a plan of cooperation between the rehabilitation departments and industrial accident boards of the states as one of the conditions under which aid is granted. One of the results of this plan of cooperation is that industrial accident cases are automatically referred to the rehabilitation officials for service. There is, and of course can be, no law governing cooperation between the state departments and private agencies whose activities bring them into contact with the disabled. Hence there is no automatic reference of other than industrial cases to the state officials.

Public education and, I might say, the education of social and health agencies as to the type of services the state is prepared to render, is essential. It is important also that a similar campaign of education be waged among employers. This can best be done through trade, commercial, and civic organizations.

The state rehabilitation departments reported as rehabilitated last year only about 7 per cent of the total estimated to be in need of the service. This record, as compared with the number of individuals or families served by some local agencies, seems relatively small. As we analyze the problem a little more closely, however, it is apparent that the amount of effort expended in dealing with these cases is tremendous. Unlike the hospital to which patients are referred for institutional treatment, the state rehabilitation agency is a field organization whose services must reach out into the smallest town and into the very homes of the handicapped. It serves persons disabled by various causes who are found in practically every community.

Intelligent decision in each case presupposes a survey covering the individual's previous training, social and economic status, his aptitudes and desires, as well as his physical condition. In many cases, before the program of the vocational rehabilitation worker may be undertaken, a disabled person must be referred to the proper authorities for further medical, surgical, or therapeutic treatment. In numerous cases problems involving compensations must be adjusted, and in some cases arrangements must be made for maintenance of the individual and of his family during the period of training. Frequently a prosthetic appliance is required, and in those states whose laws do not permit the purchase of such appliances from state funds, arrangements must be made to secure financial assistance from relatives, friends, or voluntary agencies. Once these steps have been taken and the way is clear for vocational rehabilitation, the decision must be made as to the type of service the individual requires.

It is frequently possible to effect rehabilitation through direct placement on a job. There are, on the other hand, a vast number of severely disabled persons who cannot be placed directly, but must first be trained in a new line of work. Of the total rehabilitated by thirty-six states in the year ending June 30, 1924, 3,068 were placed without training, 2,093 after school training, and 483 after training on the job (employment training).

Not infrequently the type of training and the type of job selected must

depend not only upon the individual's permanent physical handicap, but likewise upon complicating physical weaknesses which make favorable working conditions necessary. Industries throughout the territory must be carefully surveyed with the handicapped person in mind. It is readily seen, therefore, that the problem involves intensive case work on behalf of individuals scattered over an extensive area. Every case may entail contact with the man's family, his friends, physician, hospital, previous employer, prospective employers, social service agencies, training schools, civic bodies, and various state departments. In addition to supplementing the official state work in training the handicapped and providing for their placement in regular industry, it is important that private agencies continue to operate and develop services for individuals so disabled that they cannot be absorbed in regular industry. Among these services are the operation of sheltered workshops and the provision of employment in their own homes for the "homebound."

When the problem is reviewed in this way and it is noted that the service staffs of the thirty-six states cooperating with the federal board during 1924 did not exceed a total of 150 persons, it is obvious that the burden of responsibility for rehabilitation service must rest upon social service agencies, medical agencies, civic bodies, and employers, with the state rehabilitation agency as a coordinating force. This was early recognized by the Ohio state department, which developed a plan providing supplementary service in all counties of the state. An analysis of the distribution of the cases served during 1923 disclosed that they were widely distributed and were found in practically every county of the state.

The Ohio plan calls for the establishment in each community of a clearing agency, representative of the various groups concerned, with an advisory committee including in its membership leading educators, a physician, a nurse, a home visitor, and employment managers thoroughly acquainted with local industrial conditions and employment possibilities. It is important to note that Mr. M. B. Perrin, supervisor of civilian rehabilitation service in that state, believes that their progress is almost wholly due to the splendid relations which have existed between the state officials and the local people.

Another type of development has recently taken place in Minnesota. A state-wide conference on the welfare of the handicapped was held in Minneapolis May 13 and 14 of this year. Out of these sessions grew a permanent organization known as the Minnesota State Conference for the Disabled. Two meetings will be held each year, one in the spring and one at the time of the state conference of social work in the fall. A board of fifteen directors acts throughout the year to carry out the purposes of the conference. These purposes are broadly stated in the constitution as: first, to promote suitable rehabilitation services for the physically handicapped; second, to further correlation of activities for disabled persons; third, to create a suitable agency to receive and administer special funds for disabled persons whenever such shall be forthcoming.

The National Committee for the Disabled has as its special purpose the development of nation-wide interest in the welfare of orthopedic cases. It supplements the activities of the federal and state departments, and as one of its chief objectives aims to arouse public interest in the work which state officials are doing, thereby increasing the recognition and support they are now receiving. It makes studies of special problems, acts as a clearing house for the dissemination of information, works with state officials in the development of state conferences and other methods of cooperation with private agencies, endeavors to arouse interest in states where no action as yet has been taken, and counsels with local agencies concerning the problems of the disabled and the development of adequate facilities for their care.

THE CHALLENGE OF THE AGED POOR

Abraham Epstein, Executive Secretary, Old Age Assistance
Commission of Pennsylvania, Harrisburg

With the increased industrial development, the hardships encountered by the aged have become increasingly more numerous and perplexing. The very rise in the percentage of the people over sixty-five years of age, from 3.4 of the total population in 1880 to 4.7 in 1920, while the span of life, by our improvement in sanitation and medical science, has been steadily increased, has made the problem stand out pre-eminently as one demanding immediate and constructive solution. For while the number of aged people has increased and their lives lengthened, their opportunities for earning a living have diminished. It is needless to point out at length that as industry is becoming more specialized and standardized, and speed of production the most vital industrial economic factor, the dead line of employment is being pushed steadily down. Not infrequently the age of forty-five is already a bar to industrial employment. The continuous rise in farm tenancy of those sixty-five years of age and over would seem to make life in old age exceedingly precarious, even for the agricultural workers.

As the inadequacy of the present means of care of the aged began to dawn upon the public mind, a number of states were forced to appoint official bodies to investigate the subject. Although the state that first set out to investigate this subject-Massachusetts, in 1907-is still studying the problem, a number of other states have made somewhat better progress. At least, the findings of the commissions appointed to investigate the problem have proved invaluable in their shedding a new light upon the entire subject. These studies have at last effectively shattered the myth that dependency in old age is largely the result of thriftlessness and individual maladjustment. Instead, they revealed conclusively that among the leading causes of dependency in old age are the lack of family connections and impaired physical conditions.

The precarious economic status of wage-earners was also revealed by these investigations. In Hamilton, Ohio, 36.5 per cent of the aged persons investigated owned their homes free of debt, while in Cincinnati only 23.6 per cent owned such homes. In Pennsylvania 38 per cent of those past fifty years of age were found to have property possessions of one kind or another. That these few possessed remarkable fortitude is evident from the low wages they were earning. According to the disclosures of the Pennsylvania commission, the earnings of the aged during the high-wage period of 1918 were as follows: 29 per cent earned from $14 to $20 per week; 14 per cent earned less than $12 per week; while 37 per cent were not earning anything.

That our superannuated wage-earners are not relieved to any considerable extent by the existing pensions provided for this purpose by industrial concerns and railroads, states, and municipalities, or fraternal associations and trade unions have also been disclosed by the studies of these commissions.

The state reports also showed that although practically everywhere some adequate plan to take care of worn-out aged toilers has been devised, and though approximately one out of every three persons reaching the age of sixty-five years becomes dependent either upon charity or relatives, the poorhouse still remains the only place of refuge for the great majority of the destitute in the United States; and this in spite of the fact that the poor laws in our states are practically modeled after the old British poor-law system, which England has since modified greatly. Indeed, many of our state laws are still almost identical with the Elizabethan poor law of 1601. Our poorhouses are "catch-all" institutions. Rarely are there strict regulations as to admissions and discharges of inmates. There is always a heterogeneous collection in these institutions, the inmates including the young and the old, the feebleminded and epileptics, prostitutes and abandoned babes, inebriates and worn-out toilers. They are the "homes" of both the veterans of labor and the "veterans of dissipation."

The commissions which have been studying the subject are unanimous that our poorhouses are inadequate, antiquated, and exceedingly costly, considering the returns. A recent commission studying the subject in Indiana disclosed that:

The costs of maintaining these inmates of the poorhouses in the fashion that they are maintained runs from $17 a month per inmate in such an institution as that in Marion County, where conditions are revolting, to $44 per month in such an institution as that of Wayne County, where the poor farm represents a public investment of $200,000. The average monthly cost in the average institution that is well managed is approximately $35.

In 1923 five hundred of the 3,000 folks who were in the state's poorhouses died. That is an appalling death-rate. It is significant of the conditions of life in a poorhouse. It means that no old man or woman who has the strength to beg turns his steps to the poorhouse until, through want, he is tottering on the edge of the grave; and it means that life in the poorhouse is so depressing that once confined there the old men and women rapidly pine away.

A commission appointed by the United Mine Workers of America, after a personal visit to eighty of the county homes in Illinois, also declares: "we have found conditions varying from the very best to the most horrible," but "even

in the very best of the county institutions," the commission goes on to state, "it was a touching sight to see how their old faces would light up with joy and hope at the mere suggestion of a pension that would enable them to go home, however humble it might be, and live and die among friends, familiar scenes, and happy associations now lost to them forever."

The result of the above findings was that a new era in the care of the dependent aged began in the year 1923. (A law enacted in Arizona in 1914 was declared unconstitutional before it was put in operation.) Exactly two years ago two states in the west-Montana and Nevada-and the leading industrial state in the country-Pennsylvania-enacted laws which, if not in reality, in principle at least, recognized a new standard of care for the dependent aged. This was support of the dependent old in their own homes through old age pensions rather than herding them in the antiquated and degrading poorhouses which were condemned as outworn and expensive by all state commissions studying the subject. True, neither one of these three laws could in reality be termed a proper old age pension law; the Montana law provided for the payment of old age pensions by the regular county poor relief officials; while neither in Nevada nor in Pennsylvania did the legislatures grant adequate appropriations to make these laws effective. Nevertheless, the friends of this legislation felt sufficiently gratified with the early results achieved in placing three American states on record in favor of this legislation, and it was hoped to improve these laws in the succeeding legislatures.

Briefly, the old age pension laws adopted in 1923 were as follows: both the Pennsylvania and Montana laws provided for the payment of pensions to all men and women who had attained the age of seventy or upward, and who had been residents of the respective states for fifteen years continuously before the application for pension was made; in Nevada the pensionable age was set at sixty, while the state residence required was but ten years; the Pennsylvania and Nevada laws provided for a pension which, when added to the income of the applicant, should not exceed one dollar per day; in Montana the maximum amount of the pension was limited to twenty-five dollars a month; in Pennsylvania the funds for the payment of old age pensions were to be furnished entirely by the state; in Montana the pension funds were to come from the respective counties; while the Nevada law provided for the raising of the pension fund by a special levy of two and one-half mills on each one hundred dollars of taxable property.

Although pensions were paid during the last two years only in Montana, the facts disclosed anew from the statements of the applicants in Nevada and Pennsylvania have contributed significantly to the entire problem.

The commissioner of pensions in Nevada, after two years' study, reached the conclusion in his legislative report that an effective old age pension system should be put in operation in that state because: