personnel people competent to do this kind of work. I noted on my calendar several cases where I desperately wanted a case worker to look up the social conditions surrounding the claimant, in order that substantial justice might be done. The commission is not bound round by the stiff and rigid rules of the courts. Social evidence may be accepted if it is relevant to the case. The New York law is elastic in some respects and it is possible to treat a case humanly and socially if we have the evidence. The compensation money awarded to injured people does not solve all their problems. Sometimes the people get their reward and go away with as complicated a life as they had before. The accident often merely serves to intensify a problem which has been there for many years. We had the usual number of domestic problems, all sorts of complication in family life. For instance, often when the wage-earner of the family is injured other members of the family become an intolerable burden-the old, the tubercular, the mentally deficient-something has to be done about them because the family economy is deranged.

I determined to ask for funds to add a few case workers to the staff of the Workmen's Compensation Bureau. Governor Smith was interested in the plan, and it was the governor himself who invented the name "After-Care Service" for that branch of our work. The Finance Committee of the New York State Legislature recommended and the legislature appropriated in the general budget funds to establish this aftercare service with a director and two field agents. There was no attempt to make political appointments, the people who were selected had no political references at all. I wanted someone who had been through the charity organization society and Red Cross Home Service mill and had a little experience, but I was rather anxious that they should not have too much charity organization society experience. Such work in the service of a department of government work could not be done in a dogmatic, but must be done in a broad fashion. The money going to claimants has no relation to their behavior, nor to the advice given them. The money belongs to them under the law and they get it whether they take the advice of the case worker or not. The whole relationship between claimant and after-care agent must be one frankly free from compulsion and wholly democratic. Two quite remarkable women were selected and after they came they developed the work in a very fine and satisfactory manner. Now, as to what they did and how they did it. Their technique was not different from that of other case workers. They knew the social resources of the community. The only difference was that they possessed no moral coercion as a tool of their trade. They were on the whole unbiased in favor of the claimant, although most of their work was, by its nature, in the interest of the claimant. When they first came the young men who represent the insurance companies before the commission eyed them with great suspicion. They did not know what these two young women might do to help claimants, and were surprised to learn that they had respect for truth and justice, and if they found an Italian playing sick when he was not they said so truthfully. Of course most of the reports were in favor of the claimants. It is the commission's duty to help the claimants. Claimants are told that the commission will represent them and therefore it is important that the commission should be equipped to make that representation. The work of these young women was not only the making of investigations and reports on the cases, and rendering general social service to claimants, but as time went on they found themselves spending a certain portion of each week in the hearing rooms testifying.

People about the commission grew to have confidence in them.

At the beginning there had been certain discussion among us as to how the aftercare division would get cases. I would refer cases to them and one other commissioner would do so, but was there anybody else on the commission who would do so? The fact is, after the first month they never had a moment in which to wonder about new cases. Everybody from the chairman down to the policeman at the door was referring cases to them. Then they began to get cases referred to them by the insurance companies, at first surreptitiously, then openly. This came about through their great success in persuading people to have operations. The prejudice against operations is common among many people. Any compensation case is likely to have need of an operation. I began referring cases where it was perfectly obvious that an operation was needed, to the after-care people, asking them to go to the home and establish friendly relation and then talk over the situation quietly and calmly. So the insurance companies began to get confidence in these after-care people and began also referring cases to them. The last report shows that in the month of May eleven cases were referred to them by insurance companies, usually from the medical department.

There were several types of cases that they got regularly. First, the cases where we needed social evidence in addition to the legal evidence which we already had—such as where a man or woman wanted to buy out a business or perhaps a farm, and needed a certain amount of money all at once. The law gives the commission the right to decide upon matters of this kind when in their judgment it seems that in this way substantial justice can be done. It is serious to give people all their compensation money at once, and it is necessary to have knowledge about what kind of people they are, in order that we may decide whether the venture they propose will be successful. Then in case they wanted to buy a farm we needed to know whether the land they had in view was good land, we needed to know whether they knew how to cultivate it, or whether they knew how to carry on a dairy business, etc. Often people wanted to go into the shoe cobbling business. We needed to know whether they knew how to cobble shoes, and how to carry on the business of shoe cobbling. These things the after-care department had to investigate. I think on the whole their advice has been good in these matters, although they always hesitated to give advice in such cases; they got the social facts and brought them to the commission for decision.

There was another important piece of work that was constantly coming up-the putting of cases receiving inadequate medical care in touch with medical agencies. This sometimes means taking a patient away from a private physician and getting him into a hospital. It meant pretty straight talk with the medical service of the insurance companies. We had always with us the problem of those people who were not equipped mentally to battle with life. We had coming before us the insane, the feeble-minded, the neurotic-cases most difficult and important, not only to themselves, but to the community at large. The After-Care Service frequently had to arrange for the putting away of insane people. They had to find relatives and attempt to get them to cooperate. Then there were the feeble-minded, where the accident had brought to light the fact that they were feeble-minded, and were a public menace, and needed special care. Also, the problem of the neurotic. Before many years medical science will begin to understand and do something about the prevention of these accident neuroses. Now, before industrial commissions all over the country, are coming cases of people who have been working and considered normal until they had an accident, but the accident served as a determining factor which brought to the surface all the neurotic tendencies in the patient. We do not get these cases early enough, but usually after

the malady is firmly fixed. The practice of making a small lump sum award in these cases of neuroses is commonly recommended by the medical profession as an aid to cure, but this method is most unsatisfactory and uncertain. People have come back years afterward not cured at all. The insurance company, the physician, and the claimant must co-operate to discover those individual accident cases which have the possibility of neurotic developments later on, and put them in touch with agencies in the community which can best break up the tendency. Sometimes a new kind of work will break up a neurotic tendency. A man's mind must be cleared temporarily at least of the things that are worrying him. If it is his wife's disposition, send him, or her, away to the country for awhile. We found all kinds of tricks that would work, if only we could find out what was worrying the worker and get rid of it.

Another important part of the work of the After-Care Service was finding jobs for disabled people—the rehabilitation of cripples. That is increasingly important. Then, there has been the making of proper connections with the right kind of relief agencies who would supply the inadequacies of the compensation law, in cases where it was necessary.

I wish I had time to tell you exactly what we accomplished in the first six months of this work. But I can only sum up their activities from the report the workers have made to me. There were cases involving children, 23; cases involving the giving of a lump sum, 29; employment and rehabilitation cases, 37; neurotic and mental cases, 20; cases involving additional, or change of medical care, 32; cases where the compensation was inadequate to the family need, 22; miscellaneous cases, 56. These latter included a lot of diverse and interesting cases.

The after-care workers have done much to humanize the work of the commission. They have found men and women whom the investigators could never have found, and they have also served subpoenas on people whom the burly process servers could not serve at all. So I think there is a great future for intelligent and reasonable and democratic case work in this department of the government. It is having a setback just now in New York State, and this work will be dropped or curtailed, I hear. It is false economy, and before many months have gone by the insurance companies, the trade unions, and the claimants themselves will recognize it as false economy, and the politicians will then realize that it is false economy. In the meantime I hope that some of the progressive states of the west will go ahead and try this thing out in their workmen's compensation bureaus and try it out on the basis of intelligent case work, co-operating with claimants and with the public. Such work should always be under the direction of people like yourselves, who have a large vision of what community life and social life should be, and of what real civilization is.

DIVISION III-HEALTH

MAKING HEALTH KNOWLEDGE THE PROPERTY OF THE
COMMUNITY

Haven Emerson, M.D., Medical Adviser, U.S. War Risk Insurance, Washington Such a title expresses a hope more than an accomplishment. The hope is worth interpreting and we owe it to ourselves to analyze the limitations of the undertaking. By health knowledge we mean at least two distinct classes of information and instruction. First, the acquisition and application of such facts of hygiene and sanita

tion as will permit healthy people to increase in vigor, maintain a normal work capacity, and take full benefit in recreation. Those who are not handicapped in mind or body through mischance of inheritance, environment, or personal conduct, should, we conceive, be so informed that the maintenance and even increase of all their powers may be matters not merely of accident or good fortune, but the well-earned results of a reasoned manner and control of their own lives.

In the second place, we are all determined that much of what has heretofore been the almost exclusive knowledge of the liberal professions and especially of the medical and associated professions, and perhaps of a small group of the better educated in a community, in matters of disease, its recognition, its causes, its natural history, its manifestations, and the relief or cure of its processes should be made more generally available as far as the intelligence of the people permits.

Not that there are included in these general statements all that may properly be classed as health knowledge, but for the present and until we have at least assembled, delivered, and put into use in communities these relatively simple blocks of knowledge we can spare ourselves more extensive ideals and efforts. As a matter of fact, health knowledge is limited only by the scope of human knowledge, the bearing of any fact, act, or thought upon the human mind and body having an appreciable effect upon the completeness of life which we term health.

In the presence of such modern philosophers and social engineers of collective existence and adjusters of human relationships as are here assembled it would be presumptuous for me to attempt a definition of a community, but from some experiences in the practice of individual and public medicine I am inclined to suggest that a community depends more upon a state of mind than upon numbers, location, or density of population; more upon the consciousness of mutual relationship, dependency, and interest, whether material or spiritual, than upon political or geographical limitations of area.

As it is obvious to all, whose professions take them into homes, that parents and children do not alone suffice to constitute that precious foundation and anchor of civilization called a family, without the bond of common life and perspective, so an assembly of human units does not constitute a community. Briefly, a community of whatever size is a group of people who are conscious of their collective interests, needs, fears, and their interdependence in matters of education, health, occupation, and possibly also in political and religious affairs. We have progressively committed ourselves in this country to a gregarious existence, and we are constantly developing more communities out of these human aggregations.

This has been possible only through acceptance of self-restraint, the willingness to be controlled individually in the interest of the whole. Sanitation in large measure has been created by cities, and in its turn has caused or permitted them to be. Our first difference between liberty and license came through the recognition that neither property rights nor individual freedom of action were as valuable as the health rights of the group. This followed inevitably the proof of communicability of disease. We now see personal liberty as precious in proportion to our willingness to sacrifice it for the sake of others. That health or life-rights take precedence over poverty or possession rights is recognized by our highest courts.

Health knowledge was preceded by many centuries by great familiarity with disease. The physician saw only the sick. Those who developed the facts of life—

the physiologists, the chemists, the physicists, and biologists-had no contact with the people as a direct educational force. The beginning of what we are discussing was probably in some home or family circle where the trusted physician who had watched a patient recover from or die of some preventable disease, some child perhaps a sacrifice to ignorance of diet, was asked how others might be spared and what to do to prevent a repetition. Only since the causative agent of infectious or the true origin of functional disorders has been clearly defined has it been possible to give the answers. Only by the asking of such questions has the demand for such knowledge been in a measure satisfied.

And until recent times the outlook upon disease has made attempts at health education impracticable. We have passed through the submissive and evasive stages and are now aggressive in our attitude toward ill health or lack of health. Sickness, once a visitation for our sins, an inescapable affliction to be borne by virtue of religious resignation, then recognized as avoidable by separation, by precautions of time and place, by quarantine and segregation, is now a reproach, an object of attack to be met and overcome in its strongholds, to be searched for and uprooted by intelligent action. What a great psychic revolution it was when the slogan "Keep the well baby well" replaced the call for a summer corps of doctors and nurses to attend the sick infant in our tenements. From now on we shall not only attack sickness and its causes but educate for health.

Understanding of the meaning of the words communicable and preventable as applied to common and serious diseases and the truth of the term remediable in referring to defects of development in mind and body have created the modern demand for health knowledge which should extend to the outer bounds of our information on the laws of health and reliable means of disease prevention.

We now know that obesity creates a serious liability to diabetes. We now know that alcohol is a depressant, habit-forming, narcotic drug and not a stimulant safe for use as a family remedy. We know that continence is compatible with healthy development. We know that typhoid is avoidable by vaccination; that diphtheria is preventable by active immunization of susceptibles; that paresis, locomotor ataxia, and aneurysm are sequellae of syphilis and not diseases independent of previous infection.

It is no easier to declare the right laws of health than those for healthy business, and panaceas are sought and advertised with the conviction of enthusiasts in both spheres. Each cult is an expression of confidence in a panacea, and under the cloak of religion, commerce, or beneficent patronage we are offered Christian Science, osteopathy, and birth control as discoveries of laws and resources which still lack proof and confirmation as to their soundness or wisdom for community health.

In our efforts to give communities health knowledge the strong arm of the police power of the state was enlisted, usually in the presence of epidemics or fear of them. Then precautions were taken by the community, through its agents, for sewage disposal and water supply, an educational process of the officers but hardly understood by the community. We have passed on now to a stage in many parts of the country where further progress in prevention depends almost wholly on what the individual will do to himself and for others. This requires a new step up in the range of his information. We have largely reached the limit of administrative resources without voluntary and determined individual and community participation. Enforcement, sanitary engineering, quarantine, licensing, reporting, all are necessary but limited.