January 9, 1920] 



SCIENCE 



29 



the environment to the individual. The pri- 

 mary interest of the health officer has been 

 transferred from the swamp and the dung heap 

 to the control of infections and thence to the 

 detection of non-contagious physical defects 

 and the hygienic guidance of the individual 

 living machine. 



In the development of the public health cam- 

 paign to the realization of its fullest oppor- 

 tunities there is taking place to-day a swing of 

 the pendulum backward to a new interest in 

 the environment, but an environment of a na- 

 ture very different from the simple environ- 

 ment with which Simon dealt. General 

 Gorgas at Panama fully grasped the signifi- 

 cance of the wider and more subtle environ- 

 ment which most of us are just beginning to 

 glimpse as an essential problem in the public 

 health campaign. He eliminated yellow fever 

 and malaria by the drainage of marsh lands, 

 but he attempted to deal with pneumonia by 

 raising the wages of the employees upon the 

 Isthmus, for he realized that in the case of this 

 and many other diseases the most effective 

 weapon at our disposal is the building up of 

 general vital resistance, which depends upon 

 the maintenance of a satisfactory social and 

 economic level. 



Dr. Emmett Holt has said that there are two 

 causes of infant mortality — ^poverty and ig- 

 norance. In the infant welfare movement, the 

 anti-tuberculosis campaign and every other 

 field of public health, we come sooner or later 

 to a realization of the fact that education and 

 medical and nursing service, while they can ac- 

 complish much, can not cope successfully with 

 the evil effects of standards of living too low 

 to permit the maintenance of normal physical 

 health. 



As I have elsewhere pointed out, in the 

 Johnstown survey, Miss Duke tells us that the 

 infant mortality in one ward was 271 deaths 

 per 1,000 births against 134 for the city as a 

 whole and 50 for the ward which showed the 

 lowest rate and the explanation is that " this 

 is where the iworest, most lowly persons of the 

 community live — families of men employed to 

 do the unskilled work in the steel mills and the 

 mines." Dr. Sydenstricker and his associates 



in the TJ. S. Public Health Service in a report 

 on the relation between disabling sickness and 

 family income among cotton mill operatives in 

 South Carolina find that a monthly income 

 equivalent to less than $12 ■per person (on an 

 adult male unit basis) the sick rate was YO.l 

 per 1,000 ; with an income between $12 and $14 

 it was 48.2 per 1,000 ; with an income between 

 $16 and $20 it was 34.4, and with an income of 

 $20 and over it was 18.5. 



We can conclude from these figures and from 

 many similar investigations that poverty and 

 sickness are closely correlated. We can not 

 conclude that the poverty is responsible for 

 the excess of sickness. In some instances the 

 relation of cause and effect may be reversed.- 

 In other cases both poverty and disease may be 

 due to underlying inheritance. People do not 

 usually live in the poorest quarters of a city 

 or work at its underpaid employments by 

 choice or by accident. In general, and on the 

 average, we shall find in such districts and 

 such employments a concentration of tubercu- 

 lous stock, of alcoholic stock, of feeble-minded 

 stock — poor protoplasm and a bad environment 

 supplementing each other in a vicious circle. 



No one can perhaps tell just how far 

 poverty in such cases is the real and effective 

 cause of the failure to achieve and maintain 

 a normal standard of physical health. It is 

 clear, however, that there is a certain standard 

 of income below which the maintenance of 

 health is impossible; and it seems reasonably 

 sure from the studies of Eoyal Meeker, of the 

 U. S. Bureau of Labor Statistics, that a cer- 

 tain not inconsiderable proportion of the 

 population of the United States has to-day a 

 family income below that figure. 



If an initially normal family can not gain 

 a livelihood adequate for its minimum phys- 

 ical needs, there is evidently a problem of 

 social readjustments which our nation must 

 face as a fundamental of post-war reconstruc- 

 tion; but what shall we say of the family 

 which on account of inherent physical or 

 mental defects is unable to reach a minimum 

 level under a wholly fair and equable basis of 

 compensation? There are but two alterna- 

 tives as I can see it; since the moral sense 



