1. Principles Underlying the Social Hygiene Program. New Haven has definite advantages over many other cities for developing and carrying on a broad social hygiene program. Its social welfare activities are so organized as to indicate recognition by the community of a considerable group of social problems. This fact, in addition to its being a great university town and a center for medical training, a city whose residents realize the need for constructive social betterment, and a city whose public recreational and educational systems have been well organized, make New Haven a community with unusual opportunities for becoming a model city in the field of social hygiene. Some of the essentials for such a demonstration have been recognized and well provided for; other opportunities have been allowed to pass. It will be attempted in this report to call attention to the manner in which New Haven is dealing with social hygiene problems and to point out those features of the present activities concerning which experience in other cities and states suggests some change; also to propose for consideration certain additional measures.
Social Hygiene, as understood in the United States, deals largely with such problems as the combating of the venereal diseases' the promotion of sex education, the reduction of c oommercialized prostitution, and other social problems growing out of sex as a factor in human life, such as marriage, divorce, and illegitimacy. President Charles W. Eliot for the purposes of the constitution of the American Social Hygiene Association endeavored to define the practical range of voluntary effort in the field of social hygiene as being: 1. To acquire and diffuse knowledge in its field, and to conduct on request inquiries into present conditions. 2. To advocate the highest standards of private and public morality. 3. To repress commercialized vice. 4. To organize the defense of the community by every available means, educational, medical or legal, against the diseases of vice.
For the present ends, the last of these purposes is stressed, but one of the recommendations will be that advantage would accrue to New Haven if a local social hygiene society or major division of some existing organization were established to continue studies and voluntary effort in the whole field.
"Hiding behind a mask, man's most dangerous enemy strikes in the dark, and adds two out of every thirteen deaths to his score," - so syphilis is described in a statement recently made by the Metropolitan Life Insurance Company. The disease, gonorrhea, does not so frequently kill, but it has a disastrous effect upon the living. In fact, it prevents life, for gonorrhea is the chief cause of sterility.
Up to the time of the World War, little attention was paid to the problem of the control of venereal diseases. Then the United States government put into effect a successful program, known internationally as the "American plan," consisting of education, recreation, legal and protective measures and medical and public health work. These measures are recognized today as the essentials in a social hygiene program.
Education includes not only the informing of the patient about his disease, and his duty in the protection of others, but far more-the directing of the sex life of the individual to wholesome expression under adequate control. Thus social hygiene education in all phases is a powerful force in the prevention of venereal disease.
A community program of recreation for both sexes, if sufficiently interesting, may be counted on to occupy leisure time, some of which might otherwise be spent in vicious amusements. Such a program, when well organized and directed, sets up high standards of fair play, social justice, and consideration for others, for lack of which much individual and domestic shipwreck now results. Recreation, especially when correlated with other protective measures, becomes an important factor in the reduction of those moral hazards which often result in exposure to the venereal diseases.
The relation of legal and protective measures to social hygiene and public health is fairly obvious. Anything that is done to curtail the exposure of susceptible persons to venereal disease carriers will depress the venereal disease rate. Those who indulge in promiscuous sex relations are practically all actual or potential carriers of venereal diseases. They are, therefore, mainly responsible for the spread of these diseases. Social hygiene legal and protective measures are calculated to limit the accessibility to the public of the most dangerous of such carriers. Good laws are a prime essential in the handling of sex delinquents. Proper administration of the laws is even more important.
Protective measures, on the part of official and voluntary agencies, deal both with individuals and with their environments. They provide social safeguards which aid in the guidance and direction of the habits of young people who are drifting into sex difficulties and whose parents have been unable to provide such direction themselves by reason of death, separation or other cause.
They follow such of these pre-delinquents as have later become delinquents through the courts and supplement the court and institutional machinery by sympathetic advice and practical assistance in making their subsequent adjustments. They provide the needed assistance to both minors and adults who are mentally unfitted to meet adequately the problems of sex.
In addition they provide certain activities which are calculated to make for a wholesome environment, such as traveller's aid work, supervision of public playgrounds, school visiting especially in connection with truant cases, and provision of adequate lighting of parks.
Medical and public health work has for its chief objectives the prevention of disease in a broad sense, and the discovery, treatment, and follow-up of infected individuals, in order to restore them to health and prevent the exposure of their families and others in the community.
* Full data in regard to the extensive study on which this summary is based will be presented and published as a separate appendix.
2. Prevalence of Venereal Disease in New Haven. Early in the survey an incidence study was undertaken to discover the extent of the medical problem. "How prevalent are syphilis and gonococcal infections in New Haven?" On the answer to this question depends largely the program for the prevention and control of the venereal diseases. How great is the problem? What are its complexities? Who is seeing the cases? Are the majority of infections under the care of licensed medical practitioners? Do the public health authorities collect statistical data which are essential to the proper handling of the venereal diseases from an epidemiological standpoint? Do they apply this are fundamental to the understanding and evaluation of the public health aspect of the social hygiene activities in New Haven.
For information the student turns first to official records for such data. The state law requires that physicians report to the health officer of the city all cases of venereal diseases coming to their attention. A report is to be made by office number, with the provision, however, that if the patient fails to return for treatment while in a communicable stage of the disease, he is to be reported a second time by name and address. The State Department of Health received through the City Health Department reports of 677 cases of venereal diseases from New Haven for the year 1927, including 292 cases of syphilis and 385 gonorrheal infections. These reports were furnished by 74 physicians, 2 hospitals, 2 clinics and the jail.
To supplement official data, an incidence census was taken to find out how many cases of gonorrhea and syphilis were actually under treatment or observation by physicians and other licensed practitioners, clinics and hospitals on a given day. In all, there were approached 380 physicians, 48 other practitioners of healing arts (osteopaths, chiropractors, and naturopaths), and 11 clinics, hospitals, penal and reform institutions. Of the 380 physicians, 296 proved to be actively practicing medicine, and of these 38.570 reported that they were treating one or more cases of syphilis or gonorrhea. Fifty-one had cases of both syphilis and gonorrhea under their care, 38 reported only syphilis cases, 25 only gonococcal infections. Of the 11 institutions, 36.4% reported cases. None of the osteopaths, chiropractors, or naturopaths reported any cases.
In all, 1,403 cases of syphilis and gonorrhea were reported as under treatment or observation in New Haven
knowledge? These and other questions of a similar nature on May 12, 1927. This shows a rate of 7.39 cases per 1,000 total population. Of these, 857 cases were syphilis-a rate of 4.52 per 1,000 of population, and 546 were gonorrhea- a rate of 2.88 per 1,000. Males (1,007 cases) showed a rate of 10.46 per 1,000 of the total male population of New Haven, and females, (396 cases) a rate of 4.24 per 1,000 of the similar group in the total population.
It is interesting to compare the New Haven incidence figures with original data collected by the United States Public Health Service and the American Social Hygiene Association in other urban and rural districts. For purposes of comparison some original data collected by the United States Public Health Service and the American Social Hygiene Association in other cities and counties are quoted. In any comparison, however, it must be remembered that there are many important factors to be taken into consideration, such as size, density, and composition of population, its economic and social status, racial and nationality groupings, municipal policy toward prostitution, availability of free treatment, - all having a bearing on the prevalence of venereal diseases. Atlanta, Georgia, showed a rate of 19.56 cases of syphilis and gonoccocal infection combined per 1,000 population; Detroit, Michigan, 13.47; Cleveland, Ohio, 9.37; Peoria, Illinois, 15.60; Huntington, West Virginia, 10.49; Decatur, Illinois, 14.64; Pike County, Kentucky, 5.21; Morgan County, Illinois, 4.19; the New Haven rate was 7.39 per 1,000 population.
Among the urban communities studied, it is seen that New Haven has a relatively low rate. It is interesting to speculate upon the accuracy of this figure. The low incidence rate in New Haven or any other city might be more apparent than real. In other words, there might be a large number of cases which are not receiving treatment from licensed agencies and which could not, therefore, be included in this kind of enumeration. In New Haven, a drug store canvass made to test this possibility showed considerable but not an unusual amount of drug store treatment and sale of nostrums. Probably about one-third of the total number of cases receiving any kind of treatment were of this class. This was somewhat less than has been found in other places or localities of similar size and composition. Other tests were made without disclosing evidence of an unusually large number of individuals not under treatment. No effort has been made as yet in New Haven to try the effect of an intensive campaign of public information to bring to the clinics and to private physicians those not being treated. It may be that in the large foreign population much ignorance exists in regard to the nature of these diseases and the necessity for proper treatment.
Certain facts are favorable to a belief that New Haven may have an unusually low incidence of venereal diseases. It is in a state which showed a comparatively low incidence of venereal diseases among men examined in the army draft in 1917. A considerable number of the young male population are college students, which group, according to information received from various sources, are relatively free from these diseases. Of the general population, more than half are female, a group generally with low incidence, while in both Detroit and Cleveland, the population is more than 50 per cent male, large numbers of them industrial workers. The Negro population is relatively small and socially and economically well off in New Haven in comparison with the other districts cited. Sex, social status, and economic status are all factors having an effect on incidence.
In the further tabulation of the data collected in the New Haven one-day census, many significant facts were revealed. Some of them are here summarized. Of the syphilis cases, about 63% were male; of the gonorrhea cases, 86% male. In Cleveland, 61% of syphilis cases were male, and 75% of gonorrhea; in Detroit, 63% of syphilis and 78% of gonorrhea were male; in Atlanta, 57% of syphilis and 58% of gonorrhea were male.
Of the total 1,403 cases, enumerated in New Haven, about one-fourth were acute or early (of all the male cases, 28.2%; of the female cases, only 17.4%). In Cleveland 38% were early or acute; in Detroit, 41%; in Atlanta, 47%. New Haven seemed to have a relatively small proportion of new infections. In New Haven there were many more acute gonorrhea cases than there were early syphilitic infections. Of the total gonorrhea infections, 43.4% were acute; of the total syphilis cases reported, only 13.5% were early. Early syphilis and acute gonorrhea were found in the other cities in the following proportions: Cleveland, syphilis 32%; gonorrhea 44%; Detroit, syphilis 35%, gonorrhea 47%; Atlanta, syphilis 43%, gonorrhea 52%. New Haven's proportion of early syphilis was apparently small.
While venereal diseases in general were distributed between physicians, and clinics and hospitals, in about the proportion 60~ and 40~, syphilis alone was almost evenly divided between private practice and public treatment. Early syphilis cases, however, were much more frequent in private practice than in clinics, while late cases of syphilis were apparently more widely treated in clinics than in private practice. Gonorrhea cases, both acute and chronic, were treated in private practice four times as frequently as in clinics and hospitals.
To the question included in the questionnaire, "In your experience, has there been an increase or decrease of the venereal diseases of late years, and what have been the probable causes of such increase or decrease?", 92 physicians made reply. Of these, 17 (19%) believed that there had been no change in the trend of the diseases either upwards or downwards in late years; 14 (15%) thought that syphilis and gonorrhea were increasing; 61 (66%) that they were definitely decreasing.
Various statements were thus made concerning the trend of the venereal diseases, and the reasons for its upward or downward movement.
Those who believed that venereal diseases were increasing named the following factors as influential: lax moral standards, after effects of the War; increase in drinking leading to promiscuity; inadequate prenatal care; and lack of education in the use of prophylaxis. Several doctors believed that the apparent increase was not one so much of actual incidence but rather one of bringing to notice previously unrecognized cases by better diagnostic methods.
Physicians holding the opinion that syphilis and gonorrhea were decreasing attributed the change to the education of men during war-time, more careful habits in sex hygiene, improved medical treatment, decrease in drinking of alcohol, the use of protectors and prophylaxis, better clinical facilities, and the present educational and preventive work of the United States Public Health Service the American Social Hygiene Association, the American Medical Association, and other health organizations. Several times the statement was made that physicians were seeing fewer cases because the clinics were drawing them away.
3. Social Factors in the Problem. As has been pointed out in the introduction to the report of the survey, New Haven has a large foreign-born and native-born-of-foreign-parentage population. Each foreign group has its own characteristics and tendencies - its superstitions, customs, and habits. Each group, also, has brought with it its own impressions and views in reference to relations between physicians and patients, health in general, clinics, self-treatment, and the corner drug store. These must be taken into account in studying the venereal diseases and social hygiene efforts of New Haven. Especially prepared educational material should be available for use in these groups.
The annual influx of Yale University students adds several additional thousands to the city's population, but the study indicates that although they add to the community's social problems their venereal disease incidence rate is thought to be low and their diagnostic and treatment needs are met by the University department of health or by private physicians.
New Haven has many large and important industries. The economic hazards of venereal diseases are, therefore, of added importance, not only from the standpoint of wage loss, heightened production costs, and inefficiency due to labor turnover, but particularly, in a railroad center, from the standpoint of possible loss of human life and property due to wrecks attributable to paresis. Employers, because of their liability as insurers, are confronted with the question of accidents complicated by the factor of latent syphilis. Such complications often make for delayed recovery, and hence for the payment of increased compensation.
In the study of the extent of promiscuity and the accessibilitv of promisenous persons to the general population, every available source of information was sought. These sources included members of the underworld. taxi drivers, keepers of hotels, roadhouses and speakeasies. Among the general population, students, teachers and social workers were interviewed. Among officials, the Police Department, the courts and the records and reports of institutions were consulted. The information from all these sources may be summarized as follows. Prostitution in the city of New Haven is neither open nor flagrant. Comparatively little solicitation was found to exist upon the streets. Such prostitution as exists is mainly clandestine in connection with rooming houses, hotels and apartments. The most serious situation as regards New Haven apparently centers around the use of the automobile and the roadhouses outside the city. A number of individuals and one or two of the social agencies have studied this latter problem in detail, and are convinced that it is a serious one. One such agency during the year obtained definite names and addresses of 192 girls who admitted sexual misconduct, many of them utilizing the roadhouses and automobiles. Ninety-two were said to be beginners.
As regards the measures in operation in New Haven, both of prevention, protection and punishment, it may be said that good beginnings have been made in all these directions. The city police are active in the suppression of prostitution and other forms of sex promiscuity. The high percentage (75%) of convictions in the City Court, where almost all these cases are disposed of, testifies to the efficiency of the police as gatherers of evidence. It must be remembered, however, that most of the persons brought into the city court are charged with "lascivious carriage" which means, for example, that a couple were found together by the police under circumstances which justified the charge that they had committed fornication or were about to commit it.
The existence and use of such a law obviously renders the task of the police much easier than it is in some other communities which have no such law and must prove prostitution or the offer to commit it by the testimony of one of the participants or of a policeman who was solicited. The use of the "lascivious carriage" law in New Haven has this advantage also that it enables the police and the courts to deal with men and women equally. This avoidance of sex discrimination by the police and courts of New Haven in dealing with its promiscuous persons is a noteworthy achievement and goes a long way to explain the comparative cleanness of the city from commercialized vice. This condition has been achieved in spite of the fact that the penalties which are meted out by the City Court are often of a kind and degree (small fines and jail sentences) which most other progressive communities have discarded as having no deterrent or rehabilitative value.
The condition of the Court records was such that it was impossible to classify or analyze the work of any one year. It was apparent, also, that the judges had before them, at the time of sentencing convicted persons, a paucity of information as to their histories, and their environments, and also as to their mental and physical conditions. It is perhaps for this reason that probation as a method of treatment is so infrequently used (3% of convicted persons were put on probation in 1926).
The probation officers, particularly in the Juvenile Court, do not, as a rule, visit the probationers or otherwise closely supervise their activities during the probationary period. They are said to devote part time to other duties such as the collection of fines of convicted persons and to collecting support money for the "Department of Domestic Relations." They rely mainly on the periodic visits to their office of the probationer for information concerning the latter's activities.
There is only one woman police officer. She is apparently given discretion in dealing with delinquent girls, and has to spend part of her time in serving warrants and performing various duties assigned her by the Department of Domestic Relations. Several agencies and individuals pointed out the lack of adequate cooperation with voluntary agencies dealing with delinquents and pre-delinquents. They also stressed the need for greatly increased patrol work by women police with adequate training and experience. There is evident need for assignment of such qualified officers particularly in the neighborhood of the University and the High Schools.
The Florence Crittenden Home was found to be receiving a number of girls committed by the court for various offences, as well as girls voluntarily applying for admission. Close quarters in the institution have made it impossible to separate these two groups, with a consequent intermingling and crowding which is considered undesirable.
4. Educational Problems. On the question of community understanding of the problems of venereal disease control, it seems fair to say that the importance of adequate public information has not been fully realized by official and voluntary agencies in New Haven. Some pioneer work has been done through occasional lectures, but thus far there has been no adequate community program. But little use has been made of such publicity media as pamphlets, posters, exhibits, motion pictures, and lectures, all of which have been found of great value in other cities.
Interviews were had on the streets with 80 men in various parts of the city to test the current views of young men. The interviewers asked where an infected person might best go to be cured. Fifty individuals advised him to use "home remedies " for self medication, or to go to drug stores; some had insufficient information on which to hazard any answer. Of the remaining thirty, nineteen recommended that he go to a physician; and eleven suggested clinics.
The New Haven Library, on Elm Street, contains a fairly comprehensive collection of social hygiene literature accessible to the general public. The Yale University Library, however, at the time of this study, had its social hygiene books restricted or so widely scattered that such reference publications, for example, as Flexner's "Prostitution in Europe" and the Journal of Social Hygiene were not readily accessible for use, even by students directly interested in sociology, history, community planning, and other related subjects.
It is encouraging to note that sex education-which the United States Public Health Service and many state and city health departments are finding of great value in supplementing their more direct health educational programs - has made a well-grounded start in New Haven. The results of this survey indicate that, while quantitatively the numbers of young people receiving such education through school and church sources are as yet small, the quality and spirit of the work are good. Two hundred senior girls in the high school now receive definite instruction as part of their course in biology; this instruction could readily be extended to all of the seven hundred boys and girls taking biology each year. With tact and careful selection of the teachers such work might now be considered for adaptation, even more generally, in the high schools.
The Young Men's and Women's Christian Associations and Young Men's and Women's Hebrew Associations have cooperated during the past year in five lecture series for men and women. In addition, the Young Women's Christian Association has instituted a leader-training course under the direction of social hygiene experts.
Several churches have arranged occasional discussions and one church provides for the individual instruction of each child approaching puberty. Through discussion groups for youth, the consideration of questions of social relationships is provided.
Yale University, at present, is giving definite instruction to only the 110 students electing personal hygiene, but the University has a standing committee on sex-education which is studying the advisability of a broader program.
These demonstrations and the response from leaders of other agencies is a further indication that the efforts of a local social hygiene society or division of some existing body would be welcomed.
5. Medical Care of Venereal Diseases. The proposal has been advanced in support of health conservation that next to the maintenance of law and order in the State it is the duty of scientific government to endeavor to control endemic diseases, and that for economic reasons alone governments are justified in spending for prevention of such diseases a sum of money equal to the loss which is inflicted upon the people, and that the money so spent should be apportioned in accordance with the amount of illness and mortality caused by each disease; and finally that it is the duty of governments to make and enforce all necessary regulations for the prevention of such diseases, and the duty of the people to comply with the provisions of such laws.
If this proposal be accepted, it is logical for a health department to assign a generous proportion of its budget to activities in cooperation with physicians and voluntary agencies in a program looking toward the prevention and control of the venereal diseases. In such a program the public health, medical, nursing and related measures which should receive adequate support are:
Because of the nature of syphilis and gonorrhea and the frequent lack of readily detected evidences of infection, the primary responsibility for the treatment and control of patients with a venereal disease rests upon the medical profession. For the same reasons the community has an added incentive for discharging its duty to those persons who are not able to pay for the services of a private physician. New Haven has recognized both of these obligations in large measure. The facilities for hospitalization of patients requiring bed care are adequate.
There are two services available for the treatment of persons infected with syphilis or gonococcus infection. The City Clinic is under the supervision of the Health Department. The New Haven Dispensary is a polyclinic and under the direction of the Medical School. The former has the disadvantages of an isolated clinic; the latter has the advantages of a polyclinic. Neither is operating to the full capacity of many clinics which provide the increased efficiency in diagnosis, care, and preventive effort which might be attainable through some combination of the two.
A careful study of the records shows that neither clinic is carrying an expected normal case load. Average new admissions per annum for both clinics are under five hundred. The study shows further that the type of services furnished by the New Haven Dispensary more frequently meets the needs than does that of the City Clinic. The type of individualized service which is given in the New Haven Dispensary, where a large consultant staff is available, obviously cannot be provided at the City Clinic, because of the difference in the fundamental types of organization.
The case record system of the New Haven Dispensary compares favorably with that of other university clinics of similar high standing, except that lack of a diagnostic file makes it impossible to extract records on specific subjects. The records of the City Clinic were not up to this high average.
Both of these clinics fail to meet the needs for adequate social service and follow-up of their cases.
As has been indicated, there is some evidence that a considerable number of infected persons are attempting to treat their own diseases, either by purchasing from the druggists advertised nostrums, or by having prepared remedies which have been recommended by well-meaning or ignorant friends. In an important percentage of cases, it was found that druggists were attempting not only to dispense remedies but to diagnose and to prescribe specific treatment.
While the incidence of syphilis and gonococcus infections in New Haven was found to be low in comparison with other cities studied, there is, nevertheless, good reason to believe that greater effort on the part of both official and voluntary health agencies to locate infected persons and to educate the general public in regard to the danger of these diseases and to inform those exposed of available facilities for diagnosis and treatment would discover additional cases and still further strengthen the City's program for the control of these diseases.
No adequate facilities for either diagnosis or treatment are provided at present for two groups which require more attention than has yet been given them, viz., those persons convicted of sex offenses and those committed to the County Jail in connection with their sentences. These groups comprise men and women who have already indicated their disrespect for law and their disregard for the protection of others. They should be given a general examination, including examination for syphilis or gonorrhea, and if infected, should be treated before being given unrestricted freedom.
6. Appraisal of Community Program. An attempt was made to evaluate New Haven's activities for the prevention and control of the venereal diseases in terms of the appraisal form devised by the American Public Health Association for the purpose of studying and measuring performance in municipal health work. Under venereal disease control three criteria are named: first, reporting (scoring 12 points); second, clinical service (30 points); and third, cases returned to physicians or clinics (8 points).
The standard for reporting is 400 cases per 100,000 population (New Haven population, 181,907 in 1926). On this basis, 728 reports for venereal diseases should have been received by the New Haven Health Department during 1926, instead of 449 actually received. This gives a rating of 7.4 points out of a possible 12.
The standards for clinical service are first, clinical registration (10 points), 800 registrants per 100,000 population, and second, clinic visits (20 points), 10 visits per new patient registered. On the first of these two standards, the rating would be 5.6 out of a possible 10. This rating is based on an estimated clinic registration of 825 for 1926 (exact figures for all clinics not available) as against a standard requirement of 1,456 registrants. On the second standard, clinic visits, there were 427 new patients registered, while a total of 12,755 visits were made to clinics, thus giving a full credit of 20 points on the basis of 10 visits per new patient as standard.
Under cases returned to physicians or clinics (per cent of cases returned to physicians or clinics after having stopped treatment) the standard is 60 per cent of discontinued cases returned (8 points.) Records of such cases were too inadequate to serve as a basis for computing a rating. The survey showed that follow-up work in clinics was not well organized, and such as was done was not recorded. The amendment to the reporting law (p. 180 of this chapter) should be of great aid in the follow-up of delinquent patients.
Taking all these factors into consideration, on the basis of standards outlined in the Appraisal Form, New Haven would score a rating of 33 out of a possible 50 points allotted to venereal disease control. Even though it may be claimed that this poor showing is partly accounted for by lack of records on which to compute the necessary figures, the lack of records is in itself a serious commentary on the efficiency of the agencies who should supply them.
7. Recommendations.
Recommendation 37. It is recommended that the social hygiene program of the Health Department, in cooperation with other official and voluntary agencies, be made more comprehensive by making available to selected groups speakers who will give sound information and advice; also by making available to physicians, special groups, and individuals pamphlets and other suitable literature on social hygiene, in various languages; by furnishing physicians and clinic staffs leaflets of instruction on gonorrhea and syphilis to be given patients under treatment; also by the inclusion of motion pictures and other display material on venereal disease control, adapted to special health exhibits; and by making it widely known that personal advice and information service in regard to the venereal diseases is available to all through the health department.
Recommendation 38. It is recommended that provision be made for a full time Medical Director of Social Hygiene activities in the Health Department.
Recommendation 39. It is recommended that a definite annual program of instruction be developed for both Visiting Nurse Associations and school nurses in problems relating to venereal disease control, for the benefit of new workers and to stimulate interest in those who have been on the staff for more than a year.
Recommendation 40. It is recommended that a determined effort be made by the Health Department to secure more complete reporting of acute venereal disease cases by the medical profession in compliance with the State law:*
Recommendation 41. It is recommended that the two clinic services be combined and operated as part of a well organized polyclinic with provision for the continuance of evening sessions.
Recommendation 42. It is recommended that the private practitioners, the clinics and the hospitals be encouraged to greater efforts to secure the source of infection in all cases of venereal diseases, and that these sources be followed up for the purpose of bringing under observation and treatment infected persons, either by the physician where practicable, or by the constituted health authorities.
Recommendation 43. It is recommended that a sufficient number of trained social workers be provided for the follow-up of patients in clinics treating venereal disease cases. For the best results and the proper correlation of these services in relation to the clinics and hospitals, these social service activities could be more adequately supplied through a special division.
Recommendation 44. It is recommended that the record systems in the city and juvenile courts be reorganized and extended and that necessary personnel be added. Annual reports should be prepared in which the cases coming before them should be classified and analyzed in detail and the methods and activities of the probation and other court personnel described. A program of activities for employing the leisure time of persons detained at the Children's Building should be established.
Recommendation 45. It is recommended that the state's attorneys for New Haven county and other counties nearby, in cooperation with the state police, should attempt to secure injunctions against the owners and operators of disreputable road houses accessible from New Haven and have them abated as public nuisances as provided in Section 2705, Rev. 1918. Criminal action might also be taken against some of these places, and the owners or drivers of cars who visit them under Chapter 77 of Acts of 1919.
Attention is also invited to the new Massachusetts Road House Law (Chapter 140, Section 182, as amended by Chapter 299, Acts of 1926; and Sections 183A, 183B, and 183C as enacted by Chapter 299, Acts of 1926). Under this law all road houses must be licensed under terms and conditions satisfactory to the licensing authorities. In towns having less than 2,5OO registered voters, the license must be approved by the State Commissioner of Public Safety. Such licenses may, after notice, be suspended and, after hearing, revoked. Severe penalties for operating without a license or for violation of the terms of the license may be inflicted by the courts.
Recommendation 46. It is recommended that provision be made for at least six police women whose qualifications should equal the minimum proposed by the Committee on Qualifications of the International Police Women's Association.
Recommendation 47. To aid in carrying out the recommendations contained in this report, it is recommended that a New Haven Social Hygiene Society or Committee be organized as soon as may be practicable, or set up as a major division of some existing agency. Such an agency in particularly needed in New Haven (a) to help in coordinating the many worthy social activities now being carried on, (b) to support the Health Department in its efforts for a comprehensive venereal disease control program, (c) to cooperate with the officials in the enforcement of laws against prostitution, (d) to promote an informed public opinion on the social hygiene problems of the community, and (e) to serve as a clearing house for information, discussion, and action on these problems. Such a society, because of the prestige of the city and university, and because of the close contact that can be planned between the local society and the national association, has possibilities of making New Haven an outstanding example of community development in the social hygiene field.
In addition to the above recommendations the study indicates that consideration might well be given to the following suggestions:
It is suggested that the Health Officer and the Public Health Committee of the New Haven Medical Society might collaborate further in preparing a joint social hygiene program for close cooperative efforts of physicians and department staffs in this field of public health endeavor.
It is suggested that greater attention should be given by the probation staff of the city to social hygiene problems. Consideration of this matter, however, may involve an increase in personnel and reorganization of their assignment and direction.
It is suggested that the visiting teachers' service might likewise be increased with advantage under the direction of a specially trained and experienced visiting teacher, unless the same end can be attained through some existing home visiting agency.
It has also been suggested that a study should be made of the influence of vocational guidance available under the direction of an experienced and trained director in the public schools.
It is suggested that consideration should be given to a return of the Florence Crittenden Home to the function of caring for unmarried mothers and pregnant girls voluntarily admitted, with the transfer of committed girls to some other institution.
The detailed divisions of the report and source material on which this general statement is based will be filed with the Community Chest for study and reference. These divisions are I. Informational Measures, II. Educational Measures, III. Legal and Protective Measures, IV. Medical Measures.
* The Connecticut Statutes, Chapter 127, Section 2415 of the Revision of 1915, as amended in 1927, states:
"Every physician shall report in writing every case of cholera, yellow fever, typhus fever, leprosy, smallpox, diphtheria. membraneous croup, tvphoid fever. scarlet fever, diseases of a venereal nature or other contagious or infectious diseases occurring in his practice, to the health officer of the town, city or borough in which such case .shall occur, within twelve hours after his recognition of the disease, providing in reporting and disease of a venereal nature, the name of the patient suffering from the same shall not, be disclosed, except that any physician who has been treating a case of venereal disease shall report the patient by name, address, age and occupation when the patient shall fail to return for treatment while in the communicable stage of the disease. Every person who shall violate any provision hereof shall be fined not more than twenty-five dollars."