Part 18

Three very potent arguments have been brought forward in favor of closing the schools: (1) As long as the schools are open children from infected homes are forced into contact with children from uninfected homes, and we are at present unaware of the extent to which the disease may be carried by a third person. (2) Children in as yet uninfected homes which are comfortable and hygienic are far better off than they are in school, and can hardly be considered in the same class with children from unclean tenements. (3) If the period of greatest contagion is before symptoms develop, inspection, while valuable for the institution of treatment, cannot hope to aid in curbing the epidemic. It is evident that different measures must be employed in applying closing orders to crowded cities, moderately large towns and rural districts. The difficulty lies in determining the best means for serving each community.

The Closing of Public Dance Halls

Public dances should undoubtedly be prohibited during epidemics. They not only present all the bad features of other public gatherings, but during the dancing people are brought in very close contact and often breathe directly into each other’s faces. In addition, air currents are stirred up and a certain amount of dust is raised. During the exercise the dancers breathe more rapidly and deeply, thus inhaling unusually large amounts of dust, droplets and contaminated air. Another feature is found in the “resistance-breaking” element of alternate overheating and rapid cooling of the body.

Regulation of Public Eating and Drinking Places

Public eating places are a necessity and cannot be closed. People should be cautioned against using them as places of amusement and of congregation during epidemics. Boards of Health should feel it just as much their duty to see to the sterilization of dishes and eating utensils as they do to the enforcing of any other public health functions, and they should also insist on the daily inspection of the employees of such establishments. The beer saloon question may be passed over for the present, but the soda-water fountain as conducted during the 1918 epidemic was undoubtedly a great menace. Ice cream, syrupy mixtures, etc., of various kinds are readily contaminated by pathogenic organisms which may serve as secondary infectors, if in no other capacity. The syrups, moreover, adhere to the spoons and glasses, which are rarely thoroughly washed and are practically never sterilized between customers. The use of paper dishes and glasses is probably a step in the right direction, but the spoons should be thoroughly washed and sterilized. The fact that soda-water employees are not always selected for high-grade intelligence, and are generally left largely to their own hygienic procedures, makes the chances of transferring infections at these places enormous. If soda fountains are allowed to continue business at all during the epidemics, it should be only under the very strictest supervision by Boards of Health. The scalding of all utensils should be enforced by law.

People generally should be cautioned to use exceptional cleanliness in the preparation of all foods in the home. In discussing the recent epidemic Lynch and Cummings (50) stated that “the mess-kit wash water proved the major route of transmission from sick to well in the army.” Vaughan said: “I am pretty certain, not convinced, that hand-to-mouth infection is of more importance than droplet infection.”

Regulation of Traffic

Business must be conducted in epidemic as well as in normal time, and employees must go to and from their places of occupation. In cities where the distance from the residence to the business districts is great, street cars and other public conveyances must be used. Their use undoubtedly increases the number of contacts and leads to a wider distribution of the disease, but, like eating in public restaurants, it is a chance which many have to take. Few places offer better opportunities for exposure than street cars—where people of all grades of intelligence, representing all states of health and degrees of cleanliness and uncleanliness, are crowded closely together, breathe into each other’s faces, and handle the same straps and supports.

In Pittsburgh the cars have a seating capacity for from 30 to 50 persons, but during the morning and evening hours they are crowded to capacity, and are commonly seen to carry more than 100 passengers at a time. Here, too, the unkempt, indifferent foreign element is conspicuous, and these people are known to disregard all hygienic teachings. A few days after the appearance of the epidemic the street cars were placarded with warnings against coughing, spitting and sneezing. The cards instructed people who became ill to go home, to go to bed and to remain there until they were well. Later a second order appeared which gave notice that all windows in street cars were to be kept raised six inches and that no heat was to be allowed in the car. The order was intended to improve ventilation, and, for a wonder, it was enforced. During the first few days the weather was fine, warm and clear, and the draught caused by the open windows brought no discomfort; but later the weather became cold and several days of drizzling rain set in. The cars with open windows became very uncomfortable, but the streetcar employees insisted upon obeying the order to the letter. No judgment was exercised by them, and the windows were kept open night and day, cold or warm, crowded or empty, in fair and rainy weather alike, and no heat was allowed to be turned on. Many people preferred standing to exposing their backs and necks to the cold draughts, and it is more than likely that such use of open windows did far more harm than good. As above quoted, Vaughan pointed out that crowding is just as dangerous out of doors as indoors, and it is certain that crowding in cold, draughty cars is dangerous, both from the close contact and because of the added danger of lowering bodily resistance.

In an attempt to decrease the crowding on public conveyances the so-called “stagger-hour” system was adopted in New York. Under this arrangement manufacturers and business houses changed their working hours in such a way that the morning and evening travel was spread out and the average number of people carried per hour was proportionately decreased.

Looking backward over the methods used to decrease the spread through the use of public conveyances, it seems that the following procedures have the best claims for retrial: (1) Placarding the cars. This appeared to reduce the amount of coughing and sneezing, even in face of the fact that the cars were unusually draughty and chilly. (2) The adoption of the “stagger-hour” system where the practice is feasible. (3) The instruction of the people to use the street cars as little as possible.

Enforcement of Anti-Spitting Ordinances

All street cars and trains carry anti-spitting notices either to the effect that spitting will be prohibited on penalty and fine and imprisonment, or giving stated amounts of the fine. Yet spitting is constantly indulged in in these places and one rarely sees or hears of the enforcement of the law. If the ordinance was worth making a law, it is certainly worth enforcing, and yet there is probably no law so flagrantly broken. Ordinary police officers pay no attention to the enforcement of the spitting ordinance and have been known to refuse to even reprimand spitters. The incident of a sanitary officer wearing a uniform and a cap, indicating to the public his official position, who was seen sitting in the smoking car in a local suburban train and spitting profusely on the floor has been recounted on very reliable authority. Another incident is known in which a street car conductor was asked by one passenger to stop another who was expectorating abundant mucoid sputum upon the floor. The conductor replied that he had orders not to notice such things. It is no wonder that people are indifferent to such impotent measures. Whether it is possible to convey epidemic influenza or not by means of sputum, it is certain that tuberculosis is spread in this way, and that influenza predisposes to tuberculosis and causes old healed tuberculous foci to become active. People should be made to understand that they may have tuberculosis without knowing it themselves, and that by spitting it may be transmitted to other persons. Spitting by persons aware that they have tuberculosis is criminal negligence and such persons should undoubtedly be prosecuted. If a person knows that he has tuberculosis and deliberately spreads about the infection so that other persons contract the disease and die from it, he is directly responsible for the deaths. It would be hard to imagine trying to control manslaughter committed in any other way by merely putting up signs in conspicuous places forbidding the act. The average boy acquires the spitting habit between the ages of 8 and 12 years, and in many instances carries it to the grave. The one possible way of stopping spitting seems to lie in teaching the dangers of it to children, beginning in the kindergarten and emphasizing it throughout the child’s education. It is possible that in this way spitting may become obsolete in two or more generations.

Increasing Natural Resistance by Augmented Healthfulness

If there is any way of increasing the natural resistance against epidemic influenza, it is a most desirable goal toward which to work, but it must first be determined along what lines the effort is to be directed. It was not the aged, the unconditioned nor the physically unfit who suffered most from influenza, but was rather the best trained, most healthful and most robust young persons we had. Those in the army had been selected because of their physical fitness and they had further received excellent physical training in the various camps and cantonments. It would not be possible to bring any large percentage of the general public up to such a stage of “augmented healthfulness” as healthfulness is generally understood. It has been said that men in the military camps were more commonly infected because they were more active, went about more and were, therefore, more frequently exposed. In one particular this statement is true, for men marching rapidly and exercising violently breathe more deeply and at a faster rate than they do under ordinary conditions, so that they naturally draw greater quantities of air into their lungs. It was an obvious fact that those persons given to sedentary lives were less often affected than the active and vigorous. Practically speaking, it would seem that during influenza epidemics people should be instructed to take more than the usual amount of sleep and rest, to indulge only in mild exercises, to eat good, wholesome food, to wear warm clothing, to seek mental and physical relaxation at home, and, above all, to avoid crowds and public gatherings.

In some instances the constant use of oils in the nose and throat was advised, the theory being that the oil served the double purpose of preserving the healthy condition of the mucous membranes by lessening crusting, crevicing and drying, and of mechanically protecting from infection by the presence of the layer of oil. Many of the different liquid paraffins, both medicated and in the natural state, were used. It is probably advisable to apply such oils either with a swab or from a medicine dropper, rather than to attempt to spray them, since in the latter method there is some danger of blowing infectious material down into the trachea and larynx.

It is hardly necessary to point out the importance of augmented cleanliness of the mouth, teeth and throat by means of mild antiseptic washes and tooth-cleansing materials during an epidemic.

GENERAL MEASURES

Public Health Administration

Unless one had had a wide experience in the administrative side of public health matters, it would be useless for him to try to discuss the details of handling any sort of an epidemic, and even then local conditions vary so much in different cities and States that each administrator’s experience must differ greatly. The difficulty with reports of epidemics by public health officials is usually found in the fact that the reports are impersonal compilations and convey no idea to the reader, or rather to the student (for no mere reader is attracted to them), of what situations were faced, of what difficulties were in the way, of how the conditions were met, or what the administrator after due reflection would advise doing next time under similar circumstances. In the face of inexperience the writer ventures the following suggestions for improvement, though no originality is claimed for the ideas.

The administrative powers should be centralized in one individual, or in an executive officer acting for a competent board of advisers, who should be endowed with the powers to carry out the measures which seem best suited to meet the situation at hand, and who should be beyond the pale of political interference and in position to prevent political fiascos, built more or less directly on health regulations.

The United States Public Health Service should work toward standardizing health laws and penalties for all States.

Thorough enforcement of ordinances requiring the reporting of all cases and all deaths as now demanded by public health rulings should be insisted upon. These reports are so important to a knowledge of the progress of the epidemic that the section on preventive medicine of the American Medical Association (51) has just advised the consideration of eliminating from membership in the Association any physician who willfully fails or refuses to comply with the regulations requiring the reporting of communicable diseases. Additional information can be obtained by daily canvasses of the schools, when open, of the large industries, and of the daily admissions to hospitals. Data on the daily facilities for the handling of additional cases in hospitals should be on file in the office of the administrator of health.

Printed instructions giving in detail the proper procedures for isolation of the patient and the protection of the family should be supplied to physicians for distribution at the first visit to suspected cases.

Desirable Laws

Some specific laws governing the following points would be of great advantage during the progress of an epidemic: (a) A law providing for the commandeering by boards of health of vaccines, sera or other substances for which a sudden unusual demand may occur, and for the distribution of such substances by the authorities to the public at the prices ordinarily asked. (b) A law permitting the exclusion from the daily papers by boards of health of advertisements containing obviously false and fraudulent statements relative to the epidemic. (c) A law permitting the health authorities to go into public eating places and demand proper sterilization of dishes and eating utensils with the alternative of closing the establishment. (d) A set of laws making the penalties sufficient to prevent violations of the regulations.

Education of the Public

From the beginning to the end of an epidemic the health authorities, aided by the medical profession, should take the public wholly into their confidence. At the first news of the approach of the disease a general bulletin should be issued giving all of the main facts that are available. This was done in a way by the American Public Health Service, but the bulletin reached only a small fraction of the people, and although parts of it appeared later in the daily papers, it was pretty generally missed. The papers should be used freely and the space paid for when necessary, so that the news of the epidemic is featured emphatically. The establishment of a question and answer department or a bureau of information would take care of a great deal in the way of denying misinformation. The public should be encouraged to report helpful facts of all kinds, but with the understanding that no rumors would be published without investigation and confirmation. In this way it would be possible to prevent articles advising harmful and useless remedies from reaching the press, and aid in suppressing some of the “Sure Cures,” so many of which appeared to abuse the confidence of the unwary during the 1918 epidemic. Several such cures have been most interestingly discussed in a recent bulletin of the United States Public Health Service. The bulletin divides the “Sure Cures” into three different classes, as follows: “First comes the individual who has a specific remedy, the formula of which he will sell for a price * * *; next comes the person with a pseudo-scientific treatment, e. g., isotonic sea water, ‘orzono therapy,’ ‘harmonic vibrations.’ * * * Still another type, who gives freely of his advice that humanity may be spared from pestilence.” Among the latter are found advice for placing sulphur in the shoes, wearing of amulets, inhaling of alcohol, chloroform, etc., as well as numerous religious and mental science treatments, etc. A frank statement of facts and a discussion of the ridiculous side of many of these claims would undoubtedly benefit the entire public. The placarding of the cars and the warnings posted in conspicuous places no doubt helped greatly, and this method undoubtedly should be continued. As long as theatres are allowed to remain open, speakers may be used to advantage to emphasize important points. The County Medical Societies should be asked to appoint committees for supplying information or for seeing that the information given to the public is authoritative. In large cities committees may be organized among hospital superintendents, so that the heartiest co-operation between health authorities and hospitals will be available. The ever-ready aid of the Red Cross and of every other auxiliary body should be employed to the fullest extent to allay apprehension and relieve suffering.