upplanted or is trying to supplant the conceptions of nutrition which were current a lecade ago. At the risk of repeating the obvious, I believe we should constantly insist hat the newer knowledge of nutrition does not supplant but does supplement⚫our Former views. All that we have ever known about protein and calories is as important is it ever was, and we have learned to appreciate the importance of the mineral elenents and vitamines also. Each of these four factors should be given due emphasis without overshadowing any of the others. Calories, protein, mineral elements, and vitamins all are equally important in the sense that each of these four factors or groups of factors is absolutely essential and must be properly provided in order that the food supply may be adequate. In order to make proper application of our present knowledge of nutrition every food supply should contain such proportions of fruit or vegetables and of milk, along with other foods which may be cheaper sources of calories, that the eating of enough food to satisfy the appetite and the need for calories shall at the same time meet all other needs as well. If we could make our present knowledge of food values, and of the ways in which different foods supplement each other, so clear and convincing that everyone would follow it in the choice and use of food this would certainly mark one of the very greatest advances in the application of knowledge to human welfare. For good nutrition is an even larger factor in health, happiness, and efficiency than we have hitherto realized, and our present knowledge of food and nutrition guides us not only in so planning a food supply as to make it adequate in all respects, but also in showing how a food supply which is already adequate may be made still better so that it will support a higher degree of health. The Century Dictionary defines health as: "Soundness of body; that condition of a living organism and of its various parts and functions which conduces to efficient and prolonged life. . . . . Health implies also, physiologically, the ability to produce offspring fitted to live long and perform efficiently the ordinary functions of their species." We are somewhat accustomed to quantitative ratings of soundness and efficiency and much more so to data of growth-rates, birth-rates, and statistics of duration of life. In human experience so many factors may enter to influence health in the course of a lifetime that it is hard to separate and measure the effects of food alone. But this can be done with laboratory animals of rapid growth and early maturity like the rat, and in experiments with the rat it is possible to determine under conditions uniform in all other respects the influence of food upon the various factors of health comprised in the definition just quoted. While agreeing with the eminent pediatrician who said that "a rat isn't a baby and probably never will be" yet I would also point out that by properly planned and adequately controlled experiments we can learn much from rats which is applicable to the feeding of babies and grown people as well. Among the recent findings of nutrition experiments carried through successive generations of such laboratory animals the results of which are, I believe, directly and fully applicable to the problem of the attainment of the highest degree of human health, is the fact that starting with a diet already adequate we may by improvement of the diet induce a higher degree of health and vigor. This has been rather strikingly shown in experiments with rats in which different families from the same stock have been kept for successive generations upon two different dietaries; the first diet adequate as shown by the fact that it has supported healthy growth, development, and reproduction in some families for no less than six generations; the second diet differing from the first merely in that it contains a higher proportion of milk. These experime . Among the evidences of a higher degree of health which we find to result fr increasing the proportion of milk in a diet already adequate are the following: ne rapid growth; more efficient growth, i.e., a greater gain in weight for each 1,000 calor of food consumed; somewhat larger average size at all ages; greater vigor as indicat by earlier maturity, larger capacity for reproduction, and greater success in rear. the young; the period of full vigor was prolonged and the proportion of families dy without issue was greatly reduced; the weight of the mother was better maintaine while suckling her young and the young grew and developed better during the suck period; both infant mortality and the death-rate after infancy were reduced, and t notwithstanding the fact that the females had borne and suckled more young. There is no reason to doubt that all these findings, as thus stated in qualitati terms, will apply equally in human experience and that a higher degree of health i follow an improvement in the dietary of the individual or the food supply of the con munity, such as an increase in the proportion of milk, even where the original dietar was already adequate according to all current standards. Let us then seek to use our present knowledge to insure not only adequacy in t food supplies of all our people, but such food supplies and food habits as shall inda? the highest degree of health and efficiency. SOCIAL HYGIENE AND VENEREAL DISEASE CONTROL RELATIONS AND DUTIES OF PUBLIC HEALTH NURSES AND Edith Shatto King, American Association of Social Workers, New York Yet there is apparently a lack of understanding of purpose or even knowledge of one another on the part of some nurses and doctors on the one hand and some social workers on the other. Possibly we may look for a better understanding in the future because of the improved instruction now given in the training schools of both groups. I believe that all the best schools now recognize both-the nurses' training schools the necessity for some knowledge of social facts, the social work training schools of some medical knowledge for every worker, with specialization for those entering medical social work. In developing my subject I found one important point of contact for the social worker and the medical workers, both nurse and doctor. This was in the clinic. Clearly there must be real team work at this strategic point if the greatest service is to *be rendered the patients. An analysis of the work done in the clinic, therefore, is pertinent to the subject. In my study of the routine work of the syphilis clinic, I examined job analyses of those engaged in the nursing and social work professions. These I obtained through personal visits or through correspondence with about sixty clinics. I also interviewed doctors, nurses, and social workers, who are familiar with the general subject, and I secured from clinics and outside social case work agencies, case records of families or individuals where syphilis was an important factor. And here I may indicate a single conclusion drawn from my study. I believe that much irritation might be avoided and much more constructive work accomplished in developing a new profession such as social work, if sufficient time could be given to analyzing each individual job, and then carefully and with real consideration, selecting the best person for the position regardless of old traditions, old prejudices, and biased points of view. There are at least four rather well-defined jobs to be done in a syphilis clinic. The first is the work of medical diagnosis and treatment and this is the concern of the doctor; the second is the providing of necessary clinical assistance for the doctor. This includes the arrangement of room and supplies, and attention to patients, and is the clinic nurse's job. It is evidently a job in itself, especially where assistance is given in actual treatment; third, there is social work, which I will refer to in detail later in the discussion; fourth, the clerical work—the keeping of records, and help given in a follow-up system through written correspondence. This should be done by the clerical assistant. It is evident that the fullest use is made of the clinic only when all of these four functions are adequately performed. Frequently, I found that a nurse with no training in social work had been assigned to a clinic and called a social worker. One such person when asked as to her duties as a medical social worker, replied, "I get the patients in to the doctor in their proper order and quickly. I line them up and as the doctor is ready I say, "One, two, three, etc." If they are not paying attention and do not come when first called, I make them take a back place in the line." This person was doubtless a good clinic nurse, but why call her contribution social work? The use of the term in this connection results only in confusion and irritation. In sharp contrast with this experience I visited another clinic in a large city, characterized by both the head of the local Visiting Nurse Association and also the most prominent medical social worker, as accomplishing the best work with syphilitics in that community. Here a nurse social worker, besides managing a large clinic beautifully, with a marvelous follow-up system both as to mechanical detail and effectiveness in securing the return of patients, was doing social case work in a selected number of cases. For instance, when the doctor told a young girl of rather low grade intelligence that she must stop her work as a candy packer because she was in an infectious stage of syphilis, this social worker knew that the patient was alone in the world, that she would not have resourcefulness enough to plan her own future, and the doctor's order to quit her job might mean the streets for the girl unless assistance was given at once. As a first step the social worker found the patient a place to board while coming to the clinic for treatment. This was done through the aid of a society for the care of girls, and later, when the girl was ready to earn her own living, the social worker helped her to secure employment in a box factory and remained her counselor, guide, and friend. This social worker had also established effective co-operative relationships with other medical and social agencies in the city in many cases, and through facts obtained by intensive case-work assisted the doctor in charge of the clinic in the preparation of a special medical research study. In addition she occasionally spoke to women's clubs and other public opinion agencies. She had time to intelligently interpret her job to me, and also sent me some of the best medical social case records which I have seen. In this work she had the help only of a clerical assistant. She was a college graduate, a registered nurse, and had taken a year's course in social case-work in a school of social work. I might add that in addition to this particular person's training and ability, the help of the clerical assistant was an important factor in obtaining results. Turning now to the type of clinic where the non-nurse medical social worker is a member of the staff, I found a non-nurse social worker in charge of social work activities in one of the best-known clinics for the treatment of syphilis in the country. She not only has established her work on an excellent scientific basis, but she has an intensely human and sympathetic understanding of patients, and is able to give an exceedingly clear picture of the relationship of this disease to individual and community social problems, as well as to purely medical diagnosis and treatment. Probably the largest number of syphilis clinics are presided over by public health nurses who are in attendance on clinic days held several times a week. They perform all the clinic duties, both nursing and social, and between times make home visits for medical follow-up and health instruction. In the use of the term social worker, I have already suggested that it is frequently applied to an assistant who is not, never was, and perhaps never will be able to do social work. In my investigation I met social workers with a nurse's training and without such training, social workers who had obtained a college degree and those who had not, those with school of social work and special medical training, and with apprenticeship experience under good supervision, and some also who "just grew." In many instances the same kind of social work duties were being performed in the various clinics and this with apparent success and happily. When I refer to the social worker, then, I have in mind the person who is doing the social work job, whatever her previous education, training, and experience may have been, whether she had or had not a nurse's training in the background of her education. Before giving my conclusions as to what constitutes real social work, I wish to say first of all that there seems to me to be one important duty in the clinic which must be shared in common by the workers, whether doctor, nurse, social worker, or clerk; and this is the maintenance of the proper atmosphere. The spirit of courtesy must be in evidence, of neighborliness and friendship, of regard for privacy and for confidences extended by the patient, as well as regard for social justice in the sense of respect for other persons' rights. The first function in social work is attention to certain details in the management of the clinic. I have been told repeatedly also that the first interview with a new patient offers one of the best opportunities for effective social work. Here is a chance to gain the patient's confidence, to help overcome shame, fear, or undue retic in fact, to set the pace for the whole process of treatment. Certainly, too, no lo this job successfully without a working knowledge of normal and abnormal psychology. A second important part of social work is teaching in the clinic. This is most essencial and is truly social work. In a large clinic, and, in fact, in many smaller clinics, the doctor and nurse are so occupied in giving treatments that they have little time for this teaching process. In such cases the social worker may supplement their efforts. The third function of the medical social worker is the interpretation of the medical facts about a given patient to outside agencies, and this, it seems to me, is one of the most important functions of the social worker in the clinic. Outside social workers such as the family worker, the protective officer aiding young girls, the child-placing agent, and the employment worker, frequently bring patients to the clinic and they should expect an explanation of the medical facts which have a bearing on the social facts if they are to act intelligently. Non-medical social workers and even some public health nurses are astonishingly and sadly ignorant of the prevention, treatment, and cure of syphilis. Social workers on the outside also need to know, not how many salvarsens or mercury treatments have been given, or even when the patient should return for treatment, but whether he is infectious and whether the patient can go to work and if so, under what conditions. Nor should they be expected to be mere errand runners for the clinic in securing the patient's return. The fourth function of the medical social worker is the general contribution to the education of the community, by indicating the relationship of cause and effect, and the social causes and results of syphilis. This is the public health function of the social work job. It may be done both with individuals in teaching the prevention of infection to others, or in group fashion through community propaganda. The fifth function is the intensive social case-work necessary in the successful treatment of many clinic patients. In many instances this is not being done at all, and perhaps in the majority of cases. It certainly is a part of the work rarely seen successfully accomplished. In social case-work the medical social worker must picture the environmental and psychological factors to the doctor so that better treatment may constantly be given. After the doctor has made his diagnosis, decided on the necessary treatment, and advised the social worker regarding the patient, there must be on the social worker's part endless and untiring personal work with individuals in their homes as well as in the clinic. As the patients go through the experience of facing the consequences of the disease, regardless of how they acquired it, their mental attitude and readjustment is clearly, as pointed out by a social worker, the biggest part of the problem, "whether it is the readjustment of the point of view of the wife toward her husband, of the father toward his children, of the girl toward society, or of the delinquent male patient toward the law." On the other hand, outside social workers frequently fail to provide necessary social facts. In one clinic I visited the social worker said that in the twenty-six months of her service she had had only one communication from an outside social agency giving an intelligent social history of a patient who had moved to another city, the reason why a previous medical history was requested and some report of the later medical history. |