The figure of $2.50 per capita for health work includes bedside care of the sick on the basis of one district nurse doing all varieties of administrative, educational, as well as bedside care for each 2,000 of the population, with a deduction of 15 per cent in the cost by receipt of fees from patients able to pay for nursing care or educational visits. However, there are communities where 40 per cent of the cost of visiting nursing is met by the fees paid, and there is one community of 200,000 where I understand that 81 per cent of the cost of sick nursing is met by fees (Borough of Richmond, New York City). The $2.50 per capita does not include the cost of hospital or sanatorium care of tuberculosis, or for hospital care of venereal diseases among the indigent. As much as 85 cents per capita should be added for these services ($3.35). This figure does not include the cost of incorporating in the school curriculum the teaching of health and its attainment. This is a proper charge on the educational, not on the health, budget. Nothing the schools can do is so valuable an educational investment in method and in results as teaching the biological relationships and the facts of the natural sciences upon which human survival and evolutionary development of mankind depend. As Bernard Shaw has well said, "Human survival, human hope, are incompatible with the infantilism of organized ignorance in matters of natural science."

The per capita cost includes an item of 5 cents per capita for milk control, probably, next to clean water and laboratory facilities for detection of communicable diseases, the most profitable of all health investment costs.

There is included a small item of a cent or two for the examining of food handlers, and it is doubtful if this is an excusable or profitable investment, properly chargeable to the community.

This does include a very modest item of 10 cents per capita for dental care of school children, but nothing for their psychometric and psychiatric supervision. It does include a charge of 40 cents per capita for the hospital care of acute communicable diseases.

There remains to be considered the cost of hospital, dispensary, and accessory services for the sick not provided for under the health budget as above outlined. If we consider that five hospital beds per 1,000 of the population are needed for general medical, surgical, and obstetrical care, including children, we shall need six beds per 10,000 for convalescents and five for chronics, which, at prevailing costs of good care, will require a maintenance charge of $1.93 per capita, but since only 20 per cent to 50 per cent of the cost of hospital care is for persons unable to pay, we need to add only from 40 to 95 cents per capita as a community charge for the care of the sick in bed.

The cost of dispensary care and medical health examinations for indigent persons is even less easily determined, but probably would amount to from 25 to 50 cents per capita.

We have, as you see, assembled items, all desirable and, as a fact, usually provided with more or less skill in all of our well-organized municipal communi

ties, which, under the general heading of health protection and development and care of the sick, would cost: Health services, $2.50; Sickness care-bed, $0.40 to $0.95; Sickness care-dispensary, $0.25 to $0.50; Sickness caretuberculosis, venereal disease, $0.85; total, $4.00 to $4.80. Since adequate health services have nowhere yet been provided, no one can tell what they really

cost.

We have, however, fairly reliable means of recording and estimating the cost of the neglect to invest in health. It may be fairly stated that it costs any individual or group of them not less than four times as much to go without health protection and adequate sickness service as to pay for it.

For those who wish to test the adequacy of their health services, I recommend the earnest study of the method and results of appraising city health work which are now appearing from the American Public Health Association and the American Child Health Association. For those who are uncertain as to the character of sickness care, let them study the course of recovery of recently discharged hospital patients in their community. The incompleteness of much of present-day service for the sick will soon be revealed.

We shall never know what adequate health service costs until we try to give it. At present we are giving hardly more than half of what science and the labors of past generations have put into our hands, as trustees, to be used.

HOW THE SOCIAL WORKER MAY HELP TO SECURE ADEQUATE SUPPORT FOR PUBLIC HEALTH WORK

William J. Norton, Secretary, Community Fund, Detroit

If there is a difference between a health worker and a social worker I am not aware of it. I am aware that there is a mental barrier in this age of specialization that makes workers at different jobs in the social field think there is a difference. Nevertheless the two tasks are so completely dovetailed into a single whole that a worker in one of them can step over into the other with practically no loss of momentum or efficiency. Common sense says they are integral parts of a general field of social work.

In thinking about the support of any part of social work, health work as well as any other, there are two things which we need to consider and to master. One is the elements of social finance, and the other the elements of interpretative public education. Money comes from the public, the great mass of citizens, and we need to know how it is supplied and what we can do to stimulate its flow into a larger volume.

The sources of support for social work are four in number: endowment earnings, voluntary contributions, tax funds, fees paid by clients. Each of these 'Minimum and maximum costs.

can be stimulated into larger productivity by the application of intelligent methods. Earnings from endowments, or permanent funds, while the smallest source of revenue, are extremely important because of greater flexibility of use. An examination of endowments throughout the country discloses that an overwhelming proportion of them are devoted to higher education and to health work. Education is America's favorite method of equalizing opportunity. Bad health is the most obvious and the most feared of the accidents that defeat a person in his life's ambitions, or hinder him. It is quite natural that those who are thoughtfully leaving to the public the accumulations of a lifetime should choose health work as one of the major lines of service for their benevolence. The health worker therefore has a distinct advantage over other kinds of social work in securing endowments because he can go with his prospects along lines of least resistance. Endowments hitherto have been left to chance. We have asked for them occasionally but with no organized effective plans. They have been given as a result of good impulse, without guidance. Today, with the use of the community trust and the evolving plans of the community funds, more and more endowments are being left.

Yet endowment earnings at their maximum represent only a small portion of the income necessary to carry on public work. My own belief is that they should be used for two purposes. One is for experimental work not yet popularized. The other is for work too costly for individuals to bear the full charge, in which they supplement fees for service rendered.

The average work that has been developed from the experimental state should be transferred into the second column of support, voluntary contributions. Here we have developed the highest skill in our production so far. Health work gets its full share from this source of support, and no doubt will continue to do so. That we have reached the limit of production in voluntary contributions I do not believe. But we have increased enormously in recent years, and have arrived at a point where increase will be slow. We have demonstrated that the ambitions of social work outrun the total volume of support from these two sources of revenue combined. Therefore, after a piece of health work has passed through the experimental stage with endowment earnings and through the popularization stage with voluntary contributions, it should be passed on either to tax funds or to client earnings.

There is much for us all to learn about this question of taxation. We need to know some very simple things, such as budget-making processes, kinds of taxations, bonded debt limitations, and ways and means of increasing government receipts without tax levies. Yet when all is said, there are limits to government revenues that also outrun our desires for public work. I am inclined to believe we should throw into government therefore those things which take care of people too poor to pay for what they get, and those pieces of group work which cannot readily be assessed against separate citizens.

The last source of revenue is fees for service rendered. Here we come into

a pool of funds limited only by supply and demand. If a piece of health work is good enough to get people to pay for it individually, the only limitation upon its extension is the number of people who will use it. Everything that we can put upon this basis is to the advantage of the entire movement for public health.

All of these sources of revenue, and particularly the last-named one, depend upon the skill we develop as educators of the great public. There are many meetings going on in this conference dealing with various aspects of this problem of interpretative publicity. Its various aspects are being discussed so fully that it is futile to go into the matter here. I have just one suggestion: that every social worker and every health worker needs to recover the simple tongue of the average citizen, to interpret the technical jargon of his problem in simple English, and to drill himself into becoming an educational interpreter. This is one phase of our great field of effort that we dare not leave to specialists. We must all participate in it if we are to gain the popular understanding needed for adequate support.

A MEANS OF INCREASING POPULAR SUPPORT

FOR HEALTH WORK

W. F. Walker, Research Associate, American Child Health Association, New York The city fire department, in responding to a call with clanging bells, brightly painted apparatus, and shrieking siren, is a sufficiently potent advertisement of the service to fill every window on the street with craning necks, and to attract people on the run to see this service in action. Yet the public health nurse, in her more somber garb, responds to calls whose potential economic importance to the community compares favorably with many fire alarms. The matter of securing popular support for any of our municipal or community activities is, in the last analysis, a problem in advertising.

Certain services possess such a well-known token that there are but few people unacquainted and unappreciative of the work. No one has to be told what a spark is, or for what it is used. Everyone appreciates the need of an adequate water supply, but the service that has little on the surface to indicate its existence, no matter how far-reaching or how important it may be, must engage in campaigns of public education or advertising in order to grow. Few cities have difficulty in raising funds to relieve a water shortage, though a continuous fight is required to obtain adequate sewerage, for only a limited part of the population can have a clear idea of the nature and extent of the problem.

The director of any public service finds important and steady employment in advertising or turning a sufficient amount of community interest toward his particular field.

Community interest or popular support may be considered to be composed in the main of two elements: first, that usually rather small group of individuals who give definite and unfailing support to all movements for civic improvement, and second, that very much larger group whose interest and support is a variable quantity, blowing first hot and then cold, and always ready to chase the spectacular will-o'-the-wisp.

It is to this latter group that those engaged in welfare work must make a constant and definite appeal. Let us then consider some of the fundamentals of advertising which may apply to this problem. A first principle I would lay down is the necessity of a definite idea of what is desired to be accomplished before beginning operations. The advertising of "all kinds of clothes for all kinds of people" gets nowhere. Similarly, the advertising of a complete health or welfare service for a community lacks the explicitness which attracts the individual.

It is of almost equal importance to have in mind a definite audience when preparing your advertising material. You may seek to attract and hold the interest of the mayor or city manager, the tired business man, perhaps the mythical old lady interested in social welfare, or the common or garden variety of voter. These groups have separate and distinct approaches, usually aligned with their self-interest, and it is rare indeed that the approaches to two groups are coincident. A common element in all these approaches, however, is simplicity. The statement of needs or the comparison of conditions which is simply expressed is easily remembered, frequently quoted, and so becomes the vehicle by which information is carried beyond the small group of original

contacts.

You are no doubt thinking that these theories of advertising are all very well, but how can this specific detail and simplicity be applied to such complicated fields as public health or social work. How can a city's accomplishment in public health be reduced to a single statement or a number? Can the work of the various agencies in the field of health be expressed in terms which show their worth and their relation to the entire program?

Within the past year a group of health officers, working with the national health agencies, have developed an appraisal form or measuring rod for community health work. The idea of scoring health department activities is not new, and several persons have proposed rating schedules based largely upon their individual judgment and experience. This, however, is the first time that a practical, professional health group, with wide and varied experience and having access to recent surveys of the public health activities in all cities of 40,000 population and over in this country, have set themselves the task of scientifically preparing a method for appraising community health work by objective standards.

Last August there was adopted a schedule to be used as a basis for further field study and investigation, to be revised from time to time to keep pace with