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is not so evident in times of peace and plenty, it becomes painfully apparent in case of any national disaster or economic depression.

The size, complexity, and standards of living of our United States make so many demands upon local units of government that, with the exception of a few of the wealthy industrial and agricultural states, their educational, public health, and welfare requirements cannot be met fully without some outside assistance. Many places have already reached the limit of their taxing power, while others simply need a stimulus to provide funds adequate to their needs. In view of the decided differences among our forty-eight states-differences in wealth, in intelligence, and zeal for public betterment-the most logical source from which to draw additional funds for welfare purposes is the national exchequer.

The unwillingness or inability of the states to meet the exigencies of an increasingly complex social order has led the central government to take a hand in many fields. Federal grants-in-aid have proved the most effective means of encouraging the states to assume greater responsibilities for the public welfare. Whenever any measures shall have been proved to be of distinct benefit to the citizens of a republic, those measures will finally be secured, either through the voluntary consent of the individual states or under the benevolent stimulus of a system of federal subsidies. The potential danger of the latter lies in the tendency to create a bureaucratic control by the central government and gradually to undermine the initiative and self-direction of the individual states.

There have been four more or less clearly defined periods in the development of federal grants-in-aid in the United States. The first extends from the founding of the Republic up to the year 1862. During this period the federal government made outright gifts of land and money to the states, with very little, if any, central control. The beginnings of our public school system, of public highways, and postroads took place under the stimulus of these grants. As Swift succinctly states, "these funds of federal origin were wheel, ballast, and lever of the states' systems of free schools. They set these systems in motion and kept them going." It must be recorded, however, that this open-handed federal policy, without any adequate check on the funds, led to many abuses, mismanagement, and the squandering of millions in money and in potential land values.

The second period begins with the passage of the first Morrill act of 1862 "donating lands for colleges of agriculture and mechanic arts," and extends up to the year 1914. This may be designated as the era of the land grant colleges. During this time a number of extensions under the land grant colleges took place. Certain requirements were laid down by the federal government in the distribution of lands and in the use of derived funds. Reports were required of the treasurers of the various institutions enjoying the grants, and these had to be prepared under several schedules prescribed by the federal authorities. While a closer check was kept upon the funds by this method there was very little attempt on the part of the federal government to dictate the local use of money

or to set up general standards to be accepted by the states. Trial and error during this period played considerable part in the extension of the principle of federal grants-in-aid.

The third period was ushered in with the passage of the Smith-Lever act of 1914, providing cooperative agricultural extension work between the land grant colleges and the United States Department of Agriculture. This initiated several new features not contemplated in the previous acts. It provided for a basic sum of money to each state upon acceptance by the state legislature of the provisions of the act, and also additional sums contingent upon the state matching the federal appropriation dollar for dollar. The acts passed since then which provide federal aid to the states have required legislative acceptance by the states and matching of federal funds to obtain full benefits. Federal supervision of their expenditures has been secured and assured by the creation of special boards at Washington. The states must now submit detailed plans and budgets to the federal boards for approval. A careful federal audit of all expenditures under the grants is now made by direction of these boards. Regular reports of projects and activities must be submitted on approved forms. A certain amount of inspection and supervision is carried out by agents of the federal boards. Should the plans submitted by the states prove unsatisfactory and the funds be expended for purposes not specified in the acts, the federal boards have the power to withhold further allotments. Appeal may be taken to Congress, but this has been done only on one occasion, by the state of Georgia.

The Sheppard-Towner act for the promotion of maternal and infant hygiene incorporates the best features of the other recent acts and also has certain provisions which improve upon any of them. For one thing it provides for direct appeal to the president instead of to Congress. The most important acts having a relation to the public health and social welfare passed since 1914 are as follows: Smith-Lever act of 1914, providing for cooperative agricultural extension; Federal Highways acts of 1916 and 1921; National Defense act of 1916, providing for federal control and supervision of the state militia; Chamberlain-Kahn act of 1918 for the prevention of venereal disease; Smith-Hughes act of 1917 for the promotion of vocational education; Sheppard-Towner act of 1921 for the promotion of the welfare and hygiene of maternity and infancy.

The growth in extent and influence of federal grants-in-aid may be seen in the increasing amounts of money appropriated to the states year after year. In 1912 the total federal appropriation to the states was about $6,000,000. By 1915 this sum had been doubled, and in 1917 the considerable sum of $53,000,ooo was distributed to the states. In 1919 the federal allotments to the states reached to over $87,000,000, and in 1922 it rose to the enormous sum of $180,000,000. It is estimated that about $200,000,000 was distributed in subsidies of various kinds during 1925. In other words, federal subsidies to the states increased over 3,000 per cent in a little over a decade. It should be noted that this rapid extension of federal subsidies and increasing expenditures of the states

under closer supervision of Washington has not taken place without considerable opposition, and assertion on the part of some of the states that their sovereign rights were being purchased at a relatively low price by the federal government.

The granting of federal subsidies, contrary to the expectations of many, has stimulated the states to put more and more of their own money into the projects contemplated under the various acts, in some cases as much as three and four times the amounts allowed by the central government. Any concerted attempts to break down this system of grants-in-aid at present would result in confusion in many departments of government. The departments of Agriculture, Commerce, and Labor have largely been built up under this system. State education, agricultural extension, highway construction, vocational education, the protection of maternity and infancy, etc., would all be seriously threatened. It is questionable, even with a conservative and economical administration in power, whether any definite steps would be taken to curtail the federal grantsin-aid now in force, although it seems likely that efforts would be made by leaders working under such an administration to prevent any further extension of the system.

The crucial test of the efficacy of federal subsidies cannot be derived from any theories of government, but must rest upon an evaluation of the actual benefits conferred upon the citizens of the several states. Measured by this criterion there can be no question that, even with the woeful mismanagement of funds and losses during the early experience with federal subsidies, the sum total of benefits nationally and in the states has been far greater than could have been secured from exclusively state development of public schools and colleges, national highways, agricultural extension, and public health.

As the Sheppard-Towner act typifies the best form of federal aid to the states which lends itself most readily to integration with the established official public health work, a brief summary of the workings and results of this act during the four years it has been in operation will throw some light on the question as to whether federal subsidies for state health work are justifiable. The Sheppard-Towner act for the promotion of the welfare and hygiene of maternity and infancy became a law on November 23, 1921. While the bill was before Congress it created widespread interest and discussion and centered the attention of the entire country upon the necessity for better protection of our mothers and children. One of the first effects of its passage was the increase in the number of state bureaus of child hygiene. In 1920 thirty-two states had bureaus of child hygiene as part of their public health machinery. At present every state has a bureau of child hygiene or child welfare, and forty-three states have accepted the provisions of the Sheppard-Towner act. In order to share in its benefits the states were led to create such bureaus, a logical and sound administrative step in the public health work of the states.

Another important effect of the act was that the states were led to study

more thoroughly their own local health problems and submit plans to the federal board best calculated to afford adequate health protection to their mothers and children. In doing this it has been possible for the state health officials to judge better the relative importance of various measures proposed and to concentrate efforts upon those which gave promise of the most productive results. Furthermore, the federal Children's Bureau has kept all of the states well informed as to progress in the field of maternity and child health, and has rendered a real service in bringing together committees of experts to draw up minimum standards for prenatal, infant, and child care. The directors of the state bureaus have assembled once a year in Washington to discuss mutual problems and exchange views. In this way it has been possible for each state to draw upon the experience and methods of every other state.

One of the most far-reaching results of maternity and infancy work has been the opening up of opportunities for a considerable number of well-trained public health nurses. These nurses have been of untold value to the mothers and children in the rural districts, and especially in the remote, sparsely settled areas of the Middle and Far West. Public health nurses in ever increasing number have made their services indispensable in the communities where they have worked. The education of the communities to better maternal and child care has also stimulated the parents to demand better and more skilled professional services on the part of physicians, dentists, and nurses. Not the least of the benefits derived from this form of federal subsidy is the necessity for careful planning of all work and strict accounting for all funds under a budget system.

Public health officials throughout the country are almost unanimous in their approval of the administration of the Sheppard-Towner act. The state and provincial health authorities of North America, with few dissenting votes, have urged the renewal of the provisions of the act after its five-year trial period. About the only objections which have been raised to this type of work have come from certain groups in the medical profession who continually raise the specter of state medicine, and from cults which frankly admit they are opposed to any form of organized health service. Such opposition, however, can have but little effect upon the public health movement, and only tends to consolidate the gains already made. The more progressive and public-spirited physicians are finding in the workings of this act an opportunity to render larger and more satisfactory community service in an era which stands for preventive medicine.

From the national standpoint the contribution of greatest significance has been that the poorer and more backward states have been given an opportunity commensurate with the more fortunate to afford health protection for their mothers and children. This is as it should be. Certainly healthy mothers and children are as great a national asset as well-bred cattle and fine pigs, whether they happen to be born in Missouri or in Massachusetts. Very few objections have been raised to the expenditure of huge sums of federal money to protect

and improve the live stock. Why object to similar expenditures for the public health?

Health is today regarded as one of the major objectives of education. Health education cannot be divorced from health service. The effectiveness of the Sheppard-Towner act, or any other of the public health measures assisted by federal funds, cannot be measured solely by reduction of the death-rates. The condition of those who survive would be a much better index. Are mothers and children now living under more wholesome and healthful conditions on account of the widespread health education and better medical and nursing service stimulated through such federal grants-in-aid as the Sheppard-Towner act? That such is actually the case cannot be doubted by one who has had the opportunity to observe conditions over the whole country before and since the Sheppard-Towner act. The fact that parents, teachers, and health officials throughout the length and breadth of the United States are the strongest advocates for the continuance of such measures speaks eloquently for their success.

There is no logical or practical reason why federal subsidies should not be given for public health purposes. They are an established and legitimate means of cooperation between the central government and the states and, under suitable safeguards, have proved their value to the states and the nation.

ORGANIZATION OF PUBLIC HEALTH

THE PLACE OF SOCIAL WORK IN PUBLIC HEALTH
Harry L. Hopkins, Director, New York Tuberculosis
Association, New York

This paper is an attempt to present a brief outline of the influence of social work upon the public health movement in this country. The two fields, it seems to me, have been artificially divided until now we erroneously speak of social work and public health in two distinct classifications.

The public health workers as a group resent being classified as social workers because the average health administrator thinks of social work as being synonymous with case work—a rather natural deduction in view of the development and emphasis which communities all over the country have placed on this single phase of social work.

The influence of social work on public health administration is found in the development of every branch of that service in the past fifty years. The recreation movement, the child welfare movement, and such special developments as workingmen's compensation in the industrial field have all been influenced by the humanitarian interests of the forces interested in social work, and each of these has had a direct bearing upon the health of the several communities in this country.

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