(b) Is the consumption of milk a matter of accurate or complete record?

A positive answer can hardly be given to this question at present, but some facts of obvious value can be reported from reliable sources, and unpublished data can be made available.

The Department of Agriculture is authority for the statement that in 1900 the nonfarming, i. e., the urban and suburban population of the United States, purchased milk and cream exclusive of milk used in the making of butter, cheese, and condensed milk products, to the extent of 23 gallons per capita or 184 pints per capita, or one-half of a pint per capita per day throughout the year. The average per capita consumption of whole milk in the United States is given by the same authority as 0.93 pint per capita per day in 1917, 0.94 pint per day in 1920. The figure for the urban and suburban population of the United States given above, namely, one-half a pint per capita per day of milk consumed in 1900, apparently was duplicated by the experience of Philadelphia as late as 1900, while in London, England, in 1892, the amount used was officially given as 0.25 pint per capita per day. In New York City, for which I was able to obtain the most nearly accurate information for the past five years by months, the daily per capita consumption of milk has varied as follows, using for each year the highest mid-year (i. e., June, July, and August) receipts and the population of the city as of July 1, based on the figures of the Federal Bureau of the Census: 1917, 0.52 pint; 1918, 0.39 pint; 1919, 0.37 pint; 1920, 0.46 pint; 1921, 0.44 pint; 1922, 0.41 pint; 1923, 0.54 pint.

Among the tables published by the United States Department of Agriculture in June, 1922, in the Handbook of Dairy Statistics is one showing the variation among a number of countries from which we can calculate the daily per capita consumption in pints, showing Sweden (1914) at the head with 1.5 pints per capita per day, Denmark (1914), Switzerland (1914), Germany (1913) following closely, all using more than 1 pint per capita per day. Canada (1916), Hungary (1914), and the United Kingdom (1914) fall in the low group using just above (0.57 pint, Canada) or just below (0.49 pint, United Kingdom), 0.5 pint per capita per day.

Apparently in this country there is fairly consistent experience in the past five years in the use of milk, about 47 per cent of the total production going to household use and ice cream, and another 4.5 per cent to condensed milk. The waste or loss of all milk production runs about 3 per cent per annum.

Among the 83 cities of the United States of 75,000 population or over studied by the committee on municipal health department practice of the American Public Health Association in 1920, 14 had no records sufficiently reliable to permit calculations as to per capita daily consumption of milk. These represented urban populations aggregating 2,055,985.

Of these 14 cities 6 were in the Pacific Coast States, 3 in New Jersey, 2 in Massachusetts, 1 each in Kansas, Ohio, and New York. Of

Published by the Government through the Public Health Service and is available for distribution as Bulletin 136, United States Public Health Service. It is probably the most accurate and comprehensive study of the functions and results of the municipal health departments in this country which has been made.

the remaining 69 cities 6 reported a daily per capita consumption of

Seventeen cities reported a daily per capita consumption of less than one-half pint.

It will be noted that of these, 13 are southern cities, New York, Indianapolis, Elizabeth, and Worcester being the other 4. The remaining 52 cities studied reported daily consumption from 0.5 to 0.99 pint per capita.

As might have been expected, study of the general death rates, the death rates from tuberculosis, and the infant mortality rates of these cities show no relationship with the reported per capita consumption of milk in these cities. And I would like to emphasize this fact because we are so prone to measure every health activity by its effect upon death rates, and particularly upon the infant mortality. What we are dealing with is the sickness or inefficiency due to consumption of milk; it is not death, but the incidence of a lower vitality and all that multitude of nutritional disorders which do not appear in the records of the health department or hospitals or physicians or dispensaries. In other words, we have no index of sickness or disability which we can compare with the consumption of milk, and we can not properly use death rates as a measure of the effect of the consumption of milk upon health.

It must be admitted that there is laxity and indifference among health officers of municipalities in this country in the accurate recording of the quantity of milk consumed in their community, whatever may be the character of their administrative control of the chemical and bacteriological quality of this food, concerning which the chapter of the forthcoming report dealing with milk inspection in these same cities (American Journal of Public Health, 1922) gives valuable information.

(c) Taking the most favorable situation, that of a city where the health officer knows the quantity and quality of the milk consumed,

is it his function as a public official to attempt to influence the people in the use of milk?

As has been suggested above, the health officer in our cities is more and more expected to direct or encourage educational efforts of schools, civic associations, and private health agencies so that all members of the community as may be proper to their age and condition will consciously and intelligently take a personal interest in their own health and follow the teachings of physicians, not only in self-protection against the acute communicable diseases, but in the subject of nutrition and growth and development upon which wellbeing and self-support so largely depend. The health officer should lose no opportunity to teach the public, and particularly those groups in sections and districts where, by reason of ignorance, poverty, alien racial customs, and lack of adaptability to new and unfavor able industrial and environmental conditions, he finds among the school children, in the preschool clinics, at the baby health stations, in the prenatal clinics, in the records of tuberculosis, the evidences of unsuitable or inadequate use of foods which would be largely corrected by the increase of milk in the family dietaries. Not only among the poor and the handicapped but among the people of means do physicians find the evidences of poor dietary habits in the serious undernourishment of children.

No one, so well as the health officer, can create and develop confidence in the safety of the milk offered for sale, or take part as representative of the public in controversies and conferences where the producer and distributer require the steadying influence of the consumer's needs to prevent them from taking unwise advantage of their control of this public necessity.

It is probably of quite as much importance to the health officer to know the distribution of milk by districts, corresponding to the population units upon which he bases his analyses of deaths and sickness, as it is to know the birth rate by wards, assembly districts, or smaller permanent sanitary or block units. Only by having such exact information can he speak with point and accuracy in his teaching of the relation between family milk consumption and the health of the children. So far as I know, no city provides among its records of food control for current information as to use of milk by districts in the community. This could be arranged for with but little difficulty by cooperation with the milk distributers.

We are accustomed in this country to think of a city as a homogeneous, uniform mass of people all of the same intelligence and habits and needs. By a very simple method of using the Federal census figures, the city of New York has adopted a method of reporting its sickness, births, and deaths which has proved invaluable. Suppose we thought of New York City as a place where the death rate in tuberculosis was 93 per 100,000. That doesn't mean anything when we know that in the Riverside Drive section the rate is 50 and in the Bowling Green section it is 1,170 per 100.000, higher than in any other section of any city that we know of. Remember that you must analyze every community by reasonably consistent neighborhood and population groups. Therefore health officers have to divide their community arbitrarily into such districts as to be able to make a study by those districts. It is an entirely practical

thing to do. If he finds that the Italians, perchance, are using a quart of milk per day because of some intensive education among them, and that on the other side of the main thoroughfare a Jewish group from southeastern Russia has not learned at all to use our whole milk in this country, it is up to him to swing his education where it is needed, and not to consider the community as all of one uniform condition in intelligence or information.

(d) Once exact information as to the daily per capita use of milk for the whole community or by subdivisions is obtained and these data are available by months or seasons and for several years, there will arise at once comparison among cities and queries as to the reasons for increase or decrease in use. While lack of information as to its value is perhaps the most obvious cause of failure to use to full advantage anything offered for sale, there may be other factors of importance. We have noted during the war period and subsequently an unwillingness on the part of the buying public to continue to pay higher prices equally for all articles, however reasonable the increase of price might be. While apparently willing to pay 100 per cent or greater increase in the price of shoes, clothing, and meats, for instance, the resentment against even a 50 per cent increase in the price of milk was so great as to cause marked reduction in use. No such statements as this can serve in place of thorough economic studies, but it is of some significance that during the years 1917 to 1923 the prevailing New York price for grade B milk net to the farmer rose from 5.68 cents per quart in 1917 to 7.58 cents per quart in 1919 and 1920, and dropped again to 6.42 cents per quart in 1921, the retail prices showing similar changes. The daily per capita consumption of milk followed a reverse curve during the same period, being 0.52 pint per capita in 1917, 0.37 (the lowest for many years past) in 1919, rising again to 0.44 pint per capita in 1921 and to 0.54 in 1923.

The public still needs much education as to the price of milk and the fact that milk purchased even at the present higher level of prices is a bargain in food value.

Some people living where there is little or no sanitary control or Pasteurization of milk have limited its use to cooked products in the household. Others who conceive a dislike of the taste of the Pasteurized product have similarly reduced their use of milk. In some of our large eastern seaboard cities, with enormous immigrant and first generation populations of foreign parentage, where the southeastern European peoples predominate, we have racial customs acting as a cause of lowered per capita consumption. These people rarely use raw whole milk in their own countries and are unwilling to use the Pasteurized product when they have been accustomed to soured or fermented milk.

(e) Conversely, as the price of milk has fallen, as the campaign among school children for normal height and weight gains has become widespread and popular, as confidence in the safety, uniformity, and value of milk has grown through the teaching of health officers, doctors, nurses, dietitians, and other social workers, the per capita use of milk has increased.

Certainly the slogan of the war period affected the habits of many a family, and housewives commonly observed the advice to buy a pint of milk for each member of the family before buying meat. I have been informed by personal communication that in one city of first rank in Canada, where a benevolent monopoly of the milk distribution has been developed in the hands of one man, and in a similarly important city in the United States, where a cooperative undertaking including milk production and distribution was brought about following difficulties between the city distributors and the wagon men, the price of milk has fallen and the consumption risen, but I could not obtain exact facts to quote here.

(f) Accepting, then, as facts that the daily per capita use of milk for food has in few if any cities of this country reached the optimum of consumption proposed above, and that the great majority of our larger cities do not record even the minimum advantageous daily use of milk as a food, and, furthermore, that our information is extremely crude and leaves many points of importance as to use open to doubt, what shall be the program or attitude of the health officer, whether of cities, counties, or States, in this matter?

The four essential services of probable value to the public, which a health office might properly engage in, fall under corresponding adminstrative divisions of any well-organized health department.

1. Through the statistical office all information as to the sale, distribution, and use of milk which can be obtained from any source should be assembled and correlated with the facts of record as to population, distribution, and the incidence of preventable defects, disease, and deaths.

2. Through the educational channels of the health department the public should be taught the simple essential facts, sanitary, economic, and nutritional, which will develop confidence and knowl edge leading to a larger use of milk as a food.

3. Through inspection and laboratory control at an expense of probably not more than 5 cents per capita per annum, an adequate service for control of the quality of milk offered for sale can and should be maintained in the interest of health and public safety, as indicated in the report of the committee above referred to. A city without sanitary control of its milk supply is taking quite as great risks with its citizens as if there were no fire or police protection provided.

4. It is the particular function of the health officer to be informed and prepared to act in behalf of the consumer to see that all unnecessary costs and handicaps are removed from the production and distribution of milk so that the lowest price consistent with reasonable profit for the farmer and the trade is maintained with the minimum of seasonal variation.

I hope those who are interested and particularly concerned with the industry will not misunderstand that statement. The health officer has been responsible for a great deal of the obligatory increase in the price of milk, and his restrictions have been in the interest of public health and confidence in the milk industry. But there are conditions of distribution in cities brought about by laws meant to apply to other matters which seriously interfere with the economic distribution of milk, and it is the business of the health