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solve the whole problem of the care of the chronic sick in
New York City; but unquestionably it will constitute an
essential part in the slowly developing program for the
integration of all services and facilities, public and private,
for combating the unseen plague that afflicts probably
700,000 of the city's people.

The needs of the chronic sick have never been met in
New York or any other city in this or any other country.
The chronic sick, casually fitted into the existing hospital
or institutional framework, have been the stepchildren of
medicine with the general public under the illusion that
chronic illness is mostly an incurable affliction of old age,
that nothing much can be done about it and that it's a
pretty depressing subject anyway.

In my earliest experience in this field, some fifteen years
ago, I encountered apathy on all sides with little awareness
of the social implications of chronic illness or of its pressing
importance in all matters of public health and welfare.

By 1924 the chronic sick had achieved five pages of a
340-page volume reporting a study of the hospital situation
in the city, published by the public health committee of the
New York Academy of Medicine. Nevertheless this report

376



pointed out that proper facilities for the chronic sick consti-
tuted one of the outstanding needs in hospital organization.
The first great impetus to a broad attack on the problem
came in 1928 from the survey of chronic illness conducted
by the research bureau of the Welfare Council, the results
of which were interpreted by Mary C. Jarrett in two sig-
nificant volumes, Chronic Illness in New York City. This
led, in 1933, to the formation of the committee on chronic
illness of the Welfare Council, its purpose to initiate and
sponsor a community program for the care of the chronic
sick. With the advent the following year of a new and
enlightened administration in the city department of hospi-
tals, a municipal program for the care of some of the chronic
sick was launched.

The new Hospital for Chronic Diseases, for the conduct
of the professional services of which two medical schools
of the city have assumed responsibility, is a part of that
program. Even more significant, perhaps, in the long view
is the small Research Hospital for Chronic Diseases, already
operating under the College of Physicians and Surgeons of
Columbia University, which will be incorporated into the
new hospital when it is completed. This unit, with seventy-
five beds, associated research laboratories and a full time
staff of physicians, chooses particular diseases for study and
admits patients with these diseases for special investigation.
It is supported in part by the city, which has made a special
appropriation of $22,000 for research in chronic diseases,
and in part by funds from foundations and individuals.

The magnificence of these initial steps may give us a
false sense that the whole problem has now been met and
that no further steps need be taken. There are many steps,

SURVEY MIDMONTHLY



most of them far from simple, which must be taken before
a sound adequate program is achieved.

It must not be assumed that New York has been without
any provision for caring for the chronic sick. On the
contrary it has many facilities, but so unrelated to one
another, so lacking in common policy, that the result has
been a mad confusion of patients and institutions the
patients scrambling to find refuge wherever they may, the
institutions admitting them grudgingly, but unable to give
them the care best adapted to their needs. Public and
private hospitals, homes for the aged, convalescent homes,
nursing and visiting doctor services, sheltered workshops,
medical social service departments, family service agencies
every one of them accepts with reluctance the burden
of the chronic sick, and tries to shift the responsibility.

THE majority of the patients who flood New York's
general out-patient clinics suffer from some form
of chronic disease, often in its earlier, more hopeful stages.
But treatment is too often haphazard and opportunist.
Even in the best clinics, little thought is given to the re-
lationship between clinic care and that offered by other
agencies in the community. Single-handed, the physician
can accomplish little for many of these patients. It is only
when his disease is so far advanced that he is completely
and often permanently disabled that a patient can gain
admission to a hospital where, more frequently than not,
he is only patched up a little and sent on his way. Fully
20 percent of the patients in general hospitals in New York
are suffering from chronic diseases. Most of them are in
general hospitals because there is no other place to send
them and, once admitted, it is difficult to discharge them.
Many are sent to their homes even though the homes have
no facilites for their care; the illness again progresses, and
the patient is readmitted to the same hospital in a worse
condition than before. He may be transferred from a volun-
tary to a municipal hospital ; but even the municipal general
hospital tries to dispose of him as quickly as possible, usually
to the city home or almshouse.

Convalescent facilities, meager at best, are often misused
for the care of persons permanently incapacitated. In spite
of the avowed policy of these homes not to accept the
chronic sick, about a third of their patients are just that.

Homes for the aged, although planned for the able-
bodied, actually are caring for a large number of the
chronic sick. The Welfare Council survey of 1928 revealed
that nearly half of all of the guests in the city's sixty private
fiomes for the aged were chronically ill. In the public
homes for dependents that same year, two thirds of the
residents were reported as chronically ill. The situation
probably has not changed greatly in recent years.

The chronic sick who are not in institutions and are
confined to their homes, unable to attend out-patient clinics,
are probably the most neglected class. Their homes are
poor, living conditions unsuitable and medical or nursing
care lacking or inadequate. It is impossible to estimate the
number of such persons. In 1934 the three visiting nurse
associations had 5500 chronic patients under care. Since
1936 medical and nursing service has been furnished to
chronic patients who are receiving home relief. Approxi-
mately 1800 such patients are under care at present.

To sum up, it appears from past studies that voluntary
agencies are carrying the load of about three fourths of
the chronic sick under care in New York. The problem
is growing and the voluntary agencies are finding it in-



creasingly difficult to carry the financial responsibility. To
be sure the city steadily has increased its contribution to
voluntary agencies for the care of the chronic sick and
that is as it should be. But past experience with tuberculosis
and insanity, special forms of chronic illness, has demon-
strated that the care of the chronic sick in all its phases
is primarily a responsibility of the municipality, and mu-
nicipal facilities will have to be developed further.

How shall New York City meet its obligation to the
chronic sick? The prime need is for a policy and for the
correlation of the various facilities, public and private. The
existing institutions represent a haphazard development
which has not been guided by any consistent policy; each
pursues its own individual development without regard to
the whole situation. The whole problem has so many facets
and ramifications that a wise first step would seem to be
the establishment of a special administrative division for
the chronic sick in the Department of Hospitals.

A completely equipped and staffed hospital for chronic
diseases must be the nucleus of the service for the chronic
sick. That of course is where the new Hospital for Chronic
Diseases comes in, but it is only one element in the com-
plete service. Every chronic invalid admitted to the pro-
posed division for the chronic sick in the Department of
Hospitals should first enter the Hospital for Chronic Dis-
eases for diagnosis and study of his social problems by a
medical social worker, and an intensive attempt at physical
rehabilitation. This medical and social survey would de-
termine whether the patient should remain in the chronic
hospital, be transferred to the custodial division, receive
treatment in an out-patient clinic or medical and nursing
care in his home. Economy for the taxpayer in the care of
the dependent chronic sick hangs to a great extent on an
efficient social service department that can develop the
patient's own resources, employ available community re-
sources in his behalf and contribute to treatment planned
to reduce as far as possible his disability and dependence.



USTODIAL institutional care for the chronic sick
whose disease does not progress nor demand active
medical care is an important phase of the program. These
patients must be placed in institutions because the combina-
tion of a physical handicap and poverty makes home care
impossible. The problem is not one of supplying medical
care, but of providing a decent abode wherein most of
these helpless people can remain for the rest of their lives.
At present these custodial patients are housed in the City
Home and in the Central Neurological Hospital in build-
ings so totally unadapted to their present use that there is
only one thing to do with them and that is to tear them
down. To meet the immediate need of the chronic sick the
city should have at least 7500 custodial beds in units closely
related to the Hospital for Chronic Diseases. Each should
have its own infirmary, but any patient seriously ill should
be transferred to the hospital.

The present policy of the Department of Hospitals of
paying for destitute patients in voluntary institutions should
be continued, and the practice systematized to insure that
the institution admits only the type of patient for whose
care it is equipped. As the provision of the federal social
security act makes it possible for more of the aged to
remain at home, some of the voluntary homes for the aged
well might consider a change in policy to admit more of
the chronically ill in the middle and later years of life.
Such homes could then be used more extensively for city



DECEMBER 1938



377



charges under conditions formulated by the Department
of Hospitals.

Home care is much more economical than institutional
care even when all necessary medical, nursing and social
service is provided, and is often a much happier solution
for the patient and his family.

The Welfare Council survey showed that about four
fifths of the chronic sick living at home did not need insti-
tutional care. But at present, home care of the dependent
chronic patient is as haphazard and unplanned as is insti-
tutional service. Among the agencies giving nursing care
to chronic patients in their homes are the visiting nurses
organizations, medical social service departments of sev-
eral hospitals, four orders of Catholic nursing sisters and
the Department of Welfare for its home relief clients.

In a well planned program home medical care would
be under the Department of Hospitals and not, as at pres-
ent, under the Department of Welfare. This would allow
maximum flexibility in following the changing status of a
patient from hospital to home care, or from home care to
hospital, dispensary or institution without interruption of
the medical and social program. The facilities of the mu-
nicipal hospitals would be available for the many labora-
tory tests needed. The best form of administration of home
medical care has not yet been devised, but it might be
feasible to make the out-patient clinics the centers from
which would emanate home medical and nursing care for
chronic patients. The time is not far off when physicians
will be paid for work in the clinics, and such compensation
might well include the responsibility for a certain num-
ber of home visits. Under such a plan the visiting physician
would refer to the chronic hospital, patients for whom home
care was no longer indicated, and the hospital in turn
would transfer suitable cases to appropriate institutions.

There is a question whether nursing service should be
operated under municipal auspices, or should be bought
from the voluntary nursing organizations already in the
field. For the present, at least, it seems wisest to employ
the existing agencies. Comparatively few of the chronic



patients for whom home care is adequate require highly
skilled nursing. The majority need no more than care by
an attendant under the supervision of a trained nurse. For
many, the visiting housekeeper can give all the service re-
quired. The time has arrived when the experiences gained
from many different forms of home care under different
auspices can be evaluated, and a comprehensive plan de-
veloped whereby the hospital department can provide a
system of care in the home for the chronic sick.

The National Health Survey has put before us a na-
tion-wide picture of chronic disease in relation to the popu-
lation. We can no longer remain apathetic to this major
cause of disability and poverty which is responsible for
most of the unemployables on relief, which fills our alms-
houses and homes for incurables with crippled invalids, and
contributes a large proportion to the population of our
hospitals and homes for the aged. We know now what the
problem is and we glimpse its sinister threat to our na-
tional health and social well-being. We know some few
things that can be done about it: education for prevention
including the education of the rank-and-file of physicians
well supported laboratories for research into causes of
chronic diseases; proper facilities for treatment and an
organized program of care all of these bound together by
purposeful planning.

I would not minimize the difficulties implicit in planning
to control the effects of chronic diseases. There is no one
method for the prevention, cure and relief of all of them.
But I insist that without planning and without the accep-
tance by municipal authorities of a larger degree of re-
sponsibility than most of them thus far have taken, the con-
fusion that now prevails in this whole area will- continue
and the threat to our national health and well-being will
become more menacing, New York's new hospital is wel-
come evidence that in this one city at least a program is
taking form. But the effectiveness of any program in New
York or elsewhere must integrate all services and facili-
ties, and engage the united effort of the medical profession,
social workers and agencies and the community as a whole.



The Other Side



By WILBER IRVIN NEWSTETTER

Professor of Social Administration and Dean, School of Applied Social Sciences, the University of Pittsburgh;
President, American Association of Schools of Social Work



WHEN fat flares up in flame, one is usually startled.
[See "The Fat Is in the Fire," by Arthur Evans
Wood, Survey Midmonthly, October 1938, page
313]. There is an implied aspect of shortcoming on some-
one's part that this unhappy condition should have been al-
lowed to arise. Why wasn't more care taken? The situation
must be faced or a serious conflagration may result, particu-
larly if there is a wind blowing to make things worse. The
most important thing under the circumstances is to make
every effort to bring things under control in a cool-headed
manner, and then to press on in one's task, profiting from
experience.

The possibility of urging some of the state universities
contemplating curricula in social work to consider an ade-
quate one year postgraduate plan had been discussed infor-
mally in the Association of Schools of Social Work as a



possible alternative to setting up a two-year program in mere
technical conformity to existing association requirements.
President Bizzell's "protest" startled the association into a
clearer realization that the schools must give immediate at-
tention to the issues raised. An advisory committee on state
universities and membership requirements, authorized in late
January 1938, was appointed by the executive committee of
the association in March. It was headed by F. Stuart Chapin
of the University of Minnesota. The membership consisted
mainly of representatives from member schools in the state
university group. Meanwhile the president of the association
wrote to the president of the National Association of State
Universities (President Bizzell) and to the president of the
Association of Land Grant Colleges and Universities (Presi-
dent Dale) recognizing that both these groups had been re-
quested to make a study in the field of social work educa-



378



SURVEY MIDMONTHLY



tion, and oHcrmg to cooperate in piaung at their disposal
any information or experience from the schools of social
work that might be helpful. It was stated further that the
Association of Schools of Social Work had appointed a new
committee on state universities and membership require-
ments, which anticipated the benefit of advice from the
groups addressed. It was also suggested that if these groups
-.uv fit to appoint special committees to deal with the sub-
ject, the association's committee would welcome an oppor-
tunity to meet with them. A joint committee on accrediting
was subsequently appointed by the state university and land
grant groups, with President John J. Tigert of Florida as
chairman.

It was impossible to find a suitable time last spring for a
joint meeting of Dr. Chapin's and President Tigert's com-
mittees. However, the association furnished President Tig-
ert's committee with certain informative materials, and he
in turn indicated some of the points that his committee was
likely to raise.

DR. CHAPIN'S group met last spring to formulate a
preliminary report which was approved by the Seattle
meeting of the association last June. Meanwhile, a com-
. mittee on the revision of by-laws under the leadership of R.
Clyde White of the University of Chicago has been at
work dealing, among other things, with certain inade-
quacies of the admission requirements in the light of past
experiences.

Last spring and during the fall, Marion Hathway, execu-
tive secretary of the association, visited a number of state
universities and land grant colleges, so that when the meet-
ing of President Tigert's and Dr. Chapin's committees took
place in Chicago on November 8, the stage was set for a
thoughtful and constructive exchange between the two
groups. George F. Zook of the American Council of Educa-
tion also was present as well as several university presidents
not members of the committee.

Without benefit of minutes, let me describe briefly the dis-
cussion. Dr. Chapin's committee reviewed the history of the
Association of Schools of Social Work : the early beginning
in 1919, as a conferring group; the formation of the Amer-
ican Association of Social Workers, a separate organization,
in 1922; the changes in membership requirements of that
association in 1933, which had the effect of making the
Association of Schools an accrediting agency with duties it
was ill equipped to handle because of lack of field service;
the lack of funds for field service to assist and evaluate new
schools applying for membership tending to result in the
use of mainly quantitative criteria; the recent Rockefeller
grant to the schools which makes possible the utilization of
more qualitative criteria. The objectives of the association
also were reviewed.

President Tigert. chairman of the joint meeting, called
on President Bizzell to speak for his group. The original
"bill of particulars" in President Bizzell's "protest" had
boiled down to two or three points. These were thoughtfully
discussed. The interest of the schools in the problems of
rural training; the qualifications of faculty; the distinctions
between graduate work and postgraduate professional work ;
the relation of schools of social work to social science depart-
ments and to professional schools in law, medicine, and
business administration ; the admission requirements of the
association ; the fact that teachers in schools of social work
are not required to be members of the AASW; the fact that
persons can be admitted under certain conditions to the



AASW who have been graduated from schools other than
members of the Association of Schools ; the reasons why any
accrediting seems necessary in the field of social work ; the
relation of accrediting to the developing public social ser-
vices all these items were reviewed.

To the Association of Schools the results of the meeting
were constructive. On the one hand, there was every evi-
dence that the facts brought out in the discussion had cleared
the atmosphere of many misunderstandings on the part of
President Tigert's group. On the other hand, the schools
had the benefit of excellent suggestions, none of which were
at variance with present trends in the association. Dr. Zook's
suggestions were particularly helpful. The association does
not feel there is the slightest threat to professional stand-
ards; nor does it believe President Tigert's group has any
idea of recommending the establishment of a new accredit-
ing group. Parenthetically, one might wish that a like
number of presidents of universities in which member
schools are located were as well informed on the problems
of professional education for social work as are those presi-
dents who were present at the Chicago meeting.

It may appear that the schools are claiming a victory. It
was not that kind of a meeting. There was no battle. Each
group was trying to understand the other's actual position.
N<> serious difference of opinion appeared.

Professor Wood, in his article, took the schools to task
about the large proportion of part time students in member
schools of the association. This is a real problem and should
receive more attention than it is getting at the present time.
But when Professor Wood implies that all the part time
students are practicing social workers taking courses because
they need a few credits to entitle them to membership in the
AASW, he is in error. His discussion of the rejection of
sociologists seems equally mistaken. Schools of social work
had a great many sociological progenitors, whose contribu-
tion is deeply valued. But as the schools have reached adoles-
cence, there has come the struggle of youth to estabish its
independence. A few of these sociological parents still want
the youngsters to be dependent. Anyone familiar, as Pro-
fessor Wood must be, with the fact that other social science
disciplines are fully as important to social work as sociology,
should realize that the development of a school in the field
of applied social sciences should not be associated with a
single department. The writer has recently assumed the
deanship of a school, the sociological progenitor of which
advocated the setting up of an independent postgraduate
professional school to meet the requirements of an expand-
ing profession.

THE Association of Schools was somewhat startled
when "The Fat Is in the Fire" appeared. We feared
that the article, coming out before the Chicago meeting,
might complicate the procedures between groups working
toward rational solutions to perplexing problems. These
fears proved unfounded ; we had underestimated the states-
manlike character of the state university and land grant
groups. It was startling, too, to see in bold print some of
the skeletons in the closet of professional education no
one likes to have his shortcomings aired in public.

The schools also felt that Professor Wood's article was
at many points inaccurate and misleading. But to enumerate
these points now seems unnecessary'.

In a current motion picture emphasizing fire prevention,
a very effective method of dealing with fat burning in a
skillet is demonstrated: a handful of bicarbonate of soda.



DECEMBER 1938



379



THE COUNTY WORKER'S JOB

Learning from the Job

By JOSEPHINE STRODE



OUT in the cornfields of case work practice, rural
social workers are learning on the job. They are
learning how to do from having to do, which is
true education. Their learning, however, springs from ex-
periences and a way of life very different from those of the
urban social workers. It is the difference of the rolling
sweep of countryside, fenced in by winds, sky and sun, and
the constricted tenements, walled in by the smokestacks of
industry and serried by tragic deprivations and disease.



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