COLORADO PUBLIC HEALTH NEEDS A I? D HOW TO MEiT THEM January, 1946 *** Soghia Smith Beaosch Boom January 1946 PUBLIC HEALTH IN COLORADO Scope and Sponsorship of Study. The health study, of which this is a preliminary and partial report, is being made, at the request of the Governor, the Health Committee of the Governor's Post-War Planning Committee, the State Board of Health, and the Colorado Public Health Association, by the American Public Health Association through its Pield Staff.* The study is being made without cost to the State of Colorado through a grant to the American Public Health Association by the Commonwealth Fund for the purpose of conducting health studies in a few care- fully selected states. This and other state surveys are made under the sponsorship and supervision of the Sub-Committee on State and Local Health Administration of the Committee on Administrative Practice of the American Public Health Association.** -99-9, *Field Staff: Carl E. *Buck, Dr. P.H., Field Director Rosooe P. Kandle, M.D., Associate Field Director **Members of the Committee on State and Local Health Administration Ira V. Hisoock, Sc.D., Co-chairman - Dean of the School of Public Uealth, Yale University, New Haven, Corm. George B. Darling, Dr. P.H., Co-chairman - Secretary of the National Acadew of Sciences, Washington, D.C. Gregoire F. Amyot, n.D., Provincial He,alth Officer, Victoria, B.C., Canada Floyd C. Heelman, M.D., Secretary, State Board of Health, Topeka, Kansas Roland R. Cross, M.D., State Director of Public Health, SpringfieId, Ill, Martha K , Eliot, M.D., Mzdicul Director, U.S. Children's Bureau, Washington,D.C. Carl M. Gambill, M.D., Director Division of County Health Work, State Dept. of Health, Louisville, Ky. Vlado A. Getting, M.D., State Commissioner of Public Health, Boston, Mass. Benjamin G. Horning, M.D., Field Dirtictor, W.K. Kellogg Foundation, Battle Creek,, Mich. Joseph W. Mountin, M.D., Director of States Relations, United States Public Health Service, Washington, R.C. George T. Palmer, Dr. P.H., United States Public Health Service, Washin&ton,D,C. Carolina R. Randolph, Director of Studies, Division of Public Health, the Commonwealth Fund, N.Y.C. Hugh B. Robins, M.D., Director Calhoun Crsunty Health Department, Battle Creek, Mich. Clarence L. Scamman, M.D., Director Division of Public Health, the Commonwealth Fund, N.Y.C. John W. Shackelford, M.D., Assistant Health Officer, Memphis-Shelby County, Memphis., Tenn. Felix J. IJnderwood, M.D., Executive Officer, State Board of Health, Jackson, Miss. Henry F. Vaughan, Dr. P.H. (Consultant) Dean of the School of Public Health, University of Michigan, Ann Arbor, Mich, 1. The statements in this report are those of the field staff and do not necessarily represent the opinion of the American Public health Association or its Sub-Committee on State and Local Health Administration. The field staff acknowledges with deep appreciation the splendid assist- ance of Dr. Roy L. Cleere, the Executive Officer, and the members of the State Division of Public Health and the State Board of Health. The consideration and careful study which this report is receiving in the Health Committee of the Intorim Committee, through its chairman, Mr. Hubert Henry, is worthy of special mention. The interest and support of Mr. Harry Huffman, the Chairman of the Govern- or's Post-War Planning Committee, and the enthusiastic, sound, and untiring efforts of Doctor Florence Sabin, the distinguished Chairman of the Health Committee, and the members of her Committee, constitute the study's most important and far-reaching asset. The field staff is also deeply appreciative of the helpful advice and counsel given by Dr. Fred T. Foard, Director of District No. 8, of the United States Public Realth Service and by Dr. L. B. Byington, and Dr. Ii. T, Wagner, and Mr. C. T. 'irright, all of the United States Public Ifealth Service. This is essentially an administrative study, designed to suggest a simplification of administration and a more effective approach to the problem of encouraging and facilitating the development of full-time local health pro- grams geared to meet local needs. It makes no effort to evaluate the details of professional or technical procedures, Objectives of the Study The objectives of the study arc to reduce sickness and death rates in Colorado and to suggest ways and means by which the people of the state may enjoy the maximum of goad health, health over and above the mere absence of disease, To attain these objectives it seems pertinent to examine critically, but constructively, (a) The present plan of organization and administration of the state health service, (b) The extent and soundness of the development of local health services. (c) The effectiveness of the cooperation or working relationships betweenthe public health agencies (which are essentially, but not solely educational in character), and the medical, dental, nursing and allied professional groups (which groups provide the services for which the health agencies have created a demand.) 2. (d) The extent to which there are effective wuiking relationships between health departments (state and local) fnd other govorn- mental agencies and between them and the voluntary health agencies. (e) Last, but perhaps most important, the degree to which,the people of the state wderstand.the services which they should have for thexnselvos and their families in order to enjoy the maximum of good health. Understanding of Essential Health Services Upon these several factors depends the health of tho people. In its final rrnalysis the effectiveness of all the Other factors (u,b,c, and d) depend upon (e) the understanding of' the people as to what health protection and health promotion services they need for themselves and their families. It is this lack of understanding on the part of the people, (due to the failure to conduct a well plannod, continuous program of health education or health information) in Colorado, as in many other states, which is responsible for tho failure to provido the best in the way of health protection and hoalth promotion services. To use but a few examples. If you and I don't see the value of visiting a physician and a dentist regularly we won't do so. If ~~13 don't see the need for and vduc of protecting our children against such diseases as diphtheria and smallpox we will not have them protected. If we don't understand the value of adequate medical pre-natal, obstetrical and post-natal care for our wives we will not seek those services, If we don't understand that safe, potable water supplies, adequate, safe sewerage systems, and a clean, safely pasteurized milk supply, are essential for our health, we, of course, won't care whether anything is done or isn't done about them. If we don't reoog- nize adequate hospital facilities as a necessity we will not be concerned about their presence or absence. If we don't think w need physicians and dentists in our community we won't have them. If we don't feol that contin- uous adequate appropriations for medical education nre important we non't have the best of physici&,. If w don't recognize the fact that a strong State Department of Health (freed from political interference and permitted to progress on a sOund scien- tifio basis) and ndequatcly staffed full-time local health departmnts (also freed from political maneuvering) are essential to the stimulation and developrmnt of these facilities and services, we wn:;'t have them. To state the problem somewhat differently this means that the study should endeavor, (a) to determine &at types of organization, planning and program seem likely to bring about the greatest degree of good health for the people of Colorado, and, (b) to recommend such legislation and planing as seem necessary to obtain this objective. Some, perhaps many of you, may doubt that Colorado has any important 3. health problems which need solution. The fact that Colorado has the reputation of having a superior climate unfortunately seems to have resulted in people having a false sense of security; a feeling that, because of the climate, people in Colorado are healthy and therefore no special effort is necessary to attain or maintain good health. That this is a totally erroneous conception is Lamply attested to by the records which will soon be presented. It is to be hoped that this report will oonvinoe one, (a) that Colorado has some very important un-met health problems (b) that meeting these health problems sucessfully would constitute a tremendous asset to the state and, (4 will suggest practical mans (both in terms of legislation and administration) of so reducing Colorado's sickness and death rates that it will have a htinlth record of which it can be justly proud. Some Facts Concerning Colorado's Health Record We have said that the records will prove that it is a fallacy to think that Colorado is an unusually healthy state. Let us examine the death rates (rates per 100,000 population) fron certain o`~sses which are either prevent- able or controllable to determine how Colorado stands in relation to the other forty-seven states and the District of Columbia. The following table gives Colorado's standing, among the forty-eight states and the District of Columbia in 1936 and 1943, in deaths from certain causes which are preventable or controllable. Cause *Colorado Standing *Colorado Standing 1936 1943 Scarlet Fever Diphtheria Diarrhea & Enteritis Pneumcnin (all formsj Infant Mortality Acute Rheumatic Fever Premature Births Materndl Deaths Auto Accidents Syphilis Tuberculosis (all forms) Whooping Cough Typhoid C% Paratyphoid Average Standing 6 19 10 4 4 32 17 12 15 9 16 13 3 6 7 7 8 11 14 18 18 20 26 28 31 15 *Based on death rates per 100,000 population as published by the U,S, Census Bureau. Rates for Maternal Deaths, Infant hfortality and Premature Births are per 1,000 live births. The figure given for standing (such as 4. 14 or 16) indicates Colorado's position in relation to the other forty-seven states and the District of Columbia when 1 is the highest or most unfavorable rate and 49 is the lowest or most favorable rate. For example, in 1943 in Diphtheria death rates Colorado stood 6th, meaning that it had the 6th worst re- cord in the United States; 41 states and the District of Columbia had better records, The year 1943 is used since that is the most recent year for which complete data for the entire United States is available. The foregoing table shows clearly that Colorado has an unenviable record for these preventable or controllable causes of death. There has been a slight, but a very slight improvement since 1936. In 1936 Colorado had the 13th worst record and in 1943 it had the 15th worst r&cord which means that 33 states and the District of Columbia all have better records than Colorado. In 10 of the 13 causes listed Colorado stands on the unfavorable side of the ledger. The people of Colorado and particularly Chambers of Commerce and other groups who are looking to the future of the state's development would not like to have. these facts broadcast. Yet these figures, even if they are not publicized, are available to industries and individuals who may wish to locate in Colorado. Very recently the medical school had the possibility of obtaining a sub- stantial grant from one of the large philantropic agencies. The grant was not made because the'agcncy said, "There does not seem to be suff'iciont interest in public health in Colorado to ,iustiQJ the grant which you request." Vould it not be a very valuable asset if Colorado could truthfully say that it had ant of the best health records in the nation instead of having to rely upon platitudinous statements about its superior climate? The none-too-rosy picture which these figures portray can and should be changed. These are preventable or controllable causes of death and all that is needed to attain a really good health record is to establish and support an ude- quata State Department of Health, freed from political machinations and maneuvering,, and to develop adequate local health services through the institution of full-time city-county, county, or multiple county health departments, Thus far, we have been desoribing how Colorado stands in relation to other states on the basis of death rates, Let us for a moment examine the records to see what this means te Colorado's own citizens. The following table gives the number of deaths from csrtain preventable or controllable causes in the five year period from 194G to 1944. Deaths of Colorado Citizens from Certain Causes, 1940-1944 Preventable Numbor of Controllable Numbor rf Causes Deaths Causes Deaths Typhoid Fever 24 '. Tuberculosis (all forms) 2069 Diphtheria 106 Pnoumonin (all forms) 4071 Syphilis 490 Maternal Deaths 278 Rocky 1%. Spotted Fever 18 Premature i3irths 1773 Diarrhea & Enteritis 916 Accidents 4642, Whooping Cough 169 Total f833 Mea&es 106 Total -TTET Grand Total 14,662 5. These figures conclusively refute the theory that Coloradgans do not suffer from, or die from preventable diseases. These are Colorado oitizens - 1629 of them, who died from definitely preventable cau= and an additional 12833 who died from controllable causes, making a total of 14662 or an average of 2932 each year. All of the deaths from preventable causes, 1829, could have been pre- vented and at a very conservative estimate at least half of the deaths from controllable causes, 6416, making a total of 8245, could have been prevented had the knowledge which we already have concerning preventive medicine and health protection been universally applied throughout the state. This means that at least 8245 Colorado citizens are dead who might be alive today had we had well organized and adequately supported state and local health de- partments. An average of about 1650 unnecessary deaths each year is a big toll to pay for failing to provfde a&quate h8afth protection and health promotion services. &re& tf a human life were worthnslittls as $5000 the saving of 1650 lives woubl rcpresen9 &n anntad saving of $8,250,000. As you will note, these estfragtes take no account of the misery, suffering and,economic losses which result Strom these same preventable or controllable . causes which do not end in death. (For more detailed information on deaths by suggested health districts and by counties sot Appendix A.) With such appalling, unnecessary losses, wouldn't reasonable appropria- tions for, and adequate support of good state and local health departments be a sound investment if such health departzents can, and we know they can, produce such savings in terms of life and health? The total amount of money spent in Colorado is insufficient to provide the health protection and health promotion services which the people need and ought to have. Public health budgets for 1945-1946 in Colorado total $751,799.00 or 68.3 cents per capita.* This amount includes the budget of the State Division of Public Health and the budgets of the various counties which are receiving some federal financial, aid through the State Division of Public FIealth. It does not include local funds expended for public health in Denver and Pueblo. (This information appears not to bo available.) The State Division of Public Health has $412,682.41 to spend ($475,060.97 1 es8 on estimated income of $62,378.50 which goes back into the general Fund.) or 37.5 cents per capita, Of this amount, .$107,384.00 or 9.8 cents per capita is from state tax funds, 17.8 cents from the U.S. Public Health Service, 8.3 cents from the U. S. Children's Bureau (making a total of 26.1 cents of federal funds) and 1.6 cents from other sources. Considering county health budgets we find that 52.3 porccnt of these funds are *from local health sources, 31.5 percent from the U.S. Public Health Service, and ltj.2 percent from the 1J. S. Children's Bureau. Got a cent of state money is available for assisting in the maintenance of local hcalti departments. Considering the source of funds of the total health budgets (State Div. of Public Health-and county budgets receiving federal financial aid) we find that only 14.3 percent of the money comes from state fmds, 23.6 percent from local tax funds, 40.2 percent from the U.S. Public Health Service, 19.5 per- cent from the U.S.Children's Bureau (making a total of 59.7 from fedora1 sources) and 2.4 percent from other sources. *Based on M estimated population of l,lOO,OOO. 6. There are three significant facts in these figures. First, Colorado is not spending enough from all sources to secure adequate health services. Second, the state, through state tax funds, is not assuming anything like its rightful responsibility for public health, only I? percent of tho budget being state money. Third, the actual total of state tax funds being devotod to health is 9.8 cents - think of it - less than 10 cents per capita. How does Colorado's contribution, through state tax funds, to total state health expenditures compare with that of other states in this region? As already stated, state tax funds in Colorado represent but 14 percent of total state health expenditures, In Wyoming, state tax funds amount to 22 percent cf all health expenditures in the state, in Idaho 23 percent, in Nontanu 35 percent and in Utah 43 percent.* The fact that Colorado stands lowest in its percent contribution to public health, in ccmparison with its neighboring states, is amazing v&en ono consi,-lers how strongly Coloraclo champions states' rights. 11s far as wealth is concerned, Colcrado is rmch better able to contribute a sub- stantial proportion of its total health budget than any of tho other states with VJlich it is compared; yet its percent contribution is considvrably less than any of its neighbors. (For more dctailed information concerning health expenditures see Appendix B.) Before discussing specific rocox:mlendations for the improvement of Colo- rado's health record it would seem pertinent tc mention sr:.le of the assets c7r strengths of the present health situation in the state. Strengths The State Division of Public Health is fortunate in having a well trained, capable health administrator as its executive officer. The Division of Labcratories, with its Central Laboratory and three brunch laboratories, is capably administered and is rendoring valuable service to the state. The Division of Public Health Nursing is well administered and sctund in its planning. The Division of Venereal Disease Ccntrol is in capable hanils and is probably the most highly developed service in the State Division of Public Health, The Division of Tuberculosis Control, mrking in cooperation with the State Tuberculosis kssccintion, has a well formulated plan which is making ccmmendable progross. Tho State Division of Public Health has two well trained medical social workers. The Division of Public Benlth Dentistry was quite well developed and pro- gressive in its planning but because of vacancies the Director of Dentistry has been obliged tc act also as Director of Maternal and Child Health, the E.M.I.C. program anl Crippled Children, which obviously has interfered with the normal development of the dentnl program, *Based on burlgets for the year ending June 30, 1346. 7. Colorado has a strong State Tuberculosis Association rhich, with its affiliated societies and committees in the various counties of the state, constitute a very valuable public health asset. The Denver Publie Health Council, tith its unusually strong membership, can and should have a very powerful influence in bringing about a sounder and more effective health organizational and administrative plan for the state as a whole, even though it has, thus far, been relatively ineffectual in improving the official health services in the City of Denver. The Governor*s Post-riar Plarnzing Committee, through its Chairman, Mr. Harry Huffman, has indioated an interest whioh can be very helpful to the future of public health progress izt Colorado. The Bealth Committee, of the Governor's Post-War Planning Committee, chairmanad by Dr. Florenoe Sabin, the distinguished scientist, is unquestion- ably the most potent and hopeful asset to effeotive public health effort in Colorado. Major Public Health Issues and Recommendations Designed to Meet Them The most important weaknesses affecting public health in Colorado and the recommendations which, if put into effect, will correct them are: The Place of Health in State Government The most important weakness in state public health organization is that at present public health is a division of the executive branch of government under the direct control of the governor. The health of the people in any state is altogether toa important to place it in State Government in a position to be so oompletely susceptible to political machinations and maneuvering, {If one does not believe that public health in Colorado is susceptible to, and is being politically maneuvered, there is plenty of evidence to prove it,) Public health must be completely freed from political interference and permitted to develop and-gress on a sound scientific basis. It is therefore recommended: (1) THAT THE DIVISION OF PUBLIC HEALTH BE TAKER OUT OF THE ADMINISTRATIVE BRABCB OF STATE GOVERIWEBT AND IQ'%DE A DEPARTMENT OF HEALTH COMSISTING OF TWO BRAKCHES, THE STATti BOARD OF HEALTH AS THE ADVISORY, COIJSULTATIVE, JUDICIARY, BUT NdT EXEXUTIVE BRANCH, AND THE STATE HEALTH OFFICER AND HIS STAFF AS THE EXECUTIVE B@WX. THE DEPARTMENT OF IIEALTH SIIGULD COIJSIST OF SUCH DIVISIONS AND SECTIONS AS THE STAT,4 BOARD OF HEALTM SHAIL~DECIDE. DIVISIOWS AND SECTIONS OF THE DEPARTMEIJT PWY BE ABOLISIiED OR ADDED AT THE DISCRETION OF THE BOARD. A bill should be introduced to make possible this fundamentally important change. The great majority of our states now have departments of health constituted essentially as suggested in the foregoing recommendation. (SW also recommendation 4 concerning the reorganization of the State Board of health.) Selection and Bnployrent of Personnel The next most important weakness lies in the present system of selecting and employing personnel. No person may be placed on the state payroll until he or she is accepted by the State Civil Servioe Commission. This plan would seem to be in accord with good administrative pr:i-:ictice but the Civil Service Commission is oomposed of three members Politically appzaed by the Gove.rnor for long overlapping six year terms of office. The members of the Commissjon are paid salaries and thus the Commission is an executive body rather than an advisory, judiciary, regulatory group. lkmbers of the Commission need have no special qualifications fcr the positions to which they are appointed. The Commission (Probably because it is a Paid rather than a non-paid Commission) does not have an appropriation which will permit tht. employment of an adequate staff of trainad per;;onnel. Tht ant? trained person whom it does employ is not given the authority and backing to do a good job. he does not attend meetings of the Commission at vuhich appointmonts are discussed and made. It would appear that his recommenaations are accepted when they coincide with what the Commission wants, or is told, to do,and ignored when they do not. To date, no examinations have been hold for professional iTersonne1. This is understandable because of the scarcity of professional personnel during the war but it is still in no position to give adequate, fair examinations for professional personnel. The Commission is certainly not in a position to give such examinations nor does it i.ave the trained staff to do so. Many of the clnssificutions ado;jted by the Commission arc extrornely faulty, meaningless and confusing. The salary scales, or one should say salaries, bucausi, thcro ure no salary scales, for professional personnel are among the lowest in the entire United States. The Civil service Commission instead of being an agency for the recruit- ment and employment of properly qualified persons actually is a formidable barrit;r to the procuremtint of good people. The Colorado Civil Service System is a disgrace to the state. Civic minded persons ho huve an interest in good government ought to circularize a petition for the: tibolition of the presant Civil Sorvice system and its complete reorganization, Unless public heulth'can be freed from politics by establishing a real State Department of Publi c Kenlth and by completely reorganizing the State Civil Service system, there is little hope of improving Colorado"s none-too- enviable health record. The State Division of Public Health has an alarming number of important vacancie s. At present (January 1946) there are six principal administrative positions vacant witi1 another certain to occur in the very near future. These positions are Director of Xaternal and Child Iicalth, Director of Crippled Children's Service, Director of Epidorniology, Director of Local Health Ser- vices, Director of Public Health Engineering, Dir<.:ctor of Industriul Hygiene and, to be vac::nt very soon, the Director of Labors*torics. This is by far the greatest number of import;uzt vacancies which your surveyor has found in any state, Granted that there is a scarcity of trained professional personnel 9. this alarming and unusual number of vacancies is unquestionably due to poor salaries, the lack of a training program in recent years, and the totally unnecessary and unwarranted barriers to obtaining appointments of qualifisd personnel. It is recommended: (2) THAT THE SELECTIOP ARD EMPLOYhlENT OF P&WUiU?FlL IN THE STATE DIVISION OF PUBLIC HEALTH ( RXOXXiDi.lD TO BE $IU STldE DX'i&T;&I.TT OF fw<fI ) BE TRANSFERRED FROM TIM STATE CIVIL SERVICE COX%ISS1011 TO THE STATE BOARD OF Since the State Division of Public Health receives End expends funds fram the United States Public Iionlth Service and the United Stntss Children's Bureau the merit system established by the State Uoard of Bealth would, of course, have to meet the approval of those fedora1 agencies. If this transfer of the function of selecting and employing personnel cannot be effected then it is recommended: (2a) THAT THERE BE A COMPLETE REORGAIiIZATION OF THE STATE CIVIL SERVICE SYSTa$. THE: CIVIL SERVICE COA0~ISSIO~~, CONSISTIIJG OF FIVE MEMBERS, SROULD BE APPOIHTED BY THE GOVERNOk ON A NON-PARTISAN BASIS, FOR FIVE Y&R S'J.AGGmED TERMS OF OFFICE. THE C~JKISSIOIJ SHOULD BE AN ADVISORY, JUDICIARY, kEGULATORY, BUT NOT AX EXECUTIVE BODY. MEKBERS OF THE CIVIL SERVICE C@Ji!IISSION SHOULD SERVE WI TROUT COMPE1?SATION EXEPT FOR NECISSSARY E,X'~BSES IWJRRED IN CONNECTION WITH THEIR INTIES. THE COMI:ISSIOIJ SUOULD, IUJ'V~VER, BE GIVEN 1&N APPROPRIATION The Civil Service Systom should be essentially a recruiting agency for qualified personnel. The fundamental necessities for its success are: (a) That the Commission be non-political. (b) That it establish proper classifications for positions to be filled. For oxample, Public Health physicians grades 1, 2, 3 and 4; Bacteriologists grades 1,2,3 and 4~ Public Health Nurses grades 1,2,3 and 4; Public IIcnlth Dentists grades 1,2, 3 and 4; Public Health dnginecrs grades 1,2,3 and 4, etc. (c) That it establish adequate qualifications of training and experience for the various broad classifications established and write job specifications for individunl positions to be 10. filled as the only assured method of obtainingAthe"right person for the particulur ,job. (d) To institute salary scales which will enable the Department of Bealth to recruit and retain adequately trained personnel. It is impossible to do this at present because of the very faulty system of classifisa- tions and the totally inadequate salary scales. (e) That the Civil Service Commission establish a retirement age with retirement permitted at a certain age , probably 60, and required at say 65. The same principles as have just been onumernted should of course be observed by the State Board of Health if it &vclops its own merit system. Legislation should be enacted to provide for this very important change. If a constitutional amendment is necessary, civic minded prsons throughout the state should join together in circularizing a petition to place the ques- tion on the ballot at the next general election. Local Health DC:partments There are at present only four full-time local health departments in Colorado and three of those tire now without full-time health off'iccrs. There is neod for local health department legislation which will encourage and facilitate the development of City-County, County and Multiple County full- time health departments in general accordance with the plun as outlined in Local iicalth Units for the Nation.* It is thcrcfore recommended: (3) TI%T A PERMISSIVE LOCAL HEALTH BILL BE ENACTED KHICH i'lILL PERXIT MJD FACILITATZ THE DLV~OPXtiNT OF CITY-CGUXTY, COUNTY i:rsU MJLTIPLE COUNTY FULL- TIIIE X<H DEPARTWlJTS WITiI A SIIdGLB BOARD OF HEALTLI. AND 11 SIUGLti FISCAL AGZNT FOR EACH AR% OF JQXLTH JURISDICTIOB. THE BILL SHOULD FURTHER PROVIDE TINT kHY CITY CR CITIES OF I.,ZSS THAN 50,000 POPUL6TIOX (AS GIVEIi 18 T1f.E MOST RECEIJT OFFICIAL U.S. CENSUS BURXAU REPGRT) IN AKY COBTL?:PLATED COUNTY OR WJLTIPLE COiJNTY !i&lLTH DEPART?!i;'NT SHOULD ilUTO!'ATICA12LY BbCOKE AN INTEGRAL PART OF SUCH HZALTR DEPARTF.XIJT. THE BILL SHOiJLD ALSO PROVIDE T&T A1lY CITY OF OVER 50,COO POPULATIOIJ E:iiY EL2CT TO CO1.2 I!u' OR STAY OUT OF THG CONTtiflIPL- ATED COUHTY OR WLTIPL,E W`UNTY HEALTH DZP1~RTEIENT PROVIDED, HOWVER, T&U' IF *Local Health Units for the Xation, Published by the Common-wealth Fund, Hew York, N.Y., 1945 11. IT ELECTS TO STAY OUT IT I?KJST ?&iIWTXiI A FULL-TIME HEALTH DWXHTKENT WITH LISIIED BY TBE STATE BOARD OF HEALTH. (See Appendix C for a more detailed discussion of the provisions which should be included in the bill,.) The suggestions concerning the inclusion, or exclusion, of cities of under or over 50,000 population are based on the premise that it is uneconomical for places of under 50,000 to have full-time adequately stsffed health departments and that communities of over that size should be required to provide full-time health service. The State Board of Realth The StfLte Board of Health should be reorganized. (This statement has noth- ing whatsoever to do with personnel but rather with functions and composition.) The composition of the State Board of Health is faulty and its functions are n& adequately or satisfactorily defined. There are nine members of the Board (which seems an unnecessarily large numbar)'and tile Secretary of the Board and tixecutive Officer of the Division of Public Iiealth is a member of the Board and is elected to that position by his follow members, The quul- ifications for the Executive Officer of the State Division of Public Bealth are inadequrlte. The qualifications are merely that he be a physician licensed to practice in Colorado and bo experienced in public health work. This latter phrase is obviously indufinite and relatively meaningloss. Xhile it might never happ311, with the present plan, it would be possible for the governor or succeeding governors to appoint .a State Board of Wealth of eight laymen and one physician. That physician regardless of the fact that ho might not halve any real knowledge of public health would have to be elected us State Health Officer. It is recommended: (4) TEAT THE STATE BOARD OF HEALTH BE CCKPOSED OF LITHER FIVE OR SEVEiJ h93IBERS APPOINTED FOR REASOIJABLY LOXG OVERLAPPING TER!!S OF OFFICE. IF TIIE; BOARD IS TO BiZ A FIVE I%Z.!BER BOARD THE TZRXS OF OFFICE SHOULD BX FOR FIVE YEARS; IF OF SLrVEN I.lE%BCRS, THE TERZS SEIO'ULD BE FOR SEWN YEARS. THE ORIGINAL APPOINTIMNTS SEC032 AT T';?O YEARS, ETC. AT ITS FIRST bl&ETIXG T!IE BOARD SHOULD Di2T,3%INE BY SHOULD BL: FOR FIVE OR SEVEE YZAR Ti;R!..lS AS THE ChSd IlAY 52. L'il.CNBCRS OF THE BOARD SHOULD BL' APPOIITTED BY THi: GOVdRNOR OK A Iu'O$Jv'-PARTISM BASIS. Hi3GARDLESS 12. OF THE SIZE OF TIIE BOARD NO BUSINESS OR PRCFESSIONAL GROUP SHOULD COIJSTITUTE A !lAJORITY OF S'IJCB BOARD. L4EMBERS OF THE BOARD OF HtiALTH SHOULD BE AFPOIPJTED 01: THZ BASIS OF THEIR 'INTEREST-Ii1 CIVIC AFFAIRS AIlD IIGT BW'&SE OF ANY POLITI- CAL AFFILIATIOB. MEMBERS SIIOULD SERVE WITHOUT R2WJNERATIOiJ EXCEPT FOR EX- PENSES IUCURRED IIJ CONlJECTIO!L WITIi THEIR DUTIES. THE BOARD OF HEALTH SBOULD BE THE ADVISORY, COlJSULTATIVk:, JUDICId?Y, BUT NOT THE EYdCUTIVE BRAlJCH OF TIIE STirT'r: DEPARTMENT OF LlCALT?l. THE STAT2 HlhL~TIf OFFICER AND HIS STtLFF siio:iLD COlJSTITUTE THE l:XECUT IVE BRdKJH OF THE DdPkRTl~WrJT. THE STATE fI<El OFFICtiR OR STilTi; DIH1.?,CTOR OF Il1~ALTJ-J SHOULD B5 Wi'OINTED BY THE STATE BOARD OF FIEALTii FOR h FIVE YtiAR TEJM OF OFFICE PROVIDklD, HOWEVER, THAT BE MUST MEET TUti QUALIFICATIOl*'S FOR 3:CH OFFICL: F1EREIIJAF'i'l:R ENUMERATED. IF IT IS IMFOSSIBLE TO PUT IIJTO EFFECT TH2.S R~COI~li:~~I~DXTIOEJ THE STliTE IiE&TII OFF'ICi3 9R i>IHdCTCR OF HEALT! i SBOULD BE APPOIlJTED BY THE GOV~WJOR, ON THE H~COhlMCl~DATIOl~ OF TJ-l.li STAT2 BOAHD.OF I-ICALTiI, FOR A FIVE YL;& TERM OF OFFICE + HE SHOULD BE ELIGIBLE FOR I~~APPOIIJ'TliK~lJT AT TII8 DISCRETION OF THE APPOINTIVZ AGENCY (THE STATE BOARD OF HEALTH OR THE GOVkMOR ON THi3 RECOLJl~;ENDBTION OF TEE BOARD OF HEALTH.) THE PRINCIPAL FUNCTIONS OF TBj: STATE BOARD OF HEALTH SHOULD INCLUDE: (a) TI1.!3 APPOIl?TL"liQJT OF THE STATE H<H OFFICZI:. (b) 013 TM R~CO3f3JDATIO~J OF TEiE STATE lii2~.TH OFFICZR, TO PASS SUCH RULES AND ~iE;GUihTIUMS hS IT DEEMS :JECESSAKY AND ADVISABLE FOR THE PRO'i'~~CTIOIJ AND PROMOTION,OF TI-11: PUBLIC Hi:ALTH. SUCH RuI,dS AND HEGULhT IOIJS SHOULD HAW THlI dFFECT OF LAW id LONG h8 THEY AiiE NOT III CONFLICT 'dITH l3XISTIMG LEGISLATION. (c) TRE RESPOIJSIBILITY FOR SEEING TO IT THAT THE STATE HEALTH OFFICER EIJFOCCES STATE HEALTJl LAWS, AND RULES AlJD REG'JIATIOIiS OF THE STATE 13. BOARD OF HEALTH. (d) TO HOLD HEARINGS FOR EMPLOYEES, COMPANIES, CORPORATIONS, OR INDIVID- UALS WITH ALLEGED GRIEVANCES AGAINST THE STATE DEPARTn!EZJT OF HEALTH WHICH ALLEGED GRIEVANCES CANUOT BE SATISFACTORILY DISPOSED OF BY THE STATE HEALTH OFFICER. DECISIONS OF THE BOARD SHOULD BE CONSIDERED FINAL. Legislation should be enacted Foviding for such a Board of Health as has been recommended in the foregoing paragraphs. Qualifications and Functions of the State Health Officer As previously indicated the provisions concerning the qualifications of the state health officer are weak and relatively meaningless. It should be borne in mind that public health is a definite profession with specific qualifications. A doctor of tncdicine is not qualified to be a health officer unless ho or she has had training and experience in public ht>alth. A nurse is not a public health nurse unless she has had special training and experience in public health. An engineer is not a public health engineer simply because he is a graduate engineer. It is important that we recognize these facts if we are to keep public health out of politics and obtain properly qualified personnel to carry on our health services. It is recommended: (5) THAT TO BE ELIGIBLE FOR APPOIIJTBIEIJT AS SThTE HEALTH OFFICER OR DIRECTOR OF HEALT!i A PERSON SiiOULD BE A GRADUATE OF A GRADE A 1iEDICkL SilIiCOL AND BE ELIGIBLE FOR LICENSE TO PRACTICE IN COLORADO. HE, OR SHE, SHOULD HAVE HAD AT LEAST ONE YEAR OF POST-GRADJJATE CURRICULAR WORK IN A?J ACCREDITED SCHOOL OF PUBLIC WALTH AKJ AT LEilST THREE YEARS SUCCESSFUL EXPERIENCE IN A FULL-TIME ADElINISTRATIVE POSITIOIJ III AN APPROVED J-ZZBLTR DEPARTMENT OR OTHER HEALTH AGENCY. IN LIEU OF THE YEAR OF POST-GRADUATE WORK IN AIJ ACCREDITED SCHOOL OF PUBLIC HEALTH ONE SHOULD BAVE ITAD A TOTAL OF r\T LEAST FIVE YEARS SUCCESSFUL EXPERIENCE IN A FULL-TIME ADMINfSTRATIVE POSITIOIJ IJJ AU MTROVED IH.JQLLTH DE- PARTMENT OR OTHER REALTIJ AGENCY. (THE QUESTIONS OF SUCCESSFUL EXPERIENCE AND APPROVED BEALTH DEPARTEEIJT OR OTHER HZALTII AGEJJCY SHOULD BE DECIDED BY THE STATE BOARD OF HiZALTH.) QT~ALIFIC~ITIOK~ ESTABLISIIED BY TIj.E i%WIT Oil CIVIL SE;cVICE SYSTE?;. TiX STATE liZAL,TfI OFFICEii: SliOilLD BE itESPO;jSIBLIG, r?I'fI-Zli i'iZI:SOIJALLY OIL BY STATE BOt'GD OF HEALTTI. (This recommendation should be included in state legislation.) The Milk Supply At present the legal responsibility for milk and other dairy products is with the Department of Agriculture. The control of the public health aspects of milk and milk products is r: basically important public hcnlth function which should be vested in the health department. It is therefore recorznended: (6) TI?.AT TIZ PUBLIC :IEALTII ASPCY'CTS OF T!IE COIITliOL AI\TD SUPEiiVISXOI'J OF MILK (This recommendation could be "gentlemen's agreement" effected either by legislation or by a between the Departments of Agriculture and IIeulth.) The success,%1 and affective control and supervision of the milk supply will depend 1 rrrgo.1~ health departments. on the establishment of full-time adequately staffed local State Tuberculosis Sanatorium There is an insufficient number of beds for the cart of the tuberculous and a number of the institutions for tuburculous arc not equipped to provide anything more than custodial care. A recent study by the United. States Public Zonlth Service recommends the establishment of a State Tuberculosis Santitorium of from 300 to 400 beds, to be erected on the grounds of the University of Colorado i.ledicul School. In this recommendation rz must heartily concur. This would seem to be a paramount need if Colorado's pressing tuberculosis problem is to be met satisfactorily. 15, It is rucommendedt (7) THAT A STATE T-UBkXCULOSIS SANATORIUM OF FROM 300 TO 400 BEDS B% EiitiCTi2D 01,: THE GROUNDS OF THE UIIIVEi~SITY OF COLOM)O ~IIXDICAL SCHOOL f&D, TO ASSURE TIiX FIJLFILLME~JT OF ITS MOST iJSCFUL IlOL% II? RELATIOR TO THi2 2NTIiiE TUBi2itL:ULOSIS COIITROL P~iOGiW, IT IS FITKTREi.: R1:COkUiEI?DED TIiAT: (4 (b) (4 THE STATE TUBERCULOSIS SAiJATOHIL$I BE CLOSELY ALLIED TO TILE UMIV8RSITY OF COLOitADO MEDICti8 SCXOOL, IN Oi:D&Z THAT IT MY BE USED AS AN IbIPOltiTANT TEACNIU'G C2HTER. TI5.2 STATE TUBERCULOSIS SAKATORIU'bl BE ESSENTIALLY FOi[ TIiE CAkE OF THOSE TUBERCULOUS PATIEYJTS WXO :IEXD SPECIAL TUBERCULOSIS SlXGZRY 02/AND ADDITIOKAL !\.;EDICAJ., CM Sm;GICAL S2WICGS NOT AVAILABLE AT OTHEiI TUBER- CULOSIS INSTITLJTIO1~S. THE STAT3 DEPhilTYZJJT OF iiE:ALTli Iihvi: A T~@tii&CtJI,OSIS CCQ!@TltOLLEil WI0 SI!OULD, IIJ GEidi?&L, B2 X!XPOijSIBL$ FOR THE 2:BTIi(E STATA PltOGIW,! OF TUB%iiCULOSIS COKTROL AND l.lO;iti STXCIFIMLLY 96 iiESPOI;SIBLE FOR: I. ALL OUT PATISKTS SGEiVICXS XSTAilLISHED BY TiiE STliTii: DdPAi~TI.dXT OF IIZALTII. II. THE -4DKISSION TO i'diD DISCiHAi:G% F2Old THE PROPOSED STi';TZ TUBER- CULOSIS SAHATOHIUN d:ID ALL OTfiEI: IBSTIT'UTIONS, CI&iiIG FOR THIi: TUBl%CULOUS, WHICH A2.E SUBSIDIZED BY TIlE STATE. I]Ci.Tm ESTABLISH~~J~~T OF (SUBJECT fro Tm mmovia 0~ TRE STATE HEALTH OFFICEI: AND TIfE STATE BOf&D OF ll%LTH) kIINI?2Uib! I:l.JLES ND i?XGmA- TIONS, FOR ALL INSTITUTIONS ilECEIVI!JG STATE SUBSIDY FGi: TlIE CARE OF THE TUBERCULOUS AliD TlIE E~JFORCELIEJJT OF SUCII RUL,ES Af*'D REGULA- TIONS. 1JO Il%.TITUTIOil CMIIJG FOI: THE TlJBE2CULOUS SHOULD RECEIVE ANY STATE 02 FEDiW~L~ SlJBSIDY BLESS OR -UNTIL IT I&S BEEN AP~M!~ED _--- BY THE TUBEitCULOSIS CO&T~;LLLER. (This recommendation will require legislation.) 16. Water and Sewerage Colorado has many-unsafe or potontially dangerous water supplies and there are very, very few adequate scwags disposal plants. Legislation with respect to public water supplies and sewerage systems is not adequate to assure full protection for these public health essentials. It is recommended: (8) THAT STATE LEGISLATICIJ XTB hESPECT TO WATE11 AND SE&'ERAGE BE SC STilXJGTHENED AS TO IIJSUiti TO TIIE PEOPLE OF COLOXADO: (a) SAFE, POTABLE WATER SUPPLIES (b) hD3&iATE, SAFE SEWEitiGE SYSTti;T:S. (See Appendix D) Public Health Training Colorado should be training public health personnel in accredited schools of public health. Funds are available for this purpose but the present state administration has refused to permit training outside of the state and at present there is no school of public heulth in the state. Because of the governor's attitude it has been difficult if not impossible for nurses in the state service to obtain public health nursing and training even in the state. This failure to train personnel in the past several years is now a serirus drawback because there is absolutely no backlog of trained persons. It is strongly recommended: (9) THAT CIILOBADO IXXEDIATELY BE-ESTABLISII ITS Pi1OGiMI i)F TMINIIJG PUBLIC IIEALTI! PEI&.XJFEL, BOTII KITBIN THE STATE AND $B&:ti iJ.WESSAliY OUTSIDE TIiE STATE, AS THE CIJLY LOGICAL MEAIr'S OF ASSlJkIIJG hilEQUf~T1:Ly QUALIFIED PEilSCI@?EL FIX PUBLIC HEALTB SEWICE I11 TIIE STATE. The present exceptionally large number of vacancies in the state health service is ample testimony as to the need for such a training program. (This recommendation requires no legislation, merely a change of attitude on the part of the state administration. Ifealth Education At present there is no Division of Health Education or any trained health educator in the State Division of Public Health. As previously stated, the future of public health progress in Colorado will dcpond largely upon the extent to which there is widespread understanding of the health protection and health promotion services which they should have for themselves and their families, There should therefore be a Division of Bealth Education, with 17. adequately trained- personnel paid decent solaries, carrying on a continuous year-around program of health education or health information. Doctor Sabin's Health Committee CM and should constitute the backbone of the finest kind of health education program. It is recommended as one of the very fundamental essentials of good publio health service: (10) TBAT A DIVISION OF WALTH EDUCATION WITH A WELL QUALIFIED Al?D WELL PAID DIRECTCX3 BE ESTABLISHED AT THE EARLIEST POSSIBLE OPPORTUNITY, (This recommendation does not need legislative action; merely a change in tho attitude of state administration.) Medical Education In its final analysis the health of the people of any state or area will depend upon four major factors: (a) Full-time adequately staffed and decently paid state and local health departments. (b) A sufficient number of well trained physicians. (c) Adequate, modern hospital facilities. (d) A general understanding of the noed for and value of these facilities. All four of these factors need further development. Colorado has a well organized and administered medical school v&ich, however, has not always had sufficient appropriations to do the job of which it is capable. The State Tuberculosis Sanatorium (alreudy recommended) should prove an aid to medical education. It is greatly to be hoped that effective working relationships between the University of Colorado Medical School and the Denver General Hospital can be brought about. Some plan might be worked out by which the City of Denver would own (as it now does), and operate the hospital from the standpoint of house- keeping, general administration, and the control of admissions and discharges, and would finance the resident and interne service and the University of Color- ado Medical School would furnish the medical and surgical service including the visiting medical staff and the appointment of residents and internes. (Th is is very similar to the plan now in operation at the San Francisco Hospital.) At present there is no school of public health between California and Michigan. There has been considerable discussion concerning the possibility of establishing such a school in Colorado. It is to be hoped that a dchool of public health in the University of Colorado can and will be established and it seems probable that the Committee on Professional Education of the American Public Health Association will so recommend. The successful operation of such a school of public health will depend in no small measure on the stabilization nf a sound, progressive state department of health and the establishment of a well organized, adequately staffed, and ade*ately financed Field Training 10 Center either in 'or near Denver or in a community not too far distant from Denver and Boulder. It is recommended; (11) THAT A SCIiOOL OF PUBLIC HEALTH BE ESTABLISBED IN THE UNIV?JRSITY OF COLORADO. It is also strongly recommended: (12) THAT THE PEOPLE OF COLORADO GIVE ACTIVE SUPPORT TO THE PROCUREWNT AND MAINTEIWCE OF ADEQUATE APPROPRIATIONS FOR THE COLORADO MEDICAL SCHOOL AND ITS HOSPITALS AS THE ONLY ASSURED KEANS OF OBTAINING THE BEST TYPE OF PHYSICIAZJS FOR THE&SELVES ARD THEIR FXKILIES. (This recommendation needs widespread public support to obtain necessary legislative action.) Although the State Division of Health has worked closely with the State Nutrition Council there is no trained nutritionist in its (the Division of Health) personnel. Nutrition is altogether too important as a basic health need to be so neglected in a state health service program. It is recommended: (13) THAT A JL'LL TRAIZED NIJTRITIONIST, PAID A DECENT SALARY, BE ADDED TO THE STAFF 0F THE STATE DIVISION 0~ PUBLIC HEALTH (REC~~EIJDED TO BE TRE STATE DEPARTZENT OF HEALTH.) As previously pointed out state appropriations for public health are very meagre and inadequate; less than 3.10 per capita and only 147: of the total health budget. It is therefore recommended: (14) THAT MORE ADEQUATE STATE TAX FUNDS BE APPROPRIATED FOR PUBLIC HF&TE TO; (a) INCREASE THE SALARIES OF PROFESSIONAL PUBLIC ,BEALTH PERSOIJNEL IN THE STATE DIVISION OF PUBLIC HEALTH (RECOMIWDED ~0 BE THE STATE DEPARTBIEBT OF HEALTH) WICH PERSONNEL 'KILL GIVE CONSULTATION ADVISORY SERVICE TO LOCAL HEALTH DEPARTMEWS AND (b) TO ASSIST LOCAL AREAS 111 DEVELOPIHG FULL-T7R:E ADEQUATE LOCAL BEALTH,SERVICES, 19. Hospital facilities, in certain areas of the state are inadequate or non- existant. A survey now being made by the State Division of Public Health, with personnel loaned by the United States Public Health Service, under the sponsor- ship of the Health Committee of the Governor's Post-War Planning Committee, will make recommendations for a state-wide hospital program. These are, of course, not the only needs which should be met but they do, we,believe, constitute the more important basic needs which can only be met satisfactorily by a comprehensive and enlightened understanding on the part of the people throughout the state. Vhile it is realiced that this group is naturally essentially concerned with its own health problemsi we ass&e that it also has an interest in the basic health needs of the state as a whole. As a matter of fact thu kind and quality of health services which you will have in your own comnunities will depend largely upon the effective solution of these basic state-wide health needs. Xhether or not these recommendations are actually put into effect will depend largely on the active and enthusiastic support and backing of this group and the numerous agencies and organizations which it represents. Obviously many of these recommendations will require legislative action. If you decide to actively support these recommendations, as we hope you will, and the bills for their achievment have been satisfactorily formulated and if you are interested in the future health of Colorado, do not permit your legislators to be "pressured" into accepting amendments which will make the bills worse than useless. Doctor S&bin and her Health Committee, of which you are affiliated members, are relying very heavily on you people to bring about a health record for Colorado of which you can be justly proud, 2i;. APPENDIX A FIVE YEAR DEATHS AND DEATH RATES FROM CERTAIN CAUSES IN SUGGESTED HEALTH UNIT AREAS and deaths by counties Tablet, 1,2, and 3 *SUGGESTED IN LOCAL HEALTH UNITS FOR THE NATION PUBLISHED BY THE COMMONWEALTH FUND, NEiY YORK CITY, 1945. (1) UNITS Unit 1 2 3 4 5 6 7 a 9 IO II 12 13 I4 15 21,670 IO 26,81 I I2 64,626 39 27,075 33 44,641 168 31,318 I5 67,567 30 91,557 34 331,000 123 91,933 26 71,850 56 42,273 145 56,737 I14 59,904 31 59,989 61 1,089,351 907 8 4 19 I4 17 6 If 29 I66 20 23 25 23 0 13 388 3 0 1 3 2 10 I 1 2 I 2 4 I I 4 3' I 0 0 I 5 I I 23 5 2 7 0 0 5 5 0 14 4 I 8 I 0 4 I I I2 0 0 104 24 I8 3 3 8 6 21 9 2 5 IO 8 z 7 5 4 106 * THIS TABLE DOES NOT AGREE WITH COUNTY TABLE SINCE DEATHS IN INSTITUTIONS COULD NOT BE ALLOCATED TO PROPER UNIT POPULdT ION TABLE 1 DEATHS FROM CEkTAlN CAUSES IN THE FIVE YEAR PERIOD 1940 - 1944 * PREVENTABLE CAUSES CONTROLLABLE CAUSES m w ii Y 3 28 I02 143 6t I4 8 4 332 B 33 I86 146 122 27 I9 7 507 IO 93 369 293 lB3 64 61 23 993 15 73 253 t.26 133 50 20 II 593 15 227 569 162 287 35 13 22 1088 I 41 I46 158 130 56 32 12 534 5 49 260 249 204 96 67 13 889 IO 86 356 315 257 224 74 24 t250 24 353 134a 1287 1133 803 342 51 4964 3 64 347 3% 261 209 73 23 1269 13 119 412 291 247 108 62 I4 I I34 25 220 534 238 307 100 37 25 f241 t6 169 398 307 125 90 53 25 998 14 64 288 229 133 45 70 I5 700 7 97 368 241 177 79 41 9 915 169 ti'i6 5936 4541 3760 2000 972 278 17,487 (I) THESE UNITS ARE THE HEALTH UNIT AREAS SUGBESTED IN LOCAL HEALTH UNITS FOR THE NATION, THE COMMONXALTH FUND, NEW YORK CITY, 1945 fl) UN IT Unit I 2 3 4 2 7 8 9 IO II 12 13 14 15 RATE FOR STATE POPULAT 1 ON 21,670 26,811 64,626 27,075 44,641 31,818 67,567 91,557 331,000 91,833 71,850 42,273 56,737 59,904 59, $89 I ,089,351 TABLE 2 DEATH RATES FROM CERTAIN CAUSES IN THE FIVE YEAR PER100 1940 - 1944 PREVENTABLE CAUSES CONTROLLABLE CAUSES 9.2 7.4 2.8 0 44.8 132.0 56.3 12.9 7.4 I.8 9.0 3.0 2.2 1.5 66.0 108.9 91.0 20.1 14.2 2.5 12.1 5.9 3.1 9.3 52.5 90.7 56.6 19.8 IS.9 3.3 24.4 IO.3 1.5 0.7 73.8 93.1 98.2 36.9 14.8 3.2 75.3 7.6 I .a 0.4 112.6 72.1 128.6 15.7 5.8 4.4 9.4 5.0 2.5 I.9 49.5 99.3 81.7 35.2 20.1 4.2 a.9 3.3 0 0 40.7 73.7 60.b 28.4 19.8 2.0 ?.4 6.3 1.1 0.2 36.4 68.8 56.1 4a.v to.2 2.5 7.4 10.0 I.9 0.03 39.9 77.8 68.4 48*5 20.7 1.5 5.7 4.4 1.5 0 42.0 77.5 56.8 45.5 15.9 2.8 18.4 6.4 1.4 I.1 53.8 81.0 60.0 30.1 17.3 I.8 60.6 11.8 6.6 1.9 112.4 112.6 144.8 47.3 17.5 5.3 40.2. 8.1 2.8 0.4 55.7 108.2 54. I 31.7 IS.7 3b5 IO.3 2.7 1.3 0.3 44.3 76.5 43.4 15.0 23.4 2.3 20.3 4.3 4.0 0 55.0 so.3 59.0 26.3 13.7 l-3 16.8 9.0 I.9 0.4 52.0 85.2 74.7 38.0 18.2 2.4 (2) (I) THESE UNITS ARE THE HEALTH UNIT AREAS SUGGESTED IN LOCAL HEALJH UNITS FOR THE NATION, THE COMIONWEALTH FUND, NEW YORK CITY 1945. (2) THESE RATES ARE BASED ON 1000 LIVE BIRTHS. ALL OTHERS ARE @ASED ON WO,OOO POPULATION COLORADO koktcl ALAMOSA ARAPAHOE ARCHULETA BACA BENT BOULDER CHAFFEE CHEYENNE CLEAR CREEK CONEJOS COSTILLA CROWLEY CUSTER DELTA DENVER DOLORES DOUGLAS EAGLE ELBERT EL PASO FREMONT GARFIELD GILPIN GRAND GUNNISON HINSDALE HUERFANO JACKSON JEFFERSON KtOOA KIT CARSON LAKE LA PLATA LARIMER LAS ANIMAS LINCOLN LOGAN MESA MINERAL MOFFAT MONTEZUMA MONTROSE MORGAN OTERO OURAY PARK PHILLIPS PtTKlN PROWERS PUEBLO RtO QLANGO RIO GRANDE ROUT1 SAGUACHE SAN JUAN SAN MIGUEL SEDGWICK SUMMIT TELLER WASHINGTON WELD YUMA I 00 I 1672 20 52 II9 22 2 12 4 I 7 4 8 8 204 750 I 5 56 i 5 I '59 I5 I I I9 9 57 I 13 32 4 2 21 I 7 2 211 25 22 13 2 I29 2 32 5 4 2 3 5 7 31 7 I 3 40 a 5 3 2 I? 20 94 3 I8 2 16 6 I5 CASES OF CERTAIN COMMUNICABLE DISEASE% IN I945 204 7 5 lb 6 35 3 I I I I i 4 2 3 2 I 4 I9 34 9 5 I ? 2 3 6 12 3 I 2 2,915 34 70 166 23 3 95 20 15 2 I 2 7 6 21 1075 I 7. 6 135 20 B I 15 77 2 82 32 24 36 7 I62 3 36 219 lb 6 15 46 60 6 I2 31 I 21 130 21 24 21 6 5 79 I DEATHS FROM CERTAIN C&USES IN THE FIVE YEAR PERlOD COLORADO ADAMS ALAMOSA ARAPAHOE ARCHULETA BACA BENT BOULDER CHAFFEE CHEYENNE CLEAR CREEK CONEJOS COST ILLA CROWLEY CUSTER DELTA DENVER OOLORES DOUGLAS EAGLE ELBERT EL PASO FREMONT CARF I ELD GILPIN ORAND GUNNISON HINSOALE HUERFANO JACKSON JEFFERSON KIO'YA KIT CAdSON LAKE LA PLATA LARIb"&R LAS ANlhMS L INCOLN LOGAN MESA :d I NERAL MOFFAT MONTEZUMA MONTROSE MORGAN OTERD OURAY PARK RiICL~PS PITKIN PRO!YERS PUEBLO RIO BLANC0 R10 GRANIE ROUTT SAGIJACHE SAN JUAN SAN hItWEb SEOGWlCK SUMMIT TELLER WASHINGTON WELD YUMA INSTS. PDPULAT ION t,O89,351 21,301 9,302 33,950 3,458 6,405 9,562 35,991 6,681 2,739 2,560 10,890 6,586 4,846 1,go7 14,770 331,000 1,932 3,187 4,742 4,642 64,354 17,665 9,476 1,046 3,774 5,586 279 13,142 1,622 32,800 2,580 6,920 7,28 J 12,495 31,576 29, I31 5,534 16,660 29,800 024 3,705 7,954 15,068 16,084 21,761 1,621 2,304 4,528 1,455 11,583 71,850 2,721 I 1,659 0,848 5,380 1,236 3,367 3,666 1,553 4,457 7,373 59,989 10,593 169 916 ago 3 I6 IO 3 35 6 3 7 7 6 4 6 5 2 20 b 4 16 5 6 2 I I4 3 47 2 I 13 f 3 8 1 3 I4 5 24 123 lb6 1 I I 3 7 1 I 2 20 I4 1 9 6 3 4 1 I 2 6 51 6 I 3 IO 8 2 2 I4 I 2 I2 5 22 I2 I I4 6 I6 94 19 2 8 4 I 5 13 9 I 2 I 3 6 1 2 II .5 3 19 6 4 69 9 8 Ii 2 13 66 23 13 3 58 5 15 4 5 14 3 I I 3 1 2 12 7 61 I3 2 3 7 102 106 I I I 3 23 I 2 4 I 1 4 2 13 4 I I 6" I 5 I 4 I 7 12 24 18 1829 I 34 48 19 I I4 II 29 c 26 a IO I 7 59 I 17 13 II I 2 30 5 2 353 2 2 I2 3 44 I 25 I I II 3 I 3 to 2 25 d 9 I 42 23 P I 147 6 14 2 32 1 5 I I4 2 22 1 35 I 91 I I 24 4 119 7 I 76 II 26 a 4 2 3 97 I 8 5936 4642 129 71 113 39 104 II6 34 IO 32 28 s9 31 t,bo 152 41 31 10 a 13 33 139 29 25 22 33 I5 5 4 94 68 1348 1287 I1 7 6 22 50 37 13 7 245 220 79 '83 46 42 6 6 19 I4 21 39 162 81 6 10 104 89 13 20 30 34 72 38 III 51 I20 97 372 157 19 I6 81 54 167 135 4 4 31 21 87 46 a: 61 97 71 I92 I68 6 IO II 13 24 25 2 f 69 45 412 291 8 8 191 46 38 90 97 22 IO I2 t8 19 21 18 5 9 24 49 26 I8 368 241 39 43 4071 62 42 99 13 8 I2 I21 30 13 15 a2 28 I2 7 37 1133 6 23 13 177 68 32 5 7 24 69 3 76 7 II 54 72 83 238 18 39 77 13 4 2 35 14 8 2 52 I7 I3 5 33 13 17 3 59 51 20 II 4 9 5 1 a 3 1 1 17 I 12 2 3 3 1 1 27 15 13 3 247 lo8 62 I4 8 II 78 4 4 5 30 8 6 I 56 5 I 4 6 6 i 13 2 II IO 4 0 2 2 23 7 2 4 lb 3 9 177 79 41 9 18 6 If 5 2069 994 278 17,990 55 17 5 4 4 2 73 30 9 2 1 2 4 2 12 3 8 61 37.6 5 7 4 I2 I 3 3 2 I4 3 7 8 I4 7 8 I I I 8 ? 0 803 342 51 2 I 3 5 1 5 4 2 2 3 4 I89 49 It 44 21 7 9 5 t 4 II I I 6 3 1 23 12 12 I 89 23 7 3 5 4 4 5 8 2 26 12 6 35 30 7 77 25 13 3 8 2 I6 I3 5 28 35 8 339 204 422 60 76 125 517 II8 35 69 274 68 76 I8 222 4964 28 43 I21 42 891 302 135 23 42 94 2 359 20 388 48 83 I 79 278 372 882 66 208 450 9 7J 192 232 234 501 35 37 81 17 I72 II34 26 328 173 185 35 54 61 18 I09 72 915 1.24 109 130 303 63 22 518 HEALTH OISTRICT * UNIT I GRAND JACKSON MOFFAT RIO BLANC0 ROUTT 2 UNIT ALAMOSA CONEJOS COSTILLA MtNERAt RIO GRANOE SAGUACHE UNIT 9 OEUYER UNIT 12 BACA BENT CRO'#LEY KIOWA OTERO PROWEAS UNIT 2 EAGLE GARFIELD LAKE PARK PITKIN SUUMIT UNlT 6 CHAFFEE CUSTER FAEMONT GUNNISON HINSOALE UNIT IO CHEYENNE OOUGLAS ELBERT EL PASO KIT CARSON LINCOLN TELLER UNIT 14 LOGAN MORGAN PHfLLlPS SEDGWICK WASHINGTON YUMA UNIT 2 DELTA MESA MONTROSE OURAY SAN MIGUEL UNIT 7 BOULDER LARIMER UNIT II PUEBLO I5 UNIT WELD UNIT 4 ARCHULETA DOLORES LA PLATA MONTEZUMA SAN JUAN UNtT B ADAMS ARAPAHOE CLEAR CREEK GILPIN JEFFERSON UNIT 12 HUERFANO LAS ANIMAS 'AS SUGGESTED IN "LOCAL HEALTH UNITS FOR THE NATION," PUBLISHED BY THE COMMONWEkLTH FUND, NEW YORK, 1945 APPENDIX B HEALTH EXPENDITURES TABLES . I, 2, 3, and C TASLE I COLORADO ?UeLlC HEALTH EUOGET - YEAR ENDING JUNE 3C, I946 SHOWING SOURCE OF FUNDS STATE DIVISIOI: OF PUBL IC HEALTH AOMlNlSTRAT!ON EPIDEMIOLOGY VENERRL DISEASE T UBERCULOS IS CONTROL CANCER CONTROL DENTAL HEALTH MAT. 6 CH ILO HEALTH CR I PPLED CH ILDREN P. H. NURSIYG LABORATORIES SAN. ENG INEERING T;SUt,~.T tNG UN IT FOOD AND DRUGS PLUMBING VITAL STATISTICS IND. HYO IENE TRAINING BEDDING INSPECTtON HOSPITAL INSPECT ION STATE 16,361.21 6,ooo.oo I ,626.oo 5,?94.20 5,189.60 45,ooo.oo I ,456.OD 16,865.60 5,599.20 2,e97.00 26,034.oo 7,771 .oo 20,492.OO 3,619.oo 5rO47.20 IN SERVICE F IELD-OR IEEIT TOT. STATE DIV. OF PUBLIC HEALTH 169,762.21 POPULATION - I, 100,000 GEh.ERAL HEALTH U.S. P.H. SERVICE V.O. T.B. 23,930.oo I ,ooo.oo I ,472.OO 4,908.40 41,599.20 47,134.oo 2,783.oo 7,Cl3.00 2,508.OC t7,940.20 9,207.60 I ,693.OO 5r599.20 9,092.oo 1,200.00 8,278.oo 2,OOC.~O 9,996.03 lVO.OO 3,ooo.oo 3,oco.oo cgL;k&J;;V. o 8,44:.20 ? 34,260.76 76,102.80 26,18:.00 45,906.40 I 4,691.20 16,823.40 26,044m 7,771 .oo 22,008.20 9,996.OG 3,o:o.oo 3,619.oo 51047.20 6,ooo.oo 10.3 I.C 10.0 9.9 4.3 I .8 7.2 ID.0 5.5 9 .: ?.I 3-5 5.5 I .6 4.6 2.1 0 .7 0.6 I.1 I.3 4.5 0.4 4.3 4.3 I.9 0.0" 3.1 6.9 2.4 4.2 1.3 1.5 2.4 0.7 2.0 2.9 0.2 0.3 C.5 0.6 80,262.60 62,552.eo 52,639.oo 39,641.36 42,553.OO 9,6oc.o0 18,@00.00 175,060.97 lOO.0 43.2 U.S. CHILDREN'S BUREAU :ii . C . H . C.C. 2,490.OO 3,509.20 2,650.CO l7,770.96 31,102.80 7,466.00 7,341 .co i,S4E.S0 600.00 1,516.30 P,?CO.Oc) E.3. I .C. 300 .oc 9,300.co OTHER TOTAL 09~062.41 4,908.45 47,559.20 FJ ELI) iRMY 47,igc.co 16,000.~0 PERCENT ?ER CAP. TOTAL TABLE 2 CQLORADO PUBLIC HEALTH BUDGET - YEAR ENDING JUNE 30, 1946 COUNTIES ADAMS ARAPAHOE EENT BOULDER CLEAR CREEK CROWLEY V.O. CITY L CO. - DENVER DOUGLAS EAGLE Et PASO - CITY I CO. FREMONT GARF IELO GUNN I SON JEFFERSON LRKE LA PLATA LAR IMER LAS A#IMkS CO. H. UNIT LOGAN MORGAN OTERO CO. H. UNIT . PUEBLO ROUTT WELD CO. H. UNIT YUMA TOTAL PERCENT OF TOTAL LOCAL PERCENT 3,69 I .oo 42.9 7,429.oo 60.9 1,347.00 40.8 7,332.oo 73.6 l,28t.50 50.0 a61 .oo 25.6 30,327.20 57.8 975.00 41.0 I, 466 .oo 50.0 43,32 I .OO 60.t 1,361 .oo 50.0 1,316.oo SO,.0 I ,610.oo 61.6 6,204.20 59.2 2,574.28 65.2 1,367.00 50.G 8,606.OO 70.7 12,322.~ 44.1 1,361.oci 5c.: 1,316.0!! 50.2 8,758.X 32.7 1,5?7.:-L: 29,436.90 1,616&3 177,466.so 52.3 GENERAL HEALTH 4,769.oo I ,247.OO 1,771.oo I ,46< .oo 13,250.OO 4,339.2o 924.20 2,95cj.o0 I2,95y.O0 rs,a75.5o 62,55:.90 U.S. PUBLIC HEALTH SERVtCE U.S. CH. BUR. V.D. 708 .oo 708.00 22,167.oo 4,328.40 450.00 7ca.co 2,470 .JC I ,D4O.L" 6,63$.~ 39o.s; 39,&7.43 TOTAL T.B. U.S.P.H.S. I ,932.oo I ,932.oo 4,769.oo I r955.00 2,479.oo 22,167.oo I ,466.OE 17,578.40 4,339.2G I ,37:.20 708 o oo 2,5 32.00 7,960.30 l3,999.00 6,633.o~ 19,265.50 ,4,464.~; 106,622.30 (I) M.C.H. WEANS MATERNAL AND CHILD HEALTH PERCENT iLC.H.( I) PERCENT TOTAL 22.4 2,983.OO 39.1 59.2 2,632.oo 1,281.50 74.2 42.2 I ,405.oo 5o.c 24.4 I l,t52.00 1,361.oo 1,316.00 I ,004.GO 40.8 34.8 I ,367.oo 5.8 2,859.OC 28.5 7,658.40 1,361 .oo I ,316.o~: 52.2 .!,03e.x IG0.O I ,5c7:x 32.7 lO,l71.4i; 1,6th.oC' 55,028.33 31.5 34.7 26.4 5o.c 59.0 15.5 50.0 50 .o 3a.4 50.6 23.5 2714 5c.o 50 .o IS.1 52.2 17.3 55.0 8,606.OO 12,19E.00 3,302.OO 9,964.oo 2,563.OO 3,340.oo 52,494.20 2,360.oo 2,932.oo 72,051.40 2,722.OO 2,632,oO 2,514.oo 1~,623.40 3,938.40 2,734.30 12,173.OC 27,94;.4o 2,722.:: 2,632.x 26,795.co 6,63s.c3 3,Ol4.?d 58,873.8C 3,232.S 338.116.6~ 16.2 1 2 : . ; PERCENT OF TOTAL 2.5 3*6 0.9 2.9 0.8 I .o 15.5 0.7 0.9 21.2 0.8 00.8 0.7 3.1 1.2 0.8 3.6 8.2 3.8 0.R 7.9 2 .z -1 . * 9 17.4 I .c TABLE 3 COLORADO PUBLIC HEALTH BUDGET - YEAR ENDING JUNE 30, 1946 SHOWtNG SOURCE OF FUNDS STATE OIV. OF PUBLIC H. PERCENT PER CAF IT A+ FUNDS USED LESS INCOME(I) PERCENT PER CAP ITA+ COUMY HEALTH BUDGETS PERCENT PER CAPITA* GRAND TOTAL (2) PERCENT PER CAPITA* + BASED 01 POPULATION OF STATE 169,762.21 35.6 15.5 107r383.71 26.0 9.8 107,383.71 IO.3 9.8 I,l00,303 GENERAL LOCAL HEALTH 80,262.60 177,466.os 6215w.93 52.3 16.1 177,466.~ 142.813.50 23.6 r6.1 (I) INCOME REVERTS TO THE STATE GENERAL FUND (2) GRAND TOTAL LESS INCOME (BASED ON 1945 INCOME] U.S. P.H. SERVICE U.S. CHILDREN'S BUREAU V.D. T.B. TOTAL L.C.H. C.C. E.hl. I.C. 62,552.~~ 52,689.K 195,504.40 41.2 17.8 1?5,534.40 47.4 17.8 39,607.a 4,464.m Io6,622,30 31.5 9.7 102,160.20 57,153.x 3c2,126.70 40.2 27.5 39,64l.36 42,553.W 9,600.~50 91,794.36 t8,c'!x.O0 475d60.97 $ 62,378.50 19.3 3.9 lO0.O PERCENT PERCAP ITA 8.3 I o 6 43.2 91,794.36 13,0:3.;5 412,682.41 54.9 37.5 22.3 4.3 100.0 8.3 1.6 37.5 55.C28.30 55,C28.30 339,116.60 3C.8 16.2 103.0 5.0 3: .a 94,669.66 42,553.N 9,603.0@ 146,822.66 18,OC3.30 $ 751,7S9.11 45.1 19.5 2.4 IOO.@ lOO.0 13.3 1.6 68.3 68.3 TOTAL (3) INCOME OF OtVlSlON OF PUSLIC HEALTH 1945 RESTAURANTS 27,610.03 PLUM3 ING 7,725.50 BEdD 1 NG IIISPECT I ON 10,575.w HOSPITAL IriSPECTlON 26.20 VITAL STATISTICS 16,442.~ TOTAL $ 62,37a.50 (3) OTHER TOTAL rNcohE TABLE 4 COLORADO COUNTY HEALTH BUDGETS FOR THE YEAR ENDING JUNE jO,f946 SHOWING SOURCE OF FUNDS COUNT 1ES POPULAT 1 ON ADAMS 21,301 ARAPAH OE 33r850 BENT 9,562 BOULDER 35,991 CLEAR CREEK 2,560 CROWLEY 4,ab DOUGLAS 3,187 EAGLE 4,742 *ELPASO -CITY-COUNTY 64,354 FREMONT 17,665 GARF fELD 9,476 GlJNNlSON 5,556 JEf FERSON 32,800 LAKE 7,281 LA PLATA 12,495 LAR IMER 31,576 o LASANtMAS CO. H.UNIT 29,131 LOGAN 1 l6,660 MORGAN 16,084 +OTERG GO. H.UNIT 21,761 ROUTT 8,848 *WELD CO. H. UNIT 59,989 YUHA JO,593 TOTAL 460,338 LOCAL 3,691 .oo 7,429.OG 1,347roo 7,931.00 1,281.M 86 1 .OQ 975.00 I ,466,oo 43,321.00 1&1.00~ I ,yLoo I ,6io,30 6,284.20 2,574.20 I ,367.oo 8,606.OO 12,322.oo 1,361.oo 1,316.oo 8,758&O 1,557.oo 29,436.90 1,616.co 147,138.80 FEDERAL 4,9l5*00 4,769.00 I ,955.oo 2,632.eo 1,281.50 2,479.00 I ,405.oo I, 466.00 28,730.40 l,$l.OO 1,316.oo 1,004.oo 41339.20 1,374.23 1,367.oo 3r567.00 15,618.40 l,36l.W 1,316.oo 18,037.QO 1,507.GO .29,4$.90 1,616,oo 132d353.60 * FULL-TIME HEALTH DEPARTMENTS; ALL OTHERS ARE PART-TIME. TOTAL PERCENT PER CAPITA IN CENTS 8,606.OO 42.9 17.3 12,198.00 60.9 21.9 3r332.00 40.8 14.1 9,964.oo 73.6 20.4 2,563.m 50.0 50.0 3,340,OO 25.8 17.7 2,380.50 41.0 30.6 2,932.oo 50.0 30.9 72,051.40 60. I 67.3 2,722.OO 50.0 7.7 2,632.oo 50.0 13.9 2,614.oo 61.6 28.8 10,623.40 59.2 19.2 3,948.40 65.2 35.4 2,734.OO 50.0 IO.9 12,173.00 70.7 27.3 27.940.40 44. I 42.3 2,722.OO 5w 8.2 2,632.oo 50.0 8.2 26,795&o 32.7 40.2 3,014,OO 50.9 17.0 58,873&O 50.0 49.1 3,232.00 So.0 15.3 279,992.45 52.6 32.0 LOCAL FEDERAL PER CAP tTA PEROENT IN CENTS PERCENT TOTAL PER CAPlTA IN CENTS 57.1 23.1 100.0 40.4 39.1 14.1 100.0 36.0 59.2 20.4 100.0 34.5 26.4 7.3 100.0 27.7 50.0 50.0 too.0 100.0 74.2 51.2 100.0 68.9 59.0 44.1 100.0 74.7 50.0 30.9 100.0 61.8 39.9 44.6 to5.0 Ill.9 50.0 7.7 100.0 t5.4 50.0 13.9 100.0 27.8 38.4 18.0 100.0 466.8 40.8 13.2 . too.0 32.4 35.3 18.9 100.0 54.2 50.0 10.9 100.0 21.8 29.3 II.3 lO0.0 38.6 55.9 53.6 100.0 95.9 50.0 8.2 100.0 16.4 50.0 8.2 100.0 k6.4 67.3 82.9 ICC.? 123.1 50.0 17.0 100.9 34.0 50.0 ' 49.1 100.2 98.2 50.6 15.2 IC0.D 30.5 47.4 28.8 100.0 60.8 DENVER AND PUEBLO COUNTIES HAVE SEEN OMITTED BECAUSE OF LACK OF INFORMAT ION AS TO THEIR CO:rPLOE BUDGET8 PROVISIONS ljJH1C.H SHOULD BE INCLUDED IN A LOti EULTH BILL (Appendix C) A bill to permit the establishment of full-time county, city-county, or combination of county health departments should ?Fovide: (1) (2) (3) (4) (5) (6) 0) That the County Commissioners of any county may vote to establish a full-time county health department. That two, three or four but not over four counties may combine for public health purposes to establish a full-time health department by the favorable vote of the several Boards of County Commissioners. More than four counties may combine for Dublic health purposes only with the psrmission of the State Health Officer. That the city-county, county or counties involved in the establish- ment of a full-time health department may, through their duly constituted appropriating bodies, appropriate such funds as may be necessary for the operation and maintenance of such full-time health department. That where available tax funds are insufficient for the maintenance end operation of the health department the County Commissioners of the county or the several counties included in the proposed health department may by a majority vote levy a tax of not to exceed one mill per each dollar of assessed valuation for maintaining and orerating such department. That in such county, or multiple county, health departments, cities of under 50,000 population (as shown in the last U. S. Census) shall become integral parts, for purposes of public health administration, of such health departments. That cities of over 50,000 population (as shown in the last U. S. Census) may elect to come into the county or multiple county health department or to maintain their own health departments. If a city of over 50,000 Do@ation decides to maintain its own health department, it must have a full-time qualified health officer (a health officer meeting the qualifications for full-time health officers as established by the State Board of Xealth). (This and tho preceding provision PJC based on the premise that it is not economical for a city of less than 50,000 population to maintain its own independent health department rnd that, if it is large enough to support its own depcrtment, it should be required to employ properly qualified personnel to conduct it.) That nothing in this bill shall be construed as in any way intcr- fering with the appointment., prerogatives, or financial support of local boards of health, health officers or other locrtl ho?Jth personnel except that the full-time county or multiple county health officer shall be the senior health officer of the area and shall have general supervision.over other health officers of the area except full-time qualified health officers of cities of over 50,000 pomlation. (Appendix C - I) (8 ) T&hat, similarly, nothing in tho bill should be construed as preventing other local health jurisdictions in full-time county or multiple county health department areas from abolishing such local health jurisdiction functions if they so desire. (9) That the properly constituted authorities, in a county or counties establishing full-time health departments, be authorized to negotiate with the State Dopzrtmcr,t of Public Hc?Jth for such financir.1 assistance for the operation ,and maintenance of the full-time county or multiple county health department as the St;.te Department of Public Health may be able to provide through sto-te ' -a.- f 0a0rd. f~ikt. (10) That the properly constituted authorities in a county or counties establishing full-time health departments be authorized to accent private funds, d0mti0ns, progcrty and materials for the use of such health departments. (11) That there be a Board of Eealth as the advisory, judiciary, policy forming, `but not executive body, for each such county, multiple county or city-county health department established in accordance with the provisions of this act. (12) That the Board of Health of a single county Health Degartmcnt be appointed by the Chairman of the Soard of County Commissioners and consist of five members, appointed for five year staggered terms of office, two of whom should be physicians and three from other walks of life. (13) That the Board of Health of a combined City-County Iiealth Depnt- mcnt consist of five members, three of whom should be appointed by the Chairmr?n of the Board of County Commissioners, one of whom should be a physician, and two should bo appointed by the Mayor of the City, one of whom should be a physician. If the population of the city is larger than the population of the remainder of the county, then the city should appoint three nembors and the county two. At the time of origin21 a?pointncnt the five members thus appointed should determine by lot which members shall serve respectively for one, two, three, four md five years. All sub- sequent amointments should be for five year terms. (14) That where two or more counties establish a Health De$artment the Chairman of the Board of County Commissioners of each participating county should qqoiht ono member of the Board of Health except that where only two counties are participating two members should be appointed from ccch county ,and the county having the larger po_pula- tion should appoint the fifth member. Two members of the Board of Health, whether it be a Board for two, tkrce or more counties, should be phys icizna. At the timo of original appointments of Boards established in accord?.nce with the provisions of this clause the ner;;bcrs thus appointed should determine by lot the length of term to be served by each member. A11 subsequent appointments should be for f ivo year terms, (Appendix C - II) (15) Any Board of Health, established in accordance with the provisions of any of the preceding clauses, should appoint a single fiscal agent for the health Department. (16) That any Board of Health, established in accordance with the provis- ions of any of the preceding clauses should have the right to make such rules and regulations as it deems necessary for the protection and promotion of health provided, however, that such rules and regulations must not be in conflict with state legislation or with rules and regulations of the State Board of Iiealth. Rules and regulations adopted by local boards of health may be more stringent but not less stringent than state legislation or rules and regulations of the State Board of Health. 07) The Board of Health of any such county, multiple county, or cit:r- county health department should appoint the health officer provided, however, that he or she must meet the qualifications for such health officers as are established by the State Roard of Health. 08) The appointment of tho health officer should be for five years and he or she may be rcuppointod at the discretion of th