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sided in the county only one year, had no almshouse in his township. He has commandeered the house in which the patient is lodged, has employed a trained nurse at $4.00 per day, and maintains the nurse by providing board outside the house at an approximate total cost to the taxpayers of $180.00 per month. His fellow-overseer wishes to remove the patient to his home and agrees to care for her at the rate of $75.00 per month. Neither plan is in the interests of the patient nor the taxpayer, and both suffer under such arrangements.

In order to make effective the hospitalization of the almshouse there are certain fundamentals which must be kept in mind. The first of these is that the political unit to be served must be sufficiently large to provide the necessary funds by taxation to maintain the plant, and sufficiently populous to make it economically sound to establish such a plant. Therefore nothing less than the county should be considered as the organized unit, and in less populous regions district hospitals should be the aim. Good roads now make a district hospital practical. The personnel for the management of the institution must be professional, not political; if sufficiently large, a competent physician, serving full time, is essential; if not large, a registered nurse superintendent with a competent visiting physician (or staff) is required. Unless the professional spirit is permitted to dominate the institution, the aim sought in the "county hospital" will be lost, namely, the study, treatment, relief, or cure of chronic disorders in a large group of adults in the prime of life. The establishment of such hospitals for the care and treatment of chronic disorders will add a link in the chain of medical service which is sorely needed.

The Pennsylvania Department of Welfare has supervision of 160 general and special hospitals, caring for more than 300,000 patients yearly. In the wards of these hospitals there is a gradual accumulation of chronic patients which seriously interferes with the flow of acute curable cases into the hospital. Dictates of humanity compel the hospital executives to give space to the chronic cases long after they should have been evacuated down the line to institutions in which bed space and daily care are not so costly.

The population of one hospital studied some months ago in relation to chronic cases gave the following results: of 251 patients, 56 were found to have been in the institution over three months; 44 had been in residence eleven months or less; 2, from one to two years; 3, from two to three years; 3, from three to four years; 2, from four to five years; I, over seven years.

There are only nine institutions in Pennsylvania which undertake to receive chronic cases, and their bed capacity is very limited. It is, therefore, obvious that the development of "county hospitals" whose primary object is the care and relief of chronics will meet a very pressing need, and will be needed even if old age pensions become a reality.

In addition to an adequate plant with hospital equipment and medical and nursing personnel and occupational therapy, there is an important service which even today should be supplied in every county home and in connection

with outdoor relief, and that is professional social service. No modern hospital is complete without social service; no program of relief for the handicapped can be successful without the trained family case worker. Our county hospital must render a service combining both of these functions, for physical rehabilitation must be accompanied by social reconstruction of individuals and families if we are to diminish the load which the taxpayer carries.

Dr. Boas has demonstrated that a much larger number of chronic cases can be rehabilitated by careful diagnosis and active treatment than has ever been supposed. We know from the statistics reviewed that public officials of the future will have an increasing number of surviving adults, suffering from chronic disorders, who will have to be provided for out of the public purse unless a program to reduce that number is operative; the medical profession and the life insurance companies know that the next big battle in the conservation of life lies in that sector which aims to prevent chronic disorders in adults in the prime of life.

If by intelligent, tactful leadership we can win the cooperation of our poorlaw officials, who handle vast sums of the people's money, in this campaign for hospitalizing and socializing the administration of the almshouse, we shall have rendered a real public service in the evolution of our democratic institutions.


Jeffrey R. Brackett, Member, Advisory Board, Massachusetts
Department of Public Welfare, Boston

The Transportation Agreement is an effort to bring a reasonable system into the sending of persons from one place to another. It is in contrast with a lack of system, still seen, which was wasteful of money and human resources, and which was often most unkind to persons in distress.

This Agreement was administered for nearly twenty years by a committee appointed by this National Conference. Then, in 1921, at the request of this Conference, it was taken over by four agencies whose work, nation-wide, is through their local members, with families in distress. A fifth like agency joined last year; other like agencies would be welcomed. The committee which administers consists of one member each from the agencies and as many members at large.

These agencies all encourage their local members or branches to sign the Agreement. One agency, the American Association for Organizing Family Social Work, requires its constituent members to sign. It is signed yearly, to insure a continued active interest. There are 585 signers. Of these, 301 are members of that association just named, that is, family welfare societies, by whatever name, the country over. Travelers' aid branches number 107; tuberculosis so

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cieties, 79; children's agencies, 44. Agencies which are public, as overseers of the poor or state boards of charity or public welfare, number only 15, beside four agencies which say that they cannot sign but that they approve and will use the Agreement.

The next point to make plain is the Agreement itself, that the form which agencies are now signing is a new and simplified form. Here are the rules, in brief, to which you agree: that before you provide transportation you will be satisfied, by adequate evidence, of two conditions. The first is that the prospect of the applicant in opportunities shall not be decreased by sending him to a proposed place. That is, that he shall not be worse off! And secondly, that at the place proposed he shall have resources for maintenance (such as relations ready with support), or is a proper charge upon agencies there, or has a legal residence there. And you agree further, before sending a person, to make reasonable effort to obtain a report, on those questions just given, from an agency at the proposed destination. Thus a family welfare society or a travelers' aid would inquire of a like society. Thus may information be had to insure the wisdom of the proposed sending, and objections may be weighed beforehand if good objections should be reported. Also, if the person is sent, an agency in the proposed destination knows of his arrival there. Finally, you agree to make provision for the applicant through to the destination which is determined. There is no more passing on. Such are the rules, conditions of combined real sympathy and good


But there is agreement also to abide by the interpretation of the rules as set forth by the Committee on Transportation. Those interpretations, in the new 1925 leaflet, are in eleven paragraphs. Several are decisions of the committee itself. Most of them are in decisions made by a subcommittee which considers matters of complaint between two signing agencies arising out of actual transportation. Those interpretations which are of sufficient importance to be noted here fall under the following few heads. First, of fundamental significance to public agencies, is that such agencies are not obligated by the rules in any particulars when those conflict with settlement laws of their states. Next, the rules apply to any expression of help to transportation. It may be gasoline for an automobile, or merely advice. If one agency plainly understands from another of a proposed transportation which seems plainly in violation of the rules, the first agency becomes a party thereto unless it tries to discourage such transportation. The call in the rules for "adequate and reliable evidence" has resulted in several complaints and illuminating interpretations. Complaint has brought out also that an agency at an intervening place which is used en route and which changes the plans made by the sending agency without explicit approval of that agency, thereby becomes responsible for what may follow. If an agency en route faces new conditions which raise questions as to plans, then that agency should open up the case as if it were a new one. Finally, an agency is to keep a full record of the essential facts on which the furnishing of transportation is based, and

is to give at least a summary of such on request from any signer of the Agreement. These interpretations are points which largely, if not wholly, should "go without saying" in a sympathetic and thoughtful use of the rules.

This new issue of the rules and interpretations contains also several suggestions of procedure and three interesting "Illustrative Decisions" selected from the fourteen cases decided, in about as many years, by the special committee on decisions.

Conditions under which a person may be considered "a proper charge" upon agencies in a place have been considered in several decisions, such as that on the Allen family, one of the three given, to which I shall refer later.

You will notice that appeals to the Transportation Committee are regarded in no way as unfriendly acts between agencies, but as means of obtaining interpretations of the rules. In these simplified rules there is no penalty provided for failure to accept and follow a decision. A suggestion under the head of "Procedure❞ says that an agency which cannot accept a decision of the special decisions committee shall report its specific reasons to the larger and responsible Committee on Transportation. An agency which so appealed and still disagreed might be dropped from the list of signers. But the spirit of the simplified Agreement, like its letter, is to win support from agencies in a cooperative movement of general helpfulness.

So we reach the essence of the whole matter: that transportation is one form of relief, of helpfulness to persons in need; that persons, if sent anywhere, should be sent to the place where there seems to be the greatest promise of improvement in their condition; and that such a process means the application of what is well known today as good "social case work."

This developing process of good social case work is just one of the many expressions of growth which we see going on in social work. A public officer, such as an overseer of the poor or county agent in sparse communities, may be a storekeeper nine-tenths of his working time and an overseer only one-tenth; but if he is both a kind and a thoughtful man, he should wish, if he has occasion to send off a needy person, to use that form of relief in the most kind and wise way that is possible. Probably many public officials would follow the Agreement if there were a strong national association of public relief officers to encourage its use. Cannot state welfare agencies do more for it? The fact that several important public agencies now sign and use the Agreement shows that there is not in it any general organic obstacle to its use by public officials. And, as we have shown, an interpretation of the rules as part of the Agreement specifically releases public agencies from following it in any particulars when those particulars are in conflict with local legislation.

I have long been sorely troubled by suggestions that public officials must, by the nature of things, be very conventional, mere followers of crystallized customs; and that therefore the public official must wait for private, voluntary work to blaze all the ways. Of course public officials are to observe the laws; but

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who can be better leaders for modifying laws bearing on their own duties than thoughtful public welfare officials! I learned a good lesson when taking up work as head of a large city board of charity and correction. When I asked the city solicitor about certain powers under the new city charter, he answered: "What work does your board wish to do? I shall let you do it, if possible." He knew the possibilities of leadership in getting what is earnestly desired in such a field as public welfare when the hearts and heads of a community can be touched.

In conclusion, I would illustrate the essence of the whole matter of transportation by a brief`story of the family called Allen, from the first of the three "Illustrative Decisions" printed with the Agreement. Please remember that the rules of the Agreement give a "legal residence" as one condition out of three which may justify transportation. Some states only have poor-law settlements, while all recognize residence. Mr. and Mrs. Allen had lived for forty years in a city called D. They had been assisted by the overseers there during every year but one during a period of ten years. They moved, with six children, without assistance, to S, a city in another state. There they soon had to be helped. A private agency took them up. Fourteen months after arrival there, the agency, having spent over $100 on them, raised with a like agency in D the question of prospects in D and the propriety of a return there. As to opportunities as between D and S, there was no satisfactory, clear-cut evidence; there were no resources for independence established in D; so the one question remaining was whether this family was a proper charge or had a moral claim on D. The agency in S, seventeen months after the family came there from D, assisted it back to D. The Transportation Committee, appealed to, gave a decision from its subcommittee on decisions that the agency in S had not erred. The committee, reaffirming an earlier decision, held that the meaning of being a "proper charge" should be settled on the basis of evident responsibility for care of a person because of previous dealings with him. We notice that in this case a residence had been lost in D and a new one acquired in S; but the committee held that the Transportation Agreement emphasized the possibility of sending to places where there is not a legal residence.

I wonder what would have happened if a public agency in S had dealt with this family. A person may lose a legal residence, or a poor-law settlement, if such exists, in one place, and may or may not gain it in a place in another state. The place of most promise for a family, or the place where good sense and kindness indicate that it belongs, may or may not be the place of legal residence or settlement. Should not the conditions of most promise be allowed to govern? For to improve the conditions of persons, rather than to win in technicalities as to payment for care, is what we all, public officials or private agencies, should strive to accomplish.

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