IS AN INDEPENDENT ADMINISTRATION OF HEALTH AND

SOCIAL WORK DESIRABLE?

Edith Foster, Director, Health Service Training School,
Milwaukee

In an age of combination and consolidation one hardly dares to predict either the possibilities or the limitations of social trusts. The question in the title of this conference paper implies doubt in things as they are and suggests a gigantic merger. There cannot be attempted within the limits of this paper more than a few of the considerations which should help to answer this inquiry.

In the field of big business, when mergers are contemplated, appraisal companies make elaborate studies of the bookkeeping of all the corporations involved. The bookkeeping of health and social work is not in such satisfactory columns as those of big business. No satisfactory unit for measuring efficiency of administration in either health or social agencies has yet been devised. In public health work vital statistics furnish partial measurements through mortality and morbidity figures. Extension of the life-span, for instance, measures real accomplishment. Reductions in death-rates from a number of diseases can well be looked upon as interest on the investment in public health. The fact of death rarely escapes notice, and therefore furnishes our best, but still a rather unsatisfactory, measure of efficiency in health work. Unfortunately social work lacks even the crude measurements possessed by public health. Nothing so final as death occurs in the field of social work. Even a life sentence to a penal institution does not carry so great finality in disposing of a delinquency case while the pardoning power exists and is used so generously. Figures on illegitimacy, desertion, delinquency, dependency, unemployment, neglect of children, and other social problems are far from complete. Studies of these problems in selected communities at various times seem to point to a rather constant rate in which these conditions occur. The accomplishment of social agencies in dealing with such problems can be measured with but a little more than pretense of accuracy.

Social work as now conducted by case working agencies concerns itself principally with these problems, all of which have health aspects, unemployment not excepted. The Milwaukee Family Welfare Association reports that in 2,728 families treated last year there were 1,590 cases of illness. This figure carries conviction that agencies dealing with dependency need to be interested in public health. The teaching of modern case work methods lays good emphasis upon the responsibility as well as the wisdom of referring health problems to medical agencies. The point at which problems are recognized by the social worker is, however, more important than the acceptance of the principle. There are almost unlimited possibilities of developing understanding of the nature of more or less prevalent chronic diseases, the ability to recognize the earliest symptoms, and the conviction that the best, and perhaps we shall come to

realize the only good, method of prevention is the periodic health examination. Social workers and, I fear, health workers, have not yet embraced this faith personally, as is evidenced in the far too many staff casualties.

It is obvious that health agencies have increasingly adopted various kinds of social service as adjuncts to their work. The hospital social worker has certainly come to stay. The psychiatric worker has already justified her training and the making of a place for her in the mental hygiene program. It is equally evident that social agencies have found it effective to incorporate certain health activities into their programs. The results obtained from what might be called partial mergers in health and social work have fully justified the combinations. This limited plan of combining health and social work is, however, more likely to succeed conspicuously than is the combination of various kinds of health agencies or the collection of several kinds of social agencies under one administration, theoretically desirable as these arrangements may be. The stimulation which comes through accomplishment and produces initiative is manifested in better individual case work through these combinations. The same stimulation is harder to find in a merger of agencies carrying on educational work through lecture and field service, publications, and general newspaper publicity, although there can doubtless be demonstrated considerable economy in handling the problems of distributing educational material furnished through the written and the spoken word.

The health agency which has conducted traveling clinics has learned that the public has a confirmed interest in health which makes for the rather ready acceptance of the health worker. While this is true, the health agencies will stand to lose more of the favorable opinion of the public in a merger of public health and social work than will the social agencies.

The limits of this paper make it necessary at this point to answer the question in the title with an affirmative. I am indebted to wise consultants and friendly critics of this paper for the expressed conviction that a merger of health and social agencies would reduce to a lowest common denominator the functions of all these agencies, with a resulting mediocrity of standards. One consultant believes that "no specialist would be attracted to the position of executive in such a merger without placing too much emphasis upon his specialty and reducing all other activities to a dull routine. There would also be the probability that the 'ideal' executive for such a heterogeneous organization would be that colorless personality of no enthusiasms who is too often found in political fodder." So long as there are limitations to the field which one person can master, so long will there be limitations to the combinations which can successfully be effected in health and social work, for here as everywhere, leadership is para

mount.

Since the inquiring title of this paper suggests some inefficiency in the present administration of health and social agencies, I should like to be evasive in answering the question and try to suggest a substitute or a group of substi

tutes. The best substitute I have to offer is education and more education; training in its best aspects, and still more training. It is significant that this year for the first time the National Conference has a section on training activities. This presents a new and exceedingly promising opportunity to health agencies. Recent observations in case committee meetings and personal interviews in social agency offices have deepened a conviction in the writer that health agencies have often assumed that the social worker knows enough about preventive medicine to give his client the best possible chance for health. One finds morbid fears amounting almost to confirmed phobias with respect to some health problems, and an utter lack of concern about other conditions which may be considerably more serious. Schools of social work have not devoted anything like a just proportion of time to the subjects dealing with health. One needs only to scan the bulletins of all of the larger professional schools to get the impression that the early emphasis upon other conditions met in social work was much too great. This is probably due to the fact that health agencies, having developed earlier and functioning more or less efficiently, tended to remove health problems from the group of chief concerns in social training. There may have been a more or less unconscious recognition of medicine, as an exact science based on biology, in contrast to sociology, which is still feeling its way to a scientific method and a recognized technique. The teaching that all health problems must be referred to medical agencies was considered sufficient. But this is not sufficient. Every health agency executive should be jealous of the time devoted to less important subjects than health in the programs of social work training schools. The emphasis is growing, but the objectives of health agencies are not yet ingrained in social workers. Now that almost all courses for public health nurses are connected with universities, perhaps we may hope social service will receive deserved attention.

Harboring the belief that far too many Conference papers are written in generalities which sound well but are hard to translate into action, I venture to break through my natural modesty, and in behalf of my organization describe an activity which has been in operation for nine years. The Wisconsin AntiTuberculosis Association, in 1916, began the training of public health nurses for Wisconsin communities. It was recognized that what was needed was not a post-graduate brand of hospital training, but some knowledge of how people live, what they must know to live more healthfully, and some of the best ways of circulating that knowledge. Obviously, training for a task like this required not only the cardinal principles of preventive medicine, not only the history and practice of public health nursing, not only a working knowledge of health and social legislation and institutions, but also at least a few elementary principles of social psychology. Popular education through the medium of the newspaper and the spoken word has been taught through a course which might well be entitled "reaching the people." Not the least important feature in this training of public health nurses was the recognition that it could be combined with the

training of lay health workers and later with social case workers. When the same teaching material is presented to nurses and social workers in the same classroom at the same time there is produced at least an embryo impression that after all there is but one big "art of helping people out of trouble," that there are many subdivisions of this art varying with the many disabilities which come to human kind. Since February, 1922, training for social work has been carried on under a cooperative arrangement by and with the Wisconsin Conference of Social Work, the University of Wisconsin Extension Division, and the Milwaukee Central Council of Social Agencies. The courses given in the training of both groups, public health nurses and social workers, include the usual list of subjects associated with such courses, but with the lectures given in the home office of the Wisconsin Anti-Tuberculosis Association, where there is an atmosphere of public health. Observation of the work of the graduates of the social work course a year or two after the training has confirmed our feeling that “it pays to advertise" in this particular way. To illustrate: During the writing of this paper a 1924 graduate now employed by the Family Welfare Association came to our office to report trouble with three tuberculosis cases where much effort had been spent to achieve sanatorium care, and then the plans exploded for various reasons in which the worker thought we might concern ourselves. Personally, I was conscious in this interview that we had done very effective tuberculosis work in the training of this student who, we knew, was to be employed in a family agency.

Carrying education into another avenue, for months we have had occasion at weekly case committee meetings of social case working agencies to direct attention to health problems, usually tuberculosis, following the case presentation. Health workers should seek invitations to membership on case committees of social agencies. One hour per week of this activity is an excellent investment of time, likely to yield far more than much broadcasting at random. Out of this case committee experience has come a request, admittedly more or less primed, for a series of terse bulletins on tuberculosis and other health subjects. These will take the form, not of essays, but of actual desk advertising, attractively set forth with striking bits of truth brought down to date and written expressly for the group of social workers who go into family homes and see people who need truth.

One more example of a partial substitute for a merger of health and social agencies was the Milwaukee Vocational School health examination project undertaken by the Wisconsin Anti-Tuberculosis Association. The plan for following the 5,348 examinations for the purpose of securing corrective work where indicated drew in all the large and many of the smaller private social agencies, in addition to the city health department, the county dispensary, and the juvenile and municipal court probation departments. The cases were assigned after clearing in the social service exchange. If our sole objective had been economy in administering this particular activity, the plan would have

had worth, but its greatest value lay in the more or less unconsciously received education of the workers in the agencies participating. Health agencies should engineer projects of this kind as vehicles of education.

These illustrations of cooperative effort by health and social agencies have been presented with the frank purpose of proving an alibi. Then, to conclude, a separate administration of health and social agencies is desirable in this year of complexity, 1925, but not independent in the sense in which the oil companies use the word to denote having nothing to do with each other. On the contrary, there must be the greatest recognition of dependence, the one group on the other, if we are to fulfil our large contract.

HEALTH BUDGETS IN MUNICIPAL ADMINISTRATION
AND HOW SOCIAL WORKERS CAN HELP

WHAT ADEQUATE HEALTH SERVICE COSTS
Haven Emerson, M.D., New York

Adequate health service for an individual will cost between ten and seventyfive dollars a year, according to location, work, and intelligence of the person and of the physician responsible. There is, over and above this, the burden which properly falls on the individual for his own health, an obligation, moral or legal, voluntary or compulsory, to provide preventive and treatment facilities which can only be operated with advantage as public services. Some of these public services are essential to the life and happiness of everyone, and should be supplied out of the tax levy, free; others, while commonly bought and paid for by the well-to-do individually, must for the indigent, and often for the wageearner, be provided out of a common purse or for a nominal or minimum wholesale cost charge. It is the public or communal health services we are to consider here, and of first importance is a definition of the inclusions under our term. But, before attempting that, let us agree upon certain indispensable preliminaries.

We must assume that there are, in effect, statutes dealing with what is known as sanitary law or codes, and housing or building law, with, it is to be hoped, zoning law, and industrial conditions or compensation law, i.e., legal authority for control of the individual and his environment so far as these may be required to protect himself and his fellow against preventable diseases.

We must assume that there is authority for the appointment of technically trained professional officers to carry out the provisions expressed under the law and included in the police powers vested in the states.

Let us also assume that such details of communal housekeeping as the provision of an unpolluted and palatable water supply and the disposal of sewage and garbage and cleaning of streets are not to be charged to the cost of health service.