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demands upon the chests. Contributors began early to ask
questions: Just how necessary is all this work? How well
is it being done? Could it be done better in some other
way? In the very next year after the Cleveland Federa-
tion held its first campaign, a council was organized among
the functions of which was an effort to answer such ques-
tions. In other cities councils of social agencies preceded the
fund or soon followed it. Councils in some communities,
chest budget committees in others, still are seeking the an-
swers. Some review of the whole program is likely to take
place when the budget committee determines the relative
and total appropriations. But more searching inquiry was
demanded by communities, especially after the depression
years. If all this money wasn't for relief of the unemployed,
what was it for, anyway? People did not begrudge their
contributions if they could be convinced that funds were
being expended wisely and for necessary work. But they
had to be shown.

In partial response to that demand sixty-three studies
and surveys have been made since 1930 under the direction
of Community Chests and Councils, Inc., nine of them last
year, with six more requested in the first few months of
1938. Probably the most thorough-going are the Hartford
survey in 1934, Providence in 1936, and the one which
Minneapolis is now beginning the most comprehensive
survey yet undertaken by the national association. To re-
view and revalue the work of the agencies, to help them



to reshape it if necessary, may run counter to tradition or
to "vested interests," but it is what the community requires
of the modern chest and council. As much as 50 percent
change in the basic function of participating agencies over
a ten-year period has been achieved in some cities by such
cooperative planning.

A pressing need for objective standards by which to
measure results of welfare services has been disclosed by
these studies. In every community study, the representa-
tives of cooperating national agencies work toward such
standards, which may be based on such factors as trends
in juvenile delinquency rates, in divorce and other family
breakdowns, or in morbidity rates for various diseases.
These national representatives are increasingly critical of
the "water-tight compartment" specialization which they
often find in local social work: the children's agency, for
example, seeing only the child when the family is the real
problem ; the family agency seeing only dependency when
juvenile delinquency has become the aim of modern social
planning and surveys.

Each of these developments of chest and councils and
I have selected only a few has left a special responsibility
in its wake. To meet these responsibilities with any success
calls for a combination of all the wisdom and experience
and good will that can be mustered.

Have we tried to see the problem whole? We are not
succeeding unless we consider governmental welfare, and
public health, with their vastly greater financial resources,
with their relatively undeveloped resources of citizen par-
ticipation and guidance, as definite parts of the community
service job.

Have chests stabilized giving and increased it? Then
they must constantly exercise care that gifts are secured with
full understanding of their purpose, without economic pres-
sure, and with full willingness.

Are they acting as a unifying force ? The chest and coun-
cil ought to have something to contribute to the new crises
in labor relations, in racial discrimination, in partisan
cleavages.

The chest as an emergency appeal has little place in the
world today. Chests and councils that are living with their
communities year after year are placing more and more
emphasis on the values of bringing laymen and social work-
ers, agencies and central federations, official and voluntary
groups, to face the total need and to shoulder it together.



"Oh, Those Nurses!



Bv KATHRYN CLOSE



(( T WISH that nurse wouldn't. . . ."

"I wish that social worker would. . . ."
-*- Family welfare agencies, like nursing organiza-
tions, have their basic professional policies and procedures
for cooperation, and their executives, like nurse executives,
disavow the existence of friction when workers on the job
are "good." You must go to the stair-climbers and the door-
knockers among the social workers, as among the nurses,*
to discover what happens when everybody isn't 100 percent
'"good," and what they think might be done to smooth off
the occasional rough edges of day-to-day contacts.



*Sec "Oh, Those Social Workers!" by Kathryn Close. Sure
monthly, March 1938.



On this tour of discovery stair-climbers and their super-
visors in family welfare agencies in four New York coun-
ties were interviewed. After some preliminary sputtering
over current incidents they all, without exception, came to
the conclusion that the irritations which arise between so-
cial workers and nurses are the result of fundamental at-
titudes toward their jobs, and are inculcated by their pro-
fessional training.

The education and training of the social worker stresses
freedom of individual thought and action while the nurse's
training holds implications of obedience to direction and
authority. Although these divergent emphases are basic
in the two professions they almost inevitably produce dis-



102



SURVEY M1DMONTHI.Y



tortion when one individual presumes tt> judge the work of
another. The nurse's job is to her clear and distinct the
treatment, under a doctor's direction, of a patient's physical
condition and the prevention of further illness in his family.
To the social worker, however, physical illness in a fam-
ily is only a part of a complexity of problems playing upon
one another in the inner lives of the various members of
that family. In main cases her job is onlx to act as a sort
nt while the members of the family bring about their
own mental and >ocial adjustments. If the social worker
is modern, she probably does not fix inflexible goals for her
efforts. To her the nurse seems limited. To the nurse,
the social worker seems vague, unreal and experimental.

THIS difference is seen as the root of the misunderstand-
ing which exist between the social worker and the
nurse in the field, misunderstandings which are not dimin-
i>hed by the zeal with which the social worker guards the
confidences of her clients, or by the nurse's expectation of
complete cooperation from other professionals. Some social
workers are outspoken in commenting on their zeal in
safeguarding confidence: "Until we can recognize the right
of other professionals to a frank statement of what we
ha\e learned in our contact with a family in other words,
our social diagnosis and prognosis we can scarcely claim
the right to the professional confidences of others on a
:i*e." They see the justice of the charge that the psychiatric
social worker in particular often withholds information
that might be of value to the doctor and nurse in their
dealings with the client. They admit that their ethical
obligation to guard the client's confidence sometimes may
appear to nurses as professional "high-hatting," as an as-
sumption that the nurses' ethics are on a different, and
probably slightly lower plane. They admit too that pos-
sihlv some social workers treat the nurses as "tools" of the
job. useful in times of stress, but only "tools" in the social
worker's comprehensive plans for the family.

But admitting motes in their own eyes they point out
some pretty sizable beams in the exes of the nurses. Social
workers, they say, see a family situation whole back of
it, around it and under it and treat it for all of its com-
ponent parts. Therefore, when a nurse complains that the
social worker "fails to give aid when it is needed," the
probability is that the nurse is myopic. Need may be less
urgent and real than it seems. For the nurse to get excited
about it when she knows the social worker is in contact
with the family betrays emotionalism or at least mistrust
of the social worker's professional judgment. It sometimes
happens that the nurse "goes off the handle" when her at-
tention is called to empty plates on the family's table. She
does not know that in modern constructive case work, not
only the giving of relief but also, under certain conditions,
its withholding, are considered and used for their thera-
peutic values, along with other forms of treatment. Here
the social worker suggests that the nurse use her head on
the material which she has said she wants, the summary
of the case history and the plan for the family. For a nurse
to refer a family to a social agency is commendable but the
diagnosis of the economic need in that family should re-
main with the agency.

In most instances the nurse's effort goes no further titan
to push for immediate relief, but in others she may some-
times go over the head of the social workers and herself
arrange for relief in some form or other. This, the social
workers >ay, undermines the family's confidence in the



agency, and in its plan for their welfare. Thex admit that
they sometimes may have been lax in interpreting to the
nurses the philosophy of their program and approach in re-
lation to relief but they stoutly maintain that they never
well, hardly ever expect from the nurses, in this regard
as in others, a greater desire to cooperate than they them-
i-elves evince.

Another "regret" that social workers have about nurses
concerns the nurses' blind spot in the reason for referral of
cases. Nurses, they say, are most generous in referrals for
special kinds of relief but rarely indicate any awareness
of the incapacity that may prevent a family from provid-
ing such things as Christmas treats and summer outings
for its own children. "The nurses seem to have no under-
standing of the content of case work treatment. Right
under their eyes in many homes are acute problems of mal-
adjustment that we are equipped to treat, but unless there
is also economic difficulty it rarely seems to occur to the
nurses to refer the case. They think of us merely as alms
givers."

The complaint that nurses fail to refer cases for any-
thing but material assistance seems to be fairly general. The
tendency is to blame it on what social workers dub "the
nurses' limited social vision" which harks back again, they
say, to her training and the circumstances of her practice.
It is suggested that ideally a community nurse should rec-
ognize social problems while not becoming involved in
them. This ideal probably is attained by nurses as a pro-
fessional body, but doubt exists as to xvhether the run-of-
the-mill community nurse has reached it. Of course work-
ing as she does under the direction of the doctor this is
sometimes difficult for her. When a doctor gives up the
nurse must give up, at least in all matters touching on
nursing care. But it is only the not-so-good nurse, sax the
social workers, who gives up on all scores. They \vill tell
you plenty of stories of energetic nurses who "clear" with
the doctor ("Have you any objection, doctor, if we try
to pursue this trouble and see if xve can find help else-
where?") and then follow through vigorously on matters
of prevention, health education and the promotion of good
medical care.

SOCIAL workers, they themselves admit, do not need to
watch their steps as closely as do nurses. They need
not take "No" for an answer in any of their activity in
behalf of the client. The good social worker will keep
prodding every available resource until she finds one which
can give \vhat the client needs. If none is to be found she
keeps on prodding anyway in the hope of stimulating com-
munity interest in the need for which it has failed to pro-
vide. She is free to drive ahead on all counts.

Social workers in public agencies are less critical of the
community nurse than those in private family agencies
and more frequently report good cooperative relationships.
Perhaps this is because the administration of relief is more
clearly definable than the "counselling service" offered by
private agencies, and both social worker and nurse are more
sure of their ground. In most communities the public relief
field is fenced by hard, fast rules. The worker in this field,
constantly beset by problems with which she has neither
the freedom, the time nor often the training to cope,
is grateful for the surety with which she may turn to the
nurse for help. With the nurse she says she can really xvork
cooperatively and get somewhere. The nurse, on her side,
knows definitely what can and cannot be expected of a



AI'KIL 1938



103



public agency where eligibility is nearly as concrete as the
nose on your face, though sometimes she may become im-
patient with the red tape in establishing that eligibility.

If social workers in private organizations criticize the
nurse's acceptance of professional limitations, most of them
readily admit that their own freedom may lead them afield
into the nurse's territory. They apologize for this on the
ground that health is one side of the family picture which
must be seen for a complete understanding of the polygo-
nous whole. But in seeing it their zeal, they admit, often
carries them to an attempt to correct it, and they give
unauthoritative advice on diet or unwisely approach the
delicate subject of birth control. Supervisors in discussing
this excessive zeal are prone to debit it to the young, un-
trained social worker. Some of them, however, believe that
the approach to the suggestion of birth control, with all
its emotional implications, lies as much within the province
of the- social worker as of the nurse.

In spite of the edgy places in day-to-day contacts, social
workers, be they heads of organizations, supervisors or
stair-climbers evince respectful professional friendliness for



community nurses. They do not deny misunderstandings
and occasional irritating incidents but they agree with the
nurses that misunderstandings would be cleared up and in-
cidents reduced to a minimum if the social worker and the
nurse each would learn more about the other's profession,
its code, its aspirations and the practical limitations of its
practice. They agree that this should start in the training
schools of both professions and they cheer heartily for be-
ginnings already made in that direction. Meantime, they
urge the joint case conference as a practical means of re-
solving difficulties. They know it takes time, and that
nurses are busy women, maybe as busy as social workers,
but they hold that in the long run the case conference will
be worth all the time it takes.

Both social workers and nurses are fully aware that as
the public services of health and assistance broaden, the two
professions are coming closer together in the common cause
of ministering to people in trouble. In that ministry pro-
fessional misunderstanding has no place and the sooner it
is resolved the more effectively both professions will func-
tion. The solvent, they all agree, is knowledge.



A World Safe for Mothers

Mother's Day, May 8, 1938

By THOMAS PARRAN, M.D.
Surgeon General, U. S. Public Health Service



IN 1843 it was quite a piece of effrontery for a young
professor of anatomy at Harvard University to dare
present a paper on the thesis that "the disease known
as puerperal fever is so easily contagious as to be frequently
carried from patient to patient by physicians and nurses."
He was challenged by "routinists and unthinking artisans"
of medicine who attributed the dreaded childbed fever to
accident or to Providence, and disliked to have the dust
shaken out of their traditions. But the young professor had
assembled facts to prove his thesis.

History has proven Doctor Oliver Wendell Holmes
right. Thus, with crusading spirit and with unassailable
logic, did he seek to reform the midwifery abuses of his day.
Today the same spirit is needed in fighting to save mothers
and babies from untimely death or injury.

The war must be carried to the enemy, and the first
enemy is poverty. It is well known that the largest families
are found among the lowest social and economic groups.
The same one third of our people who are poorly housed,
poorly clothed, poorly fed, also get poor obstetrical care.
Nearly 240,000 mothers were delivered last year by ig-
norant, superstitious midwives and for at least 40,000
births there was no attendant.

In most communities we have good doctors, safe hos-
pitals, well-trained nurses. But either we have not cared
enough to use these facilities for good medical care in the
prevention of maternal deaths or else we have not known
how to do it.

We need a plan in the nation and in each community
for the provision of good care to mothers and babies, from
tax funds if need be. It will cost money, but we cannot
afford the higher price of neglect.

Ignorance is the second enemy. Various studies through-
out the countrv indicate that one third of all maternal deaths



are caused by ignorance or lack of cooperation on the part
of the patient. Mothers and fathers take for granted that
because childbirth is natural it should be normal. Too fre-
quently such is not the case. Every mother needs to be
watched by her doctor from the very beginning of preg-
nancy for the first signs of abnormalities or complications.
If found early, these need cause little worry; but, if allowed
to continue until dangerous symptoms occur, it may be too
late as it was for thousands of women last year.

The third enemy is abortion. Between 1918 and 1932,
the abortion index increased more rapidly than the birth
index. Of 3000 pregnancies in New York City, 30 percent
terminated in abortions, three fourths being illegally in-
duced abortions. One fourth of all maternal deaths follow
interrupted pregnancies. Nearly three fourths of the deaths
associated with abortion were due to sepsis, the dreaded
childbed fever, so gallantly fought by Dr. Holmes nearly
a century ago.

These figures are appalling, but they represent only the
known cases and constitute only a small fraction of the
total number. Were we aware of the real facts, the mag-
nitude of the problem would be more overwhelming.

A fourth enemy is syphilis. While syphilis is not a direct
cause of maternal deaths, it is the greatest single cause of
stillbirths. An average of one baby in every sixty in this
country carries the germs of syphilis in its body, yet no
woman need bear a syphilitic child. Treatment before the
fifth month of pregnancy will prevent congenital syphilis
nine times out of ten.

Save mothers and we help to preserve family life. Savei
mothers and we help to prevent delinquency and untold
human suffering. We can save mothers by the provision of
good maternity care to every mother who needs it. That
will come when the people of America want it.



104



SURVEY MIDMONTHLYi



The Education of an Examiner

By MARIE DRESDEN I.ANE

Social Worker. Region II, Works Progress Administration



THIS is the "inside" story of how a large state depart-
ment of public welfare went about the business of
examining candidates for its social work staff. It is
the story of social workers and of candidates for jobs, but
primarily it is the story of the laymen, business men, manu-
facturers, college teachers, bankers, doctors, club women,
trades unionists, engineers, lawyers, psychologists nearly
everybody but deep sea divers who did the examining and
who carried off the honors of the show. They learned more
about aid to mothers, old age relief, pensions for the blind
and every other form of public assistance than they ever
before had dreamed and they learned it, believe it or not,
by examining candidates for positions in those fields.

They learned, also, what social workers are like, how
they talk, look and dress, what special abilities lie behind
their strange phraseology and then they went out, these
laymen, and told the world about it. Within a few days
they had gained a whole new light on places hitherto dark
to them. Even within a few hours some of them wanted to
know why the state's absurd old residence law wasn't re-
pealed ; why there had to be one budget for a family with
a father and another for a family without ; why something
wasn't done "to give vocational education to children in
families on relief?" Their enthusiasm made them good ex-
aminers but I am getting ahead of my story.

You see, the Rover boys thought they had it all sewed
up. The Rover boys are the roving political opportunists
and district leaders of Pennsylvania no offense, every state
las them and in this instance they were set to control
ippointments to some 5000 jobs available through the estab-
ishment of the Department of Public Assistance of Penn-
ylvania.

You have read of that department in Survey Midmonth-
>. It was established last June and Governor Earle named
Carl de Schweinitz as its first secretary. Mr. de Schweinitz
resigned in January and went back to his old job as direc-
t>r of the Pennsylvania School of Social Work. All that is
ncidental to this story, which is of how the Rover boys met
heir match.

The act establishing the department provided for an em-
>loyment board, its function to prepare and conduct ex-
aminations for the 5000 positions. The provisions relating
to examinations were a compromise between the demands
of those who wanted a first class civil service type of ex-
amination and the demands of those who wanted "local
politics" to control appointments. Pennsylvania has no state-
wide civil service system.

The Rover boys knew that the department would have
$140 million to spend in the biennium 1938-39. No sum to
sneezed at, with the jobs and the relief money it repre-
sented. The Rover boys did not sneeze. To them the jobs
that would dispense the relief money held the key to its
control all along the line.

As a result of compromise the act had some interesting
clauses. True, 'he examinations were to be "practical in
character" and were to test fairly the "relative capacity and
fitness of persons" to discharge the duties of the positions



they sought, but there were other clauses. One, that "no ap-
plicant shall be required to have had any scholastic educa-
tion in social service work, nor to have had any other special
scholastic education or special training or experience."
What did they want all the local highschool graduates or
only the eighth graders? After all, this was a Department
of Public Assistance into which had been merged the func-
tions of emergency relief, mother's assistance, pensions for
the blind, and old age relief. It wouldn't be extravagant to
think that the performance of such functions called for
some slight special training or experience. But the act said
that none was needed.

Another provision was that applicants must have been
legal residents of Pennsylvania for not less than a year and
of the districts in which they were to work for not less
than six months. Both the omission of special training and
experience and the insistence on local residence showed
the subtle hand of the Rover boys.

You see, with an office in each of the sixty-seven coun-
ties, with a central state office and with an expected case
load of 300,000, the estimate of 5000 jobs was reasonable.
The Rover boys were more interested in the jobs than in
the clients.

Well, written examinations were held and 62,000 peo-
ple took them. Sixty-two thousand residents of Pennsylva-
nia (and of their own districts!) stepped up and said they
wanted jobs with the Department of Public Assistance.
In the written examination 20,000 of the 62,000 made
grades entitling them to further consideration. For the mo-
ment the Employment Board was stumped. What to do?
It could make no intelligent choice without a further sift-
ing process.

The act mentioned no oral examination and certain legal
minds contended that the board's powers of examination
were completed with the written test. But, the board rea-
soned : "How are we going to know that these people will
do well by their clients? How know that the unemployed,
aged, blind and mothers in want, will receive the assist-
ance to which this law entitles them? It is our job to pick
the right people."

WHO are the members of the Emplpyment Board of
the Department of Public Assistance of Pennsylva-
nia this unpaid lay board with no fixed tenure of office?
The chairman is Shippen Lewis, lawyer by profession,
member of a family of Quaker descent (you might have
guessed it), long prominent in affairs of civic improve-



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