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workers were graduates of a school of social work, we would
have little difficulty in adjustment. But as yet there is much
to be hoped for in the training of both groups. Too often
the nurse believes that the only legitimate work of the social
worker is to give material relief, while the social worker
feels the only real use of the visiting nurse is to give bed-
side care.

The supervisor of our Associated Charities defines "social
work" as "an effort to develop the personality of the in-
dividual and to bring him up to the highest level of which
he is capable." Reflect what a big part health and adequate
care in sickness must play in working out such a program.
How can social work and public health nursing keep from
becoming interwoven? Our problem is to find the means
by which they can work together to the best advantage of
the individual and the family whose ultimate good is the
real desire of both workers.

Intelligent cooperation between agencies must begin with
the executives and extend through the entire staff. The
executives must have a thorough understanding of each
other's work and problems; a friendly attitude goes a long
way in the adjustment of difficulties. If criticism must come,
let it be constructive. When a spirit of antagonism exists
between the heads of organizations or the supervisors, it is



useless to hope for intelligent cooperation among workers.

In Erie we have a twice-a-month luncheon meeting of
the executives of the various organizations and their assis-
tants, which has done much to bring about a better under-
standing. Subjects of common interest are studied and rec-
ommendations made. A more formal meeting with oppor-
tunity for discussion and recommendation is found in the
advisory councils of community chests.

In working out a policy of cooperation, a friendly and
intelligent interest and understanding between the differ-
ent staffs is essential. They must know each other face to
face, not just by telephone conversations. They must know
the work, aims and limitations of each other's organizations.
This has been done by having the executives of the different
organizations come before our staff and explain their work.
Our staff is urged to take this opportunity to ask questions.
In turn, I have gone before the staffs of other agencies to
explain our work, limitations and aims, and I feel, after
such a contact, a definite advance in this technique of co-
operation. We have a Monday Club to which many work-
ers go, giving the staff nurse and the visitor a chance to
meet socially. A tea or a joint party occasionally offers
another friendly contact.

I wish every public health nurse would become familiar
with Karl DeSchweinitz's Art of Helping People Out of
Trouble or Mary E. Richmond's What is Social Case
Work?, and that every family welfare worker would read
Mary Gardner's Public Health Nursing. It might help
them toward a better understanding of what each is trying
to do.

Wherever there is a family case-conference committee, the
nurse in the district is included, and here again is a chance
to hear different sides of a question talked out and to meet
practically every worker in the territory. One of the points
we have emphasized is the necessity of taking time for con-
ferences between the workers in the same family. Our
different hours have been a source of difficulty here, for
nurses come to the office at 8 A. M. and are in their dis-



April 15, 1927



THE SURREY



87



tricts at 8:45, not returning to the office again that day,
while the social worker is usually not in her office until 9.
To solve this difficulty the Associated Charities has given
us a schedule of the time each visitor is in their office, so
the nurse can call from the field if she wishes to make an
appointment with a visitor. This schedule is posted on the
bulletin board and the nurses are held responsible for get-
ting in touch with the visitors. The visitors and nurses are
urged to find out each other's telephone numbers so they
may reach each other out of hours if necessary. Is it fair
to encroach on their time off duty? So far, we have had
no complaints and a better understanding exists where it is
not necessary to wait several days to talk over a question
of immediate importance.

Among public health nurses there is a generally accepted
principle that no two groups of nurses should visit the same
home at the same time, but between the nurse and the social
worker such an arrangement is not possible. Neither can
do the work of the other, so they must work side by side,
with as little overlapping and duplication of effort as pos-
sible. Tolerance and understanding of each other's work
and willingness to cooperate will make for the permanent
good not only of our organizations, but of the patients and
clients whom we serve.

Educating Doctors

By Michael M. Davis

THE Commission on Medical Education, headed by Presi-
dent Lowell of Harvard and including in its member-
ship several other general educators as well as a distinguished
gathering of physicians, medical teachers and scientists, has
just issued a preliminary report, avoiding conclusions but
presenting the facts which it has collected. Chief among
the topics considered in the study, directed by Dr. Willard
C. Rappleye, are such questions as : What is medical practice
today? What does the community demand of the practising
physician? What kind of work is asked of him among the
many different sorts of activities which physicians may now
engage in? The Commission set out to gather facts which
might help in setting an objective or goal for medical edu-
cation.

The objective basis so far obtained is slim enough, consid-
ering the size of the problem and the variety of conditions
to be considered. Some five hundred "recent graduates in
medical practice in communities of 50,000 or less, in twenty-
four states and two provinces," reporting on a questionnaire,
"estimated that less than 10 per cent of their patients needed
hospital care and that they felt competent to diagnose and
treat over 90 per cent of the complaints met in their prac-
tice without the aid of consultants or specialists."

On the other hand, the Commission found that a great
proportion of recent graduates are actually entering special-
ties rather than going into general practice. No data are
collected from the larger cities, in which one-third of the
population of this country and more than one-third of the
physicians are located. Here the picture might be different.
Nor is anything said concerning the lay habit of seeking
specialists, now well drilled into the general public in both
large and medium-sized communities by a generation of
rampant specialism within the medical profession.

The trend of this preliminary report is to suggest that the



goal of undergraduate medical education is the training of
the general practitioner, a conclusion which most laymen
whose sick relatives have gone the rounds of many specialists
are likely to hail; but that is a very different thing from
implying that medical practice in the future will be con-
ducted largely by general practitioners. Presumably later
study will include city and town conditions, and future
reports will make more clear the implications of the facts
instead of leaving them to interpretation or misinterpretation.
To find a group of men dealing with so deeply profession-
alized a subject as medical education who step, at least
momentarily, from the box of the specialist into the spacious
areas of general education is refreshing and significant. As
in school-work, the recent emphasis has been not on the
subjects to be taught, but on the help that a child needs to
develop aright in a modern world, so the report of this
Commission begins by pointing out that

While changes in community life are modifying the char-
acter of medical practice, the great growth of knowledge of
the causes, treatment and methods of preventing illness has
had, at the same time, marked and far-reaching effects on
individual and community welfare. . . . With these and
other general considerations in mind, we have felt that the
sound approach to the problem of medical education would
be an attempt to secure an adequate picture of the demands
for medical services and of the actual health needs of the
population. These demands and needs obviously should not
be the sole guide in shaping a basic course but they should bft
kept in mind as the ultimate objective of medical preparation.

Those at all familiar with medical schools will appreciate
how radically different is this approach to medical education
from that which starts by considering such matters as
whether third-year students shall receive clinical instruction
in the out-patient department or in the hospital wards!



THE PRICE of the House of Health series of booklets pub-
lished by the American Child Health Association is ten cents
each, not five cents, as was stated erroneously in The Survey
of February 15.

"NAW, IT WON'T HURT" was the slogan adopted for the
campaign to abolish diphtheria in the town of Ogden, Monroe
County, New York. Apparently it worked, for Dr. Charles G.
Lenhart, health officer, reports that 340 children were pro-
tected at one clinic and that more than 90 per cent of the pre-
school children, the most susceptible group, had been immunized.

LIKE time and tide, the course of disease takes no account of
human convenience or ordinary office schedules. Hence the
Department of Health of Springfield, Illinois, has installed a
refrigerator at a centrally located fire-house so that physicians
may get "biological products," such as diptheria antitoxin, at
any hour of the twenty-four. Sometimes only a little time
might make the difference between life and death.

THE graduate nurses of Virginia have just completed the most
arduous task they ever have undertaken as a body, "to their
intense relief," as Agnes D. Randolph, R.N., reports in the
last issue of the American Journal of Nursing. Since the 1923
convention of the Graduate Nurses Association of that state,
they have been engaged in the just finished campaign to raise
$50,000 to establish and endow a chair of nursing at the Univer-
sity of Virginia. "The nurses deliberately gave financial sup-
port to the apex the college rather than the base the train-



88



THE SURREY



April 15, 1927



ing school," Miss Randolph writes. "Creative effort was re-
quired at the apex, and the public had no will to create. At the
base, only reorganization and grading are needed." This is the
second chair of nursing to be established by nurses themselves,
following the somewhat similar position opened at the Univer-
sity of California on January I (See The Survey, December 15,
1926, page 385) as well as the well known schools of nursing
education at Western Reserve, Yale University and Teachers
College, which were the gifts of individuals or foundations.

AT least 24 official registries have made provision to furnish
nursing service on an hourly, paid basis, according to a study
recently made by the American Nurses Association. In most
of the cities the rate is $2.00 or $3.00 for the first hour's
service, and from 50 cents to $i.OO for each succeeding hour.
Some agencies stipulate that the hourly fee shall not exceed a
day's fee; others that the nurse shall not give more than three
hours in a day to a single patient. Among the southern cities
which have developed this type of nursing service are Louis-
ville, Charleston, and Baltimore; while the northern converts
to it, where it is more generally popular, dot the states from
coast to coast.

WITH the start of the new year Newark, New Jersey, en-
tered into an agreement between the Children's Aid Society,
the Catholic Charities, and the Health Department for the
inspection of boarding-homes and the placement of children in
them. All persons who wish to board children apply to the
Department of Health for a license. An initial inspection is
made by the district nurse of the Child Hygiene Division of
the department, to determine whether or not the physical con-
ditions of the home entitle it to a license. If her approval is
gained, the request is referred to the Catholic Charities in the
case of a Catholic family, or the Children's Aid Society if the
home is Protestant. If they find the social conditions suitable,
the Fire Department is asked to examine the house for possible
hazards before the license is finally granted. A list of all
licensed homes is referred regularly to the agencies and the
Social Service Bureau, so that they may know at all times
what places are available. Any person who applies for a home
for a child is referred to the agencies. "We believe," writes
Dr. Julius Levy, director of the Division of Child Hygiene,
"that this plan of cooperation marks a definite step in the
coordination of the social and health supervision of children."

CONTRARY to the general impression, the pension plan for
nurses sponsored by the Harmon Association for the Advance-
ment of Nursing does not require private patients to contribute
anything whatever to the retirement fund,
according to a pamphlet just issued by the
Association and to be had for the asking
from its offices at 522 Fifth Avenue, New
York City. Membership in the Harmon
Association, which carries with it the right
to participate in the retirement plan, is open
to every registered nurse and associate mem-
bership to hospitals, visiting nurse associa-
tions and other health institutions. Dues for
individual members are one dollar a year; for institutions one
dollar a year for each participating nurse in their employ-
ment. Retirement benefits are made up from deposits by
individual members and by institutions. Individual members
deposit a minimum of five dollars a month and institutions,
participating in the plan, deposit five dollars a month for each
depositing nurse. The amount of annuity which these de-
posits will procure depends upon the age of the individual
member at the time of starting deposits, the sex, and on the
age at which the member elects to retire. Members may
retire and secure an annuity at any age from 50 to 65. It is
quite possible for a nurse to join the Association, make her
regular monthly deposits and secure a retirement benefit with-




out the cooperation of any employer, but it is the aim of the
Association to enroll as many institutions employing nurses as
possible so that retirement benefits may be proportionately in-
creased for many members. A nurse may go from one in-
stitution to another or into private duty without losing credit
for deposits made for her by any employer, provided only she
keeps up her own deposits. These will be returned to her
in full at any time, if she desires, or to any beneficiary she
names in the event of her death, minus only the pension pay-
ments which may have been made to her if she has retired
at that time. Should she drop out of the profession before
retirement, the payments made on her behalf by any employer
will not be returned to her individually, but will be credited
to the members who remain, substantially increasing their ben-
efits over and above the regular amounts. The entire plan is
safeguarded and guaranteed by the Metropolitan Life Insur-
ance Company.

INFLUENZA is again prevalent in Europe, though not in a
severe form, and the British Minister of Health has issued a
revised memorandum summarizing what is known of its con-
trol. Despite the research since the epidemic of 1919, little
further has been learned of specific ways of prevention or
control, yet the methods which have been evolved, "feeble as
they are, are not negligible, and their judicious application
produces results not to be despised." Chief among these is the
organization of home medical and nursing service on a district
basis, with the cooperation of local district nursing associations,
and the education of the public as to ordinary prudence in diet
and mode of life, the early isolation of the sick, cleanliness and
the avoidance of infection. Except in rural districts, where
excluded children would have little opportunity to come in
contact with each other, the closing of the schools is not
recommended.

IT takes a fat volume of 354 pages to hold the report of the
four years work of the first of the great child health demon-
strations, that of Mansfield and Richland County, Ohio, from
1922 to 1926. The demonstration represented the effort of
the American Red Cross, working through a National com-
mittee, to help a fairly typical industrial and agricultural

county to develop
protective and edu-
cational measures
for the health of its
children as soundly
and as broadly as
Funds possible in the al-

lotted time. It had
two objectives: to
integrate all forms
of child health




1921 1922 19?S 1934 1925 19R8



work and to hold fast to the ideal that whatever was accom-
plished should be rooted in local soil. As one concrete meas-
ure of the latter the report offers a comparison between the
waxing expenditures for health work made by local groups,
public and private, and the waning contribution of the demon-
stration itself, which felt its work successful in the degree to
which it was taken over by the community. The solid line
shows the rise of the local appropriations from 33 cents per
capita in 1921 to 92 cents in 1926; the dotted line the demon-
stration's share dropping from 65 cents per capita in 1922 to
36 cents in 1925. The first and last years of demonstration
expenditures have not been included since they represented
expenses associated with the opening and closing of the program
rather than the cost of actual health work. Copies of the report,
which is full of detailed suggestion and finding in health educa-
tion, medical and dental work, nursing, fresh air camp, nutri-
tion, and the activities of the board of health, may be obtained
from the American Child Health Association, 370 Seventh
Arenue, New York City, Price, $i.



INDUSTR Y



The Barefoot Boy

By AGNES E. BENEDICT




"ES, my daughter gave up her job in the factory
to spend the year on the farm with us, but
lands the work here was too much for a delicate
girl like her. She had to go right back to the
factory." To most people, this remark of a
middle-western farmer would sound absurd. Nevertheless,
recent studies made by the federal Children's Bureau and
the National Child Labor Committee of the work of chil-
dren on the home farm and as farm hands hired by the
day,*' bear out the farmer and reveal an appalling dis-
crepancy between public recognition of the one form of
labor and of the other at least insofar as this recognition
is expressed in protective legislation for children. For
example, the twelve-year-old sister of this farmer's daughter,
had she sought work in the city with her sister, would have
been turned back by law from the
factory and told not to return for
two years. If she came back at
fourteen, the hours and conditions
of her labor would have been
definitely prescribed until she was
sixteen. Yet no law whatever stood
between her and the burden of
farm work from which her older
sister found it necessary to escape,
and which, as a matter of fact, fell
heavily upon this child. Again, it is
astonishing to reflect that the child
welfare laws of her state could be
invoked to protect her from various
forms of parental "abuse," such as
neglect, severe punishment, lack of
school opportunity, yet "abuse" in
the form of exploitation and over-
work in the fields is practically
unrecognized by the laws of any
state.

The studies referred to covered
a wide area in the general farming regions of Colorado,
Illinois, and North Dakota and on the truck farms of
Maryland and New Jersey. They show that, while the
farm work of children is seasonal while it differs from
factory work in its problems and the possible ways of
meeting them nevertheless, it does present at its worst
many of the evils of factory labor at its worst, with addi-
tional evils of its own.

Farm work compared with factory work suggests free and
unrestrained movement, as opposed to cramped positions




Abuse in the form of overwork in the
fields is practically unrecognized by laws



* Work of Children on Illinois Farms, Federal Children's Bureau. Pub.
No. 168; Child Labor in North Dakota; Work of Children on Illinojs
Farms, by Dorothy Williams and Mary E. Skinner, Federal Children's
Rureau, Pub. No. 168.



and strains; initiative and self-directed effort, as opposed to
the relentless drive of a foreman. Yet these studies forcibly
show another foreman, quite as inexorable as the factory
boss: the urgency of a perishable crop. They show his
pitiless strawbosses, labor shortage and economic strain.
Under the drive of these forces, the various farm processes
preparing the ground, planting and harvesting are
pictured as going on hour after hour, day after day, for
eight, ten, and eleven hours a day, monotonously, endlessly.
When their day in the field is over, many farm children
find two or three hours of "chores" waiting for them.
Here the factory hand has the advantage of the rural
worker, for he turns his back on his labor when the
whistle blows.

The reports emphasize the physical strain of certain
processes, such as the continual
stooping in picking tomatoes and
cucumbers, the danger of sprained
wrists in twisting dry onions, the
weight of carrying and dumping
35- to 4O-pound baskets of tomatoes
or sweet potatoes. Hamlin Gar-
land's description of harrowing is
quoted : ". . . your heels sinking into
the soft loam bring such unwonted
strain upon the tendons of your
legs that you can hardly limp home
to supper, and it seems that you
cannot possibly go on another day."
Many farm processes are carried on
in intense heat or severe cold.

Most states in the Union have
taken account of the hazardous
nature of machine work for chil-
dren and set a sixteen- or eighteen-
year age limit for certain "dan-
gerous occupations." But these laws
affect machinery in factories only.
The extent to which the machine age has laid hold of the
farm is hardly appreciated, and never in terms of menace
to the child worker, yet a partial list of the machines re-
ferred to in the reports includes the transplanting machine,
the disking machine, the grain binder, the cultivator, the
threshing machine and the plow. These are not harmless
tools. Here is a picture of a threshing machine: "The
worker pitches the bundles to a moving belt which carries
them under a set of moving knives. ... He works in such
proximity to moving machinery that he is in danger of
being caught by knives, belts or parts of the machine."
In the state of North Dakota, of 845 children studied,
104 had been injured in farm work. Fifty-four had

89



90



THE SURREY



April 15, 1927



been injured while the children were using farm implements.

The figures on school attendance in the reports show how
completely crops are put before education. The extent to
which public opinion countenances this attendance situation
is illustrated by a thirteen-year-old son of a member of a
local Illinois school board, who had lost 75 days of school
for farm work during the year ! Considering that attendance
has been proved to be a decisive factor in school progress,
the percentage of retardation among farm children reported
in most studies is not surprising.

This comparison of children's work on the home farm
with child labor in factories has not been made with any
idea that the two problems need the same solution. In fact,
with our limited information on the rural situation, only
tentative remedies can be suggested. Many authorities feel
that an attempt to regulate the work of children on the



home farm through a labor department would only mean
waging a blind guerilla warfare; that it might be more
successfully and more logically handled through juvenile
courts, as a "child welfare," not as a "child labor" problem
To the writer, it seems, however, that the first step in
the solution of the problem is a change of viewpoint in
regard to it a willingness to accept the situation a desire
to face the facts. Such a changed viewpoint will inevitably
be slow in coming. To see country life as it really is mean
blotting out of the picture many of the cherished associa
tions of beauty and glamor which we have put there as
visitors going to the country on vacation, or as grown-ups
looking back at our childhood on the "dear old farm" of
another and a simpler time. It will mean substituting for



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