That vaccination prevents smallpox no intelligent person acquainted with the facts can doubt. An overwhelming ma.s.s of incontrovertible evidence can be found in every medical library. The mortality statistics of different countries tell the same story. A single example shows the general experience: In seven provinces of the Philippine Islands there were 6,000 deaths annually from smallpox alone. In his 1906 report, Dr. Victor G. Heiser, Director of Health in the Islands, describes how drastic measures were taken to stamp out the disease. Under his direction practically three million one hundred thousand persons were vaccinated. The following year, instead of 6,000 deaths from smallpox, there was not one.

For 13 years the Board of Education has had upon its books a rule requiring vaccination as a prerequisite to admission to the schools.

That rule has never been adequately enforced. In July, 1914, City Ordinance 32846-B was pa.s.sed, one section of which reads: "No superintendent, princ.i.p.al, or teacher of any public, parochial, private school, or other inst.i.tution, nor any parent, guardian, or other person, shall permit any child not having been successfully vaccinated, nor having had smallpox, to attend school." Although pa.s.sed a year ago, that ordinance has not yet been enforced. Exact figures cannot be secured, but it is probable that there are in the Cleveland schools today more than 50,000 unvaccinated children. For each of these the superintendent, princ.i.p.al, teacher, and parent may be held liable to a $200 fine, 60 days imprisonment, or both.

FUTURE DEVELOPMENT

Compared with other large cities, Cleveland has an unusually good system of medical inspection. Where other cities are still struggling with details of organization, record keeping, and the like, Cleveland is ready to lead the way into new and immensely important fields.

Medical inspection includes four fields of endeavor: prevention of epidemics, discovery and cure of physical defects, provision of healthful surroundings, and formation of correct habits of thought and action in regard to health. The first two are concerned with remedying present conditions, and here Cleveland is doing excellent work. The latter two provide health insurance for the future. In these, Cleveland has made a beginning but should carry her efforts far in advance of anything now attempted.

Thirteen years ago a crusade was started against the common drinking cup. Today there is not a school in the city which is not supplied with sanitary drinking fountains, and the common cup is a thing of the past. Nine years ago individual towels were supplied to children in certain schools. At the present time individual towels, soap, and hot water are available in every building. In 1906 the first shower bath was installed in an elementary school. Now there are 37 buildings so equipped. The windows in some of the cla.s.ses for the blind are made of amber tinted gla.s.s. For years there has been agitation in favor of adjustable seats and desks, and although conditions in certain schools are still very bad, these are exceptions, and the general seating provision is in accordance with the laws of hygiene.

[Ill.u.s.tration: Shower baths installed in an old building in a crowded section.]

But the Division of Medical Inspection must go farther than this. The physician must join with the psychologist and the educator in scientific research to determine the conditions best suited to the education of the child. Shall blackboards be of slate, composition board, or gla.s.s? Shall they be colored black, green, or ivory white?

Is light chalk on a dark ground better or worse than dark chalk on a light ground? Is prismatic window gla.s.s superior to plain? To what extent is glare from polished desks detrimental to eyesight? How large must be the type in textbooks in order that young children may easily read it? What variations from the present school program are necessary in order to make adequate provision for change in the use of different sets of muscles, and relief from nerve strain?

These questions and hundreds of others are facing educational authorities. The method of answering them affects not only the children of one city but the children of all cities throughout the country. Everywhere schoolmen are on the alert to gain information which will help in solving these problems.

In addition to regular work of inspection and examination, the doctors and nurses of Cleveland spend a great deal of time in conferences with parents, talks with teachers, lessons and talks to children, toothbrush drills, and the like. The importance of work of this kind can hardly be overestimated, but it must be far more than "talks at people." It should be the aim of the Department of Medical Inspection to establish right habits in regard to health. For this reason, although both methods are helpful, drill in the use of the toothbrush is more effective than lectures on the need of using it. As a result of the work of doctors and nurses, Cleveland's children,--and her teachers as well,--should not only believe in plenty of sleep, but should go to bed early; not only disapprove of too much tea and coffee, but have strength to refuse when it is offered. Through cla.s.ses for the anemic and pre-tubercular, the public schools help each year between two and three hundred children. This is worth doing, but they will render a far greater service to Cleveland if, in addition, they succeed in giving to 80,000 children, so firmly that it will never be broken, the habit of sleeping winter and summer with wide open windows.

The dentist, the oculist, the physician, should come to be regarded, not as dispensers of cures nor sympathetic listeners to hypochondriacs, but as leaders to whom intelligent people go in order to forestall trouble,--specialists in health rather than disease.

Leading its future citizens to form right habits of thinking and acting in regard to health is one of the greatest educational services which the public school can render.

TEN TYPES OF HEALTH WORK

As the work in Cleveland develops, it should aim to include all those types of activity which extended and varied experience has shown to better the health of school children, safeguard them from disease, and render them healthier, happier, and more vigorous. Among such activities the following are of special importance:

1. Medical inspection for preventing the spread of contagious disease and for the discovery and cure of remediable physical defects.

2. Dental inspection for the purpose of securing sound teeth among these school children.

3. The steady development of the work of the school nurses to the end that their co-operation with doctors, teachers, and parents may progressively contribute toward improving the health of the children.

4. Open-air schools for giving to the physically weak such advantages of pure air, good food, and warm sunshine as may enable them to pursue their studies while regaining their physical vigor.

5. Special cla.s.ses and schools for the physically handicapped and mentally exceptional in which children may receive the care and instruction fitted to their needs.

6. School gardens, which serve as nature study laboratories, where education and recreation go hand in hand, and increased knowledge is accompanied by increased bodily efficiency.

7. School playgrounds, which afford s.p.a.ce, facilities, opportunity, and incentive for the expression of play instincts and impulses.

8. Organized athletics, which aid in physical development, and afford training in alertness, intense application, vigorous exertion, loyalty, obedience to law and order, self-control, self-sacrifice, and respect for the rights of others.

9. Systematic instruction and practice in personal and community hygiene and sanitation.

10. The progressive improvement of all adjuncts of better sanitation in school houses, such as sanitary drinking cups and fountains, systems of vacuum cleaning, improved systems of lighting, heating, and ventilation.

HEALTH AND EDUCATION AND BUSINESS

There is one condition in the Cleveland school system which rises like a mighty barrier against the possibility of completely fulfilling any such program of health education as that outlined in the 10 planks of the preceding platform. This is the fundamental fact that the Cleveland school authorities have not yet conceived of health work as being an integral part of education.

In this city the work of the Board of Education is divided into three main departments. These are the executive department, the educational department, and the department of the clerk. The executive department is under the leadership of the director of schools and it deals with the business activities of the Board. The educational department is under the superintendent of schools and deals with teaching.

Under this organization the activities carried on by the Board of Education must be a.s.signed to one or another of the departments and this entails in most cases arriving at a decision as to whether the work in question is predominantly of an educational nature or of a business nature. In dealing with health work in the public schools, the Board of Education rendered its decision both ways. It decided that provision for health in education was a series of business transactions and so it placed medical inspection in the executive department under the leadership of the director. It also decided that provision for education in health was a teaching problem and so it placed physical education and training in physiology and hygiene under the direction of the superintendent of schools.

Despite its decision that provision for health in education is a business matter, while provision for education in health is a teaching matter, the Board realized that some sort of unity was essential if the different sides of the work were carried forward efficiently. They met this situation by employing a competent director of health work and giving him an official dual personality. As the official held responsible for health in education, he is the director of medical inspection and is subordinate to the director of schools. As the official responsible for education in health, he is an a.s.sistant superintendent and is responsible to the superintendent of schools. In one capacity he is appointed by the superintendent and receives a portion of his salary from educational funds. In his other capacity he is appointed by the director of schools and paid from business appropriations. As an employee of the educational department, he is appointed for a term of one year, but as an employee of the business department, he is on the civil service list with an indeterminate period of employment.

In his educational capacity, he may arrange for the organization of basketball teams for this is held to be a matter of physical education, but in order to have a basketball game actually played at any time outside of regular school hours, he must get the permission of the director, for this is held to be a business transaction.

Instruction in infant hygiene is given to the girls in the upper grades. Part of the teaching is done by the regular teachers, the rest by the nurses of the medical inspection department. When the instruction is given by the teachers, it is considered an educational activity and is under the supervision of the superintendent; when the same cla.s.s is taught by the nurse, it is considered a business transaction and is under the authority of the director.

As chief medical inspector, representing the business department, this official discovers a feeble-minded child whom he wishes to transfer to a special cla.s.s. Since the transfer of this child is an educational problem, he reports the matter to the a.s.sistant superintendent in charge of the district. Since the medical inspector is also an a.s.sistant superintendent, these two men are co-ordinate educational officials. The a.s.sistant superintendent of the district reports the requested transfer to the city superintendent who deals with the matter as an educational problem and issues an order to the chief medical inspector in his capacity as a.s.sistant superintendent in charge of physical education to make the transfer.

This whole situation, which arises from a.s.signing some phases of the health work to the business department and other phases to the educational department, has not given rise to as many or as serious difficulties as might well be expected. This relative freedom from trouble and friction is an impressive tribute to the unremitting tactfulness of the officials most directly concerned. The chief medical inspector is a conspicuous example of a man defying holy writ by successfully serving two masters.

Health work in Cleveland public schools is on a higher plane than in most other cities. Its present accomplishments have carried it further than similar work has gone elsewhere. Its future possibilities are unusually bright because the early stages of development have been successfully pa.s.sed. The one thing that we may be sure of is that this future development will tend toward an ever closer relationship and more intimate intermingling of the activities which make for health in education and those which are directed toward education in health.

Each new development and each forward step renders a separation of the work into educational and business activities progressively difficult.

To discover decayed teeth and to teach children to care for their teeth are intimately related matters and their separation is bound to be theoretical and not real. To attempt to separate the testing of vision from teaching concerning the conservation of vision is to lose an opportunity for the most effective sort of instruction. Similarly, if one scrutinizes all of the 10 items that have been suggested as indicating the health activities which Cleveland should continue to develop in its public schools, he can hardly fail to appreciate the utter impossibility of successfully dividing the work into certain activities which shall be educational and certain other activities which shall be business. Sooner or later the theory that this can be done will be destroyed by the logic of events, for health work in our public schools is constantly becoming a more intimate and integral part of the every-day education of all the children.

Sooner or later serious difficulties are bound to arise from an administratively unsound arrangement in which a school official in charge of a most important division of work is responsible to two entirely independent chiefs. The opportunities for honest but irreconcilable conflict of views are so numerous that they will surely arise in time. One chief may favor vaccination and the other be opposed to it on principle. One may deem it the duty of the schools to have the doctors and nurses give instruction in s.e.x hygiene while the other may be utterly against anything of the sort. One may hold that the only useful physical exercise is that gained through games and athletics, while the other may favor formal gymnastics. One may believe in school gardens, and the other deem them a waste of time and money. One may believe that courses in infant hygiene should be provided for the girls in the upper grammar grades, while the other may hold that such instruction should be reserved for continuation cla.s.ses for young women.

All of these are matters on which educational authorities are sharply divided in opinion and there are many more of the same nature. The present director of schools, the present superintendent of schools, and the present chief medical inspector have so far worked successfully under the present arrangement of divided duties and responsibilities, but a reorganization along sounder administrative lines should be made before, instead of after, serious trouble arises.

Eventually, if not now, Cleveland must realize that health work in education must be placed under the direction of the city's highest educational official who is the city superintendent of schools.

SUMMARY

1. Cleveland employs 16 school physicians, one oculist, and 27 nurses.

It spends $36,000 a year on salaries and supplies for these people, and maintains 86 school dispensaries and clinics.

2. Through medical inspection, the educator and the physician join hands to insure for each child such conditions of health and vitality as will best enable him to take full advantage of the free education offered by the state. It recognizes the intimate relationship between the physical and mental conditions of children. It realizes that education is dependent upon health. It betters health conditions among school children, safeguards them from disease, and renders them healthier, happier, and more vigorous.