for the prevention of disease, but also for creative health activity. Every child should have the benefits of skilled medical attention. Pediatricians and clinics for children have multiplied greatly in large cities.

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Yet a recent survey of Chicago public school children found 60 per cent of them to be in need of medical care. In rural districts, trained doctors and facilities are generally wanting. A more liberal provision for expert attention to children is the most important aspect of the problem of the extension of medical care in America. The relationship of children to their family and clinic doctors is more often a happy one than tradition indicates. In a good regime the doctor sees his youthful patients frequently and over a long period of time. He often becomes a friend. Such relationships are valuable social assets. Health conferences are particularly good insurance in childhood. They should be held every month for the first six months of life; every two to three months for the second six months; at least every six months to the age of six years, and annually after that. It is worthy of note that pediatricians, the doctors who care for children, are not specialists in the usual sense. Their concern is not with a part of the body or person, nor a type of illness. Their sphere includes the whole individual. The study of the development of children, particularly the very young, in other than physical aspects is of relatively recent origin. In the past, concern has been largely with formal school training. In the last twenty years many valuable studies of the general development of children have been made. At the Yale Clinic of Child Development, Dr. Arnold Gesell has studied the mental growth of

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young children under four headings: (1) motor development, (2) adaptive behavior, (3) language development, and (4) personal-social behavior. We have been slowly learning that children, even infants, are individuals and that they have physiological and psychological peculiarities which set them apart from adults. Those who work much with children recognize the parent problem as of equal difficulty with that of the child problem. Visiting day in a children's institution is by no means the happy occasion one would expect. If parents must learn to recognize the personalities of their children, children on their part must learn to adapt themselves to their parents and to other adults. The child has a dual set of social adjustments to make: one to his equals in development, and the other to adults. As he grows older he has to discover that he must make a place for himself in the workaday world. Out of his development have to come, besides some knowledge of how to live, adequate earning capacity from some trade, technical or professional ability, and appreciation of his responsibilities and privileges in respect to his fellow men and women, both superior and inferior. As a nation we are not at this time solving the general problem with conspicuous success. As children develop, their activities change progressively from the long hours of sleep which are necessary in infancy, through "childish" play to more purposeful recreation and study, ending in

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some cases all too soon in the hard labor which should be reserved for mature men. Room and facilities for appropriate activity and encouragement in it, after good food, are what children most need. Crowding is especially hard for them to bear without ill results.8 Formal schooling has for a long time begun at the age of six years. In some communities day nurseries for infants up to two years of age and nursery schools for children to six are available for limited numbers. These institutions not only benefit the children and families whom they directly serve, but also act as demonstration centers in spreading knowledge of methods of child management. The circumstances of modern life make it desirable to increase their numbers, so that a larger proportion of the industrial population may have access to them. The fear that infant nurseries and nursery schools necessarily mean further weakening of family ties does not seem to be well founded. In England, the demand for women workers has led the Ministry of Labour to establish nurseries, which are financed by the government, for the children of all 8 A study by the United States Children's Bureau of 28,000 births in eight cities disclosed that the infant death rate was two and a half times as great in homes with two or more persons per room as in homes with less than one per room. The National Health Survey found that diphtheria in children under five years of age was 2.7 times more frequent in the more crowded families than among those in roomier quarters. It is noteworthy that the excess of diphtheria with crowding was less in children aged five to nine years.

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women who are engaged in full-time work. An urgent need for similar provision in this country will exist when the armament and munitions program reaches its full development. The period of later schooling may be passed over for our purposes, except that some reference must be made to child labor. Many citizens hardly realize that children still do men's work in the United States, but in some parts of the country the abuse flourishes. Only twelve states prohibit full-time employment below the age of sixteen. In twenty-five states youths of sixteen to eighteen are permitted to enter hazardous occupations. It is officially reported that the number of minors employed in the first half of 1941 was three times as great as in the similar period of the previous year. Child workers in general are all too often among the very badly nourished. In such cases stunted manhood is the best that can be expected. Where action is required, the reform of this practice should be promptly carried out. Even the urgent needs of a war program must not be used as an excuse for the prolongation, not to mention the extension, of improper child labor. On the other hand, legal formalities sometimes absurdly compel idleness in individual cases in which suitable work is desirable. Youth must gradually assume the responsibilities of manhood, including that of toil. Age alone is an unsatisfactory criterion, although some restriction of all regular labor below the age of sixteen to eighteen years is desirable. Both the

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type and conditions of work and the health of the individual must be considered. A local committee, including a medical representative and acting within a broad legal framework, might be set up to issue, on the merits of individual cases, specific working licenses good for six months only. Children from the beginning of school age should have some knowledge of the state of war; a policy of hushing up the war would do more harm than good. They should gradually acquire a realization of its significance. They need some protection from its balder horrors, but they readily assume a matterof-fact attitude. The gratuitous introduction of a great deal of sentiment, whether bellicose or pacifist, is harmful by reason of the subsequent disillusionment, if on no other account. Children thrive on an appropriate share in the cares of their elders. It is altogether fitting that they share in ways that cannot harm them the sacrifices which war imposes upon the nation. By all means let children save their pennies by economy in their purchases of candy, ice-cream, tickets to moving pictures, and the like; let them invest the proceeds in national defense stamps and in funds for less fortunate children to whom war brings new sufferings. Play at warfare is inevitable; it is the spirit in which it is done that matters. Left to themselves, children do not become grim-faced protagonists. English boys and girls have been found to draw pictures of bombings without being emotionally stirred. A spirit of

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humor and ridicule is more healthy than hatred. Laughter and fun should be encouraged, even in the midst of danger. Above all, children must be kept busily active. As for actual experience of warfare, the air-raids of England showed that children of themselves are not often acutely upset, although the contagion of fear on the part of their elders is great. If adults are calm and confident, children likewise will remain serene. In order to take every possible precaution for the safety of children, it is necessary to plan to move huge numbers of them out of large coastal cities to places of greater safety. Several hundred thousand London children were removed to the country in September 1939 without a hitch. Not a child was lost or misplaced. In their country billets there were many hitches. Such evacuations must be planned not alone by transportation experts. Especially in their foster-homes must the children be under the guidance of those who are wise in the ways of city children and expert in their management. The national gift for organization will stand the country in good stead in face of the need to furnish food and other supplies to thousands of children torn from their homes. Given good health, good food, and a good general environment, children take an interest in putting themselves in rapport with those about them. The sense of response on their part is pleasurable to them. The nation's children represent its greatest asset.

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A striking summary of the significance of the saving of young lives in this century was recently given in the Statistical Bulletin of the Metropolitan Life Insurance Company, under the title of "Dividends in Man-Power," in which the author pointed out that 11 per cent of those now between the ages of twenty and forty-four are alive because of the decline in mortality. Early in 1942, a National Conference on Child Protection in Wartime, under the auspices of the Children's Bureau in Washington, adopted a "Children's Charter for Wartime," which calls upon all citizens, young and old, to: "Guard children from injury in danger zones. "Protect children from neglect, exploitation, and undue strain in defense areas. "Strengthen the home life of children whose parents are mobilized. "Conserve, equip, and free children of every race and creed to take their part in our democracy." Even though adequate provision for the children of the country increases our hardships, even though we are in the midst of a great war, we must surely be ready to make whatever sacrifices are necessary to assure the welfare of the citizens of tomorrow.

CHAPTER VII T H E AGING AND THE AGED

AR, at least participation in hostilities, has always been considered the prerogative or duty of youth. After World War I, it was said by some that old men had started the war and then forced youth to wage it. This was an ill-considered statement. Modern wars engulf the old as well as the young. No section of the population can escape the potentially devastating effect of total war on a world-wide scale. On the obverse, all ages, excepting only young children and the helplessly crippled or decrepit, have to bear a share in the struggle for victory. The proportion of Americans who are aging and aged has increased rapidly in the last generation. If we consider those who have reached sixty-five as aged, the proportion has more than doubled since 1870. There has been a parallel, though smaller, increase in the relative numbers of individuals in the decades forty-five to sixty-four, in which the aging process sets in (see the table below). In the century and a half since the first census was taken in 1790, the median age of white males has nearly doubled. Statisticians tell us that this development will continue.

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This shift in the age-distribution of Americans arises partly from the decline in youthful immigrants and partly from the decline in births, but mostly from the increase in average longevity, which AGE DISTRIBUTION OF POPULATION IN THE UNITED STATES, IN PER CENT Age in Years

1870

1900

1930

1940"

Under 5 5-19 20-44 45-64 65 and over

14.3 35.4 35.3 11.9 3.0

12.1 32.2 37.7 13.7 4.0

9.3 29.5 38.3 17.5 5.4

8.0 26.5 39.0 19.7 6.8

* 1940 values are based on preliminary data. MEDIAN AGE OF WHITE MALES IN THE UNITED STATES 1790 1850 -

15.9 19.5

1900 1920 -

23.8 26.1

1930 1940 -

27.2 29.0*

* 1940 values are based on preliminary data.

has been brought about by the application of preventive medicine and by the elevation of our national standard of living. In 1789, according to data gathered in Massachusetts and New Hampshire, the expectation of life at birth was thirty-five and one half years. By the end of the nineteenth century, longevity for Americans in general had risen to forty-nine, and in 1940, to over sixty-three years. Leaving out of consideration any lasting untoward effect of World War II, we may look for further in-

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creases in the American expectation of life, possibly by another decade (the longevity of American white women is now over sixty-seven years). The increment in the average duration of life comes mostly from a fall in deaths at ages under forty. The proportion of persons who reach a ripe old age of eighty or ninety or more has not significantly changed from what it was long ago. There is no evidence whatever of any lengthening of the absolute limit of human life, which remains somewhere in the neighborhood of a century. In a word, about nine million Americans are now at or over the traditional age of retirement and incipient enfeeblement. This development poses numerous problems, most of which concern our health both as individuals and as a nation. For some years, attention has been increasingly directed to the subject of old age. A survey was made by a group of experts in 1938. The results, which were published in a single volume, summarize all that we really know about the process of aging.1 In other words, our information is scanty in contrast to the existing large body of knowledge and considerable understanding of many aspects of the development of infants and young children. The survey of old age which was just mentioned amounts to a series of questions which cannot now be answered. Before the war came upon us, the problems of our elderly 1

Edited by Ε. V. Cowdry, Problems of Ageing William and Wilkins, 1939).

(Baltimore:

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citizens cried out for attention. In order to emerge victorious from the long and arduous struggle which lies before us, we need the best efforts, both physical and mental, of the older generation as well as of youth. Our present cue, therefore, is not to postpone further the solution of all the problems which are presented by age, but rather to include in our war program measures designed to help those past the prime of life to make maximal contributions to the national success. A good deal that has been written about old age, even though in many instances it is part of the world's great literature, is purely sentimental. Old age may be pictured as beautiful, but old people are rarely felt to be beautiful. The trite comparison of the old to children is so superficial as to be nearly meaningless. The individual mental qualities and behavior patterns which are commonly attributed to old age are found not only in children but also in persons of all other ages. The sentimental point of view is not very helpful. Nor do the introspections of the elderly advance matters far. The characteristics of old age and the phenomena associated with it are beclouded by the many diseases which accompany it. Indeed, old age itself has sometimes been looked upon as a disease. To prove the point beyond question is difficult. The life of certain types of individual cells appears to be potentially indefinite. Nevertheless, in the case of man and similarly complex organisms, biological

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considerations seem to indicate that age is not a disease, but a natural event. Age knows no geographic boundaries. It comes to every man that is born of woman. Shakespeare's familiar description of the stages of life is cruelly expressed, yet they correspond in a measure to reality. Human life has a phasic development, first expansive and later involutional. These opposed processes may perhaps proceed at the same time in different aspects of body and mind. The process of aging, like that of childhood evolution, is highly individual. Chronological age, age in years, may mislead us completely as to biological or intellectual age. The rate of aging, as well as the functions and structures which are particularly affected, differs from man to man. It will not do to say "a man is as old as his arteries," because no single criterion meets our general needs in estimating age. A man is as old as we find him on careful study. Aging begins insidiously for most of us. Evidence of its effects is nearly always present at the half century mark, but changes commonly begin long before that time, probably even in the twenties (the American death rate is lowest at the age of ten years). Among the Incas, taxes were not collected from those over fifty years of age, while a man at sixty was known as "a man sleeping." At or near sixty-five, by common consent, we usually put into effect retirement arrangements, thereby signifying the assumption that old age has set in. Yet by that

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arbitrary decision we may miss the mark by ten or more years. When age comes to mind, we usually think at once of limitations, although there are compensations, as we shall see. The earliest alteration is diminution in speed of muscular action. Some slowing of mental operations probably occurs at an early date in many persons. In early middle age most people take longer than they did in youth to acquire new techniques which call for unfamiliar coordinations of nerves and muscles, whereas physical and mental strength is lost only at a later date. In women the menopause marks the end of the child-bearing function; while it is taking place, various bodily and mental functions are often disturbed. Men undergo a less drastic and vaguer change in their sexual functions. It is sometimes erroneously assumed that the sexual life of the aged is over, whereas there is frequently a reawakening of interest in both men and women, at least in the period between fifty and sixty-five years of age. In the psychologic realm, a lack of readiness to receive new ideas and a disinclination to enter upon new ventures appear or increase. In other words, age is relatively conservative. The memory is not so readily retentive, particularly of recent events. Adjustments to strangers and strange surroundings may not be made so successfully as they were in youth. Some uncertainty exists as to the extent to which these changes may be due to forces which

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are not inherently part of old age. The distressing state of physical and mental disability which may finally develop need not be described, for it is too well known. In its extremity, the incapacitation of old age may leave no single aspect of human vitality unimpaired. Most of the essential phenomena of aging may occur without the intervention of disease. Nevertheless, as age advances, body and mind both become peculiarly susceptible to certain diseases, as well as to a wide variety of accidents. The body is more easily injured than in youth, as is shown especially by the frequency of fractures and by the damage done in falls. The tissues heal relatively slowly after injury. Thus it happens that, as he grows older, man accumulates injuries from the diseases and accidents to which chance has subjected him.2 The rate at which accidents cause death in those over sixty-five is more than twice as high as that for the general population. Moreover, accidental death becomes more frequent with each additional quinquennium. The most important diseases to which the old are subject are vascular hypertension, arteriosclerosis, nephritis, cancer, and pneumonia.3 These diseases account for more than half of all our deaths. They cause much of the misery s The effects of this accumulation hardly suffice to account for the aging process as expressed in the increasing death rate, decade by decade, as has been pointed out by Dr. Henry S. Simms. 3 Hypertensive disease, or high blood pressure disease, is not

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of old age and add greatly to the trials of those who care for the old. Except in the case of pneumonia, the causes of these maladies are essentially unknown. Undoubtedly they are not simple, but highly complex, mechanisms, which will require extensive and prolonged investigation before they are successfully unraveled. The disabilities and difficulties of age are commonly exaggerated manyfold by the reaction of younger members of the family, of employers, and of society at large. Indeed, our whole social organization has contributed to this sad result. Aged people are all too frequently made to feel their weakness; they are oppressed with pity, callousness, or cruelty. It must be admitted that they are often a burden on the family, economically and socially. (To some extent, however, dependent elders are replacing dependent children.) Urbanization, especially life in small apartments, has brought these difficulties to an acute pass. The duty of the younger generation to live with and, if necessary, care for their elders is no longer clear. We readily admit the need of a higher standard of living for the younger group than for the aged, even beyond the difference that would be due to the burden of raising children. Not a few employers, regarding age as a liability for many reasons, seek to rid themselves of aging workers, unless these workers have been regularly necessarily a feature of old age. Although the blood pressure rises with age, the increase is now known to be slight.

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employed for many years. It is true that many large industrial, utility, and other companies have established pension systems for their retired employees, but these plans, together with the pensions available for various groups of governmental employees, have protected only a very small part of our aging population. As for the worker out of a job, if he is no longer young, his lot is hard indeed. Employment after the age of forty-five has become almost impossible to secure in ordinary times. A report submitted to the New York State Legislature in 1933 showed a progressive decline in the percentage of employed older men from 74 per cent in 1890 to 58 per cent in 1930. Our governmental tradition has entertained only a slighting, and almost a contemptuous, consideration for the aged, as a visit to almost any public home for the old will show. So far, public aid has been inadequate to permit holding a self-respecting body and soul together. It has been a part of our philosophy that a comfortable old age was only to be won as the reward of "success" in earlier life. There can be no surprise, therefore, when the aged are found to be depressed. Frustration, uselessness, dependence, and loneliness are powerful feelings, which threaten to overwhelm the unprepared. Fear of being institutionalized is widespread. Our own ideas about old age help to create the condition within us. Loss of self-confidence or, alternatively, self-assertiveness and querulousness are

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readily understandable results. When the man who has had a job which he did with satisfaction suddenly loses it, the release from duty and routine is too great a change to be healthy. The provision of a pension fails to cure this particular evil. Hence comes the puttering, the busyness over imaginary duties, which to inconsiderate youth is only ridiculous. With no duties, real or imaginary, the old live in the past, because the present is empty. Is the picture of age only gloomy? By no means. Age does not remove individuality. Each aging and each aged person has his own virtues and his own defects. Experience itself is a priceless asset. The accumulated culture of the past is handed down by the older generation with a vitality and a richness that would be impossible if we depended upon printed books and stone monuments. Conservatism in itself is not always a defect; there are tides in our affairs when it is salutary. Judgment in difficult circumstances is often best rendered by our elders. In many cases older people excel in the management of human relations. In regard to the persistence of power, Thorndike found that of ninety-one scientists and eighty men of affairs, twenty-two and nineteen, respectively, achieved their opera magna after the age of sixty.4 Examination of the question has proved that aging people can learn new tricks and that there is little difference in ability to learn beE. L. Thorndike, E. O. Bregman, J. W. Tilton, and E. Woodyard, Adult Learning (New York: Macmillan, 1928). 4

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tween groups thirty-five to fifty-nine, and over sixty years of age. Physical ability does not disappear. If the aging worker does his job more slowly, he has greater skill and takes more care. In 1930 over six and a half million Americans who had reached their sixty-fifth birthday, a third of the total number, were gainfully employed. If the problem of accomplishing the huge volume of work which the war program calls for is wisely attacked, the solution will bring some benefit to our older citizens. Many a man and woman of sixty or sixty-five is still capable of valuable work. Large numbers of them who are reaching the retiring age can continue in their occupations. The older generation will have to take over much of the everyday work in all fields which is now done by younger men. Older men often make good teachers in the industries and trades. There are some jobs in munitions and arms factories for which older workers can be found who are well fitted. Most of the burden of civilian defense should be borne by older people. Some modification of the conditions of labor is frequently necessary for the aging worker. The essential requirements are a slower pace, rest periods, and reasonable hours. Hard physical labor, rapid minute manoeuvres, and long-continued exertion may have to be excluded. Increased protection against accidents is necessary. Direct competition with youth should be neither attempted nor expected. So long as the worker remains competent,

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there is every reason to make the necessary adjustments. In some of the trying situations which arise in warfare, the psychologic qualities of age are valuable assets. We can look to the older generation for more than their share of the quiet, persistent determination which will be needed on the home front. We need not fear apprehensiveness in most elderly people, for they are not so subject to the "jitters" as their juniors. Danger and calamity are not commonly devastating to the aged. In order to enable the older generation to make their best efforts, not only during this war, but afterwards, we should do everything possible to improve their condition. Many of the needs of age are clear. To begin with, however, we must learn more about the process of aging. For this purpose the federal government has established a Section on Geriatrics in the National Health Institute. Practicing physicians and medical investigators are devoting more and more attention to the problems of old age. Our whole attitude toward age so far is unsatisfactory. In this field, as in many others, we have a frontier psychology which remains with us from the days when nearly all Americans were young. We may decry the Chinese view which has been supposed to attribute all wisdom and all authority to the most aged; yet we are probably very much in error when we blame the social and political backwardness of China on the respect of her people for age.

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We have a lesson to learn from older civilizations in this connection. Age should not hold the reins of authority exclusively or too long: due consideration should be given to the value and rights of the individual, apart from his age. There should be tolerance for the natural mental and physical limitations of old people. To single them out for regimentation is not only unjust; it is also unwise. Age calls for understanding, not for pity. It should be neither unduly exalted, nor yet debased. To effect such a change in our outlook requires a new element in our national education and in individual experience. As each citizen grows older he should acquire a realization of the nature and conditions of old age, which after all is inevitable. In middle age he must begin to adapt himself to the changes which insidiously set in. In his own way he should prepare for retirement to a life of suitable activity. It has been well said that when retirement comes, it should be not only from a job but to some significant activity. If in times of peace society does not need the older generation in everyday productive labor, many can find some piece of work which is valuable. As we grow older, we need to learn about the frailties which do so much to render old age a burden. Insight will help to forestall the development of many of the habits which are irksome to others. Even those who are already accounted old can be helped to make a better adjust-

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ment to their families and associates.5 The assumption that old people's habits are fixed beyond change runs somewhat beyond our knowledge. Psychiatrists used to consider that they could help elderly persons but little, if at all. Now they are discovering that much can be done. The support of the aged cannot be allowed to remain essentially the duty of the family. Our social system has undergone too great a movement away from this time-honored custom. The federal pension system, to which employer and employee alike contribute under the Social Security Act of 1935, went into effect in 1940. In time it will care for all industrial and commercial workers who are employed with reasonable regularity. Some fifty-six million accounts had been started by the end of 1941. The plan appears to be economically and socially sound. Various important groups of workers, however, are not included, notably farm hands. The system should be extended so that, between it and other pension plans, Americans may find at least minimal economic security in their old age. Presumably, old age assistance will continue to be needed by the less able, less energetic, and less fortunate members of society. Relief from enforced dependence benefits hugely both older and younger members of the family. Their mutual relations have a far better chance of being friendly and helpful. "See Salvaging Old Age (1930), by L. J. Martin and Claire DeGruchy.

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In the midst of World War II, Dr. J. C. C. Langford has proposed to his British medical colleagues a communal plan of life for the aged.6 His scheme is to build blocks of tiny flats, in which each old man or woman or couple would have two rooms where they could keep their own possessions, and to which they could on occasion retire and live their own lives apart from others. Cooking would be chiefly or wholly done in a common kitchen, but eating would not be in common. There would be a common entertainment room and various recreational facilities. A resident nurse and sick quarters, with a visiting physician, would be provided for the ill who did not need to be in hospital. Services could be multiplied according to the resources of the community. Such a plan avoids the worst features of institutionalization, especially regimentation and petty supervision. It makes possible the avoidance of loneliness, which is one of the great troubles of the aged. It could be reasonably economical. There is no doubt that all older Americans who are in good health are eager to take as active a part as possible in the nation's war effort. They can do much to maintain good health and to enhance their strength by careful living. The physical aspects of the hygiene of the aged have received remarkably little attention. The old are often careless of their 8 J. C. C. Langford, "Old Age Welfare," British Medical Journal, I (1941), Supplement (March 8, 1941), p. 27.

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health and toilet, like some young people, because of ignorance or indifference. Some improvement by educational methods is possible. Very little, indeed, is known about special dietary needs. The old need less total food per pound of their weight and usually are relatively inactive. Hence, they frequently overeat and suffer from various forms of indigestion, constipation, and diarrhea. In some cases these symptomatic disorders grow until they occupy the whole stage of life, at least in part because there are no other actors. Doctors habitually tell old people to eat less and to eat a bland diet. Obesity, which often begins to develop in early middle age, puts a gratuitous, ever-present strain on the heart. It confers a diminished life-expectancy on those who suffer from it. Hence, the advice to eat less is well-founded. In the years of war which are ahead, food will not be plentiful; it will be urgently needed by soldiers, by workers in heavy industry, and by children. The aging and the aged should by all means restrict themselves to their true needs. If this brings reduction from obesity to a normal weight, so much the better. On the other hand, a bland diet is likely to be chosen so as to be seriously deficient in vitamins and minerals. There is no reason why an elderly person should live on pap. There is no scientific basis for the impression that the old should eat little meat. It is possible that many do not eat enough. If time and the dentist have removed sufficient teeth to interfere with chewing, false teeth

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should be preferred to false pride. Beyond a doubt, a good intake of vegetables and fruits is as desirable as in early maturity. In individual cases these foods may have to be especially selected or prepared. In summary, the total amount of food eaten by the elderly should be less than it was before the age of forty-five to fifty; the precise amount should depend upon the physical activity. The consumption of foods which supply proteins, vitamins, and minerals should be carefully maintained at an adequate level. Further considerations depend entirely on the individual needs. Alcoholic beverages, coffee, and tea have a bad effect on at least one group of aging persons — those with any tendency to recurrent pain in the chest. The use of these drinks or of tobacco in any but moderate amounts is more clearly injurious to the elderly than to those in the prime of life. On the other hand, the established, strictly moderate habits of a lifetime hardly need be changed in the absence of some special indication to do so. Old people are often regarded as spending much of their time in sleep. On the whole, this is true only of the very aged. Many elderly persons sleep very little, in spite of the efforts of their juniors to put them to bed. It is not clear that an especially large amount of sleep is necessary. Many elderly people, night after night, struggle in vain to get to sleep early. Relief from this trouble may often be secured by having a congenial occupation for the

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whole evening and retiring only rather late. Rest is another matter. Old people need a good deal of repose and, especially, time for recuperation from physical or mental exertion. Everybody who is not ill should have regular physical exercise. For aging and elderly people, the type and amount of activity must depend entirely upon their physical condition. The exertion which accompanies any regular work should be taken into consideration. If there is no regular employment, some suitable and useful activity should be sought. Many elderly persons who have not been engaged in any regular occupation can gradually fit themselves for work which, though it be of restricted scope, will be valuable in the coming years of struggle, when man-power will be sorely needed. Handicrafts, vegetable gardening, and similar work must fill some of the country's civilian needs in these lean times. Spinning on a small scale has been developed by the British to such an extent that it helps to replace the work of factories which are turned to military production. Facilities and instructors should be provided for training in such tasks. Under favorable circumstances it is amazing how much strength and endurance can be restored to neglected muscles. By careful planning, many an aging person who is now at a loss to find something useful to do can be progressively strengthened so that he can safely go to work, or be trained to a new job in which he can do his bit for the nation. Those who

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are engaged in sedentary occupations and those who cannot look toward activities of greater social usefulness should find regular exercise. The British tradition of daily outdoor activity is one we can ill afford to smile at. Too many Americans gradually cease to exercise in middle age. In decent weather any walk can be healthful and diverting. Many who have misused their automobiles in the past can benefit by the wartime restrictions of their use. Elderly people should have facilities for general recreation, since play is not a prerogative of childhood. New York has been a pioneer city in providing "playgrounds" for its older citizens. Medical science has not yet found the means to prevent any of the serious diseases which afflict old age. These diseases, for the most part, are chronic, slowly progressive, degenerative changes. Their advance can sometimes be slowed, and their results can often be mitigated. Some forms of cancer can be cured by expert early treatment. Although these troubles cannot be prevented today, we may reasonably expect scientific advances to bring them within the scope of prophylactic medicine. It is wasteful and useless to spend large amounts of money for patent medicines which are advertised to prevent or cure any of the troubles of old age. The presence of any of these diseases means that employment should be restricted to light work at most. The best form of insurance which is now available against illness in old age is healthy youth and healthy

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middle age. The elderly have particularly good reason to keep in touch with their doctors. There should be a thorough annual medical examination. New symptoms which are not merely transient should be reported to the doctor for his evaluation. Apart from the steps that may be required to carry out the doctor's advice, disease and medical matters should, with the help of other occupations, be put out of mind.7 Longevity may be viewed from either the general or individual standpoint. The important sources of the increased general expectation of life have already been discussed. Our own country today shows how real are the effects of varied social and environmental elements. The length of life is greater among the well-to-do. It is greater among the married. It is greater in the Pacific Northwest than along the Atlantic seaboard. There can be no doubt that the amount and kind of previous illness, as well as the hygiene, good or bad, of the individual, are potent factors. Familial and constitutional endowment plays a prominent role, but the environment is more significant than the longevity of parents. Can life be prolonged by a specific measure? Can we add to the century, which nature seems to have fixed as the natural term of human individual existence? Not so far as we know. Nor is there any sign that such a discovery is at hand. While the newest medical science may be able to retard some of the developments of old age, there is nothing 'See Health at Fifty (1939), edited by W. H. Robey.

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beyond this. Claims to the contrary have been made, but they remain unsubstantiated. Medicine is concerned with the maintenance of the vigor of early life; with the postponement of old age, not with its prolongation. The natural period of human life is approached or exceeded by that of very few animals, if we except the simplest unicellular organisms. At the other end of the scale stand such animals as the humble but useful fruit-fly, Drosophila, whose life in days is said to equal that of man in years. An eminent biologist has viewed human death as essential to evolutionary progress.8 "To die," he says, "is to share a grand vital process: evolution." We "deserve death" only if we are followed by a better generation. If the development of science authorizes a different philosophy, we shall be quick to adapt our thinking. Meanwhile, is not the hope of prolonging life by a magic drug or a gland operation ignoble? The problems of the aged are by no means prominent in the minds of war strategists. Yet we are soon to discover the significance of the fact that only 19 per cent of our people are males between the ages of twenty and forty-five. An army of seven million men or more is contemplated. The armament industry must be built up to unprecedented proportions. Neither of these groups will contribute anything to the ordinary needs of life. The contraction of civilian production and services cannot 8

A. B. D. Fortuyn, "Death - An Adaptation," Human Biology, XI (1939), 408-409 (September 1939).

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be carried far enough to make up for the displacement of man-power. The efforts of older men, as well as of women, therefore, will be vitally necessary. Can they do something for the country? Beyond question they can and will. Can we do something about their needs? We can and must. Although it is a colossal tragedy, the war is a great stimulus to many of the older generation who have been jobless and hopeless. They will respond to calls for their services with determination and devotion. We should not underestimate their role. Let us call to mind the example of Winston Churchill, who stands out for his very vigor of mind and of body. Few men have meant more to the British people throughout their long history than their present leader does today. In 1942 Winston Churchill will be sixty-eight years old. The sooner we set about planning to make the most advantageous use of our older citizens, the better for the nation and the better for them. A purpose in life, some recognition, and relief from economic insecurity will make them different people. Industrial and commercial employers, and those in charge of civilian services, should study now how best to make the adjustments which are needed. Even though we are at war, we should guard the living and working conditions of the aging and the aged so that they make, and continue to make, their best efforts. If justification for such planning is necessary, the duration of the war will supply it.

CHAPTER VIII OCCUPATION AND R E C R E A T I O N

HE many and diverse occupations of Americans will all be united during the years immediately ahead by a single theme — winning the war. The "total" character of this war implies that every job is different in some degree from what it was in time of peace. Soldiers, aviators, and sailors cannot overcome the enemy today unless they are constantly supported by the populations for which they are fighting. In order to win the war, every worker must have a different reaction to his task and practically every citizen must be a worker. In some cases these changes are subtle, but there are many new occupations and new workers, so that drastic adjustments are often necessary. Although the subject is usually left to specialists, it will be helpful if all citizens acquire some knowledge of the relations between health and occupation. In this connection "occupation" should be taken in a broad sense, that is, to include all sustained and purposeful activities, whether "gainful" or not, excepting only recreation. The table on page 200 shows the distribution of gainful activities among Americans in peace time. About 30 per cent of our labor goes into mining and manufacturing industries.

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More than a fifth of it is agricultural. Nearly 700,000 boys and girls under sixteen years of age were included in the Census of 1930 as gainfully employed. Whereas the population is not far from GAINFUL OCCUPATIONS OF AMERICANS IN 1930 Total

Male

β

Female

Population 10 years and over 98.7 million 49.9 million 48.8 million Persons gainfully employed 48.8million 38.1 million 10.7million Per cent gainfully employed 49.5 per cent 76.2 per cent 22.0 per cent Occupation, per cent 21.4 91.3 8.7 Agriculture 0.5 99.9 0.1 Forestry and fishing. .. 2.0 99.9 0.1 Extraction of minerals Manufacturing and me28.9 86.6 13.4 chanical industries .. Transportation and 92.7 7.3 7.9 communication 84.2 15.8 12.5 Trade 1.8 97.9 2.1 Public service f 53.1 46.9 6.7 Professional service .... Domestic and personal 35.8 64.2 10.1 service 50.6 49.4 8.2 Clerical " U. S. Bureau of the Census, Statistical Abstracts of the United States, 1940 (Washington: Government Printing Office, 1941). f Includes the Army and Navy personnel of 1930, except those on foreign service.

evenly divided between the sexes, about three quarters of those gainfully employed are men and only about one quarter are women. But here it must

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be noted that the household work of the 35 million American families for the most part is not included, since it is not "gainful," but who will deny that it is both laborious and essential? What work is more valuable than bearing and raising children? In 1940 there were close to 96 million Americans between fourteen and seventy, of whom 45.4 million were gainfully employed, not including public emergency work (such as work for the W. P. Α.). The allocation of citizens to their most useful place during the war, which is now controlled by the War Man-Power Commission, must be carried out not only with reference to technical qualifications, but also with due regard for health in the broadest sense. The ultimate goal for the Army and Navy is uncertain, with estimates running from 6 to 8 million men, who must come from among the ablebodied workers who have been gainfully employed and from among the students of our schools and colleges. On this basis, about one adult male in seven or eight will be in the armed forces. Other Americans have jobs which are less spectacular, but not less essential. The armament and munitions industries are expected to grow until they employ 20-22 million workers, who are coming in good part from peacetime industries, but cannot be wholly recruited from that source. Much of the work which is done in days of peace must continue and, in the long run, the contraction of the numbers of workers outside the war industries will be limited. At least

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15 million men and women who were not gainfully employed in 1940 will have to be fitted into the war program. Even in this emergency, the regular employment of children under sixteen years of age should not be increased. There may have been, in 1940, 8 or 9 million capable unemployed persons over the age of sixteen (including those at public emergency work). Many of these individuals are already at work, and all can be absorbed in some capacity. A number of potential workers, including elderly persons, who have been regarded, or who have regarded themselves, as incapacitated, can be rehabilitated for jobs in some useful field. The number of Americans who are gainfully employed in the spring of 1942 is over 50 million, but a further large addition to the ranks of workers must be made, in order to bring the total up to the number needed to do the job in hand. It will have to come chiefly from among women who have not been gainfully employed. The number of women who are solely engaged in keeping house and raising children is unknown; there were in 1940, however, about 35 million families in all, and over 30 million children under the age of fourteen. Over 10 million women are normally employed in office and factory. It may be necessary to double this number before the war is over. Women now compose about one-third of the factory workers in England. The employment of a large proportion of the nation's women must not be

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allowed to cause the break-up of homes, upon which young children are dependent. Furthermore, it necessitates careful attention to the hours and conditions of work, in order to protect the health of women workers. It is impossible to give an accurate accounting, but a very rough approximation of the activities of the American population between the ages of fourteen and seventy as they were in peace, and as they may have to be in war, is shown in the table below. Activity Ordinary gainful occupations Women not gainfully employed * Armament and munitions Army and Navy Unemployed + Incapacitated Population aged 14 to 69

Peacetime Wartime millions 45 32 15 4

millions 34 26 22 6 6 2

96

96

* Presumably engaged in caring for young children or in keeping house. •f Includes most boys and girls aged 14 to 16.

The civilian population is shouldering a new type of task in undertaking its own defense, which is roughly equivalent to a tremendous expansion of police, fire-fighting, and first-aid services. Most of the many men and women who are receiving training in the various branches of civilian defense will continue to carry on their regular work, with this special stress added to it.

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This tremendous adjustment in our working population must be made rapidly and efficiently; it is one of the most difficult problems which confront the country today. After the fundamental changes have been made, die task will be to keep the huge civilian army working effectively and harmoniously. It will put a new strain on the nation's health to have such a large proportion of the population at work, especially under the conditions of war. The relation between health and occupation is obviously of a reciprocal nature, since only the healthy work to the best advantage, and, on the other hand, the occupation may depress or improve health. The effects of occupation on health are both direct and indirect. The indirect influence is great, because in general occupation determines income, that is to say, the means which the worker has to feed, house, and clothe himself and his family. By and large, the whole social environment depends upon the occupation. It is, of course, the "real" income that is significant; that is to say, income expressed in terms of the cost of living at some accepted level. We all know that yesterday's income will purchase little tomorrow if prices go up like a sky-rocket. In view of the fact that several million Americans have incomes who only yesterday had none (with more additions to the consumer income yet to be made), prices of available goods were bound to rise. The government, therefore, very wisely put limits on the prices of all goods

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which enter into the basic cost of living. More and more things will become unavailable through limitation of manufacture or importation. These tendencies will continue to put a tremendous premium on goods which remain available, and to raise fears that savings will lose their value. The necessities of life must be assured to all who, being capable of doing something, make their contribution to the common cause. To do this, and to encourage thrift, we must accept "ceilings" for both wages and prices, as well as extensive rationing. It is important for us to realize that the loss of a great many luxuries which many (but not all) Americans have enjoyed and have come to regard as necessities will not harm our health. Such luxuries include items in our habitual diets, fancy housing appurtenances, clothing frills and fashions, proprietary medicines, health fads, cosmetics, and half-aimless automobiling. Indeed, the abandonment of some of the aspects of our high standard of living (as we call it) will improve our health, as well as help to keep the country on a sound financial basis. Simplicity of life was never responsible for poor health. Thrift and health go well together. The data which are available for use in an effort to correlate occupation and health are limited in significance and in many respects are difficult to interpret. According to an American study a few years back, the death rate of unskilled laborers was twice that of agricultural workers; skilled and semi-

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skilled laborers occupied an intermediate position. For "professional men" (a remarkably heterogeneous group in the census) the death rate was the same as that for men on the farm. English official statistics show a gradual increase in standard mortality ratios (base 100) through five groups of occupations which ranged from professional (90) to unskilled workers (111); but the spread of these ratios was even greater for their wives (81 to 113), which demonstrates that the relation of these ratios to occupation is largely indirect. The amount of illness which afflicts the nation's workers is not accurately known, because too few employers keep appropriate records of absentees. Yet, apart from premature deaths, sickness is much more significant for industry than death. Illness rates do not parallel mortality rates, for the ratio between them varies from 10 to 1, to 200-300 to 1 (the higher ratios pertain to diseases of the gastrointestinal and respiratory systems). Mr. J. J. Bloomfield, of the National Institute of Health, estimates the working time lost because of illness at nearly 400 million man-days a year (about eight days per person gainfully employed). He points the moral by indicating that fifty new dreadnoughts could be built in this time and noting that a reduction of only 10 per cent would be a tremendous achievement. A Gallup poll in December 1941 is reported to show that 24 million man-days were lost to industry in the four-week period, November 24-

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December 20, a result which may indicate that a decrease has occurred. We are encouraged to hope that a helpful decrease is possible because the frequency of all forms of disabling illness among employed persons has followed a downward trend for twenty years. Analysis of data gathered by the National Health Survey in 1935-36 showed that illness was twice as prevalent among the employed as among those with no jobs. After occupational injuries were excluded, farmers and servants were found to suffer the highest rate of illness, and professional and business men the lowest, with industrial workers in an intermediate position. The difference, however, was small. It is noteworthy that, when puerperal and female genital causes of illness and occupational injuries were eliminated, the rate of sickness was 37 per cent greater for women than for men. At first glance, one is surprised to find that housewives suffered 76 per cent more illnesses than employed women.1 Among the causes of sickness, respiratory diseases (colds, sinusitis, sore throats, influenza, pneumonia, etc.) easily occupy first place, since they are responsible for over a third of the total. Among men, rheumatic and gastro-intestinal troubles come next. Confinements and diseases of the reproductive or1 The difference is probably largely due to the selection of women workers for unusually good health. (Occupational injuries and female reproductive illness are not included. When they are included, the difference is increased to 85 per cent.)

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gans cause a little more than 10 per cent of the disability of women. A great deal of the illness which keeps people from their work is of a minor character, and is not taken seriously by the patient. Any illness which keeps a man from his job for a week ought to take him to his doctor, but the drugstore or the medicine chest is often substituted. The only remedy for this shortsightedness is better understanding of the importance of health. Accidents are responsible for laying up over a fifth of the workers who are disabled, according to the data of the National Health Survey. The important known classes of accidents were represented in the Survey results as follows: home accidents 12 per cent, automobiles 18 per cent, and occupations 51 per cent. In 1941, one American in fourteen was injured by accident. Accidents occupy the fifth place among the causes of death. Over 100,000 of our citizens met death by accident in 1941, an increase of 3 per cent over the toll of 1940, which is, of course, associated with increased business and industrial activity on the eve of war.2 Occupations directly cause only about 18 per cent of fatal accidents. No one can doubt that the number of accidents of all kinds can be greatly reduced. If this matter is not taken in hand, we may see the day when every tenth death is accidental. The statisticians of the Metropolitan Life Insurance Company ' One cannot fail to be impressed by a comparison with the fifty-thousand-odd fatal American battle casualties of 1918.

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estimate that one death in three among young people takes place by accident. The death-dealing quality of the automobile has rightly been much emphasized, since 40 per cent of all accidental fatalities are due to it. That spasmodic campaigns to control this menace have not been successful is proved by an increase of 16 per cent in 1941 over the toll of 1940. The direct effects of occupation on health, as has already been indicated, are of secondary importance. It is noteworthy that, within limits, work makes for good health, a point that is frequently overlooked. Because, on the whole, careful attention has been given to the protection of large numbers of workers from specific dangers, occupational illnesses and accidents in the strict sense are much less common today than a generation ago. The chief physician of one of the country's outstanding industries reported in 1940 that the company had a total of 112 major injuries in 1939, whereas, thirty years before, it was not unusual to have 3,000 such injuries in a single year. Some hazards, such as unprotected exposure to lead, which were once common have become inconsequential. The time lost from ordinary illness is estimated to be fifteen times that lost because of occupational disease and accidents. Indeed, one large automobile manufacturing company reported a ratio of three hundred to one. It must not be concluded, however, that occupational diseases and injuries are negligible. Among the physical hazards to which workers are

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exposed, excessive heat and humidity are common. Overheating and drenching perspiration render the body unusually susceptible to respiratory infections and rheumatic diseases, unless the clothes are changed promptly when work is stopped. The great importance of the effect of undue heat through the loss of water and, especially, salt from the body has been adequately recognized only in recent years. Deprivation of salt, particularly when the water supply is maintained, leads to heat cramps, which are a sign of a serious upset in the physiological balance of the body fluids. A relatively rare occupational hazard is met by "sandhogs" and others who work in high air pressures, at which large amounts of the inert atmospheric gas, nitrogen, are dissolved in the body fluids. If the pressure is rapidly lowered, the nitrogen comes out of solution and forms small bubbles all over the body which cause painful and potentially fatal disturbances ("the bends," or caisson disease). On the other hand, abnormally low air pressures, such as aviators may encounter, result in inadequate supply of oxygen for the red blood cells to carry to the tissues, thereby causing "mountain" or "altitude" sickness, which at least in an aviator is very serious. Pilots, therefore, must be relatively insusceptible to the effects of oxygen want and must carry a supply of "canned" oxygen for use in case of need. The air which workers breathe is the most impor-

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tant source of occupational diseases, for through it they are exposed to many varieties of dust (including finely divided particles of specific chemicals), foreign gases, and disease-producing organisms. It is surprising that the importance of siliceous dust was not realized until about fifteen years ago. When air laden with such dust is inhaled for years, a chronic and incurable disease of the lungs ("silicosis") results. A survey has indicated exposure to this hazard of some two and a half million Americans, who are widely scattered in mining, chemical, tobacco, clay and stone, and metal industries. Silicosis and some other forms of pulmonary disease due to dusts are frequently associated with the development of tuberculosis. Coal dust is harmless. The chemicals which may act as poisons in the air, either in the form of minute solid particles or as gases, are legion. Included in this group are the familiar examples of lead, arsenic, mercury, and other metals, to which, as a whole, perhaps three million workers are exposed. Benzene, which is a powerful poison in the nervous and blood-forming organs, is an example of the large family of liquid chemicals which vaporize and are absorbed in the lungs; others are anilin and nitrobenzene. Many people have been slow to grasp the importance of inhalation in such cases, having in mind contact or ingestion as the method of poisoning. Among the numerous dangerous gases, carbon monoxide has properly attracted attention for years; reference has

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been made to this poison in Chapter V. Other important instances are sulphur dioxide, hydrogen sulphide, and chlorine. Contact between the skin and many substances commonly used in industry may result directly in skin ailments or, after absorption, in general disease. The explosive TNT (trinitrotoluene) is readily absorbed by the skin and may cause serious or even fatal illness. A host of substances are capable of causing dermatitis, to which individual susceptibility is remarkably variable. Skin troubles are said to constitute two-thirds of occupational illness. They are often mild, but very persistent. Petroleum products, oils, fats, waxes, acids, and alkalis are common skin irritants; soap of all kinds is a frequent offender. Among the workers with the greatest exposures to skin irritants are those in the dyeing and tanning, mechanical, baking and confectionery, petroleum, and rubber industries. Of the greatest interest is the relatively recent demonstration that certain groups of chemicals specifically cause cancer. Although it had long been generally known that chimney-sweeps in England acquired an occupational form of cancer, the significance of the fact was brought out only a few years ago, when it was found that particular products of coal tar, petroleum, and pitch regularly produce cancer under experimental conditions.3 We These compounds are characterized by distinctive chemical formulae. It is of no small interest that certain glandular secretions of the body are closely related to some of them. 8

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have already mentioned in Chapter III the fact that in animal experiments some of these cancer-forming chemicals fail to have this effect unless the animal is deprived of one of the vitamins. In direct relation to occupation, infections play a small, though important, role. Among the many such diseases, mention may be made of anthrax (a hazard of butchers, farmers, and workers in hides and wool), brucellosis (a risk on farms and in dairy factories), and tularemia (dangerous for hunters and dressers of rabbits). Persistent small breaks in the skin are often infected with a variety of pathogenic organisms. Industrial accidents, largely because of the liability for compensation, are well catalogued. The improvement which has been made in working conditions can be measured by the fact that, just before the second World War began, the number of fatal industrial injuries was only a little more than half that of 1913. In spite of this decrease, the annual loss from occupational accidents remains serious, since it comprises in round numbers 18,000 fatalities and 90,000 permanent, and 1.75 million temporary, disabilities. The estimated money value of the loss is astronomical — $5 billion yearly. The causes of accidents are numerous and complicated. In a general way, they may be grouped as associated with the factory, machine or tool, and qualities of the worker. In the first group are absence of proper safeguards, poor lighting, and crowding with either machines, goods, or men. On the part of the worker,

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sex, age, experience, carefulness, clothing, and fatigue must be considered. Women and elderly people suffer injuries relatively frequently. Even when the obvious qualities of workers appear to be equal, some individuals have more than their share of accidents, or, as it is said, are accident-prone. Accidents multiply as the day or the work-shift goes on, a finding which demonstrates the effect of fatigue. In the experience of the United States, industrial injuries have increased in two previous periods, 1916-18 and 1928-29, when industry was rapidly expanded. The increments were surely due in great part to the employment of large numbers of inexperienced workers. America is now engaged in the greatest short-time development of industry in her history. Armament and munition production on a scale suitable for the "Arsenal of Democracy" requires vast use of potentially dangerous machines and chemicals, many of which will be new to all workers. Time presses and speed is essential. We, therefore, face the possibility of a disastrous increment in occupational illness and accidents. The Department of Labor has announced that the industrial accident rate for 1941 was 29 per cent above that for 1940, although employment only rose by 11 per cent. Every available step must be taken to prevent further impairment of our labor in this way. Industrial health is more important than ever before. The health of the worker requires that factories,

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shops, and offices, as far as the work to be done permits, should meet the fundamental needs which were discussed in connection with housing in Chapter V. Good lighting and ventilation are essential. Temperature, noise, and crowding should be controlled as far as possible. It is of prime importance to study the special hazards which are involved in the individual industry or job. We cannot afford to overlook or slight this dictate of common sense as we develop our new war industries. Many hazards, once they are understood, can be isolated by appropriate measures, such as mechanical guards for machinery, enclosure, ventilation or wetting for dusty processes, and special costume for the worker. Suitable clothing, with accessories for special parts of the body when they are needed, give valuable protection against mechanical, chemical, or electrical injury. The impression exists that the American workman has acquired a distaste for proper workclothes, as if they were not a badge of an honorable position in our society. If this is the case, let us hope that war will bring a change, else someone will want to put American labor into a uniform of some special color in fascist fashion. The hours of work per day or per week of large sections of American labor were reduced in the 1930's to levels which were well within the limits imposed by consideration of health. Today the grim needs of war compel us to increase the hours of labor, at least in the essential industries. The ques-

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tion immediately arises, how far can this extension of hours go without defeating its purpose by injuring the health of war workers? The heart of the matter is the output of arms and munitions, which depends not alone on the time put in on the job, but also on the energy and application of the worker. Man is not a machine. It has been abundantly demonstrated that there is a point beyond which increased hours of work result in a reduced total output. Indeed, the information is a hundred years old, for it dates back to observations of Robert Owen, the large-minded English industrialist and reformer, who lived from 1771 to 1858. Valuable data were gathered in England during the war of 1914-18. 4 For example, men engaged in heavy work in the manufacture of fuses (the speed of which was completely under their control) increased their weekly output by 19 per cent when their hours were reduced from fifty-eight to fifty and a half. Women doing a war job on which they could only control the speed for one-fifth of the total time involved lost 1 per cent of their output when hours were reduced from sixty-five to forty-eight a week. Moreover, time lost because of sickness must be taken into account. English experience in 1914-18 again provides pertinent data. When the weekly hours of * The whole matter of the health of war workers is lucidly discussed by Η. M. Vernon in The Health and Efficiency of Munition Workers (1940). Although it is not written for the layman, many who are interested in these problems will find the book helpful.

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male war workers were cut from sixty-three to fiftyfour, time lost for sickness fell by 43 per cent. Among women there was a saving of 52 per cent when hours of work were changed from sixty-two to forty-four. During World War I, English labor often worked seventy to eighty, and even up to one hundred, hours a week. In retrospect, this seemed like a gross error, but similar time was demanded during the crisis of June and July of 1940. It is very much to the point that such long hours of work are possible (though of doubtful utility) for short periods, but cannot safely be continued week in and week out. The British have apparently settled down to a fortyeight-hour week for women, and fifty-four to sixty hours for men. Although the varied conditions of different jobs make generalized regulation irrational in a great emergency, the evidence indicates that forty-eight hours a week is a desirable limit for women and youths of sixteen to eighteen, and fiftyfour to fifty-eight for men, with exceptions only in specific cases and for limited periods. If health is well guarded in other ways, most men and women will not suffer from such hours. Women and youths should not be employed on night shifts. There are two reasons for limiting the work of women: their smaller physical strength, and their function of bearing children.5 Bound up with the hours of work ' Studies by the British Industrial Fatigue Research Board of large groups of employed men and women showed that, al-

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are rest periods, Sundays off, and holidays. There is excellent physiological basis for the provision of such respites, especially from heavy labor and close mental application, because physiological reserves are encroached upon, which can only be replenished when used muscles and nerves or the brain is at rest. Good managerial ability should be able to organize jobs and workers so as to maintain output while relays or shifts are off duty. Among the conditions which may help or hinder the worker is the position in which he has to work, since the advantage with which muscles work may be great or little, according to the direction of pull or push, and since muscles may have to be used unnecessarily. Where the job permits, a comfortable sitting position is an investment in both health and efficiency. Monotony and rhythm play a role in the reaction between the laborer and his task. Some individuals thrive on monotony, but more weary of it. Periodic changes of jobs have much to commend them, although employers frequently deny them to the worker (who may then go elsewhere just for a change). A worker who acquires a professional attitude toward his task thereby achieves a sounder psychological state than the time-server or piece-counter. Large numbers of men and women put great emphasis upon their wish though the women had 93 per cent of the stature and 81 per cent of the weight of the men, their physical strength was only a little more than half as great.

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for congenial companions at their work, but it is difficult to see how much can be done on this score. The relationship of supervisors and foremen to workers in the ranks is rightly given a high value in the determination of the morale of the group. Perhaps no other element in labor conditions, except wages, plays as large a role in output. Certain aspects of industrial hygiene are spoken of as "employee welfare" or as "extra-factory activities." In so far as actual hygienic needs of men and women during the working day are concerned, this is a mistaken conception, for all appropriate provisions should be considered to be for the welfare of the whole enterprise and should be carefully integrated with other arrangements. It might be supposed, for example, that by this time there would be general recognition of the need for adequate toilet facilities, wash-rooms, and cloak-rooms. Prompt removal of grease, oil, and grime helps greatly to keep skin troubles under control. Yet these provisions have been grossly neglected in some of the large undertakings of the present industrial emergency. Such omissions should be made good without delay. The fundamental role of nutrition in health has been discussed in Chapters II and III. Food requirements, including those for special nutrients, go up as work increases in intensity or duration. It is essential, therefore, that workers in heavy industries and all who work long hours should have adequate supplies of the essential nutrients. The rationing of

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sugar does not affect the worker's needs, as he is better off with other available foods, but when it becomes necessary to ration other foods, the needs of workers must be supplied without fail. If it appears necessary, there should be no hesitation to follow Germany's example by providing a special ration for heavy industry. The American Medical Association has taken a stand against routine and general supplies of vitamins as such to healthy workers, as irrational, unwise, and uneconomic. Everyone at work should have easy access to a plentiful supply of good drinking water, and encouragement to use it. When conditions are such that perspiration is marked, table salt should be added (usually to make a 0.2 per cent solution in water). There are many reasons for urging that the provision of supervised lunchrooms or canteens be greatly extended in industry under war conditions. A survey by the United States Public Health Service of over sixteen thousand plants with one and a half million workers found lunchrooms in 24 per cent of the plants. Communal eating is economical of both money and time, but, just as important, is the opportunity for demonstrating what good meals are, and how the restrictions of rationing should be met. Plant and office lunchrooms, when well managed, make for good morale. It is futile, however, to hope for the possible benefits from this source, if the management is left to independent contractors,

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for such arrangements are usually much worse than those which exist in ordinary public eating-places. Under no circumstances should employees be compelled to patronize an unsupervised and independent caterer. Only passing reference need be made here to transport and housing needs of America's army of workers. Obviously rapid, safe, and convenient transport is necessary to and from work in a land where homes are seldom close to the job. There never was much sense in acres of parked automobiles about industrial plants, though the time has been when they were pointed to with special pride. A good bus service, where rapid transit facilities do not exist, will fill the bill. It must be planned with reference to shifts and night work. As for our larger cities, perhaps the war will finally bring home the fact that there is no need for everyone to get to his job precisely at nine o'clock in the morning. The staggering of office and shop hours would greatly simplify the task of transportation. Housing has been discussed in Chapter V. In some occupations, medical care for the worker as such is universally conceded to be necessary. Provision for it varies from none whatever to elaborate service. The 1936-59 industrial hygiene survey by the United States Public Health Service disclosed safety directors in half of the plants which were studied; first-aid rooms and trained attendants in half of them; nurses in a third; and physicians, full-

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and part-time, associated with 38 per cent. Hospital facilities were provided at 15 per cent of the plants. It has already been noted that accident records are nearly always kept, but sickness data are gathered much less often (45 per cent of plants in this survey). Better records of absenteeism because of illness are urgently needed, in order that the problem may be known with reasonable accuracy. Medical examination on employment is fundamental in determining the fitness of the individual for his proposed job. The results are sometimes mistakenly or unfairly interpreted, however. By way of example, positive blood tests for syphilis may be mentioned. Industry has been urged to have such tests performed for the purpose of discovering those who need treatment. Then, when positive tests are found, a compaign must be waged to secure the employment of those who have no discoverable damage from the disease and no possibility of transmitting it to others, and who are willing to be treated. Such persons, provided they take proper treatment, present no unusual risk. In our great need for labor, the results of medical examinations should only exclude the prospective worker when they clearly show him to be unfit. Many remediable defects can be cared for while the worker is on the job. Health and safety education should be an important activity of all industrial enterprises. The novelty of much of the war industry and the inexperience

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of many war workers render these educational functions particularly necessary. Industry in general makes no effort to care for sickness and disability which arise outside the occupation, but naturally refers the worker in such cases to his own physician or community hospital, at the same time often providing helpful cooperation. During the war, it is obviously desirable to maintain existing industrial medical services and to extend such services to all but the smallest groups of workers in war industries. Facilities and personnel are now almost entirely limited to sizable plants, but the smaller factories bulk very large in our total production, and their workers need all the protection they can get. This is but one of many new demands on the medical and nursing professions, which have a great deal of work cut out for them. The general problem is referred to in Chapter IX. It is suggested here that those who are receiving training for emergency first-aid might continue their training so that they could be employed in industrial first-aid and hygiene education, while remaining available for emergency service. It may seem that rehabilitation should be an activity for time of peace rather than for wartime, but that is a shortsighted error. There are no good statistical data to show how many Americans are to be classed as incapacitated. The number is certainly large. We know that every year about one hundred thousand persons are labelled as permanently dis-

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abled by industrial accidents. Furthermore, about every fifth man selected for military service is rejected as unfit, even for limited duty (be it noted that this is in a preferred age group). On the other hand, only a small number of those who are classed as disabled are unable to do any work. A larger group have permanent limitations, but are capable of holding jobs, while the majority are not restricted in any important regard. Most of these unfortunate citizens need, not so much economic relief, as occupational rehabilitation. Although the effort falls short of helping all who need it, a great deal is now being done in this field. There is every reason to maintain this social service and, if we can possibly do so, to expand it during the war. Unhappily we must face the coming need to rehabilitate disabled soldiers and sailors. The techniques of physical restoration, rehabilitation surgery, and occupational reeducation do not concern us here. It seems a fair statement, however, that every citizen with an occupational disability who has a reasonable prospect of being able to do a job of work is entitled to a chance for restoration. The psychologic aspects of the problem are prominent. Workmen frequently overestimate their disabilities, sometimes dishonestly, more often not. In a great many cases the problem is one of restoring lost self-confidence. Among employers there is a strong prejudice against partially incapacitated workers, which cannot be entirely justified. Even physicians underestimate the capacity of such men for work in many cases.

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Recreation, in the best sense of the word, is closely related to occupation. We should not lose sight of the physiological basis of recreation, which is indicated by the etymologic significance of the word. Everyone who works needs recreation. The term cannot be applied, however, to any constant occupation, or to one which prevails over all others. Although various activities may be classed as good, bad, and indifferent recreations, in no field is the strength of individual predilection greater. Trench digging (for a brief space of time!) may be recreation for one man, the mathematical calculus for another, and so on. Recreation does not consist alone of night-club or dance-hall life, nor of the somewhat anemic and dull activities to which recreation centers sometimes limit themselves. Few generalizations can be made as to the acceptability of activities for recreation. The most suitable are ordinarily remote from other occupations, especially those which are gainful.6 Workers in sedentary occupations should have recreations which include physical exercise, if possible out of doors; but they have to be told so, and it is evident that there is no common inner drive in this direction. The praises of walking have long been sung without conspicuous success. The accomplished walker has a technique of carriage, of attention to the scene through which he passes, whether • There are many exceptions to this statement. It appears, for example, that trainmen support clubs for the purpose of constructing and operating elaborate miniature railroads.

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it be in the crowded streets of a great city or in the open country, and of observation of the men and women whom he encounters. Ignorance of this technique has much to do with a distaste for walking. If recreation includes educational activities, the purpose should be incidental. Most men and women want their recreation to be social, or at least not to be taken in solitude. Many people also need an apparatus of some sort, something outside themselves, to keep them amused, such as the automobile, radio, moving picture, athletic spectacle, and so on. This is entertainment, which is not synonymous with recreation. The war will restrict in some degree, perhaps very greatly, these prevalent American entertainments. If as a people we can find satisfactory recreational activity with less professional entertainment by others, we will gain and not lose thereby. If the use of alcoholic drinks is a recreation, it may be mentioned here. Neither the vast harm which it has caused, nor the great pleasure which it has given, can be denied. One word covers the problem — temperance. Those who can find a recreation in gardening will be doubly satisfied if they grow vegetables. The libraries of the country will find their books more in demand than ever before. Radio programs will be listened to more than ever, and their contents daily grow more important. It is not implied that recreation should be imbued with uplift activities. Americans are going to labor strenuously, and recreational activ-

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ities will play a large role in making it possible to do so. Their development in the communities which are growing up around new war factories should not be left to chance. In the words of Mr. J. B. Priestley, we should set the stage for "hard work and high jinks." British workmen have been through two years of gruelling effort under the most trying circumstances. American workers can take comfort in the fact that health in British factories is just as good as it was before the war. In this war which provides more than enough work for all, Americans have an opportunity to demonstrate their full capacity for organization and cooperation. The individual citizen should find a job worth doing and peg away at it, without constantly worrying about the way all the rest of his countrymen are progressing. In the effort to meet the need for ever-increasing production of arms and munitions, the cry for patriotism should not be too frequently and too persistently raised. There is something to gain by the assumption that American workmen, by which we mean the majority of adult citizens, are patriotic. The greatest satisfaction of the honest workman is his achievement itself; if this furthers the cause of his country at war, the worker's gratification, and with it his effort, assuredly will be increased.

CHAPTER IX ABOUT OUR DOCTORS AND NURSES

HE last fifteen years have seen the development of keen interest among Americans in the provision of medical care, and in the doctors, nurses, and others who are responsible for it.1 The problems which are involved in supplying and maintaining medical care for the American people of adequate quality, scope, and volume are extraordinarily complicated. They do not readily lend themselves as a whole to simple presentation in a nutshell to the layman. Yet they touch the public very closely, and widespread understanding of the basic aspects of American medicine is essential. The surveys which have been made during the past fifteen years have indicated numerous directions in which improvements are needed — a result which should surprise no one. The discussions which have taken place, both inside and outside the medical profession, have disclosed sharp differences of interpretation of the medical situation, as well as of opinion as to the best ways and means of improving medical care in the United States. The war and the condi1 In this chapter, as well as in the other chapters of this book, no sharp line is drawn between the care of sick and preventive medicine or public health.

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tions which will follow in its wake will render more pressing than ever the solution of some of the country's medical problems. Health means so much to the welfare of the nation that we surely do not wish to take hasty or ill-considered action in the matter. As one of the three ancient professions — theology, medicine, and law — the medical profession has a tradition which reaches back to the roots of our culture. In spite of attacks upon this tradition, and in spite of inadequate and distorted expression of it by individual members of the profession, medical tradition has a value for society and for sick individuals that can hardly be overestimated. Whether it has responded adequately to new social needs and to changing social concepts is another question. It is, axiomatic that any such cultural tradition should develop and grow along with the society in which it is handed down. The core of medical tradition is the duty of the physician, that is, the individual trained to give medical care, to make his services available to those of his fellow men who need them. The nursing profession was endowed by Florence Nightingale with a similar ideal at its very inception. No salary and no appointment can begin to bring out the right response to this duty in the same degree that an adequate medical or nursing education achieves. In spite of limitations which arise out of the fact that physicians and nurses are human beings, that they have to support themselves, that they may be

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afflicted with worldly ambitions, a very large number of these men and women are deeply imbued with a sense of this responsibility to their fellows. It is beyond question that this fundamental characteristic should be fostered and that no development should be undertaken which might be expected to snuff it out. The degree of mutual understanding and confidence which is desirable between physician and patient often transcends that of any other professional or business relationship. For this reason, the medical profession has sought to preserve freedom of choice in the patient-physician relation, freedom of changes in it, immediacy and intimacy in it, without the intervention of non-medical personalities. It has been an ideal of the medical profession that compensation for services in individual cases should occupy a place of secondary importance in the relationship. Modern social developments subject many medical ideals to a severe strain. Some aspects of the professional tradition lend themselves to abuse, such as group protection of a derelict individual. When one physician or a group of physicians protects another in serious errors of omission or commission, there is abuse which the profession discountenances. The like can be found in all activities, including competitive business. The public should be aware that, when doctors indulge in unlimited mutual faultfinding, the profession rapidly deteriorates, to the great detriment of patients.

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Concern for the advance of medical science and art is another aspect of the professional tradition. Even though few doctors can personally contribute to scientific progress, an intelligent and receptive attitude toward new advances is a leaven which exerts a wholesome influence. New developments which have a practical bearing are fairly rapidly disseminated and appreciated. Unfortunately, new advances are now often of such a character that many doctors may find it difficult to take advantage of them. In common with European and American civilization in general, and science in particular, medical practice in all its aspects has changed profoundly in the last hundred years. Even the last thirty to forty years alone have greatly altered the face of medicine. The full range of medical knowledge and practice has a complexity of which our grandfathers could have had but little inkling. Medicine has acquired a scientific basis in physics, chemistry, physiology, and pathology, upon which doctors must constantly strive to found their diagnostic and therapeutic activities. Inevitably, more or less elaborate techniques and apparatus have become essential to the adequate study and care of a great many patients in one or another illness in the course of their lives. Hospitals, clinics, and "groups" of doctors have steadily grown in numbers and volume of service rendered, partly because of the need for economy in time and money in the use of the new

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methods and apparatus, which as a whole are quite beyond the ability of any individual to acquire. New medicines and new surgical procedures have slowly but continuously increased the doctor's ability to cure or alleviate disease. Examples are too well known to be needed. It is worth noting, however, that the newest addition to the list of effective drugs, the "sulfa" compounds, came largely as a surprise gift, only ten years ago. The commercial manufacture of drugs has become a huge industry of great power and wealth. The development of psychiatry deserves special mention. Though still perhaps in its infancy, it has supplied enormously increased understanding of, and power over, the mental aspects of all illness. Thus it profoundly influences for good, not only the care of patients with diseases of the mind, but the whole of medical practice. Preventive medicine, which a century ago was embryonic, has steadily grown in significance. Since the application of preventive measures in a large degree concerns communities rather than individuals, public health services for local units, for states, and for the nation have been created. Solution of public health problems has been achieved partly by the development of a sanitary branch of engineering. Administrative technique bulks large in public health work. Consideration of public health has led to intensive study of the circumstances under which particular diseases occur in the population, as con-

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trasted with the individual. These epidemiological and other problems have caused medicine to draw upon mathematics for support, with the result that a special set of statistical techniques has been developed. The newest point of view in medicine is that which looks toward the enhancement of health in a positive sense, an advance which is made possible largely by increases in our knowledge of nutrition. From this brief survey, and from the preceding chapters, it must be clear that no doctor at any time in his career can be competent throughout the field of medicine. Specialists alone can master the intricacies of modern practice, or carry on advanced research. Even they must make constant effort to keep pace with progress in their own field. Specialization necessarily plays a large role in medicine today. A vast amount of illness, however, does not necessitate the attention of a specialist, and may be even better cared for by a physician with a general experience. Hence, the general practitioner retains a central and all-important role. In Chapter IV, reference was made to the decline in the incidence and severity of many infectious diseases which formerly caused a large part of the doctor's work. In Chapters VI and VII, attention was called to the greatly increased medical care which is given to children and to the elderly. In Chapter VIII, some of the needs of workers as such were touched upon. A great deal of the medical

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care which these developments call for is of quite another character from that which occupied physicians of older generations. It is obvious that medical practice could not remain uninfluenced by social changes outside itself, or develop independently of the general social structure. Thus, in turn, the closing of the pioneer period, the increasing population, industrialization, and urbanization have had their effects upon medicine. With each passing decade, social elements become more and more prominent in the determination of health and disease. It is not too much to say that the last hundred years have seen as great a change in medicine as has occurred in any human activity — a far greater change than has occurred in her sister profession of the law. America's medical work is divided among one million and a half or more persons. The table on page 235 shows an approximate distribution for the year 1932, except that the figures for graduate nurses and doctors are estimates for 1940 and 1942, respectively. It is an understatement, rather than otherwise, of the total personnel which is engaged in the provision of medical care in this country. It does not include the employees of commercial manufacturers of drugs, for example. Some of the doctors have retired from the profession; others are engaged in research or other work outside the usual field of practice (work which is nonetheless essential to

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medicine as a whole) .2 Whereas about 85 per cent of doctors are in private practice, about half of the graduate nurses work on regular salaries in hospital and other organized service. Both medical and APPROXIMATE NUMBERS OF PERSONS ENGAGED IN CERTAIN CATEGORIES OF MEDICAL WORK * Graduate doctors Dentists Graduate nurses Practical nurses Pharmacists and assistants Midwives Optometrists, chiropodists, masseurs Hospital, health service personnel Doctors', dentists' office help Total

186,000 67,000 450,000 150,000 175,000 50,000 31,000 512,000 55,000 1,676,000

0 Based on Table 2, Appendix of the Final Report of the Commission on Medical Education (New York: Office of the Director of Study, 1932), except for the numbers of nurses and doctors, which are estimated for 1940 and 1942, respectively.

nursing students quite properly contribute to the care of patients while their education is proceeding. The full variety of the occupations of those who help doctors and nurses to take care of the nation's health is not brought out in the table. Included are not only secretaries, nursing aides, and orderlies, but social workers, and other men and women with The number of unlicensed practitioners is entirely unknown, but has been supposed to be thirty or forty thousand (the number is a matter of the definition one chooses to apply). It may be assumed that such practitioners are quite without a medical education. 2

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a high degree of professional, scientific, or technical training (according to the Journal of the American Medical Association, in 1941 our hospitals employed a technical personnel of over fifty thousand). The public is sometimes appreciative, sometimes impatient, of this army of ancillary medical workers. They are all necessary, however. Many of them do their tasks with a truly professional devotion. They free the doctors for work which only doctors can do. Without them, either medical service would be terribly restricted or it would be even more costly than it is. The quality of doctors, nurses, and other medical personnel depends chiefly upon two elements: the original endowment and preparation of the prospective student or "trainee," and his medical, nursing, or technical education. The quality of medical work is influenced greatly by its organization and by the facilities which are provided. The story of the improvement in the last thirty years of American schools of medicine and nursing has often been told. Thirty years ago only a few medical schools in this country were worthy of comparison with any of the well-known European schools, but today the sixty-seven recognized American schools collectively provide medical education which is perhaps the best in the world. This change is due to the combined efforts of the schools themselves, the American Medical Association, and the two great foundations, Carnegie and Rockefeller. These schools

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graduated 5,275 men and women in 1941. In addition, several hundred graduates of foreign schools have been licensed each year in the recent past (presumably this source of graduates will disappear during the war). The number of women medical graduates has remained constant for many years (less than 5 per cent), in spite of increasing opportunities in certain special fields. There are some half dozen unrecognized schools of medicine, whose ill-prepared graduates have only very restricted opportunities. In the United States at large, the number of persons per physician is less than 800, whereas in many European countries, the number is in the neighborhood of 1,500. Since American physicians die at the rate of about 3,800 a year, there was in peace time no prospect of any deficiency. Schools of nursing graduate from 20,000 to 25,000 nurses each year — probably more than the country can support in ordinary times. Doctors, nurses, and all other medical workers have special parts to play in the war. The Army and Navy need something like six doctors per thousand men. By the end of 1942, present plans call for about 28,000 physicians and surgeons in the services. Before the war is over, as much as a quarter of the active profession probably will be, or will have been, on war duty. Furthermore, a considerable number of physicians who remain in civil life will be occupied with war work, including special research. Non-military establishments which are set

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up abroad to help carry the war into enemy lands will need civilian medical personnel. Similar demands are being made upon the nursing profession, and to a lesser degree, upon other medical personnel. Since the part of the population which is taken into the armed forces is relatively small in proportion to the medical personnel, and since we cannot reasonably expect the medical needs of the remaining civil population to be any less in war than in peace, the supply of doctors and nurses becomes a matter of some concern. Schools of medicine and nursing, which at all times are institutions of outstanding social importance, have vital functions in the war program. Teaching staffs must be held together, for a good medical teacher is worth more than a battalion medical officer. Young men and women, selected for their preparation and promise, must be encouraged to study medicine and nursing, even above military or other war service. In wartime, the study of medicine and nursing is as essential as the training of combatant officers. The schools have even been asked to expand their classes, when this can be done without sacrificing educational quality. There is no method by which the numbers of doctors and nurses can be increased in a short space of time. Most American medical schools, however, have adopted accelerated programs, in accordance with which classes will graduate every nine months, instead of every twelve. The War and Navy De-

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partments have made arrangements which facilitate the study of medicine. It is desirable that the public understand its urgent character. Early in the war of 1914-18, most British medical students left their studies and enlisted. It soon became apparent that the result would be disastrous, and such men were returned to schools, even from the front lines. In addition to a lengthy preparation, qualification in medicine and surgery requires five years of study and practice (one of which is the hospital, or interne, year). An interruption of the succession of classes would immediately greatly impair the efficiency of medical education. Since we cannot expect the war to end soon, it is desirable to provide for the further training of a small selected group, at least in such fields as surgery, in which competence is not achieved in the usual course. Civilian defense requires the training of many thousands of citizens to serve in first-aid squads, first-aid posts, and ambulance units, in case of enemy attack on American cities or countryside. A peacetime function which some members of the medical profession and other scientists who collaborate with them must continue to exercise in wartime is medical research. Most of the regular investigative interests of peace have to be abandoned, but research tasks must be undertaken to solve the endless special problems which become acute in time of war. Some such problems have

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been mentioned in connection with infectious diseases and nutrition. The most important function of the medical profession in war, as in peace, remains the care of the health of the general population of the country. The opinion of various observers that American medical services can be greatly improved, at least for the very large low-income groups all over the country, has already been mentioned. The war has made precarious the position of salaried "middleclass" citizens, whose actual income has remained fixed, while their purchasing power has fallen. The discussion of recent years has largely revolved about the organization of medical services, their distribution through various regions and social groups, and their cost. The absence of a large fraction of the medical profession on war service, the special needs and dislocations of the war, will create new difficulties. Admission to the practice of medicine is guarded by the legal requirement of a license in each state of the Union. There is no federal licensing or coordinating authority. The requirements vary a good deal among the states, so that a doctor who is quite acceptable to one state may be unable to secure a license in another, sometimes for purely technical (non-professional) reasons. In general, the states do not otherwise regulate the practice of medicine, except to require compliance with specific rules and cooperation with public authorities in cer-

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tain matters affecting the public health. The rights of patients, of course, are enforceable in appropriate circumstances in the courts. The medical profession within itself is highly organized. Two-thirds of the doctors of the country belong to county or municipal medical societies, which in turn compose medical societies in all the states. The American Medical Association is made up of the state and local societies with all their members. Through these organizations the profession exerts a powerful coordinated influence on medical education and practice. The high standards of the United States in these fields are due in large measure to the American Medical Association. These "official" societies supply the professional regulation of medical practice, including the disciplining of erring members, which necessarily lies outside the scope of statute law. One of the outstanding contributions of the Association has been the analysis and checking of the claims made for new medicines and patent remedies, thereby providing doctors with reliable information about the thousands of preparations which commercial drug manufacturers put on the market. In addition to the "official" societies, there are numerous organizations of doctors with special interests, societies restricted to particular fields, such as heart disease, research, and so forth. The "official" and the special societies between them publish a large majority of the important medical journals of the United States.

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Medical Association and certain of the special societies has resulted in the establishment of a number of boards of experts in the specialties of medicine and surgery. These boards, after examination, certify doctors who have had the requisite experience and training as qualified specialists in the field to which they have devoted themselves. The system is relatively new, but it promises to solve a difficult problem. Nearly twenty thousand specialists have been certified, but at least as many doctors as yet uncertified regard themselves as specialists (in many cases with all propriety, since the plan is not yet in full operation). The public has a great interest in this achievement, as hitherto there has been no standard of reference by which to decide who was a specialist and who was not. Provisions for medical service may be considered in three groups: the general practice of medicine in doctors' offices and patients' homes, medical care in hospitals and clinics, and public health services. These types of service are by no means sharply set off from one another, but on the contrary are interrelated in most complex fashion. The public health services of America are highly organized, except in the smaller political units. This is remarkable, because it was the smaller units which initiated organization for public health in the United States. The most efficient organizations today are the state services and the services of large cities, together

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with the federal services, which, however, are of limited scope. The effective field of activity of public health services varies from state to state, and even from municipality to municipality within the same state. These services originated from the need for common action to control the spread of infectious diseases, but they have gradually spread until they include the whole field of preventive medicine as applied to groups of people. Epidemiology, apart from experimentation, and vital statistics also come within the scope of public health services. The care of the sick in certain groups of the population, and the care of certain illnesses, especially tuberculosis and mental disease, have been assumed in varying degree by public health services. In many jurisdictions, health services are provided by bureaus and offices in different departments, whose work is often uncoordinated and sometimes overlaps, though each may be excellent in its own field. Public health is a highly technical service, yet in many communities it has not so far succeeded in gaining freedom from pernicious political influence over personnel and policies. Public health services should be conducted in accordance with scientific and technical principles, independent of extraneous political considerations, by men who are specially trained for the purpose. At least the chief servants of public health should be free of the distractions and compromising relations which arise from the need of supporting themselves by other activities.

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Yet some large American cities, and even some of the states, confide the care of their community health to individuals chosen for purely political reasons, in disregard of the need for professional qualifications. On the other hand, many states and large cities, together with a few smaller units, have excellent services. In many states, authority is delegated almost entirely to local political units, so that a state service which is excellent as far as it goes is powerless to direct or correlate local health activities. Many of the three thousand or so counties and other small municipalities of the United States are unable to afford adequate full-time health services. Hence, for both economic and political reasons, local services are the weakest part of the public health system, in spite of the fact that they are theoretically its core. Such counties and small municipalities should be willing to pocket their pride and combine into larger units in order to secure the advantages of efficient health services. The Constitution of the United States is silent on the matter of health, except in so far as it is included in the power of Congress to provide for the general welfare of the country (Article I, Section 8, Paragraph 1), and except for the provisions for a national census. Apart from the census, Congress, in the beginning, provided only for a national quarantine service and for the care of the health of federal establishments, such as the Army and Navy, and for a few special groups, such as seamen. Out

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of the first and third of these activities has grown the United States Public Health Service, which, within the scope laid down by Congress, has gradually acquired a stature and efficiency commensurate with America's greatness. From time to time Congress has created a dozen or so agencies which are concerned with health, especially in connection with child and maternal hygiene, the inspection of meat, other foods, and drugs, and industrial and school hygiene. Following World War I, there was an enormous development of facilities for the care of veterans. During the depression, it became necessary for Congress to assist the states to provide medical care for their citizens, and out of this need have come extensive programs which deal with venereal diseases, crippled children, and many other matters of health. These federal activities are scattered among many independent agencies and lack coordination in a marked degree. It cannot be said that there is in effect any federal program. The task of creating such a program is one of enormous difficulty, which cannot be accomplished satisfactorily in a short time. Yet it can hardly be finally denied that America needs a coordinated national health service, whatever may be the limitations within which it operates. During the war, there will be no opportunity to curtail our public health services. Indeed, as has been indicated in other chapters, we must expect to expand them in some directions, since public

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health is one of our best means both of offense and of defense against our enemies. In order to economize in personnel and facilities, local and state services should organize for closer cooperation and less overlapping in functions. Dislocations of populations must be adequately cared for by appropriate transfers of health officers. The hospitals and clinics of the United States furnish Americans with a huge volume of medical care. The definition of standards and periodic inspections of the American Medical Association and the American College of Surgeons have contributed largely to improvements in the last twenty-five years, which have resulted in a generally high level of facilities and service. According to the latest statistical summary of the American Medical Association, there were over 1.25 million hospital beds in 1940, about 9.3 per 1,000 population. On an average day, over 1 million Americans were in hospital. Enough days of hospital care were given to provide almost three days in hospital in the year for each American. About one in thirteen inhabitants was actually admitted to hospital in 1940. The average occupancy of the beds available was 83.7 per cent, but the range of figures for institutions in different localities and of varying types was great. The work of all the out-patient clinics of the country cannot be estimated numerically, for the data have never been gathered. The American Medical Association, however, found that over 750 out-patient departments

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of general hospitals treated nearly 4.5 million patients, who made on the average about six visits each. The total volume of out-patient attendance in clinics of all sorts, of course, is much greater. Hospitals and clinics in the United States were organized and are controlled in many different ways. Controlling agencies may be grouped as proprietary, non-profiting, and governmental. Hospitals under proprietary management are numerous, but small; altogether they supply only a little more than 4 per cent of our hospital beds. Non-profit-sharing associations control institutions which furnish nearly a quarter of available beds. The remaining 71 per cent of beds are in hospitals which are managed by city, county, or state governmental agencies, or by combinations of these units. The types of illness to which hospitals devote themselves can be classified broadly as general medicine, mental disease, tuberculosis, and miscellaneous specialties. Hospitals for general medical diseases are the most active institutions, and fill the most pressing needs. They admitted over 90 per cent of the patients who entered hospitals in 1940, although they contain only 38 per cent of all the beds. Over half of this care is given under the direction of private non-profit associations. On the other hand, patients with mental disease or tuberculosis remain in hospital for long periods of time. A large proportion of this type of care is provided by institutions which are under governmental direction.

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The distribution of hospitals is very uneven. The most elaborate are naturally concentrated in large cities, but many small communities have excellent hospitals. The provision of beds in general hospitals varies from 2.1 per 1,000 population in Utah to 8 per 1,000 in Nevada. There is some tendency, as was indicated in a study by the United States Public Health Service in 1940, for the number of hospital beds to parallel the total state income. According to the same report, the use of beds tends to be small when the state income is low. In Mississippi, where there were only 2 general hospital beds per 1,000 population in 1940, the available beds were only occupied 47.5 per cent of the time, whereas in Maryland, which has 5 general hospital beds per 1,000 population, the percentage of occupancy was 68.6. This difference could be explained by better health in Mississippi, but such an explanation is most unlikely to be correct. Doctors and nurses, of course, constitute the essential personnel of hospitals and clinics, for these institutions derive all their significance from their medical and nursing staffs. On the other hand, hospitals greatly increase the effectiveness of doctors, both educationally and in practice. The public, therefore, is much interested in the relations between physicians and hospitals. These relations vary from a full-time salaried status, which is unusual, especially outside certain government institutions, to a limited right on the part of the doctor to

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admit patients for certain purposes. In general, if a patient is admitted to a hospital as a non-paying case, the admitting physician does not have the right to continue to take care of the patient. This limitation is justified on the whole by the organizational needs of hospital wards, and the patient is probably usually the gainer for it. In recent years many large hospitals have been at great pains to achieve close relations with the physicians who admit patients to their wards, by die exchange of extensive notes about the patient's sickness and treatment before and during the hospital stay. In return for the advantages which the hospital confers on the members of its medical staff, they contribute freely a very large amount of service to non-paying patients. Many physicians in large cities have no hospital connections. Their patients, therefore, may have some difficulty in securing prompt admission to hospital when it is needed. The heterogeneous character of the origin, location, control, and scope of America's provisions for hospital care is notable, as well as the widely prevalent high standards of our hospitals. Adequate facilities are available for a large proportion of Americans, but the individual patient may have some difficulty in finding his way to the institution which can best fill his needs. Many of the nation's hospitals of all types have been planning since early in 1940 their method of operation under the conditions of actual warfare.

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All the hospitals in the country face a most difficult situation. They are not only in the forefront of home defense, but they must continue to give as much ordinary medical care as ever. Serious staff shortages in doctors, nurses, and other essential personnel are already apparent. The general solution lies in tighter, more efficient, organization. In accordance with the plans of the Office of Civilian Defense and the Federal Security Agency, hospitals of all types may take part in the Emergency Medical Service as casualty receiving hospitals. Certain institutions in "safe areas" will be used as emergency base hospitals for patients who have to be evacuated from hospitals in their own communities. The administration of institutions which serve in either capacity will remain as it is at present constituted. The federal government will reimburse hospitals for these services at a suitable per diem rate. If the war comes nearer home, room will have to be made in regular hospitals for injured and acutely ill persons by sending convalescent patients and those with chronic diseases to improvised hostels, such as may be arranged in resort hotels, or to their homes. Acting in a more stringent emergency, and dealing with a far simpler situation, the British have systematized all their hospital facilities (which were previously dispersed among three thousand independent institutions), even to the extent of combining the care of soldiers and sailors with that of the civilian population. Although this "scrambling"

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of British hospitals is in effect only for the duration of war, British observers have expressed doubt that it will ever be undone. It is of interest to consider briefly the sources of the drugs and appliances which the medical profession uses in its work. A large volume of serums for prophylaxis and treatment is made by governmental laboratories. America, however, has a huge drug industry, with over one thousand concerns, whose products in 1937 were worth more than $345 million. Surgical appliances made in the same year were valued at $77 million. As a people, we are still somewhat gullible about patent medicines. The American Medical Association has struggled for thirty years to bring reason and order into America's drug consumption, not without a measure of success. The evils of self-medication and unnecessary but costly advertising are still with us. Indeed, radio broadcasting has given a new fillip to direct and suggestive advertising, which contributes nothing to the cause of health. The drug manufacturing industry will not escape the effects of the war in any case, for it must supply the vast needs of the armed forces. Furthermore, various important drugs which are normally imported in crude or manufactured form are unavailable and must be replaced if possible by purely American drugs. One of the problems which confronts the medical profession is the readjustment of prescriptions to wartime limitations, which in many cases will make medicines

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taste different, although the essential ingredient may remain the same. In Great Britain it became necessary to issue a special wartime pharmacopeia. The drug industry should be able to devote much less of its energies to manufacturing and pressing upon the public medicinal preparations which are not strictly necessary, including the vitamins. The war is a good occasion for the public to restrict its purchases of drugs to those which are ordered by physicians and to a few simple household remedies. Some of the money which is saved can go into better foods. Health and pocketbook alike will benefit by this change. Americans receive by far the largest and most important part of the medical care they need for sickness from private practitioners in their homes and in their doctors' offices. No data exist to indicate with accuracy or detail the statistical aspects of private practice outside hospitals. Between 50 and 60 per cent of our doctors are in general practice, although many at the same time give particular attention to a specialty. It is the family physician who best preserves the ideals of close and continuous association with patients. In country districts and smaller cities the relationship continues along these valuable traditional lines, but in large cities it has lost ground among poorer and less intelligent families, who wander much from physician to physician and from clinic to clinic, or between the two. The choice of a physician is of the utmost importance

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to a patient. It must be admitted that the layman cannot easily estimate professional qualifications. Few people, however, take many pains to inquire into the matter. The advice which has often been given that hospital connections furnish some guide as to professional standing may be repeated as the best available, although it has its limitations. An important quality of a satisfactory physician-patient relationship is mutual confidence. The general practitioner often needs the help of specialists and of special equipment for diagnosis or treatment. This he may obtain as a rule from physicians, surgeons, and institutions in his own community or in nearby cities. Group practice is the result of an effort to economize time (for both physician and patient), investments in equipment, and outlay for overhead expenses. It varies from modest partnerships to a few large, complex establishments like the Mayo Clinic. Both advantages and disadvantages are inherent in the plan, which does not oifer an ideal solution to the problems of medical practice. At its best, group practice provides thorough diagnostic study and excellent treatment. Its possible worst features are complete loss of the patient-physician relationship, and unnecessary expense, in addition to "spotty" professional work. The distribution of practicing physicians has occasioned much discussion because of a drift to large cities which is out of proportion to the similar

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movement of the general population. One of the reasons for this shift is the concentration of medical facilities in our great urban centers, which more recent graduates feel they must be near. Another cause is the lower income of agricultural districts. The telephone and the motor car enable the country or small town doctor of today to cover effectively much more territory than his predecessors could. Nevertheless, a special problem exists in certain sections of the country. The incomes of physicians should be considered in connection with the cost of medical care. The average doctor's net annual income in 1929 is given as $5,700, but the median, or most frequent, net income was only $4,100. In that year nearly 25 per cent of America's doctors enjoyed incomes of less than $2,000. The average doctor is better off than the average citizen but to a smaller degree than one might expect. Most doctors have spent nine or ten years after graduation from high school in preparation for practice. Medical study proper, including maintenance, costs about $1,200 a year, or more. Large incomes from practice bulk little in the total. Obviously, a good many physicians receive very meagre returns for their long, arduous, and costly professional training. The absence of physicians from their practices on account of war service will be strongly felt by the rest of the profession and by their patients. In addition to the loss of practicing physicians to the

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military services, the greater employment will lead a great many patients to leave hospital clinics for private doctors. Patients will not be surprised, therefore, to find their doctors busier and more efficiently organized than ever. Great economy in the use of the time of doctors and nurses, and of medical and surgical supplies, will be necessary. Nursing in the home by graduates is always a luxury, since the cost per day is more than the daily income of about two-thirds of Americans. During the war large numbers of graduate nurses will be called to service with the armed forces. Institutional nursing, because of the greater service it gives, should take precedence over home nursing. Hence graduate nurses may become almost unavailable for home duty. When the great need for nursing, together with the necessarily high value of the services of thoroughly trained nurses, is considered, one is forced to the conclusion that America should have a larger corps of suitably trained "practical" nurses. The great difficulty in private nursing, however, is discontinuity of employment, for which the only remedy is still more efficient organization. The cost of medical care is very great. It cannot be otherwise, if good medical care is provided. Furthermore, sickness means not only extra bills, but also suspended or impaired earning power. America's total annual expenditures have been estimated at over three billion dollars, or about 5 per cent of the country's pre-war income. This is close

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to the total amount which is spent for educational purposes.3 In 1935-36, according to the National Resources Committee, spending for medical care was divided as follows: individuals and families for medical attention and drugs, 77 per cent; political units in taxes for medical care and public health services, 18 per cent; and industry and private philanthropy, 5 per cent. It is apparent that public, industrial, and philanthropic funds still pay only a modest fraction of our national medical bill. Individuals and families spend an average of about 4 per cent of their income for medical care (less than for automobiles, which take over 6 per cent). The percentage of family income which has to be spent on doctors, hospitals, and medicines of course varies with the income and with the "hit-ormiss" incidence of disease in a given year. The bigger the income, the better is health; and the less are medical expenditures proportionately. Specific medical requirements on account of disease cannot be foreseen, although it is clear that everyone must expect illness at some time. Medical care has been called an unwanted necessity, but there is a question of the intelligence behind this attitude. It has been pointed out that the poor, who need more medical care than the rich, cannot save toward the rainy day when sickness falls upon the family. This argument, however, should only be used in referMedical schools take less than 0.5 per cent of the nation's educational budget, although they are extremely costly to operate. 8

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ence to those in the lowest third of our income brackets. Doctors have more than carried their share of the load in the form of extended credit and cancellation of bad debts, but this elasticity and complaisance is unequal to the burden which sickness among the poor puts upon our economic system. It is generally agreed that America's medical services need to be extended and, at least in certain respects, to be more highly organized. We may look for extension of public health services in specific fields. It is worth noting, however, that these services themselves stand in great need of better organization, and that the power of the political considerations which led to and keep up the present lack of organization is not reassuring when vast extensions of public services are proposed. Our hospitals need much better organization as to their functions and field of action, and in relation to the practice of medicine outside their walls. The burning issues of the last fifteen years have largely concerned the provision of, and payment for, medical care in sickness. No one questions the need of the poorest section of the population for easier access to good medical care, including home doctoring.4 This end can only be achieved by the extension of tax-supported medical work, which, in accordance with tie ideals of the profession, should leave intact * It is a fact, however, that serious illness is best cared for in hospital. Home doctoring is not to be encouraged for sentimental reasons.

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the traditional relations of patient and physician to the greatest degree possible. Families above this level should be encouraged to save for sickness, and be provided with a method of doing so. Insurance is the obvious solution. Compulsion in this matter seems to imply a smaller degree of intelligence than one would like to attribute to his fellow-countrymen. With all its faults and all its deficiencies, there is no doubt that a vast majority of Americans at present prefer the traditional private physicianpatient system to any existing alternative. In times of economic improvement, they leave hospital clinics and municipal physicians in large numbers. In the past, health insurance has been so dear that few persons have been able to afford it. During the last ten years, however, many non-profit plans have been developed for groups of individuals or families, which provide hospital or medical service in case of need, in return for the "prepayment" of a subscription. Membership in the groups is voluntary, and free choice among the participating hospitals or physicians is preserved. The best of these schemes, having the support of excellent hospitals or of local medical societies, have been very successful.5 From among them will evolve plans which The hospital service plans ("Blue Cross") give every promise of complete success. It is expected that there will be ten million subscribers in 1942. Medical service plans are necessarily less advanced, since they deal with much more complicated problems, and actuarial experience on which costs must be based is fragmentary. B

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are suitable for the varied circumstances of different American communities. Protection from loss of income during sickness is a further need, which can only be filled by insurance arrangements with governmental support. The medical profession has sound reasons for looking askance at proposals which even vaguely suggest a huge national medical service, with a cabinet officer at the top, a hierarchy of officials, great and small, and an encyclopedia of rules and regulations. That would be the natural goal of some of the proposals which have been made. The practice of medicine is too variable, too shifting, too intellectual, and too responsible an activity to be brought to heel in that fashion. Although competition has been in bad odor in some connections, it has its value in medical work, as well as its limitations. There is food for thought in the fact that state and municipal hospitals have been constantly forced to improve their work as the result of comparisons with private institutions; the reverse is seldom the case. One of the essential qualities of any extensive organization of physicians and medical institutions must be that it leave wide scope for differences. We cannot afford to drag down any outstanding institutions or individuals for the sake of uniformity or conformity to a system.6 The out9 This is not only a windmill to tilt at, for examples of such a levelling process are known. Even in America, existing rules hamper the experimental development of medical education.

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standing professional need of practicing doctors is closer and more effective relations with good hospitals. Their outstanding economic need is a more dependable income. American medical institutions and medical practice are a part of the cultural pattern of the country, and are inseparable from it. That is the first lesson of medical history and medical philosophy. There is no implication that medical institutions are unalterable or unaltering, but great changes can only proceed slowly and hand in hand with changes in other spheres of social organization. America has been passing through a period of tremendous social ferment, which has affected medicine along with the rest of our social structure. There is no panacea for all the troubles of medicine in the United States. Evolutionary processes produce more lasting and more satisfactory solutions of social problems than revolutions. It has sometimes been claimed that health flourishes best in authoritarian regimes, but few Americans would subscribe to this doctrine. We must prove by our achievements, however, that health can prosper in a democracy as nowhere else. Under the leadership of enlightened and progressive members of the medical profession, and intelligent and public-spirited laymen, we can achieve this goal. The nature of the work to be done renders it essential that developments should strengthen, rather than weaken, the confidence, support, and cooperation which the public extends to doctors and

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public health workers. One of the most serious needs is education of the public in the extravagance and limitations of health cults and fads, and, at the same time, adequate use by doctors of any helpful methods which may be developed outside the profession. The war will intensify America's medical problems and accelerate changes which were previously in progress. It may compel the country to make drastic rearrangements in medical work as in other practical activities. The changes which are made because of wartime needs should be such as to lead to permanent improvements after the war is over.

CHAPTER Χ M E N T A L C A L M AND VIGOR

HE mind well-nigh defies definition. The Shorter Oxford English Dictionary gives the meaning as "The seat of consciousness, thoughts, volitions, and feelings." But the mind is neither a "seat" nor any other "thing." The mind, however, is concerned with the attributes of life which the dictionary lists. It is an aspect of the whole life of an individual, so that we can only know well the mind of a fellow human being if we have extensive and deep acquaintance with him and his activities, past and present, and with the characteristics of his forebears. The brain and nervous system are essential to the mind, but they cannot be said to constitute it; nor can we describe the mind of a person by examining his brain. Other parts of the body are intimately concerned with mental functions, especially those glands of internal secretion which in recent years have excited so much interest, both professional and popular. The removal of a leg may affect the mind profoundly, though presumably not the brain. All social relations exercise a powerful influence on the mind. When we say that an individual has a healthy mind, therefore, we are saying a great deal about

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him. It is quite another matter from saying that his lungs are healthy, for a man with healthy lungs may be the most miserable of mortals. Mental health indicates a well-integrated personality, with a clear and calm outlook; there is a just sense of proportion between seriousness and frivolity, between the important and the trivial, in the sphere of life in which the individual lives. It means purposiveness, vigor, and endurance in mental activities. Mental health implies a balance between ambition and sloth, between being acquisitive and being spendthrift, and so on. That a man is mentally healthy tells much about his social relations. He is in close touch with, and responsive to, the groups of men and women with whom he deals, but his harp is not hung on the bough of a tree. Such a man has an appropriate sense of duty. When the need arises, he can look to a circle of friends and associates for comfort and aid. His emotional life is vivid, although his activities are not dictated by his emotions. In short, there is harmony within the individual, and harmony between him and his fellow men. Mental health obviously indicates a state which varies with age, with social condition, and from farm to factory. Few individuals possess it in the highest degree — or ever have. It is reasonable to suppose that the rapid development of the characteristics of modern life, particularly industrial and urban growth, may have outstripped the adaptive powers of many men and

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women, but it would be easy to exaggerate the point. We must agree, however, that society has done little to facilitate adjustments by those who do not have mental health, if we consider the programs which could be carried out to that end. The war has come upon us after ten years of severe economic and social strain, which has left its mark upon the mental state of some millions of our countrymen. Furthermore, the war of 1914—18 merely interrupted a strong tendency in many Americans toward pacificism. A moment's reflection shows that the strength of the war effort will be determined by the mental attitudes of Americans at large, and that the qualities of mental health are essential to success in this great communal undertaking. From the nature of the mind it follows that mental illness may show itself in countless detailed manifestations of disordered thought, wishes, feelings, attitude, and behavior, which range from complete incapacitation for normal human existence to trivial disturbances. The relation between mental and bodily health is intimate and all-pervading, so that any serious separation of the two concepts does more harm than good. Mental illness very frequently expresses itself by bodily disturbances, such as, for instance, dyspepsia, difficulty in swallowing, diarrhea, palpitation of the heart, profuse sweating, difficulty in breathing, and so on, and so on. Physical disease, not alone in the shape of tumors and inflammations of the brain, but of any form what-

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ever, may be, and very often is, reflected in mental disorder. Indeed, it would be astonishing if serious heart disease or pulmonary tuberculosis did not affect the mind. But the interaction is by no means limited to grave disease, for it is seen with simple infections and accidental injuries which are remote from the nervous system. It appears, then, that the time-honored antithesis between mental and physical disease was founded upon ignorance and misconception. For all these reasons, the broadminded and well-trained physician gives consideration, both in diagnosis and in treatment, to mind and body together in every case which he undertakes. According to this view, mental illness means the mental aspect of sickness, which in some cases has its origin in the individual mind (or, in other words, is psychogenic), but often has other sources. Elaborate thought has been given to the classification of mental disorders, but the subject need not detain us beyond a broad and incomplete outline. One group consists of the mental diseases that arise out of injuries to the brain and nervous system as a result of infections (among which syphilis is notable), poisonings, accidents, or tumors; arteriosclerosis and senile deterioration are also associated with damage to the nervous system. It is noteworthy that, if arteriosclerosis were omitted, these diseases would not bulk very large in the whole field of psychiatry. The manic-depressive disorders and schizophrenia are interrelated diseases which involve the

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whole personality; they rest largely upon a hereditary basis. It is from these two groups that what is called insanity arises most often. Feeble-mindedness and mental defectiveness are mainly congenital, but partly hereditary, in origin. Lastly, we may group together for our purposes a large number of disorders under the term "neuroses and psychoneuroses," which will be characterized presently. The extent of the problem which mental illness constitutes is indicated by the fact that well over half a million persons are in hospitals and similar institutions because of it. They occupy more than half the hospital beds of the country. There is, of course, a much larger number of people who have mental disorders from time to time without being hospitalized. About 3 per cent of the men selected for examination for military service in 1940-41 were rejected for nervous and mental diseases (although high standards were applied, there is no ground for assuming that they were unreasonable). It has been estimated that 1.5 per cent of the adult population is incapacitated by mental illness at any given time; 2 per cent at some time in every year; and 10 per cent at some time in their lives. The estimated cost of caring for these unfortunates is one of those colossal values that defy realization: nearly eight hundred million dollars a year in all, including over two hundred million for mental hospitals. The situation is distressing, but there is no reason for dismay. It has sometimes been thought that

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mental disease has increased in modern times, although no data exist to prove the point. Statistics for recent times do not show an increase. We simply do not know what the situation was more than two or three generations ago. We do know that in the "good old days" many a family took entire care of one or more members with mental disease, even of grave nature, whereas such an effort is rarely made today. Minor illness was undoubtedly less realized, but it was none the less harmful to the sufferer and to those about him. Our attitude toward mental disorders is a matter of great consequence. We cannot ignore them. Primitive ideas have lasted longer in regard to mental disease than in any other field of comparable importance to human welfare. The imagined demonic origin of these troubles has left us more than a quaint idiomatic use of the word "possessed"; it has also left us the habit of attaching an ugly stigma to mental disease and to sufferers from it. In other ways we miss the point, for, misunderstanding the nature of bravery and truth, we label many as cowards and liars when they are really mentally ill, to mention only one sort of misconception. In short, if mental illness exists, the subject is a sick man, and the problem is to effect a cure, if possible. The material has long been available to show that repression (beyond that absolutely necessary for the sake of safety) and punishment are harmful, both to the unfortunate subject and to those who commit such follies. We

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must face the fact of mental disorder as a common human failing, learn all we can about it, and set about providing not only adequate care for those who suffer from it, but a society in which every possible means is used to prevent its development. The group of mental disorders to which reference is made under the heading "neuroses and psychoneuroses" is heterogeneous and far from representing a natural entity. These disorders involve abnormal reactions to situations and problems which life and society pose for the individual. The problems may be largely internal, though they have their origin in external relationships. The reactions in question are harmful in the long run to the subject and to some, at least, of those about him. A very simple example would be a man who found his job too difficult, and acquired incurable severe headaches instead of learning how to do his job better or getting a simpler job; or, in another direction, the deaf man who becomes convinced that his associates are constantly plotting to persecute him, because the isolation caused by his infirmity allows a tendency of his mind to take him off on that by-path; still another type is that of the man who, when he fails to receive promotion, instead of merely feeling discouragement, thinks of suicide, a reaction which is out of all proportion to the occasion. This· group of disturbances constitutes a large proportion of all mental illness. A great deal can be done to help those who suffer from these mental disorders, as well as to prevent

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their appearance.1 The war will affect mental health chiefly in this way, as we know by European experience in 1914-18 and 1939-41. The rest of this chapter will relate mainly to mental disturbances which come under this broad heading. The mental state of an individual depends upon his biological inheritance, his education and past experience — especially in social relations — the present situation in which he finds himself, and the future prospect as he sees it. The role of heredity in a general way is of great significance, but in regard to specific tendencies its place is less important than that of education and experience. It must be remembered that the separation of hereditary factors from parental influence in childhood is often impossible in the later life of an individual. The outstanding problems which we meet as we grow up and pass through life concern adjustments to other people and to the cultural pattern which we encounter. The relations within the family and with playmate and schoolfellow, and mental attitudes and behavior which develop in infancy and childhood, go far toward determining the mental reactions of the adult. (The psychological make-up of the family exceeds in importance its economic status.) The sexual instinct must be clearly recognized, and a realistic attitude must be achieved toward it; sexual activities must be assigned an appropriate role. There is no implication that medicine has nothing to offer patients with other forms of mental disorder. 1

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We are dependent on education (in the broad sense) to lay die foundation of interests about which life can be focused, from which we derive our feeling that life is worth while. Emancipation from parents must be achieved without the sacrifice of affection and mutual help in time of need. There is the need for self-support — a job to prepare for, obtain, and hold. Ambition — for money, for prestige, or for power — has to be reckoned with if it is in the endowment. A family is to be established and maintained. Provision for incapacitation due to sickness and old age must be made. Recreation and joy in life must find a place; many Americans, we are told, overdo recreations, do them badly, or choose poor recreations. Throughout all these activities, relations to others, especially to those in the immediate circles of the family, friends, and occupational associates, are of paramount importance. Upon the establishment of self-discipline, of balance between individual freedom and ties to others, of ability to manage others (including one's own children) and to submit to management by others, much depends. Rivalry may be healthy or troublesome. We should note that communication between man and man is often defective. Words are all too often our masters and fail to do our bidding; the evil consequences thereof are devastating. Physical disease is another category of risk which all must run; it may determine or condition mental illness. All adults have both endured and enjoyed, in varying proportions,

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lives of hardship and ease, simplicity and complexity; an infinity of relationships and adventures has played upon and molded their minds. Among the possible elements an observer would look for which might determine a person's mental order or disorder at any given time is a history of past mental illness, which indicates that recurrence is likely, though by no means inevitable. The observer would consider whether his subject had the esteem and affection of friends and family, as opposed to loneliness; trust or distrust in his community; capability or inadequacy, security or insecurity in his job, or unemployment, if there is no job; solvency and savings or indebtedness on the economic balance; acquiescence in or rebellion at his life; a quiet conscience or shame and guilt in the ethical realm; health or disease of the bodily organs. The individual's view of the future means much to him. The anticipation of difficulties and the calculation of possibilities are potent forces for mental disorder in many persons. Today we are all facing the added problems created by the war. Some of these are not unfamiliar: the economic changes with inevitable losses in the standard of living and uncertainty about the job; food shortages (of unprecedented degree); deprivation of luxuries and pleasures. Other wartime threats have new forms — forms of which few Americans can have had any past experience to guide them: obligatory family separations with the prospect of

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dear ones among the casualties of military or naval action; and the risk of direct attack by the enemy, with the possible loss of home and possessions, of grave bodily injury, and of death. We must be prepared to find the estimate of any of these situations or problems which is held by an individual to be quite other than the reality. For the moment, what matters to him is his own private view. The possible gains from illness must be mentioned: escape from difficulties, care and attention from others, support by family, friends, or community. Malingering, which is the conscious, deliberate feigning of disease, is not very common under most circumstances. It should never be assumed without proof or thoughtlessly charged against a person. On the other hand, people often take refuge unconsciously in physical illness in the face of troubles which are too great for their minds to cope with for the time being. When this occurs, the sufferer is mentally ill. He cannot be cured by a direct frontal attack on the symptoms which are substituted for his troubles. We should not think of this as a blameworthy state. The development of psychoneurotic or neurotic symptoms, or their failure to appear, depends in large part upon the relation between the individual's mental qualities and resources, in the broadest sense, and the magnitude of the problem or disturbance in his life which confronts him. When simple problems or minor disturbances bring forth mental disorders

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of this sort, we may be reasonably sure that there is something about the individual which sets him off from normal people, though the difference may not be very important. Psychoneurotic reactions to particular difficulties are not necessarily constant in an individual, since the personality may develop in such a way that a normal response appears in circumstances which previously evoked troublesome symptoms. At the other extreme, the severest shocks and prolonged trials may be associated with abnormal reactions of the type in question in persons who must be considered normal as far as can be told. Some of the ghastly experiences of war have been known to set up temporary mental disorders in men who never before or afterward showed the slightest trace of them. The manifestations of neuroses and psychoneuroses are legion. Nagging anxiety in general and persistent worry over particular troubles are perhaps the commonest mental states. Sufferers may be depressed or agitated; they are often full of complaints which vary from week to week, especially if superficial treatment is brought to bear on the symptom complained of. Irritability, tremor, headache, and sleeplessness are common. Poor concentration and memory, or "mental exhaustion," in both real and imaginary forms are found. The general reaction may be one of rebellion, acquiescence, or apathy. Pet fears without foundation (phobias), such as fear of germs or dirt, or particular foods or places, fre-

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quently develop. Prohibitions of harmless acts and compulsions to meaningless acts are among the mental phenomena which occur. It has already been mentioned that a great variety of bodily disturbances may serve as representatives of the mental disorder. Ordinarily these are relatively simple body symptoms, such as were mentioned above, but they may be highly complicated and bizarre. In every case in which the emotions are aroused there is bound to be some bodily reaction, since the group of nerves known as the autonomic system and the glands of internal secretion are put to their work of stimulating or inhibiting various bodily activities. These mechanisms are largely independent of conscious control, notably in their inception. In general they represent primitive reactions, which once served man well in the face of need. Civilized man occasionally finds them embarrassing. The instance of fear is discussed below. The dread of possible results of these mental and physical disorders is a heavy burden for many of the sufferers, who may fear impending "insanity." The mental disorder may be serious enough in itself, although very often indeed it would be unimportant could the whole situation be straightened out. As to the possible results, lasting physical disease can only be produced by strenuous or prolonged abuse or disuse of some part of the body, or by starvation. To date, no connection whatever is known between these mental disorders and the more serious mental diseases which may lead to "insanity."

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Man is naturally a gregarious being, and, as we have seen, his relations with his fellows always condition his mental state. Although we cannot speak of a group mind, groups of people share mental attitudes and reactions to a considerable extent, not only in panic states, but even in normal life. There is no doubt that this common bond is both comfortable and strengthening in many circumstances. In times of peace, however, there is much scope (at least in a democracy) for individual, class, and sectional differences over all the social and political issues which arise in modern life. Not since the Civil War have the people of the United States been so seriously divided as they were in 1940, when, moreover, there was not one issue, but a great number of points of difference. Thrust suddenly into a worldwide war, with powerful enemies on two sides of the country, having made almost no preparation, Americans are groping to find each other, searching for common ground, that they may unite and fight this gigantic battle together. It is obvious that the mental weaknesses which we have been discussing are serious handicaps, just as mental health is a priceless asset in this national effort. The mental disturbances which appear in wartime are essentially the same as those which occur in peace. The war of 1914-18 in Europe had very little effect on the development or course of serious mental diseases. British experience of 1939-41 has been similar. It has even been noted that patients with profound mental disturbances had a strong tendency

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to continue as they had been, without reference to the war, in spite of bombs and shells close at hand. Dr. R. D. Gillespie describes the case of a psychotic Englishwoman who passed undisturbed through the horrors of London in 1940 and, upon recovery, realized acutely that she has been "spared a great deal." Far more important are the reactions of the people at large. Although experience in the Spanish civil war ran to the contrary, mental collapse among the citizens of bombed cities was greatly feared in some quarters at the outbreak of the present war. In fact, however, serious psychoneurotic reactions in Great Britain have been few in number, and available facilities were more than adequate to care for the cases which developed. Apparently they have occurred as frequently in soldiers as in civilians, if not more often. Civilians, as compared with soldiers and sailors, have both advantages and disadvantages. Soldiers always have specified duties which may include facing almost certain death, but they are trained and disciplined, they act in groups, and they have recognized leaders. Civilians often have no specific duties, no definite leaders, and little or no protection, but they are in familiar surroundings with family and friends about them, and are free to seek safety wherever they can find it. According to the experience of Dr. F. Warden Brown, in an area of England exposed to heavy and prolonged bombing, psychoneurotic disturbances arising from air raids were much more common in

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men than in women (the ratio was three to five). Possibly the frequency and degree of exposure enters into this difference. It is well known that children (provided their elders keep themselves under control) and the aged suffer relatively little from fear of physical danger. Of eight thousand school children in Bristol, only 4 per cent had untoward reactions after severe bombing. In general, the wants and troubles of people play a larger role in wartime mental upsets than physical danger. Punch's irrepressible old lady said, "I wish we'd have the bombing again. It takes one's mind off the war." Although known psychoneurotic individuals are relatively likely to acquire symptoms as a result of wartime stresses, some patients are so immersed in their pre-existing neuroses that they are unaffected further, and some are even relieved of their symptoms by the social rearrangements which have to be made. It is notable that suicide decreases in time of war. The first impact of war creates a general state of anxiety. In such circumstances the suggestibility of individuals is heightened, so that group reactions are more frequent and more significant than they are in normal times. The emotion of fear is an acute representative of anxiety, which is aroused by an immediate threat of serious proportions, real or imaginary. An understanding of this reaction helps to control it, and anxiety as well. Fear is a signal to act immediately in the face of danger, a mechanism

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inherited for untold ages from the days when all men and women frequently encountered grave peril. Willy-nilly, the man whom fear strikes prepares for action.2 The emotion of fear pervades the whole field of consciousness and tends to suppress other mental activities. It is often precipitated by shrill noises like those of whistling bombs and vivid sights such as the lighting up of flares. Its beginning is sudden; its ending may be equally abrupt, or gradual. The onset of fear is favored by poor health, hunger, fatigue, indulgence or abuse, and idleness (especially forced inactivity) in the physiological sphere; by mental quiescence, mental fatigue, insomnia, brooding on fear, seeing fear in others, and remembering past fear in the psychological sphere. It is more frequent in loneliness, dull or oppressive weather, in unfamiliar surroundings, and in the dark. We immediately recognize in many of these circumstances the "fearful" associations of childhood, which we have thought to put behind us. In fear, there are interlacing series of mental and bodily changes. Under the influence of the sympathetic nerves, many physiological mechanisms are 1 must express my indebtedness in the characterization of fear to the vivid essay by F. Aveling, entitled, "The Emotion of Fear as Observed in Conditions of Warfare," in the British Journal of Psychology, XX (1929-30), 137-144 (October, 1929). The physiological changes are described by Professor W. B. Cannon in his well-known book, Bodily Changes in Pain, Hunger, Fear, and Rage (New York: D. Appleton and Company, 2d ed., 1929). 2

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abruptly altered. The hormones (stimulating or inhibiting secretions) of the adrenal, thyroid, and perhaps other glands take part in this process of mobilization. The heart speeds up and more blood is circulated per minute. The amount of sugar in the blood (chief source of energy in sustained muscular activity) is augmented by releases from the stores of the liver. The small branches of the windpipe in the lungs are dilated and respiration becomes faster and deeper. The salivary and gastric secretions and the movements of the stomach cease (the occasion is not one for dining). Sweat, and sometimes tears, pour out. The hair may "stand up," the pupils dilate, and the eyes become prominent. Muscular tension is heightened, and there is a tendency to assume a characteristic rigid posture. The attention is fixed. Thought, imagination, and judgment are typically quick. These reactions are not invariable, nor do they long endure in the forms just described. In extreme cases, there is a nauseous sinking feeling in the pit of the stomach, and the bladder and anal sphincters may open. Tremor and trembling are common. Instead of increased tension, however, there may be loss of muscular power, usually in the legs. In some instances, thought and judgment are retarded or clouded, and not accelerated. Complete loss of self-control (panic) or of consciousness may ensue. It was long ago pointed out by Professor Cannon, and others, that fear puts the body in a state of

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preparedness for action to be directed at the exciting agent. In a physiological sense, emotions point to appropriate actions. The bodily mechanisms go so far and no farther. The purposeful action which may be expected to follow cannot be automatic in the same sense as the preparation for it is. It must be decided by judgment and directed by will, although much of the action may have been memorized, as the result of past experience. The preparation takes but a few seconds (say ten or twenty). The action must begin promptly, whether it is to take advantage of the alert state, or to avert its progress toward incapacitation. It is to be emphasized that the object of fear may be in the outside world or in the mind of the subject. Furthermore, even if the source of fear is external, what matters is the content, form, and color in which it is perceived. Even the fear of fear may be demoralizing. Obviously, action in the face of fear may take one of several forms, all of which are appropriate in some circumstances: (1) the object of fear is attacked; (2) the subject runs away; (3) preparedness for action is turned to account in another direction; (4) the emotion may be suppressed. The more terrified a man is, the more audacious and powerful he becomes in aggressive action. "Courage" is much misused in reference to an objective quality, since the observer has no means of knowing what lies behind "courageous acts": there is no courage without fear.

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True courage is a useful virtue — a source of strength to him who possesses it and of inspiration to those who see it. One may interpret courage as the degree of potential in feeling between terror and composure which can be maintained in the face of danger. The penalty to be paid for lack of action or successful suppression of fear may be severe, since the natural end of the emotion in that case is incapacitation, which gives an active enemy just the chance he wants. If there is no hostile force to seize upon the man who is paralyzed with fear, he has still to settle with himself, for he finds he is more or less exhausted and distraught and often has a harassing sense of shame. Who has fear? Everyone, in some degree, before some type of threat. Renowned "fearless" soldiers often frankly disclose in their memoirs episodes when they knew fear. Indeed, the French writer Ardant du Picq, who lost his life in the Franco-Prussian War, showed that fear was the normal reaction in battle. All men and women share a capacity for fear in common. An untoward result of fear, as a rule, must have its explanation in the individual. There is no reason whatever for anyone to be ashamed of feeling, or reluctant to admit having, the primary manifestations of fear. When the occasion is fitting, the frank avowal of the emotion is helpful to many and makes for confidence between the members of a group. So much consideration is given to fear, partly be-

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cause we associate it strongly with war, and partly because through understanding fear we may better understand certain types of anxiety. Anxiety is a state we understand much less well; set at a different level, having a diffuse and chronic form, it nonetheless partakes of some of the characteristics of fear, the realization of which is shown by frequent vernacular confusion of the terms. Another psychoneurotic disturbance which appears when affairs are going badly is apathy — a potent ally for the enemy in time of war. This reaction was observed in some Londoners in 1940-41, when it was attributed especially to the disorganization of homes and of the daily routine of life. One can readily see how important all of these disturbances are to a nation at war. It was not until the war of 1914—18 that warring nations exercised careful forethought in regard to the psychological state of civilian populations. In the second World War, the nations on both sides realize acutely that civilian mental attitudes and reactions are as important as any other consideration. A population in which mental calm and vigor predominate has an enormous advantage over an enemy with less composure and mettle. Men and women in civil life who succumb to anxiety, fear, or apathy, whose doubts grow until they can no longer think or work effectively, are casualties as much as if they came crashing down to earth from aerial dog-fights. The psychological offensive which must be waged against our enemies does not come within our prov-

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ince, except in so far as mental health among us furthers our cause. The defense which must be tirelessly carried on is emphatically germane to our subject. The collective aspects of mental health, as manifested by morale, are discussed in the final chapter of this book. In the last analysis, however, the strength of the nation is determined by that of individual citizens. It is an outstanding task to find and develop strong men and women, as well as to discover and care for the weak. The elements which make for mental health are fundamental ingredients in the best kind of success at all times. When the nation is at war, they are doubly precious. Yet mental hygiene has been a neglected field. Treatment of the mentally ill was often literally barbarous until well into the nineteenth century. It is only a little more than a generation since the first tentative moves toward a program for mental hygiene were made in the 1890's. Not until 1907, when Mr. Clifford W. Beer published his moving account, A Mind That Found Itself, was widespread attention directed to the need for definite plans and action. Mental hygiene is thus the last field to be added to public health programs. It is still the least advanced. Public expenditure for the care of mentally incapacitated persons in this country amounts to forty times the sum spent for mental hygiene. Today we may well regret this neglect, but it will serve our needs better if we set

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about doing everything possible to maintain and improve mental health. The general conditions which are associated with mental health have already been discussed. Our inheritance we cannot change, but everything goes to show that the resultant individual is profoundly affected by education and experience. Physical health helps to preserve mental health. Proper food and sleep are fundamental. It will be recalled that there are indications that a deficiency of the Β vitamins is associated with psychoneurotic symptoms.3 A well-adjusted and satisfying home life lends much strength to the individual. America's great cities have many small families and many separate individuals who stand in great need of more social life. Our social life has shown no development which takes the place our churches have largely lost as community social centers. More Americans probably gather together in moving-picture theaters than anywhere else, but the contact has little, if any, value as social intercourse. There is a real need for simple, inexpensive clubs which are not dedicated to any religious, political, or economic purpose. War, as a common danger, has a tendency at the start to draw people together, not only in the general national sense, but in a more real fashion in small groups where they can feel, think, and act in common. Community singing, sewing, knitting, eating, and other 3 Readers are reminded that these vitamins should be in our food and not in pills.

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activities (as opposed to passive entertainment) are helpful. The air-raid shelters of London during the Blitzkrieg of 1940-41 did something more than afford protection from bombs, for many of those who went there found help and comfort in the human associations which spontaneously grew up. Under these circumstances there is a subtle transfer throughout a group of mental attitudes and reactions. Good cheer can and should be present even in times of severe trial. In their moments off duty, good soldiers are noted for their ability to joke and play. Civilians have no more reason for keeping up unremitting seriousness than their brothers under arms. There will be moments in the war when it would do us good to get "good and mad" at our enemies. Hatred, however, is an ignoble feeling, which will not serve us well; it leaves an aftermath, sometimes including a sense of guilt, which is likely to be embarrassing. The soldier going into bayonet combat must work himself into a rage; civilians who find themselves in any similar situation will have to do the same, but rage is not hatred. Rage, when action is not practicable, is weakening, instead of strengthening. Foolhardiness on the part of individuals has a bad effect on onlookers, as well as actors. On the other hand, "safety first" will win no war; it belongs at the street crossing and is not a motto for a belligerent people. Indecision, a characteristic psychoneurotic trait, is the worst of attitudes in the face of danger. The

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mental qualities which we need to build up are conviction that the enemy must be crushed and determination to do the job, confidence in our own success, and endurance in the struggle. By far the most important way in which an individual can influence directly his mental state lies through his job. This is a time for all Americans to take stock of their activities and be sure they have found a post for which they are qualified and in which they can busily take part in the national effort. Work as a member of a group, not only in appearance but especially in feeling, is most helpful, since mass interest lends everyone mental strength. Close contact with fellow workmen should be cultivated. Volunteer activities may be just as helpful as gainful labor, if the service fills a real need and measures up to technical requirements. It is important that work be purposeful, but interest is the touchstone of value for mental health. Between job and recreation there should be little time for vague rumination on the general situation, out of which anxieties and doubts are all too likely to grow. Confronted by actual fear, the individual finds his best solution in immediate action. Escape in command of self, if not of the field of strife, is not always to be despised, but strategic retreats are valuable only if danger passes. If the source of danger cannot be acted upon or is imaginary, the psychological and physiological energy of fear must be turned in another direction and drained away or, in some circumstances, simply suppressed. The

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longer the delay, the harder the control of the reaction. Any sort of shelter, even the flimsiest (including covering the face), reduces the intensity of fear. Physical activity and distraction of the attention are the most reliable antidotes. Conscious control of the respiration, instituting slow, deep, regular breathing, has been recommended. Most of us have experienced in childhood the relief that is obtained by whistling and singing. It seems that rhythmical movements are especially easy to start. Turning the mind to responsibility and specific duties opens a path of escape. Religious inspiration or a sense of shame may overcome fear; the effect of the thought of specific penalties is uncertain. The power of suggestion is at its height. Even the silent presence of others, or the sight of mascots and symbols of prestige, may turn the tide. Prompt treatment of early symptoms of collapse from fear may ward off serious consequences. Simple but effective measures are reassurance, removal to a place of obvious safety, and the application of warmth internally and externally. When a man puts down fear and goes through the experience which threatened him, he is likely to find that it was far less of an ordeal than he anticipated. Sir Philip Sidney said, "Fear is more pain than the pain it fears." 4 Familiarity with the actual risks which are involved, therefore, should moderate fear. 4

Quoted by Sir Walter Langdon-Brown in "Mental Health in War-Time," Nature, CXLVII (1941), 193-197 (February 1941).

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During the London air-raids many an escape was dramatized in the ordinary citizen's story of "my bomb," with benefit to others. Pessimistic doubters may ask whether we can really take hold of ourselves, ward off anxieties and fear, put ourselves into a better frame of mind, and get into action. It is certain, however, that everyone who is not seriously diseased can do something in this direction. All men have their limitations, but few of us live up to our abilities. Dr. T. A. Ross compares the effect of mental effort to that of the self-starter, which we use to get our automobile engines going. After the initial inertia is overcome, attitudes and actions which seemed impossible are maintained. We can often help one another over the hurdle. The potential mental strength of Americans is immense. Let each one of us bring to bear upon the heroic task in which we are engaged all the calmness, courage, and determination which we can command. Every citizen can make some effort on the psychological front. Above all, we must find each other and unite in common understanding, purpose, and fortitude as never before.

EPILOGUE MORALE AND THE SECOND W O R L D

WAR

ORALE is mental health in respect to stresses and strains in a given period and set of circumstances. It is, therefore, related to health as a whole. According to many definitions, good health does not necessarily mean good morale, but these conceptions are too nearly limited to physical aspects of health.1 The best of physical conditions by no means ensures good morale; neither does luxurious equipment or elaborate organization. As with mental conditions in general, profound knowledge and insight are required for the successful prediction of states of morale; rarely can one foretell with assurance when good morale will be present, or when it will take wings and depart. A high state of morale does not long endure when health is poor. In building morale, therefore, sound physical and mental health is an excellent investment. The morale of a group is determined by the reactions of the predominant members. It is not a social state which is independent of the individuals in the group. Morale which deviates significantly from the mediocre has

M

The Chinese, all of whom, from the American point of view, live a life of the utmost simplicity ("poverty-stricken," we call it), are ordinarily not so far from having the basic necessities as we think. This has some bearing on their magnificent morale. 1

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a strong tendency to evoke a similar state in persons with mediocre morale, or to strengthen a similar state if one already exists. Since the state of morale of a group is one of the main determinants of the power and significance of the group, the concept has great social value and we usually think of morale as a collective characteristic. Good morale means sound, well-directed mental health. It indicates confidence, enthusiasm, endurance, and team work in reference to some chosen goal. According to Professor Harold D. Lasswell, the surest test of high morale is "tenacity in the face of adversity." Indeed, good morale after a reversal suggests a return to the struggle with increased ardor. In terms of the war, it implies an active expression of a firm intention to win and a willingness to pay a high price for victory, even though it takes years to overcome the enemy. The importance of morale in fighting forces has always been recognized. Napoleon is said to have rated morale at three times the value of physical force. History tells of many campaigns and battles that bear out his judgment. The significance of civilian morale in time of war received little attention until modern times, and was perhaps not clearly realized until the first World War, when it became obvious that the civilian psychological state is of paramount importance in the production of arms and munitions and exercises a powerful influence on the morale of the armed forces. The Germans were

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the first to take concerted steps which showed that they understood how much good morale in the Fatherland and bad morale in enemy countries meant to their cause, but before the war ended, the Allies had made up for lost time. Soon after it was over, the Germans began to claim that they lost the war of 1914—18 because of a collapse of morale at home, which they attributed to the effect of President Wilson's Fourteen Points. In Mein Kampf Hitler expressly blames not only Jews but German women for stabbing the army in the back.2 Long before his advent to power, however, other Germans gave much thought to the problem, and wrote extensively on it. It was partly in this connection that great care was bestowed upon the health of German children in the 1920s — the children who are now the German army. In 1928 economic rearmament began and in the following year special psychological methods of training were introduced in the German army, but the leaders of the pre-Hitlerian Republic did not succeed in bringing their nation out of a condition of feeble morale: that was Hitler's contribution to the German state. After Hitler's advent, the use of psychological methods was greatly increased. Among the points which he stressed were the strength of a positive aim (as contrasted with 2 The memoirs of German generals show clearly that a military collapse was feared two months before the armistice was signed. It is related that the theory of the "stab in the back" was suggested to Ludendorff by General Sir Neill Malcolm in Berlin shortly after the armistice.

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the weakness of mere defense) and the significance of leadership. Great care was exercised in the selection of leaders, who were treated with unusual solicitude, as long as they served their purpose. The effect of Hitler's gift of high morale was so great that the five years from 1933 to 1938 sufficed to prepare Germany to make war on the world. In these short years Germany was changed from a bickering and ineffective state into the most powerful war machine in existence. Since the program which Hitler offered his people consisted largely of hardship, there could be no clearer demonstration of the power of morale. The speed of this change holds a special meaning for us who are among the prospective victims of this war, since in those few fateful years Hitler can only have given unity and direction to tendencies which must have been widespread and deep-seated before he became the national leader.3 We cannot do otherwise than believe that the Germans for the time being are off the path of social and political progress, that they are anti-social in a world sense. It is no mere superficial conclusion that many Germans are in a mentally disordered state much of the time — any Nazi rally shows that there is much in it. Our relations with the Japanese have many similarities to those with the Germans. The Japanese 3 It is not implied that warlike propensities or inability to live with other nations are inherent in the German people, except in this generation and those immediately preceding it, nor that all Germans are the same; but the proportion of Hitler's followers must be very large indeed.

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intend to spread to a whole hemisphere a social and political regime which is out of the line of progress. They have planned their campaign for at least a quarter of a century. They have been actively at work on it for ten long years. Their determination and confidence have been shown by the damaging surprise attack on Honolulu, while Americans were still so undecided as to be supplying them with munitions of war. Thus did the Japanese themselves close the debate. The mainspring of America's decision to go to war with these two peoples was her conception of the course which the future development of human social and political institutions should take, and her knowledge that the world is too small for her to go her own way, surrounded by aggressive national groups which are overwhelmed by the ambition to spread by force a different gospel. Furthermore, both the Germans and the Japanese have insistently stated their determination on national aggrandizement at the expense of other peoples. The new order of which they prate is compounded of a social and political regime which Americans find despicable and of international gangsterism. Americans could not stand by and watch the subjugation to Axis plans of the peoples of the world who share their ideals without joining with them in a general determination to eliminate this threat to human welfare. Germans and Japanese alike know that their world cannot exist in parallel with ours. They are

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at war with America, not to secure a peace of compromises, but to win a victory by which they expect to impose their will upon Americans. Our enemies have brought themselves to a state of supreme confidence in their success. Hitler looks for an easy victory, for he regards Americans as "soft." Did. he not say, "It will be an easy matter for me to produce revolts and unrest in the United States"? As for the Japanese, have they not told us that they will dictate peace in the White House? This struggle differs from many ancient and modern wars (which had a largely professional character) in that it is peculiarly a war of peoples. By their own declarations and by the record of their acts, we know that Americans everywhere, of all ages and all conditions, are the objects of enemy attack. Each one of us faces the possibility of injury and death from enemy action. Our immediate concern, however, is with the psychological offensive which the Germans long ago set on foot, and which the Japanese took up when the time was ripe. The like of this offensive has never existed before. It began, even against the United States, years before military operations were undertaken — in fact, almost immediately upon the coming into power of the Nazis. Hitler's methods of attack deserve thorough study by Americans. He has made no great effort to keep them secret, because he does not believe we are interested enough, or intelligent enough, to realize what he is up to. The Germans have made

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war a struggle of efficiency and morale. To them, air-raids are more significant for disintegration of morale than for material destruction. They counted on winning at least important phases of the war by psychological methods alone. No wonder, then, that huge sums of money and great ingenuity and effort go into psychological warfare, offensive and defensive. Civilians are especially exposed in this form of warfare. On the psychological front, the question is, whose neurotic tendencies will win out first? Or, better the other way around, whose mental strength is greatest? In order to achieve victory, every American must contribute a will to win. Apathy is hardly less harmful than defeatism. Germans and Japanese have both successfully completed many tasks which experts said could never be done. Let us, then, renew our acquaintance with the teaching of our copy-books that nothing is impossible. It has often been pointed out that, during the prolonged bombing and acute danger of invasion of their country, the British found it easy to sustain a vigorous and resilient reaction, but that such an attitude is much harder to maintain when the war is remote and impersonal. This lesson needs to be thoroughly learned, since our enemies have many irons in the fire and may purposefully postpone attacks on the cities of continental United States, in the hope that our ardor will cool off. It goes without saying that Americans will not think of surrender, but a sur-

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rendering tendency might insidiously develop under the guise of negotiations. Enemy propaganda may be counted upon to try this tack more than once. Let us remember Munich and Kurusu as symbols of over-much negotiation with present-day Germans and Japanese. In his campaign against the United States, as elsewhere, Hitler's general method, on the one hand, is to develop whatever pro-German sentiment can be found among Americans, and, on the other hand, to aggravate all the anxiety, disagreement, and indifference which can be unearthed in the country. His most important attitudes and moves are hidden behind a thin mask of spurious Americanism. In this psychological warfare, it is important for America to hunt out weak spots and to remove, if possible, the underlying causes of poor morale. The special objects of Hitler's attentions among Americans have been listed as follows: ( 1 ) churches, ( 2 ) educational institutions, ( 3 ) women's clubs, ( 4 ) the press, ( 5 ) radio broadcasting, ( 6 ) moving pictures, ( 7 ) industry and labor, ( 8 ) social clubs.4 Through these organizations, until the outbreak of war, German propaganda was spread to the best of the ability of Hitler's agents. Though some channels have dried up, the stream of mis-statements and false suggestions still runs on. 4 See Ladislas Farago, "The Morale Offensive against the United States," The Journal of Educational Sociology, XV (1941-42), 229-241 (December 1941).

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The favorite method of attack in German psychological warfare is to stir up trouble over racial problems. Little success has attended such efforts in America, but the campaign has dangerous possibilities. Social and economic differences are seized upon by the Germans for their own purposes — they may, indeed, be a source of weakness. Luxury and material welfare are not necessary for, and perhaps not even conducive to, high morale. Yet the roots of poor morale may often be found in social needs (including health), particularly if they are associated with a sense of unfairness and arbitrary discrimination. The Chinese are poor in available material resources, but on the whole rich in a feeling of sharing what they have. America's greatest danger arises from bickering groups, which persist in the pursuit of unessential and ill-timed objectives, in all sincerity, but in disregard of the havoc they work in the war effort. Hitler's listening posts strain their ears to catch the first faint whispers of new differences among us; all of the old ones are already carefully catalogued, and many of them have been effectively augmented by German effort. The rules America has adopted for the practice of democracy require us to expend time and energy of incalculable value on elections every two years. It is our misfortune that Hitler can turn even our legitimate political differences to his advantage. That there are isolationists left among Americans is certain, but most of us have realized that the world is round and

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small: the war which began in Manchuria in 1931 completed the circuit of the globe at Manila in 1941. As Hitler hoped to keep the United States out of the war until he had overcome Britain, so does he count on widening the splits between groups of Americans and between sections of the country. High morale has its origin among ordinary citizens. Its strength is found in street crowds, in shops and factories, on farms, and above all in homes. It is inseparable from the common culture of the people. War is a supreme test of the strength of the bonds which hold a nation together and of the ability of its citizens to unite for a single common purpose. The more homogeneous a people are, the easier the task of their leaders. This principle has been developed to a high degree by our enemies, perhaps following a natural bent in the psychological constitution of Germans and Japanese.5 It is not a principle which we would choose to follow in ordinary times. Harmony in social, economic, and political life means so much for victory in the war that differences which are not fundamental at present should be minimized or suppressed for the time being. Each citizen is in duty bound to abandon a good deal of his obstinate championship of pet causes, as well as his special dislikes and disapprovals, and to be more tolerant of those who do not see eye to eye with him — all provided that there Wilfred Trotter's book, Instincts of the Herd in Peace and War (1916), contains much that is pertinent to this discussion. 5

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is no sacrifice of the principles for which the country is fighting. There need be no fear that Americans will surrender the fundamental freedom of the individual; the nation will not permanently change its mental habits in the course of even five or ten years. The problem of welding Americans into a high degree of national unity and of preserving that unity, without the sacrifice of essential democratic principles, takes rank with the task of producing armaments, munitions, and food. Upon the success of these two undertakings depends America's future. We are more dependent upon leadership in times of peace than we realize, witness the acutely anxious months of 1931-32. In war, a leaderless nation must succumb, as France did only yesterday. The bond of trust between common citizens and those in authority, especially the national government, must be strong. To be effective, leaders and "morale builders" should be intimately associated with the groups which they seek to leaven. A successful leader is one that is known and trusted; his official quality is not over-prominent — indeed, an official status is not requisite. Americans do not take kindly to the fatherly, or to the "superior," type of leadership. We do not like our leaders to direct us, though we are used to regulation of processes and relations. We need widely scattered centers of guidance, with numerous local leaders selected from the communities in which they work. The various branches of

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Civilian Defense, and many private organizations, are gradually building up such a system, but there are too many agencies for separate purposes in each community for effective leadership. There should be no room in defense agencies for coteries of the well-to-do or specially privileged. Our leaders will find it best to make little effort to play upon our emotions (in the strict sense), for emotions are not long sustainable and tend to run in waves. If we are carried to a crest of exaltation, we run the risk of descending into a trough of disappointment. A campaign of hatred is clearly undesirable. One nation does not hate another: the only effect of such propaganda is to arouse further excitable individuals who already feel strongly. An attempt to drum up this sinister and ignoble emotion ought to be beneath us. The relations between national leaders and the people are maintained chiefly by the dissemination of news and by radio broadcasts of speeches. When a great movement like the war is on foot, our craving for news is intense. This appears to be a relatively modern development which grew out of the telegraph, but it is no longer novel, since the demand for prompt publication of news was insistent during the Civil War. The anxiety which arises when the nation is at war not only intensifies our craving for news, but also increases to a great degree our suggestibility. A condition of marked suggestibility is favored by relaxation, inactivity, doubt, and espe-

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cially by an exaggerated sense of dependence. Once important suggestions have been accepted, the process can be much more easily repeated, even with different material. When people are in such a state, scanty news readily acquires a false color, and rumors, of good news or bad, arise easily and spread rapidly, growing as they proceed from person to person and group to group. Even myths (elaborate fictions of impossible conditions or events), like that of the protecting angel of Möns in World War I, make their appearance. The degree of conviction which rumors and myths carry would be astonishing if we did not know that there is a psychological basis for the phenomenon, which at its worst is closely related to those of some forms of mental disease, especially hysteria. Reiteration is part of the technique of persuasion. The cloak of authority (in international matters, often that of the diplomatic or military "spokesman," or just "informed circles") may be used alternately with that of disinterestedness (as when Hitler uses "Radio Paris"). When propaganda runs rife, words tend to lose all meaning. A foreign correspondent in the Far East once related that a Japanese military spokesman, inveighing against the Chinese (with whom the Japanese at that time were actually, though not openly, at war), said that the Chinese were insincere in their dealings with the Japanese; they were always insincere, thoroughly insincere, perfectly insincere — "Would you say," interrupted one of his hearers,

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"that they are sincerely insincere?" "Ah, so!" said the spokesman, delighted with this perspicacity, "sincerely insincere." The Nazis put their knowledge of group psychology to full use in their daily efforts to make us give credit to false news, to spread dissension among us, to make us believe that America is weak, and even to create a sense of dependence upon them for the benefits of their new order (an aim which had at least a temporary measure of success in some circles ). It is not merely to obtain our admiration that the enemy would have us adopt a myth that his men and machines are invincible: he would have us believe that he controls our industry; that he has poisoned all our water; that he has annihilated most of our fighting forces; that he is just outside the harbor, or just around the corner.6 Rumors always relate to something out of sight, something beyond the immediate experience of all who share them. The cure for rumor and myth is twofold: a busy and welldirected mind, and prompt and reliable information. The native intelligence of Americans and their natural confidence in the future of their country should prove unfavorable to the development of Nazi propaganda, but we need to be wide awake to perceive Hitler's suggestions, since they are not labelled. A " The Nazis have also gone very far in building up a sense of invincibility among their own people, especially in soldiers, almost reminding one of the Boxers, who persuaded themselves that they were invulnerable. This is a dangerous course to over-run.

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general attitude of scepticism is not efiough, for the obvious reason that it is exclusively negative. The sickening twaddle of high-pressure advertising has brought Americans to a general state of scepticism toward all propaganda, but somehow the advertising still works, as does Hitler's propaganda, at least in some measure. The need for discrimination is illustrated by the fact that propaganda for democracy has sometimes been looked upon askance.7 The speed with which in modern times news reaches everyone and the remarkably convincing quality of certain human voices over the radio provide opportunities for mass reactions which might well fill a statesman with dread. There can be little doubt that the calamitous reaction to the economic conditions of the early 1930's in this country was enhanced by too much news in too brief a period, with inevitable suggestions of collapse. The American public has had the best news service in the world, including foreign coverage, since World War I. We cannot claim, however, that we have digested this rich supply to good advantage.8 There is no reason to fear that our news channels will dry up or that they will be filled with distorted material. The present unwillingness of Americans to believe in any atrocities, which is partly due to a reaction from the credulity displayed in 1914-18, is another illustration of lack of discrimination. 8 Far-Eastern developments during the past fifteen years were presented to the American public with unparalleled fullness, accuracy, and insight, yet the events of December 1941 took the nation completely by surprise. 7

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If we are confident of ourselves, we should be confident of our leaders and confident of the well-tried services that distribute news. We need rather to think of our individual ability to synthesize and evaluate our information. Our dependence upon news commentators is pathetic. One of the psychological difficulties which many Americans have found in the way of whole-hearted support of the United Nations in their struggle with the Axis Powers arises out of keen disappointment, and even bitterness, over the failure of civilized peoples to understand one another during the period which followed the war of 1914-18. Americans are happy in the possession of a strong streak of idealism. Our idealism, however, has had only a halting and imperfect projection into the realm of international relations. Until the first World War we had inadequate knowledge both of the greatnesses and of the limitations of other peoples. We are still lacking in understanding of and common feeling with other nations. The same can be said of all peoples. Hence, it is not truly remarkable that the world is divided. Hope for the future lies in further development of international relations. Those who view with uncertainty or suspicion our relations with other democratic nations have but little faith in mankind or in themselves. No significant effort to bring together great nations, not by conquest but by voluntary agreement, was ever made until the end of the first World War, less than a generation

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ago. That the effort then made failed is little ground for pessimism. In the sphere of business and industry, human capacity for cooperation has not kept pace with administrative and mechanical developments, yet we do not despair of economic life. So in the political world, man is still immature. Americans need faith in the future and confidence in their ability to mold it. During this war, if we have faith, we can think of the future welfare of America and of the peoples of the world. It is not worthy of Americans to value so highly the baubles and troubles of the present. Consider the boundless, sustaining faith of the Chinese in the future of their people! Forty centuries of continuous cultural history have not brought discouragement. Better understanding and closer relations between the peoples of the world require the preservation and strengthening of democracy. Democracy has lacked something of the courage of conviction. It has not been a sufficiently positive force to catch the imagination or fire enthusiasm. Some of the world's great peoples must achieve dynamic democracies in preparation for better international relations. A permanent association between nations must have its origin in a small group of peoples who have a measure of their cultures in common, and who find mutual understanding relatively easy. In this sense our relations with other English-speaking people are crucial. America's cooperation with Britain, the British Dominions, China, the Netherlands,

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and Russia — the formation of the United Nations — may lead to a higher type of international association than the world has yet known. Whether such an advance is achieved or not will be determined as largely by Americans as by any nation. Not so long ago warring nations hired mercenaries to fight their battles. Then came an era of conscription or selection of citizens for the armed forces, in the early days of which a man could buy himself out or find a substitute. In our generation, war has been pushed to the point at which all citizens must take part, sharing largely even the casualties of direct enemy action. Perhaps this total war in which nations no longer fight through representatives may be the last which world-conscience will tolerate. But before we can do any more than reflect on such a possibility, we must win this war. Americans must pull together with a singleness of purpose that brooks no interruption. As a united nation, America should put aside all suspicion, prejudice, and doubt, and work unfailingly with her allies, confident both of final victory in the war and of a better order among nations after it is over.

SUGGESTIONS FOR FURTHER READING Health books are legion. This list is selected for sound information, reliable advice, and stimulating comment. A few are not written for the general reader, but can be readily used for reference (these are designated by "Ref."). ADOLESCENCE Lloyd-Jones, Esther, and Fedder, Ruth, Coming of Age (New York: McGraw-Hill Book Co., Inc., 1941). Youth and the Future, The General Report of the American Youth Commission (Washington: American Council on Education, 1942). AGING Martin, L. J., and DeGruchy, Clare, Salvaging Old Age (New York: The Macmillan Co., 1930). Robey, W. H. (ed.), Health at Fifty (Cambridge: Harvard University Press, 1939). Steincrohn, Peter J., More Years for the Asking (New York: D. Appleton-Century Co., Inc., 1940). HOUSING Housing for Health, Papers Presented under the Auspices of the Committee on the Hygiene of Housing of the American Public Health Association (Lancaster, Pa.: Science Press Printing Co., 1941). Ref. Watson, Frank, Housing Problems and Possibilities in the United States (New York: Harper & Brothers, 1935). Wood, Edith Elmer, Introduction to Housing: Facts and Principles, United States Housing Authority, Federal Works Agency (Washington: Government Printing Office [1942]). Ref.

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INFECTIOUS DISEASES Councell, Clara E., "War and Infectious Disease," Public Health Reports, LVI (1941), 547-573 (March 21, 1941). Eberson, Frederick, The Microbe's Challenge (Lancaster, Pa.: Jaques Cattel Press, 1941). Nelson, Nels Α., and Crain, Gladys L., Syphilis, Gonorrhea, and the Public Health (New York: The Macmillan Co., 1938). Parran, Thomas, Shadow on the Land: Syphilis (New York: Reynal & Hitchcock, 1937). Prinzing, F., Epidemics Resulting from Wars, edited by Harald Westergaard (Oxford: The Clarendon Press, 1916). Smith, Geddes, Plague on Us (New York: Commonwealth Fund, 1941). Taylor, F. Sherwood, The Conquest of Bacteria: From Salvarsan to Sulphapyridine (New York: The Philosophical Library and Alliance Book Corp., 1942). Zinsser, Hans, Rats, Lice, and History (Boston: Little, Brown, & Co., 1935). MEDICINE AND MEDICAL SERVICES American Medical Association, Medical Care in the United States: Demand and Supply, Prepared by the Bureau of Medical Economics (Chicago: American Medical Association, 1939). Ref. Bradbury, Samuel, The Cost of Adequate Medical Care (Chicago: University of Chicago Press, 1937). Ref. Brown, Esther Lucile,. Physicians and Medical Care (New York: Russell Sage Foundation, 1937). Clendening, Logan, The Human Body (3d ed.; New York: Alfred A. Knopf, 1937). Davis, Michael M., America Organizes Medicine (New York: Harper & Brothers, 1941). Emerson, L. Eugene (ed.), Physician and Patient: Personal Care (Cambridge: Harvard University Press, 1929). Galdston, Iago, Progress in Medicine: A Critical Review of the Last Hundred Years (New York: Alfred A. Knopf, 1940).

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Millis, Harry Alvin, Sickness and Insurance: A Study of the Sickness Problem and Health Insurance (Chicago: University of Chicago Press, 1937). Newman, Sir George, The Rise of Preventive Medicine (London: Oxford University Press, 1932). Sigerist, Henry E., Man and Medicine: An Introduction to Medical Knowledge, translated by Margaret Gait Boise (New York: W. W. Norton and Co., Inc., 1932). Silverman, Milton, Magic in a Bottle (New York: The Macmillan Co., 1941). Smiley, Dean F., and Gould, Adrian G., Community Hygiene (3d ed.; New York: The Macmillan Co., 1941). Ref. Stern, Bernhard J., Society and Medical Progress (Princeton: Princeton University Press, 1941). Winslow, C.-E. Α., The Evolution and Significance of the Modern Public Health Campaign (New Haven: Yale University Press, 1923). MENTAL HEALTH Anderson, Camilla M., Emotional Hygiene: The Art of Understanding (New York: J. B. Lippincott Co., 1937). Bassett, Clara, Mental Hygiene in the Community (New York: The Macmillan Co., 1934). Bromberg, Walter, The Mind of Man: The Story of Man's Conquest of Mental Illness (New York: Harper & Brothers, 1937). Deutsch, Albert, The Mentally III in America: A History of Their Care and Treatment from Colonial Times (New York: Doubleday, Doran, & Co., Inc., 1937). Elkind, Henry (ed.), The Healthy Mind: Mental Hygiene for Adults (New York: Greenberg, Publisher, 1929). Gillespie, R. D., Psychological Effects of War on Citizen and Soldier (New York: W. W. Norton & Co., Inc., 1942). Ref. Landis, Carney, and Page, James D., Modern Society and Mental Disease (New York: Farrar & Rinehart, Inc., 1938).

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Menninger, Karl Α., The Human Mind (2d ed.; New York: Alfred A. Knopf, 1937). Ross, Τ. Α., Lectures on War Neuroses (Baltimore: The Williams & Wilkins Co., 1941). Ref. MORALE AND CIVILIAN DEFENSE Biddle, Eric H., Mobilization of the Home Front: The British Experience and Its Significance for the United States, A Report of the American Public Welfare Association (Chicago: Public Administration Service, 1942). Binger, Walter D., and Railey, Hilton H., What the Citizen Should Know about Civilian Defense (New York: W. W. Norton & Co., Inc., 1942). Childs, Marquis W., This Is Your War (Boston: Little, Brown, & Co., 1942). Dupuy, Col. R. Ernest, and Carter, Lt. Hodding, Civilian Defense of the United States (New York: Farrar & Rinehart, Inc., 1942). Farago, Ladisias (ed.), German Psychologic Warfare: Survey and Bibliography, Prepared by the Committee for National Morale (New York, 1941). Ref. "Civilian Morale," Journal of Educational Sociology, XV (1941-42), 193-256 (December 1941). "National Morale," American Journal of Sociology, XLVII (1941-42), 277-526 (November 1941). Strecker, Edward Α., Beyond the Clinical Frontiers: A Psychiatrist Views Crowd Behavior (New York: W. W. Norton & Co., Inc., 1940). Trotter, Wilfred, Instincts of the Herd in Peace and War (London: T. Fisher Unwin, Ltd., 1916). MOTHERS AND CHILDREN Aldrich, C. Α., and Aldrich, Μ. M., Babies Are Human Beings: An Interpretation of Growth (New York: The Macmillan Co., 1938). Aldrich, C. Α., and Aldrich, Μ. M., Feeding Our Old-Fashioned Children: A Background for Modern Mealtimes (New York: The Macmillan Co., 1941).

SUGGESTIONS FOR FURTHER READING

311

Eastman, Nicholson J., Expectant Motherhood (Boston: Little, Brown, & Co., 1940). Eliot, Martha M., Civil Defense Measures for the Protection of Children: Report of Observations in Great Britain, February 1941, Children's Bureau Publication No. 279 (Washington: Government Printing Office, 1942). Garland, Joseph, The Youngest of the Family: His Care and Training (Cambridge: Harvard University Press, 1932). Gesell, Arnold, et al., The First Five Years of Life: A Guide to the Study of the Pre-school Child from the Yale Clinic of Child Development (New York: Harper & Brothers, 1940). Gruenberg, Sidonie Matsner (ed.), The Family in a World at War (New York: Harper & Brothers, 1942). Rand, Winifred, Sweeny, Mary E., and Vincent, E. Lee, Growth and Development of the Young Child (3d ed.; Philadelphia: W. B. Saunders Co., 1940). Richards, Esther Loring, Behaviour Aspects of Child Conduct (New York: The Macmillan Co., 1932). Washburn, Ruth Wendell, Children Have Their Reasons (New York: D. Appleton-Century Co., Inc., 1942). NUTRITION AND DIET Borsook, Henry, Vitamins: What They Are and How They Can Benefit You (New York: Viking Press, 1940). Cummings, Richard O., The American and His Food: A History of Food Habits in the United States (Chicago: University of Chicago Press, 1940). Drummond, J. C., and Wilbraham, Anne, The Englishman's Food: A History of Five Centuries of English Diet (London: Jonathan Cape, 1939). Fishbein, Morris, The National Nutrition (Indianapolis: The Bobbs-Merrill Co., 1942). Orr, Sir John B., and Lubbock, David, Feeding the People in War-Time (London: Macmillan & Co., Ltd., 1940). Prentice, E. P., Hunger and History: The Influence of Hunger on Human History (New York: Harper & Brothers, 1939). Rose, Mary Swartz, Feeding the Family (4th ed.; New York: The Macmillan Co., 1940).

312

CIVILIAN HEALTH IN WARTIME

Sherman, Henry C., and Pearson, Constance S., Modern Bread from the Viewpoint of Nutrition (New York: The Macmillan Co., 1942). Starling, Ε. H., Oliver-Sharpey Lectures on the Feeding of Nations: A Study in Applied Physiology (London: Longmans, Green, & Co., 1919). Walworth, George, Feeding the Nation in Peace and War (London: Allen and Unwin, 1940 [New York: W. W. Norton & Co., Inc.]). OCCUPATION Elkind, Henry B. (ed.), Preventive Management: Mental Hygiene in Industry (New York: B. C. Forbes Publishing Co., 1931). Roethlisberger, Fritz Jules, Management and Morale (Cambridge: Harvard University Press, 1941). Ref. Vernon, Η. M., The Health and Efficiency of Munition Workers (London: Oxford University Press, 1940). Ref. POPULATION TRENDS Myrdal, Gunnar, Population, A Problem for Democracy (Cambridge: Harvard University Press, 1940). Population Trends and Programs of Social Welfare, Papers Presented in the Section on Population Trends and Programs of Social Welfare at the Eighteenth Annual Conference of the Milbank Memorial Fund Held on April 2 and 3, 1940, at the New York Academy of Medicine (New York: Milbank Memorial Fund, 1940). Reprinted from the Milbank Memorial Fund Quarterly, XVIII (1940), 189-221 and 345-402 (July and October 1940).

INDEX

INDEX References to tables are indicated by t following a page number and to footnotes by n. Abortion, in wartime, 153 Accidents, automobile, 16, 91, 208, 209; in homes, 121, 123; incidence, 155, 208; in elderly, 183; occupational, 208, 209, 213-215, 223224; and nervous disease, 265 Action, and fear, 277-280, 286-288 Aged, diet of, 31, 192, 193; numbers, 177-179; place in war, 180, 187, 188, 198, 202, 277; handicaps, 182185; diseases, 183, 192, 195, 196; social value, 186-189; assistance to, 188-190; communal life for, 191; hygiene, 191-196. See also Old age Agricultural workers, shortage, 72; death rate, 205; illness, 207. See also Workers Agriculture, development, 28; programs, 71, 77-79 Air, respiratory needs, 31, 37; sanitation, 129-132, 211, 212; pressure, 210 Air-conditioning, 132 Air-raid shelters, 116, 128, 285 Air-raids, casualties, 15, 22; blackouts, 16, 133; and children, 175; and aged, 188, 277; mental effects, 276, 288; German purpose in, 295

Alcoholic beverages, 193, 226 Allies, nutritional aid, 47, 48, 60, 63; common morale, 306. See also United Nations Altitude sickness, 210 American College of Surgeons, 246 American Medical Association, 50, 59, 236, 241, 242, 246 American Public Health Association, 113, 123 Amino acids, 31, 35, 41, 54 Anemia, 37 Animals, as disease spreaders, 84, 85, 87, 88, 97-99; sanitary control, 101, 102, 126 Anthrax, 213 Anxiety, 273, 277, 300; and Vitamin Bi deficiency, 36; differentiated from fear, 282 Apathy, 282, 295 Ardant du Picq, Charles, 281 Armed forces of United States, and venereal disease, 94, 108; immunization, 104; and exotic disease, 116; size, 201, 203; need of doctors, 237 Arteriosclerosis, 183; of the brain, 265 Ascorbic acid, see Vitamin C Automobiles, see Accidents Aveling, F., 278n

316

INDEX

Babies, see Children Bacteria, see Infectious diseases Bacteriological warfare, 114, 115 Beer, Clifford W., 283 Bends, 210 Beriberi, 35, 36 Bickering, and morale, 297 Biologic changes, and disease, 96, 99 Birth control, 150-152 Birth rate, 14, 19, 147-154 Blackouts, 16, 133 Blindness, night, 33, 34; syphilitic, 153 Blood pressure, 183 Bloomfield, J. J., 206 Blue Cross, 258n Body and mind, 264, 265, 272, 274, 278 Bombing, see Air-raids Breadstuffs, 29, 30, 40, 47, 55-60 Breast-feeding, 162, 163 Brown, F. W., 276 Brucellosis (undulent fever), 97, 213 Buildings, see Housing Butter, consumption, 30, 33; nutritional need, 54, 63, 64 Caisson disease, 210 Calcium, nutritional need, 31, 41, 50-51t, 158; sources, 54t, 67, 158; in enriched flour, 59 Caloric needs, 38-40, 50-51f; of mothers, 158; of children, 162; of aged, 192 Caloric value, of foodstuffs, 39n

Cancer, possible vitamin relation, 37; in the old, 183; early treatment, 195; coal tar, 212; and mental disease, 265 Cannon, W. B., 279 Carbohydrates, 31, 39n, 54, 164. See also Sugar Carbon dioxide, 131 Carbon monoxide, 131 Carnegie Foundation, 236 Carriers of disease, human, 109. See also Vectors Census, see Population Cheese, 54, 63 Child labor, 173, 174, 200, 202, 217 Children, national significance, 19, 20, 146, 176; nutritional needs, 39, 50-51i, 162-164, 166, 167; diseases, 120f, 153-156, 167-169; proportion of boys to girls, 148; illegitimate, 150; rearing, 151-152, 201; effect of mother's nutrition, 157-159; per cent of population, 161, 178; growth, 161, 162, 170173; and war, 165, 166, 174-176, 277; medical care, 169, 170; nurseries, 173, 174; federal health agencies, 245. See also Infant mortality Children's Bureau, 23; charter for wartime, 176 China, war losses, 15; diet, 62; absence epidemics, 116; respect for age, 188; morale, 289n, 297, 305 Chlorination, 100 Cholera, 12, 87, 98, 100, 104

INDEX Churchill, Winston, 198 Civilian defense, 22, 203, 239, 250, 299, 300 Civilians, role in modem war, 5, 15, 18, 285, 294; compared to military, 276; psychological warfare, 295 Climate, and clothing, 142, 143 Clinics, see Hospitals; Medical service Clothing, 141-145, 215 Cod liver oil, 164, 166. See also Vitamin D Colds, common, 95, 102, 113, 207 Communal activities, 284, 285; eating, 69, 220; living, 191 Communicable diseases, see Infectious diseases Confidence, 82, 105, 113, 114, 169, 304 Contagious diseases, see Infectious diseases Costs, vitamins, 52, 53; diets, 61, 69, 76-78; housing, 136; clothing, 144; living, 204, 205; industrial accidents, 213; medical care, 255-257; mental illness, 266 Cotton, 143, 144 Courage, definition, 280 Crowding, disease, 11, 102, 120, 126, 127; children, 172; accidents, 213 Cults, health, see Fads Dairy products, 62-65 Death, significance, 197 Death rate, 19; in war, 13, 14; from infectious diseases, 91; maternal, 153; infant, 154;

317

childhood, 181; by occupation, 205, 206; compared to illness rate, 206; from accidents, 208 Defeatism, 36, 295 Deficiency diseases, 27, 38. See also Vitamins Delousing, see Lice Democracy, and morale, 305 Denmark, maternal death rate, 19; Vitamin A experience, 33; syphilis control, 153, 154 Dental care, 152, 156 Dentists, number, 235f Dependence, and morale, 301 Dermatitis, occupational, 212 Diets, changes in, 28-30, 49, 55; caloric needs, 38; present-day, 40-41, 47, 81; variety in, 49, 52; daily allowances, 50-51f; choice of, 52, 67-71; sources of nutrients, 54t; deficiencies in, 55, 60, 63; in pregnancy, 157-159; of children, 162-167; of aged, 192, 193; of workers, 219, 220. See also Nutrition Diphtheria, 90, 92, 93, 102, 104, 120, 167, 168 Disease, sources, 9t; effect on dietary needs, 39; eradication, 91; control, 92; reportable, 106. See also Accidents; Aged; Children; Death rate; Deficiency diseases; Illness; Infectious diseases; Malnutrition; Maternity; Mental disease; Occupation; and names of diseases

318

INDEX

Disinfection, 100-102, 110, 112 Disinfestation, 101, 102, 126 Doctors, patient relationship, 170, 230, 258; group practice, 231, 253; specialists, 233, 242, 252; number, 235f, 237, 238; unlicensed, 235n; women, 237; hospital relationship, 248, 249, 260; private practice, 252, 253, 258; distribution, 253, 254; income, 254, 260. See also Medical profession; Medical service Drugs, 111, 112, 232, 241, 245, 251, 252 Dust, 131, 211, 215 Dysentery, 11, 84, 87, 92, 93, 100, 111 Ear, 133 Edema, war, 34, 35 Education, nutritional, 70, 71, 81; venereal disease, 95; sanitation, 100; personal hygiene, 113; old age, 186, 189, 191, 192; workers' safety, 222; professional medical, 229, 236, 237; lay medical, 261; and mental growth, 270 Employed, in 1930, 200; in 1940, 201; illness among, 207. See also Occupation; Workers Employment, see Occupation Encephalitis, 85, 95, 97 Energy, sign of health, 6, 7, 263; diet as source, 38, 39; blood sugar as source, 279 Enrichment, flour, 56-60; but-

ter, 63-64; sugar, 67; salt, 68 Entertainment, 226. See also Recreation Environment, share in disease, 9f Epidemics, historical, 9-13; definition, 84; recent, 92, 93; World War I, 96; World War II, 114, 116, 128, 169 Epidemiology, 232, 233, 243 Evacuation, of children, 175 Excreta, 85. See also Sewage Exercise, 195, 225, 226 Eye, 132, 133 Factory hygiene, see Occupation Fads, health, 41, 76, 261 Families, decline in size, 17, 184; number in America, 201, 202; war breakup, 202, 203, 271, 282; and mental growth, 269 Fatigue, and Vitamin Bi deficiency, 36; and accidents, 214; and efficiency, 216; and fear, 278 Fats, 31; caloric value, 39n; sources, 54f; enrichment, 64 Fatty acids, 31 Fear, 10, 277-282; purpose, 277, 279; description, 278, 279; results, 280; victims, 281; overcoming, 286-288 Feeble-minded, 266 Feeding, infants, 162, 163 Fire hazards, 123 First-aid, 203, 221, 223, 239 Flies, 126 Flour, purification, 29, 40; place in diet, 55; whole-

INDEX wheat, 55-60; British "national wheatmeal," 56; enriched, 58, 59; standards, 59t; production, 59 Food, wartime supply, 16, 7176; a war munition, 24, 25, 45-47; mass production, 29, 30, 79; sanitation, 29, 30, 32, 100, 101, 126, 245; caloric value, 39n; waste, 44, 80, 81; synthetic, 52, 53; imports, 66, 71; cost, 69, 72, 73, 166, 167; control of production and distribution, 76-82; source of disease, 85; protection, 100, 101, 126, 245. See also Nutrition Food and Drug Administration, 59 Food and Nutrition, Committee on, 48-51, 58 Food Habits, Committee on, 48, 70 Fortification, see Enrichment Fortuyn, A. B. D., 197 France, losses in 1914-18, 14, 15; nutrition since 1914-18, 45, 46; birth rate, 147; population loss in 1914-18, 148; lack of leaders, 299 Fruit, 30, 54f, 60, 61, 164, 166 Gardens, vegetable, 60, 61, 194 Gastro-intestinal diseases, 100; incidence, 121, 206, 207. See also Typhoid; Dysentery Geriatrics, in National Health Institute, 188. See also Aged; Old age

319

Germany, losses in 1914-18, 13, 14; nutrition in 1917-18, 25-27, 33-35; production of vitamins, 45; nutrition since 1914-18, 45, 46, 53; tuberculosis, wartime incidence, 88, 89f; drug control, 112; housing, 137; clothing study, 143; birth rate, 147, 148, 153; child-growth program, 165; industrial food ration, 220; morale, 290-295, 298; psychological warfare, 291, 294-298, 302 Gesell, Arnold, 162, 171 Gillespie, R. D., 276 Glucose, 31, 54i. See also Sugar Gonorrhea, sulfonamides, 111. See also Venereal diseases Great Britain, losses in 191418, 14, 15, 88, 89, 165; wartime health, 19, 116, 168; nutritional problems, 45-48, 56, 60, 64; communal eating, 69; food rations, 74, 75, 166, 167; clothing rations, 145; birth rate, 147, 148; infant death rate, 155; nurseries, 172, 173; war workers, 202, 217, 227; medical services, 250-252; mental illness, 275-277 Gregariousness, of man, 218, 219, 275, 284, 285 Group mind, 275, 284 Group morale, 289, 290 Growth, of children, 35, 39, 161, 164-167, 173 Handicrafts, 194 Hatred, 285, 300

320

INDEX

Hazards, occupational, 209214 Health, tested by war, 3, 4; definition, 5-7; national, 7; creative, 8, 169; state of American, 19-21; victory by, 21; and morale, 289, 297 Health agencies, local, 242, 244; federal, 188, 244, 245; state, 243, 244 Health insurance, 258 Heat cramps, 210 Heredity, share in disease, 91; longevity, 196; mental health, 266, 269, 284; of primitive reactions, 274, 278 Hill, Leonard, 142 Hitler, Adolf, 291, 292; quoted, 294 Hoarding, 74 Home, see Family; Housing Home accidents, 121, 123, 208 Home medical services, 252, 253, 255 Hospitals, growth, 231; personnel, 235f, 236, 248; volume of service, 246, 247; control, 247, 249; distribution, 248; war functions, 249-251; insurance, 258. See also Medical service Hosts, of disease, 84, 102 Hours, work-day, 215-218 Housekeeping, 134, 201 Housing, and health, 102, 119123; needs and program, 118, 119, 127, 136-141; safety, 123; sanitation, 124128, 214, 215; physiologic needs, 128-134; psychologic needs, 134-135; slums, 134-

135; costs, 136; compared to nutrition, 138, 139; crowding and children, 172; factories, 214, 215 Humidity, 129 Hygiene, see Aged; Children; Diets; Exercise; Immunization; Maternity; Mental hygiene; Occupation; Personal hygiene; Recreation; Sleep Illegitimacy, 150-151 Illness, of workers, 21, 206208; and crowding, 120f; rate compared to death rate, 206; sexes compared, 207; minor, 208; change in, 232, 234; insurance, 258. See also Disease; Medical care Immunity, natural occurrence, 85, 86, 167; definition, 104 Immunization, discovery, 86; specific diseases, 90, 103, 104; desirability, 104-106; of children, 168, 169 Income, effect on diet, 41, 42, 69, 72, 73, 77; and housing, 120, 121, 136-139; and medical care, 240, 248, 255257; of physicians, 254 Industry, see Occupation; Workers Infant mortality, 19, 154, 155 Infants, see Children Infectious diseases, definition, 9, 83, 84; in wartime, 1013, 83, 87-90, 96, 100, 109, 114-116; transmission, 84, 85, 97, 102, 109, 113; susceptibility, 85, 86, 103; control, 86-117; share in death rate, 91; changes, 96-

INDEX 99, 233, 234; immunization, 103-106; reporting, 106108; isolation, 108-111; treatment, 111, 112; personal hygiene, 112-114; morale, 116, 117; housing, 124-128; children, 155, 167170; occupational, 207, 208, 213; mental disease, 265 Influenza, 12, 14i, 95, 96, 102, 207 Injuries, see Accidents Insanity, 266, 274. See also Mental disease Insects, see Animals Institutionalization, children, 150; aged, 185, 191 Insurance, health, 258, 259 Iodine, 31, 37, 68 Iron, 31, 37, 50-51i, 54, 59, 62, 158, 163 Isolation of patients, 109-111, 169 Isolationism, 297 Italy, birth rate, 147, 148 Japan, bacteriological warfare, 114, 115; as enemies, 292294, 298 Jolliffe, Norman, 34, 55 Kala-azar, 98, 99, 111, 112 Labor, see Occupation; Work; Worker Langford, J. C. C., 191 Language, inadequate, 270; distorted, 301 Lasswell, Η. D., quoted, 290 Leaders, morale, 298, 300 Leprosy, 92, 109

321

Lice, as disease spreaders, 85, 87; delousing, 102, 126 Licensure, medical, 240 Life, stages, 181 Life expectancy, 19, 178, 179, 196, 197 Light, need of, 132, 133, 213, 215 London, air-raid losses, 15, 22 Longevity, see Life expectancy; Old age Lusk, Graham, 27 Luxuries, 205; and morale, 297 Malaria, 85, 93, 102, 111, 112 Malingering, 272 Malnutrition, 9, 11, 13, 17, 20, 21, 25-27, 35, 38, 43, 44, 45, 156-158. See also Nutrition Manic-depressive disorders, 265 Man-power, 176, 197, 198, 201-203; loss due to illness, 206; loss due to accidents, 213, 223, 224 Margarine, 64 Marriages, war, 147, 150, 151 Maternal mortality, 19, 152, 153 Maternity, national significance, 19, 20, 146, 150-152, 159, 201; nutrient needs, 39, 50-5If, 157-159; diseases, 152-155; hygiene, 159-161, 245; occupational disability, 207, 208 Mayo Clinic, 36, 253 Measles, 104, 169 Meat, 54, 65, 192, 245. See also Proteins

322

INDEX

Medical care, of children, 169, 170; of mothers, 151-153, 160, 161; of aged, 195, 196; of workers, 221-223; of mentally ill, 266, 267 Medical profession, tradition, 229-231; changes, 231-234, 260; quality, 236; control, 240, 241; organization, 241, 242. See also Doctors Medical research, 24, 79, 80, 231, 239 Medical schools, 235-239; cost, 256n Medical service, need of changes, 228, 229; personnel, 234-236; wartime problems, 237-240, 250, 254, 255; types, 242, 252; future, 254, 257-260; costs, 255, 256. See also Doctors; Hospitals; Public health services Medicines, see Drugs Meningitis, 84, 95, 102, 111 Mental disease, public health services, 243; hospitals, 247; nature of, 264-269, 272274; incidence, 266, 267; and war, 269, 271-273, 275277, 282; and Germany, 292 Mental growth, 161, 170, 171, 269-271 Mental health, definition, 262264; basis, 269-271, 275; and morale, 283, 289. See also Morale Mental hygiene, in old age, 182, 183, 185-187, 189191; on the job, 218, 219, 227, 286; among disabled

workmen, 224; development, 232, 283; needs, 284288 Metabolism, 30, 39. See also Caloric needs; Nutrition Metropolitan Life Insurance Company, 176, 208 M'Gonigle, G. C. M., 81 Micro-organisms, disease, 83 Midwives, number, 235f Migration, 11, 12, 17, 96, 97, 108 Milk, 32, 54, 62, 63, 101; American consumption, 30; solids, 58, 67; sanitation, 100, 126; in pregnancy, 158; mother's, 162, 163; for children, 164, 166 Mind, definition, 262; and body, 264, 265, 272, 274, 278. See also Mental disease; Mental growth; Mental health; Mental hygiene Minerals, nutrients, 31, 60, 62, 65; loss of, 32, 55; and Vitamin D, 38; in pregnancy, 158; in childhood, 163; in old age, 193. See also Calcium; Iron; Iodine; Salt Miscarriages, 152 Morale, 22, 70, 289-306; against infection, 116, 117; and housing, 139; children's, 174, 175, 277; elders', 188, 277; and the job, 218, 219, 227, 286; Chinese, 289; defined, 289, 290; military importance, 290, 291; German, 290-292, 294, 295; Hitler's view of American, 294; trial in war, 294-298, 302-306; sources, 298; leaders, 299;

INDEX and news, 300, 301. See also Mental hygiene Morbidity, see Disease, Illness Mortality rate, see Death rate Mosquitoes, as disease spreaders, 85, 93, 101; protection against, 102, 126 Mountain sickness, 210 Munition industry, 201, 214 Myrdal, Gunnar, 151 Myths, 301, 302 National Health Survey, 119, 121, 152, 155, 168, 208 National Housing Agency, 24, 137, 140 National Research Council, 23, 43, 48; table of nutrients, 50-51* Nature, curative power of, 8 Negroes, diet, 42; venereal disease, 94; housing, 136; medical care, 153 Nephritis, 183 Netherlands, 305; tuberculosis, wartime incidence, 89f Neurasthenia, see Psychoneuroses Neuroses, see Psychoneuroses New Zealand, infant death rate, 154 News, and morale, 18, 300, 301, 303 Niacin, 31; and pellagra, 36; nutritional need, 50-51i; in enriched flour, 59 Nicotinic acid, see Niacin Noise, 133, 134 Nurseries, 172, 173 Nurses, factory, 221; number, 235f; hospital, 248; shortage, 255

323

Nursing, infant, 162-163 Nursing profession, tradition, 229; students, 235-238 Nutrition, health role, 9, 27, 45-48, 103, 165, 233; scientific basis, 18, 28, 49, 52, 53, 79, 80; good, defined, 26; physiology of, 30, 31, 38-40; war plans, 48, 49, 56-82; compared to housing, 81, 138, 139. See also Diets; Food; Malnutrition; Obesity; Vitamins Obesity, 9; in war, 27, 76; in elderly, 192 Occupation, share in disease, 9, 10; definition, 199; peace versus war, 199-204, 214; and health, 204-209; and disease, 209-213; and accidents, 213, 214, 223, 224; and hygiene, 214-223. See also Workers Odors, atmospheric, 131 Office of Civilian Defense, 22 Office of Defense Health and Welfare Services, 23; Division of Social Protection, 108 Old age, our ignorance of, 179, 180; nature of, 180-184; education for, 189; prolongation of, 196, 197. See also Aged; Death Orphans, 150 Orr, Sir John, 27 Osier, Sir William, 111 Oslo cold meal, 70 Osteomalacia, 34 Overheating, 210 Owen, Robert, 216 Oxygen, 31, 37, 131, 210

324

INDEX

Panic, 279 Pearl, Raymond, 14 Pellagra, 36, 42 Pensions, 185, 190 Personal hygiene, 112, 113, 191, 219 Phobias, 273 Physicians, see Doctors Plague, 12, 84, 97, 98, 104, 109, 115 Plumbing, see Toilets Pneumonia, 84, 91, 95, 102, 111, 120, 183, 207 Poisoning, 9, 211-213, 265 Poliomyelitis, 95, 102, 155 Politics, and public health, 243, 244 Population, and war, 13, 147; trends, 149-151; age distribution, 161, 177-179, 197; sex division, 200; employed, 200f; ratio of doctors to, 237; census, 244 Posture, working, 218 Potatoes, 54, 61, 62 Pregnancy, see Maternity Premature birth, 152 Preventive medicine, 111, 232, 233. See also Hygiene; Sanitation; Public health services Prices, see Costs Priestley, J. B., quoted, 227 Primitive reactions, 274. See also Fear Privacy, 135 Privies, see Toilets Professional workers, death rate, 206; illness rate, 207. See also Workers Propaganda, 303. See also Psychological warfare

Prostitution, 108 Protective foods, 166. See also Vitamins Proteins, physiological role, 31, 32, 35, 37; caloric value, 39n; nutritional need, 5051f; sources, 54t, 62, 67, 158; dietary importance, 65; in pregnancy, 158; in childhood, 163; in old age, 193 Psychiatry, 232. See also Mental disease; Mental growth; Mental health; Mental hygiene Psychological warfare, 16, 294-298, 302; German, 282, 283; America's handicaps, 297, 298, 303, 304. See also Morale Psychoneuroses, development, 36, 114, 264-266, 272, 273; in pregnancy, 159; among aged, 185, 186, 192; nature and signs, 268, 269, 273, 274; wartime significance, 275, 276, 295 Public health services, 8, 242246; and control of infectious disease, 12, 99; personnel, 235i; extension, 257-259 Puerperal infection, 153 Purification, foods, 29, 40 Quarantine, 108-109, 244 Quinine, 112 Rabbits, and tularemia, 97, 213 Rabies, 84 Racial problems, morale, 297 Radio, distracting effect, 17, 18; broadcasts, 300, 303

INDEX Rage, 285 Rat-bite fever, 97 Rationing, food, 66, 73-76, 166, 220; clothing, 142, 145 Rats, see Animals Rayon, 144 Recreation, 218, 225-227, 285 Refrigeration, 30, 126, 131 Rehabilitation, aged, 194; disabled worker, 223, 224 Relapsing fever, 85, 87, 88 Reservoirs, of disease, 84; water, protection, 101 Resistance, to disease, see Immunity Respiratory diseases, 210-212; transmission, 102; and crowding, 120, 127; in children, 155; incidence, 206, 207. See also Pneumonia; Tuberculosis Rest, in old age, 194; from work, 218 Restaurants, 69, 70, 220 Retirement, 179, 181, 189 Rheumatic diseases, 95, 102, 120, 155, 169, 207, 210 Rhoads, C. P., 37 Rhythm, in work, 218; in fear, 287 Riboflavin, see Vitamin B 2 Rickets, 34, 163. See also Vitamin D Rockefeller Foundation, 236 Ross, Τ. Α., 288 Rotterdam, air-raid losses, 22 Rubner, M., 26 Rumors, 301, 302 Rural districts, diets, 43; sanitation, 100, 123-125, 127; housing, 123; medical care,

325

152, 160, 168, 170, 248, 254 Russia, 47, 306 Safety directors, 221 Safety first, 285 Salt, and physiological balance, 210; for workers, 220 Sanatoriums, see Hospitals; Tuberculosis Sanitary engineering, 232 Sanitation, see Air; Animals; Disinfection; Food; Housing; Rural districts; Sewage; Urban districts; Water Scarlet fever, 104, 169 Schizophrenia, 265 School hygiene, see Children Science and medicine, 231 Screening of houses, 102, 126 Scurvy, 34 Selectees, health, 20-21; syphilis among, 94; mental illness among, 266 Self-discipline, 270 Self-medication, 208, 251 Senescence, see Aged; Old age Serums, see Drugs Servants, loss of, 134; illness rate, 207 Sewage, 85, 100, 101, 124, 125. See also Toilets Sexes, wartime distribution, 147; birth ratio in wartime, 148 Sexual life, 7, 113; in wartime, 150, 151; of elderly, 182; development, 269 Sherman, H. C., 55, 61, 80 Sickness, sec Illness Sidney, Sir Philip, quoted, 287

326

INDEX

Silicosis, 211 Silk, 144 Sirams, Henry S., 183n Skin irritants, 212 Sleep, quarters for, 126, 127, 135; needs of young, 171; needs of aged, 193 Slums, 135, 136, 138, 139 Smallpox, 84, 90, 92, 93, 104, 105, 168 Social changes, and disease, 97, 99; and aged, 184; and medicine, 234, 260 Social diseases, see Venereal diseases Social life, and mental health, 263, 284; and morale, 297 Social services, need for, 24 Socialized medicine, 259, 260 Society, vulnerability of, 17, 18 Soybeans, 61, 62 Spray infection, 102, 113 Starch, see Carbohydrates Starling, Ε. H., 25 Statistics, health, 13, 233. See also Birth rate; Death rate; Population, etc. Sterilization, see Disinfection Stiebeling, Η. K., 54t, 73 Stillbirths, 152, 153 Stimulants, 193, 226 Sugar, purification, 29; consumption, 30, 39, 66; as nutrient, 40, 54, 66; enrichment, 67; wartime supply, 67; rationing, 67, 74, 75; mobilization in fear, 279 Suggestion, power of, 287, 289, 290, 300 Suicide, 277 Sulfonamides, 111, 232

Sunlight, 132. See also Vitamin D Surgical appliances, value, 251 Sweden, maternal death rate, 19; syphilis in, 94, 95; housing, 137 Syphilis, transmission, 84; incidence, 94, 95, 245; change in, 96; case-finding, 106108; treatment, 111; in mothers and children, 153, 154, 160; in industry, 222; of brain, 265 Taste, role in dietaries, 29, 30, 65, 67, 70, 71 Temperance, 193, 226 Temperature, of houses, 129, 130, 131; and clothing, 141145; and industrial health, 210 Tetanus, 84, 104, 168 Thiamin, see Vitamin Bi Thomdike, E. L., 186 Tobacco, 193 Toilet articles, as source of disease, 113 Toilets, 121, 219. See also Sewage Total war, 4, 177, 306 Trailer camps, 118 Transmission of disease, 84 Treatment, new methods, 19; of infectious disease, 111112. See also Medical care Tuberculosis, 84, 88, 91, 93, 96, 102, 110; mortality table, 89; incidence, 1940, 89, 115, 116, 156; and crowded housing, 120i; and silicosis, 211; and public

INDEX health, 243; hospitals for, 247 Tularemia, 97, 213 Typhoid fever, 84, 86, 87, 92, 100, 104, 109, 121, 126 Typhus fever, 85, 87, 88, 96, 97, 98, 104, 115 Undulent fever (brucellosis), 97, 213 Unemployed, in 1940, 202; illness in, 207; rehabilitation, 223, 224 United Nations, future significance of, 305, 306. See also Allies United States Department of Agriculture, 24, 48, 60, 72,

122

United States Public Health Service, 23, 245; and quarantine, 108 Urban districts, diets, 41; sanitation, 100, 124, 125, 127; building codes, 123; medical care, 152; hospitals, 248 Urbanization, 10, 17, 28, 184; and mental health, 263 Vaccination, see Immunization Vectors, disease, 85, 102 Vegetables, consumption, 30; value, 54, 60-62 Venereal diseases, 84, 94, 95, 107, 108, 245. See also Syphilis Ventilation, 102, 130-132, 215 Vigor, as sign of health, 6, 7; role of food, 31; mental, 263 Viosterol, see Vitamin D Vision, role of Vitamin A, 33, 34; protection, 132, 133

327

Vitamin A, 31; functions, 33, 34; deficiency, 34; amounts needed, 50-5 l i ; supply, 53; source, 54f, 63 Vitamin Β group: deficiency, 35-38,158; amounts needed, 50-51i; sources, 54i, 68; loss of, 55. See also Niacin Vitamin Bi, 31, 38; deficiency, 36; in enriched flour, 59; amounts needed, 50-51t Vitamin B 2 ( G ) , 31; deficiency, 36; amounts needed, 50-51i; supply, 53; in enriched flour, 59 Vitamin C, 31; deficiency, 34, 163; amounts needed, 5 0 51t; sources, 54i, 62, 68; supply, 60, 61 Vitamin D, 31, 34, 38, 54, 64, 167; needs, 50-51f; in enriched flour, 59; in pregnancy, 158 Vitamins, 31, 70; preservation of, 32; waste of, 32, 53, 220, 252; status of group, 37; German production, 45; cost, 52, 53; need in pregnancy, 158; need among children, 163; need among elderly, 193. See also specific vitamins War, a test of health, 4; total, 4, 177, 306; and mercenaries, 4, 306; Peloponnesian, 10; American Civil, 11; Thirty Years', 11, 12; and destruction of health, 16; Spanish Civil, 276 War edema, 34

328

INDEX

War Man-Power Commission,

201

War of 1914-18, 3, 10, 13-15, 153, 165, 166; and nutrition, 25-27, 32-35, 75; and birth rate, 47, 48; and infections, 87-90, 93, 96; United States battle casualties in, 208; and mental illness, 275 War of 1939-, 3, 15, 293-295; and nutrition, 74-82; and infections, 114-116, 128; and children, 175; and mental illness, 275-277 Waste, of vitamins, 52, 53, 220; of food, 80, 81; of man-power, 206 Water, nutritional need, 31, 37; contamination, 85, 92; sanitation, 100, 101, 124, 125; workers' needs, 210,

220

Wheat, see Breadstuffs; Flour Whooping cough, 104, 168 Wilder, Russell, 36, 67 Women, caloric needs of, 39; doctors, 237; in air-raids, 277; housekeepers, 201. See

also Maternity; Women workers Women workers, 159, 160, 200, 202, 203; illness among, 207; accidents among, 214 Wood, Edith Elmer, quoted, 122 Wool, 143, 144 Work, and health, 158, 209; excessive, 215-218; and morale, 286. See also Occupation Workers, dietary needs, 38-40, 75, 219-221; housing needs, 118, 139, 140; child, 173, 174, 200, 202; aged, 184, 185, 187, 198, 202; women, 202, 203; income, 204, 205; clothing, 215; professional attitude, 218; welfare, 219; medical care, 223; rehabilitation, 223, 224. See also Occupation Worry, 273. See also Psychoneuroses Xerophthalmia, 33 Yellow fever, 85, 98, 104