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the hospital situation, and points the way to a program of hospital expansion better adapted to the needs.

In February of this year the Federation initiated and financed an exhibit of medical science by the College of Medicine. Its purpose was to try to offset the progress of cults, quacks, and patent medicine vendors by giving the public an opportunity to see the inside of a medical college and by demonstrating some of the simple principles of modern medicine and surgery. Thirty thousand citizens of Cincinnati studied the exhibits, crowded the lecture halls, and saw the motion picture, "Pilgrim's Progress through the Medical College," showing how the student is taught from the time he enters until he leaves. One of the direct results of the medical exhibit is a course of public lectures to be given at the College of Medicine, starting in the fall.

A message on the prevention of goiter is now being placed in the hands of every parent in Hamilton County. We are cooperating in an effort to prevail upon the county to adopt a program that will rid the county of stray dogs and demonstrate the possibility of a rabies-free community.

Our Negro population, of something over 30,000, presents perhaps our most serious health challenge. Negroes in our city are dying twice as fast as the whites, their children three times as fast. Their death-rates from tuberculosis, venereal disease, and pneumonia are appalling. Their housing and their social problems have not responded to our efforts. With the wholehearted backing of the Community Chest, the Public Health Federation, in cooperation with the Negro Civic Welfare Association, the Associated Charities, and the Better Housing League, opened, six weeks ago, the Shoemaker Health and Welfare Center in the midst of our West End district, where two-thirds of our colored population live. Here, in a wonderful old building donated for the purpose, we have established a clinic for the ambulatory sick, with services in medicine, surgery, venereal disease, and dentistry. A children's clinic and a prenatal clinic are conducted in cooperation with the Babies' Milk Fund Association. Negro and white physicians serve side by side in each clinic. Practically every Negro physician in the city will participate through a rotating service. This affords the Negro physicians of the community their only opportunity for clinical experience. On the second floor of this center the social agencies have combined their field work for Negro families. The seven Negro field workers of the Better Housing League and of the Associated Charities, under a well-trained supervisor, are conducting a demonstration in generalized social service. Here, too, is the West End office of the Negro Civic Welfare Association, which, under the direction of Mr. J. H. Robinson, has done more to gather the facts about the Negro problem in Cincinnati and to bring about unity and constructive programs than perhaps any other force in the city. On the third floor is a demonstration threeroom flat, where Negro housewives are instructed in the art of home-making.

It has seemed advisable to present this summary in order to show that the federation of health activities has à value. We labor under no illusion that we

have done anything like a complete job. One year ago we asked Dr. Haven Emerson to appraise our work and to point out our shortcomings. While giving Cincinnati credit for considerable progress in unifying its health activities, Dr. Emerson rendered us a valuable service by pointing out numerous specific tasks that lie ahead.

Problems in federating health work. We now come to a consideration of some of the problems facing communities which are trying to federate their health work.

Should a health council consist of private agencies alone, or should it be made up of both public and private agencies? Our experience in Cincinnati leads us to believe that one of the best purposes such a council can serve is to bring together official and volunteer agencies in a united program.

Is it preferable to undertake to coordinate the general health work of the community, as the Cincinnati Federation has done, or to undertake an intensive piece of health coordination in one district of the city as has been done effectively by the Boston Health League? Experience will provide the answer.

Should the federation serve only as a coordinating group, or should it also undertake certain specific functions? Our experience leads us to believe that while in the main its job is that of coordination, there are times when it is necessary to function in a certain field temporarily in order to meet needs not in the province of existing agencies.

Should a health council in a community chest city be a branch of the community chest, or should it be entirely independent, like the other agencies financed by the chest? We have found great advantages in our close affiliation with the community chest. Our policies and plans have never been dictated in any way except as to the limitations on the amount of money available. We have been able to assist the director of the chest in many studies in the health field, and on the other hand, his wholehearted cooperation has made possible several of our outstanding objectives which never could have been achieved otherwise.

Should the health council, in cities where it is a branch of the community chest, pass upon the budgets of constituent agencies? This is a moot question. It has not been the policy in Cincinnati to do this. We are consulted on the budgets of health agencies; our advice and assistance is asked and is given; but we do not decide upon the budgets. The experience of other councils may prove that our attitude is not well taken.

In conclusion, may I present the most important problem, to my mind, that faces our communities in the field of private health efforts? Must we not begin now seriously to plan to consolidate private health agencies in our cities? The trend in recent years has been altogether in the other direction. For every new health problem arising-and there are many more that will arise—we have formed a separate agency with an additional board of directors, an additional executive, and more overhead. How long can this policy continue? Dr. Lee K.

Frankel raised this question as to private health agencies in the national field in a masterful address last week at the National Health Congress. I did not get my thought from him, as the draft of this paper had already been prepared, but his presentation convinced me more firmly that the trend of the future must be in this direction.

I believe that we shall be forced to it, not only to secure greater efficiency, a sounder, better-balanced program to promote the public health, but eventually by financial considerations. In community chest cities we are raising more money for private social and health work than has ever been raised in the history of the world. We are fast reaching our limit in money-raising, at least for the present. New needs cannot be met, necessary work cannot be expanded, unless we make better use of the funds available. I can see no way in which it can be done except by consolidating volunteer health work under single direction with the necessary divisions. Were we starting out with a clear field, would not the logical method be to organize a single agency? Is there any sound reason why private health work should be conducted by several independent groups, any more than that a city health department should have a bureau of tuberculosis, of child hygiene, of nursing, each independent of the other and with no central direction welding the whole together for the best possible protection of the public health?

I fully recognize that this proposal will meet with vigorous opposition. It may take a long time to accomplish. Perhaps no existing federation is the agency under which the consolidation should be brought about. Yet I cannot escape the conclusion that it is the next big forward step in the field of private health work.



Joanna C. Colcord, General Secretary, Family Welfare
Association, Minneapolis

Social control of marriage is often spoken of nowadays as if it were a new proposal, something radical, untried, inimical to personal freedom. But the fact had been pointed out by Professor F. E. Lumley of the Ohio State University that the individual's right to marry has always been subject to the supervision of the community, and that it is a right which may be given or withheld as the community deems best for its own welfare. "It is possible to show," he says, "that the race has never depended for its continuance upon the union of all its members. Every race has lived to this present hour because some of its members united and perpetuated a good heritage."

Nevertheless, in most of these United States the community has so far allowed any purposeful control over the marriage of its citizens to fall into disuse that proposals to make this control more effective seem novel and revolutionary. Determined opposition from many different quarters has made the securing of any improvements in our marriage laws during the last five or ten years a terribly up-hill matter. When this opposition comes from the liberal camp, it generally takes the form of protest that marriage is a personal and private affair between the two persons concerned, with which the less meddlesome interference on the part of the state, the better. The core of the conservative opposition, on the other hand, is the fear lest irregular unions and births out of wedlock will be increased by anything that places hindrance or delay in the way of marriage. "We are opposed to anything that makes marriages more difficult or divorce more easy," a committee of New York legislators reported, after what must have been a cursory examination of a bill which did not mention divorce at all, and sought merely to introduce a delay of five days between the application for a marriage license and its issuance.

Both of these contentions ignore the obvious fact that, since the product of marriage is usually children, the state has the greatest possible concern in seeing to it that these children, its future citizens, have the best possible start in life. Increasingly the community has manifested this concern with respect to children already born, in the long series of protective legislation designed to curb the The Family, January, 1923.

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power of ignorant, irresponsible, greedy, vicious, or neglectful parents. The presence of such laws on our statute books is evidence that the state recognizes that there are some parents who may not safely be left in full control of their children's destinies. But this state supervision has not been effectively directed toward children as yet unborn.

It seems obvious from all this, however, that marriage is not, and cannot be, solely the affair of two people. It is a three-cornered affair, with the state one of the parties involved. To those who follow certain religious faiths it is a sacrament of the church as well, but persons who do not marry nor wish to marry according to the rites of any church nevertheless find that the state has to be consulted about their plans. The state has retained the right to prescribe, authorize, and register the persons who shall be allowed to perform the ceremony of marriage. Clerics so authorized are empowered to exercise the functions of their church in combination only with those of the state; non-clerics act for the state alone. By this means, and by issuing a separate permit called a license to each couple about to be married, the state unmistakably manifests its status as supervising and participating in the marriage ceremony.

But the power to issue a permit or license carries with it, inseparably, the power to withhold the same for cause. The only real question involved in much of the argument about marriage legislation is: What shall be considered proper cause for withholding or delaying the state's permission to marry? No new rights of the community are involved, but only the possible extension and reinterpretation of rights which it already unquestionably possesses.

One explanation for confused thinking on these points lies in the fact, however, that many of our states have imperfectly safeguarded their own status as guardians of the gateway of marriages. Along with ceremonial marriage, they acknowledge the equal validity of so-called "common law marriages." These, of course, are voluntary unions, entered into without benefit of license or marriage ceremony, and depending upon more or less definite private agreements, and upon a successful duping of the public for their claim to being marriages at all. For the curious fact is that unless the partners in a common law marriage "hold themselves out" to be ceremonially married, and are so esteemed to be by their neighbors, the marriage will not stand the test of law. Such arrangements are nowhere recorded, of course, and the private agreements are not usually made in writing, so that they are exceedingly difficult to establish in court. The fact remains, however, that until a common law marriage has been successfully maintained as being such, in connection with some court proceeding, its validity must remain a matter of doubt. Persons who know of the existence of legal barriers to their ceremonial marriage will often not hesitate to enter into these freer relations, since the risk of conviction for bigamy when one of the marriages was unceremonial and unrecorded is small. A common law wife often has to base her claim to wifehood and to the legitimacy of her children upon such imponderables as whether the husband really meant in his own heart to regard

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