Both official and voluntary health activities have in the past been subjected to some influences which have impeded or, to an extent, frustrated their usefulness. In the former, political preferment has perhaps been the greatest stumbling block. In the latter, exploitation by plausible but incompetent or unscrupulous job-holders has played its part. Happily the past few decades have witnessed a great improvement in both of these respects, but the memories and vestiges of these drawbacks have left their impress upon the outlook of public health work. Their return must be guarded against if popular confidence is to be deserved or retained.

Owing very largely to the hindrances which have been alluded to, there has been in the past some distrust and friction between certain official and voluntary health organizations. This situation also has been very much improved, and more and more the two classes of organizations are learning to cooperate with each other amicably and effectually. There were at one time a large and unnecessary number of voluntary organizations devoted to health work. They did not get along well with the official agencies or among themselves. Within the past decade there has been a beneficial condensation of these agencies into a much smaller number of well-organized and, in general, well-financed associations having definite objectives and able personnel. Their power for good has undoubtedly been greatly increased thereby.

The need for voluntary health agencies arises chiefly from the fact that there are a number of things which should be done in health work but which, in the present state of popular opinion, are not a proper charge upon the taxpayer. Much good has also been done in the past by calling public attention to certain needful activities, demonstrating the possibility of useful work along these lines, and eventually securing their promotion as a part of the official health work. On the other hand, an efficient health official, with his broad view of all the health needs of his community, will often discover a hiatus in the scheme which he is unable to fill, with the funds or authority at his command, but which a voluntary organization could fill admirably. It is becoming recognized as the best official practice in such contingencies for the health official to seek the aid of the voluntary association.

The organization of official health work is readily understood when once the Constitution of the United States and that of the particular state concerned are considered. Legislative and police powers reside in the states. A minimum of authority has been delegated to the Federal Government by the states, which, so far as health matters are concerned, extends only to international and interstate matters. The states have also delegated powers to cities within their respective boundaries by charter. In the case of some large cities the terms of the charters are so liberal that the local health authorities have become practically-autonomous, subject only to the provisions of state law. The conditions in the counties and villages are neither so uniform nor so well denned in many states. In a good many of them the county health organization is practically an extension of that of the state, under the supervision, if not the administration, of a deputy official. In others the delegated powers of the county government enable them to maintain a health unit under the commissioners.

Considering, from this point on, only the official health agencies, it is necessary first to inquire to what extent they have been established and are being maintained proportionately to the need for their services. On this point there would be unanimity of opinion among students and practitioners of public health. Provision is still lamentably inadequate in the United States. On the other hand, the trend of the past twenty years has been most encouraging. Within this period the remaining states and important cities have provided themselves with at least the framework of a health organization, which might be filled out in succeeding years. A beginning also has been made during this time in provision for rural health service. Since nearly half of the population still lives in the country, the neglect of the rural dweller has been a serious oversight in public health administration. There has been an increasing interest in this phase of health work which has already borne fruit in the establishment of county health organizations in many of the states. This, however, has been a slow process, so that only a fifth of the counties in the country are provided with official health service, except such as may be secured in emergency from the state organization. This means that a vast number of American citizens are born and live their entire lives without the benefits of health service. There is no one to suggest to the women that they can secure healthier babies by following some simple rules during their pregnancies, no one to insure competent attention during confinement. It is nobody's business to encourage breast feeding and, later on, suitable dietaries for the babies, or to attend to immunization against diphtheria and smallpox during the first year of life. No clinic exists where children may be taken for examinations and advice and for the correction of physical defects. Nobody urges the care of the teeth, and their neglect soon leads to serious impairments of digestion or to worse ailments. And so on up through the periods of infancy, the pre-school period, the school ages, adolescence, and into adult life, there is no person in these neglected areas whose duty it is to bring the lessons and the benefits of well-established health knowledge to the attention of the people, or to provide facilities for its application of which they may avail themselves. Of course, where the local doctors are not already overworked, where they are well informed, and are, in addition, altruistic even beyond the average for their profession, some of these necessary things may get done; but the point is that it is nobody's responsibility to do them. The results of this neglect are evident to anyone who wishes to investigate, even though he lacks a medical training. The proportion of crippled, blinded, deaf, and poorly nourished children is high. Much school attendance is lost on account of sickness. Since the adults are the products of similar conditions, men and women stoop-shouldered and old at thirty-five are commonly seen. Their teeth are reduced to a few loose snags. Typhoid fever is apt to be prevalent, and in some parts of the country hookworm disease and malaria take their toll both of life and of productivity. Tuberculosis finds good soil to work on, and parents, since no one has told them better, subject their children to an exposure which is certain to lead to their infection and subsequent suffering or premature death.