ï~~f'~7 ~4 (IL. ' 4 4'?7 The Journal of the American Medical Association Published Under the Auspices of the Board of Trustees VOL. 73, No. 19 C H I C A G O, ILLINOIS NOVEMBER 8, 1919 THE EFFICACY OF EXISTING MEASURES FOR THE PREVENTION OF DISEASE * GEORGE A. SOPER, PH.D. Major, Sanitary Corps, U. S. Army NEW YORK I. THE CONTROL OF DISEASE These remarks relate to an inquiry into the different procedures for the prevention of the ordinary epidemic diseases of civil life, the object being to determine the spheres wherein substantial progress 'has been made and the tren'd in which future efforts should be directed. It is proper to state that the scope of an inquiry of this kind is necessarily limited by the fact that less than 1 per cent. of the world's population enjoys the benefits of systematic health work, and, of this small part, only a fraction compiles such records as will permit the efficacy of the work being known. It may be asked how we shall measure the efficay of procedures for the prevention of disease if vital statistics do not afford the means? The answer is that we must do the best we can with the statistics that are available, and for the rest rely on personal observation. To a considerable extent we must use our judgment. We must note where success or failure has occurred and try to find the reasons. When we turn our attention to the list of great epidemic diseases, we find that definite and effective procedures are available to combat most of them. The list includes plague, cholera, typhoid and dysentery, typhus, malaria and yellow fever. Such difficulty as exists in controlling these diseases lies in the practical application of the procedures rather than in the procedures themselves. The crux of the difficulty lies in the fact that the diseases in question often need to be combated among people to whom habits of ordinary cleanliness and decency are unknown. It is in consequence of this that when occasional cases of cholera, typhus and plague are brought to western countries there is no fear of them, and when they occur in some other countries it is impossible to stamp them out. We have spoken of the control that can be exercised over occasional cases. How far an epidemic disease may spread in a sanitary environment if a sudden and extensive outbreak of it occui-s is another matter. Sometimes it gains great headway and becomes ungovernable. It is one thing to deal with an infection in its retail aspect and another to manage it in wholesale proportions. This is 'true of all epidemic diseases. * * Read before the Seventieth Annual Session of the American Me-. ic1.Association, Atlantic City, N. J., June, 1919. Disease is like fire: only certain amounts of it can be controlled. We can do nothing with a conflagration. If a disease visits only a house, or barrack or ship, it can be restricted to that place. If it attacks an extensive locality or a group of localities, whether it shows a tendency to spread from one to another or affects all simultaneously, it is more difficult to deal with it. If the epidemic visits large tracts of country at once or in succession, it is practically impossible to stop it. And a disease that breaks out over vast areas of the world's surface at long intervals is entirely beyond human control. It is, therefore, only in their more restricted, not to say attenuated forms, that most epidemic diseases are controllable. Applying the illustration of fire again, we must seek out the sparks and quench them before they kindle a blaze. So far as the greatest of all epidemic diseases is concerned, we know nothing. We do not know what influenza is nor how it' can be prevented. We are as powerless against it as were our ancesters against smallpox before vaccination was discovered. It is to be hoped that the many intensive studies that hae been made of the recent influenza pandemic will result in effective preventive procedures being devised, but so far iothing that is practical seems to have been brought to light. CAUSE OF THE DECLINING DEATH RATES FROM EPIDEMIC DISEASE In the opinion of some persons we are as helpless against.many other diseases as we are against influenza. The assertion is made that it is due to their peculiarities rather than to any control that we are able to exercise that the infections which are commonly with us are not more prevalent than they are.. Reference is here made particularly to meningitis, poliomyelitis, measles, scarlet fever, mumps, whooping cough and diphtheria. Some diseases that exhibited alarming epidemic proportions fifty years ago no longer occupy a prominent place in mortality statistics. Scarlet fever, which formerly showed marked fluctuations and.a high rate, taking annually, in some years, 125 lives per thousand of population, has become steady in prevalence and seldom claims more than one life in 10,000 in a single year. Diphtheria, which sometimes ran an epidemic course for years, and in one state, at least, caused an average mortality of 410 per hundred thousand of population,. has subsided nearly everywhere to a steady, low death rate of about 10. Measles, whooping cough, and other so-called contagious diseases, have shown as distinct, if a less marked reduction. It is a curious fact that the diseases mentioned,. although differing markedly in prevalence among themselves many years ago, have in recent years come down i I i i u 'i;,:;;; " ii!i s _i I,,' 't _i:. 1 't '; '., ''r is;, EtI; iii 'i: l '1 li;,+ ';,,,.} i, ii;,.t t i;;; r,; 'yl '=;: <;;,;:;i K ( {y{y YS 3 y }$ k.'; t.. _F - $ '--, # y2 t FT: i EY 0