perature pasteurization processes, which dictate public health evaluation of thermometric control systems.

The established cooperative State-Public Health Service program for certification of interstate milk shippers is an outstanding and unique example of Federal, State, and industry cooperation in the resolution of environmental health problems of mutual concern. Designed to provide State and local authorities with reliable information on the sanitary quality of milk and milk products in interstate commerce, the program provides for a voluntary certification system which is operated by the States with the full support of the dairy industry, with "checks and balances" responsibility a function of the Public Health Service.

After a decade of operation, this voluntary cooperative activity continues to grow and gain prestige and national stature. The January 1, 1963, list of certified interstate milk shippers includes the names and milk sanitation ratings of 890 shippers—more than a fivefold increase in the number of shippers in 10 years-which are located in 42 States and the District of Columbia. Approximately 10 billion pounds of milk, valued at almost $500 million moved in interstate commerce under this program in 1962.

Food sanitation

For more than a quarter of a century, the Public Health Service has, at the request of State and local health agencies, provided leadership and consultative assistance in the development and maintenance of programs for the prevention and control of foodborne illnesses. In 1934, the Service developed a model sanitation ordinance and code for food service establishments, which has been widely adopted. This recommended ordinance and code has been periodically revised in order to incorporate new technical knowledge and information on improved food protection practices and administrative procedures. The most recent revision was made in 1962. The model ordinance and code is the basis for food sanitation laws or regulations in 37 States and over 1,100 county and municipal health jurisdictions, and has a population coverage of more than 125 million persons. Model poultry and vending machine sanitation ordinances and codes have also been developed in response to further State and local health agency requests for assistance. Manuals, training aids, and program guides have been developed as supplements to the ordinances and codes, and are widely used by State and local health agencies and industry.

Currently the Public Health Service is assisting State and local personnel in effecting early application of updated recommendations contained in the 1962 "Food Service Sanitation Manual." Plans are underway for field projects designed to demonstrate application of the technical and administrative provisions of the new ordinance and code. A new procedure, long needed by States for use in evaluating local food service sanitation programs, is currently under development. Public Health Service research on the interrelationship of biological and environmental factors involved in the growth of pathogens in food is providing data helpful in improving food protection measures. Current studies on the application of the principle of thermal diffusivity (a physical constant derived from specific heat, density, and thermal conductivity) to the safe heating and cooling of food, hold promise for further improvements in food protection techniques. Results of research and investigations are made available promptly to States, communities, industry, and other Federal agencies, including Food and Drug Administration, U.S. Department of Agriculture, and the Army, Air Force, and Navy.

Despite the progress which has been made in controlling foodborne illnesses, outbreaks continue to occur at an alarming frequency. It has been estimated that over 1 million cases of foodborne illness occur annually in the United States. Of concern is the frequency with which outbreaks of gastroenteritis of undetermined etiology are reported. In addition, rapid changes in technology in a dynamic food industry continue to introduce new and complex problems requiring public health evaluation.

Shellfish sanitation branch

Since 1925, the Public Health Service has cooperated with the States and the shellfish industry in a program designed to insure that shellfish shipped in interstate commerce will be safe to eat. Oysters, clams, and mussels have a unique potential for the transmission of disease, due to their production from estuarine waters and the fact they are consumed without cooking. Conventional food sanitation measures are not applicable to this class of food. Public Health Serv

ice responsibilities include research, standards development, monitoring of State programs, and a semimonthly publication of a list of State-certified shippers. The States participate in a varying degree through the use of production standards and the Public Health Service list of shippers. Control measures were extended through international agreement to Canadian production (1948) and Japanese production (1962). The Public Health Service program is coordinated with the Food and Drug Administration and the Fish and Wildlife Service through formal agreements.

The prevention of disease transmission by shellfish is based on sanitary standards for shellfish-growing waters. Numerous relocations of production areas have been necessary, due to natural causes and pollution resulting from (1) increased population in coastal areas, (2) chemical wastes, (3) nonuniformity and inadequacies in the levels of State shellfish sanitation program, and (4) international interest.

There has been an enormous population growth in the coastal areas, with resultant problems of sewage pollution of shellfish-growing areas. The construction of sewage treatment works prevents the gross effects of pollution, but cannot provide fully reliable protection for adjacent shellfish-production areas. Technical and other limitations of sewage treatment make it increasingly difficult to assure safe shellfish in areas contiguous to sewage treatment operations. Because of the increasing recreational use of coastal areas, there has been a vast increase in the number of boats, many with toilets, which discharge untreated sewage directly to the coastal waters. New problems are being encountered in protecting shellfish from radioactive contaminants, viruses, pesticides, and herbicides, all of which may be consumed and concentrated by the shellfish.

Many chemical or petrochemical industries have located in tidewater areas, because of advantageous transportation and water-supply facilities. There has been a concurrent increase in the total volume of industrial wastes and in the complexity of these wastes. Shellfish have an unusual ability to concentrate many metals or other chemicals. ( (In Japan, almost 100 cases of poisoning have been attributed to shellfish which had accumulated mercury from an industrial waste.)

Environmental health planning-Metropolitan areas

Public Health Service activities to assist State and local communities in the field of urban environmental health planning were initiated in 1958. Urbanization and industrialization in the United States continue to augment and aggravate environmental factors affecting health. Because of the wide range of these environmental problems, which are often interrelated and made more difficult to solve because of fragmented and overlapping local political jurisdictions, it has been necessary to evolve appropriate comprehensive approaches to environmental health assessment and planning. In addition-through methodology research, technical assistance, and training-public health officials, particularly sanitary engineers, are being aided in participating in local planning activities. Two-thirds of the entire U.S. population now live in 212 metropolitan areas, and 84 percent of the population growth from 1950 to 1960 was adjacent to, but outside, the core city. The 1960 census further reveals that of the 113 million metropolitan residents, nearly one-half, 55 million, reside outside the central cities. More than 80 million people live in 79 intercounty areas. Twenty-six of the intercounty areas include territory in two or more States.

To accomplish the mission of assisting States and local units to identify and plan to overcome environmental health deficiencies, the Public Health Service has established a basic competence in environmental health planning. The methodology followed to implement the assistance program is twofold: first, by studies and research projects in representative situations in order to accumulate the information needed in developing standards and criteria; and, second, by rendering technical consultation to State and local agencies to stimulate more effective use of environmental health resources in metropolitan planning and development.

A series of conferences has been conducted in 14 States, demonstrating methodology of evaluating health activities in relationship to future needs. The "Environmental Health Planning Guide," developed by the Division, is a pilot instrument for self-evaluation of local problems, and has served as a basis for the above conferences, as well as for a number of technical assistance projects and field studies.

In the housing hygiene field, there are many health aspects that deal with construction: safety, temperature, ventilation, light, space, noise, water supply,

and waste disposal. Assistance can be given to every level of government: Federal on national housing and urban renewal programs; State and local on housing codes and their enforcements; and housing quality and neighborhood appraisal techniques.

Solid wastes engineering

The Public Health Service has considered refuse storage, collection, and disposal part of its general sanitation activities for many years. Problems of diseases related to rodents and flies, air pollution, water pollution, accident prevention, and general nuisances traditionally have been associated with this field and have indicated the need for adequate refuse practices.

The common practice of feeding raw garbage to hogs, and its proven relationship to human trichinosis, prompted a Public Health Service interstate quarantine regulation prohibiting the interstate shipment of garbage for this purpose. In 1952, with a nationwide outbreak of vesicular exanthema, a disease of hogs, renewed efforts were directed to this problem by the Public Health Service and the U.S. Department of Agriculture.

The solid wastes engineering activities in the Public Health Service have only recently been identified as a specialized field needing individual attention appropriate to the scope and intensity of the emerging problem.

Significant accomplishments include the development and demonstration of sanitary landfill techniques, collation and assembly of technical information relating to the field; preparation of technical manuals; cooperative efforts with the Department of Agriculture in devising methods and equipment for heattreating garbage; study of the effects of the communitywide installation of garbage grinders; development of manuals of practice with the American Public Works Association and the American Society of Civil Engineers; and demonstration of the benefits of including refuse-handling facilities in community planning activities.

Most communities are becoming perplexed as to the long-term solution of these problems. Requests for technical assistance and information are increasing. There is an urgent need for research, technical assistance, and training in this field in order to satisfactorily cope with the immediate problems of many metropolitan areas.

Recreational sanitation

Health and sanitation programs of the Public Health Service are directly involved with the field of recreation. Environmental health safeguards and the application of sanitation standards and criteria to outdoor recreational areas and facilities must be incorporated for proper protection and enjoyment of such areas. Federal, State, and local agencies and other national organizations having recreation interests have been guided by the advice and recommendations of the Public Health Service in such fields as water supply, sewage disposal, refuse disposal, swimming and bathing sanitation, plumbing, insect and vector control, water pollution abatement, and food service facilities.

The Public Health Service has been identified closely with National Park Service recreation activities since 1922, serving as technical consultants on matters of sanitary engineering design, construction, and operation in the 186 national parks. Participation with the Federal Interagency Committee on Recreation, and in national conferences of recreational associations and groups, has continued over several years. Close working relationships are maintained with Federal agencies having responsibilities for the management of outdoor recreational areas. These include, in addition to the National Park Service, the U.S. Forest Service, Bureau of Reclamation, Corps of Engineers, Fish and Wildlife Service, and others.

Useful accomplishments include manuals of practice relating to water supply, sewage disposal, refuse disposal; and various other sanitation activities have been developed to include recreational aspects: membership and participation on the Federal Interagency Committee on Recreation since its creation in 1946: and technical services to national recreation associations, Boy Scouts of America, American Camping Association, and other groups identified with recreation.

DIVISION OF INDIAN HEALTH (BUREAU OF MEDICAL SERVICES)

The responsibility for the Indian health program was transferred on July 1, 1955, from the Bureau of Indian Affairs, U.S. Department of the Interior, to the Public Health Service, U.S. Department of Health, Education, and Welfare.

The transfer legislation, Public Law 83-568, referred specifically to "conservation of the health of Indians."

Based on the 1960 census, there are approximately 552,000 Indians, Eskimos, and Aleuts in the United States. About 380,000 of this population-residing in 24 States and living on or near reservations, trust lands, or in native villages of Alaska-represent Public Health Service beneficiaries. The Alaska component of this group totals 43,000.

Health background

The infant death rate of Indians is about twice that of the general population in the United States. More significant, however, is the sharp rise which occurs after the first 28 days of the first year of life, when the Indian mother and baby have returned to their home environment from the hospital. In 1960, the infant death rate during the period from 28 days to 11 months after birth increased to 29 per 1,000 live births-or four times higher than the general population. This is due primarily to respiratory, digestive, and infective and parasitic diseases. It represents a decline of 35 percent since 1954.

In 1960, the Indian population, exclusive of Alaska, had a death rate of 28 per 100,000 from gastritis, enteritis, and related diseases-7 times higher than that of the general population. In 1961, these diseases ranked among the highest of the notifiable diseases in the Indian population, with a rate exceeding 4,100 per 100,000 population.

In 1960, influenza and pneumonia combined to form the third leading cause of death among the Indian population, in contrast to sixth position in the general population. In 1961, both diseases were high on the list of notifiable diseases among Inndians, with respective rates exceeding 2,200 for pneumonia and 600 for influenza.

In 1961, dysentery-amebic and bacillary-among the Indian population was more than 20 times higher than in the general population. Infectious hepatitis among Indians increased to 211 per 100,000 population, 5 times higher than in the general population. The significant rise in trachoma in recent years can, in part, be attributed to the lack of available safe water supplies in the home for personal hygiene purposes.

Historical background

Until the past decade, little attention was paid to basic environmental health problems among the Indian people. The occasional visits of physicians and nurses to inspect Indian homes, and a limited education program in the schools, was the primary extent of sanitation work with the Indian people. Starting in the mid-1930's, the Public Health Service district offices provided engineering services to the Bureau of Indian Affairs on the design of sanitary facilities at governmental installations such as schools, hospitals, and agencies. There were also a few contracts with local health departments to provide public health services to several Indian groups.

In 1950, the Public Health Service assigned an engineer officer to the Bureau of Indian Affairs to provide consultation in environmental health matters and to survey field conditions. Three years later a professionally staffed sanitation activity was initiated on a limited scale.

Indian sanitarian aid concept

To bridge the problem of acceptance of modern sanitary practice by Indian groups of different cultures and traditions, the Indian sanitarian aid concept was developed.

Selected Indians, respected in their groups, are employed by the Federal Government. They are given intensive training in the basic elements of communicable disease transmission, sanitary practice, and health education tehniques. After 4 to 6 weeks of training and orientation, they are assigned to work on reservations with the Indian people. The sanitarian aid's primary duties can be grouped into five major areas:

(1) Conduct individual home surveys to record sanitary conditions in housing, water supply, waste disposal, food sanitation, and related environmental factors. This information is then compiled into an illustrated comprehensive baseline report depicting sanitary conditions and needed corrective action for the entire Indian reservation. The accompanying chart summarizes conditions on 23 Indian reservations selected at random from reports made during the period 1956–62. The sample population of 41,000 represents more than 10 percent of the total Public Health Service bene

ficiary group of 380,000 Indians, Eskimos, and Aleuts. Grossly overcrowded housing, unsafe water supply sources, lack of piped water in the home, and grossly inadequate excreta disposal facilities all contribute to the high indices of preventable diseases noted previously.

(2) Improve sanitary practices and conditions at Indian homes and communities through an educational and promotional approach by home visits and at community meetings.

(3) Demonstrate effectiveness of sanitary measures, such as residual spraying for fly control, cleanup campaigns, and modified sanitary land-fill practices.

(4) Provide sanitary inspectional services at trading posts, slaughtering operations, and Indian gatherings for celebrations which may last for a week and involve up to 50,000 Indians at one time.

(5) Serve as a key member of the reservation public health team. In this capacity, the aid arranges for rabies control clinics; participates in field investigations of environmental factors attributable to high caseloads of preventable diseases among Indians who reach PHS clinics or hospitals; and assists in conduct of food service courses.

In the conduct of his work, the Indian sanitarian aid receives technical support and program guidance from professional sanitarians or sanitary engineers. Experience has shown that efficient operations can be obtained when one aid is assigned to a population group of 1,500 to 2,000, representing about 400 homes, and when 1 professional is available to support 3 or 4 aids.

Since 1955, this activity has been expanded so that some services are now provided to about 65 percent of the beneficiary population, although in some areas such as Oklahoma, the Navajo Reservation, and Alaska, the extent of coverage is limited. An inservice program of more advanced short-course training has been instituted for the sanitarian aids, with modifications adapted to program changes.

Construction of sanitation facilities for Indians

Public Law 86-121, commonly known as the Indian Sanitation Facilities Act, was signed in 1959. This act amended Public Law 83-568 to clarify the authority of the Surgeon General to make such arrangements and agreements with Indians and others regarding contributions toward the construction and responsibilities for the maintenance of water supply, waste disposal, drainage, and other essential sanitation facilities for Indian homes, communities, and lands as in his judgment would best assure the future maintenance of such facilities in an effective and operating condition. The legislative history of the act recognized that the authorized construction work was essential to meet a health need.

The program is being administered so that, for each project, the following elements will be included:

(1) Joint planning with Indian beneficiaries and other interested agencies and groups.

(2) Active Indian participation and contribution.

(3) Design of facilities based upon practical local situations and cultural factors in the beneficiary group.

(4) Construction work using contract, force account, and voluntary labor as deemed most practicable and in accordance with the formal project agreement with the tribe.

(5) Organization for operation and maintenance of completed community facilities. (Existing organizations are used where possible, but often a separate organization must be established, service charges developed, and an operator trained.)

(6) Training of individual families in operation, maintenance, and utilization of completed household facilities.

(7) Transfer of completed facilities to beneficiaries or to local political subdivisions by formal agreement.

In effect, this program represents a public works activity in a public health setting. It stresses self-help and participation by the Indian people with the goal of obtaining better maintenance, care, and utilization of facilities. It requires staff not only competent in sanitary engineering, but also with a knowledge of the Indian people, their culture, and their traditions. It requires direct working relationships with tribal governing bodies; with the Indian people; with other disciplines of the local health unit; with contractors; with Bureau of Indian Affairs officials; and with State health departments.