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Mr. ROBINSON. I am glad my State is so progressive.

Dr. RUDE. Regarding State boards of health, I think the fact that we have to-day only five States which have Child Hygiene divisions actually in operation a very good demonstration of how slowly State boards of health act.

Mr. ROBINSON. Hasn't the main trouble been, Doctor, they haven't had the means to act with the public has not been educated up to the point of providing funds for the work.

Dr. Rude. That is perfectly true. That is what this bill provides for. It is primarily an educational extension bill. I can not see that it will do anything but assist the States that have undertaken this work by giving them Federal aid, and it is true that wherever work has Federal approval, it does carry more weight than where it has not.

Mr. ROBINSON. There is no doubt about that.

Dr. RUDE. There is something in the psychological effect of governmental approval. A State will go ahead and do work that otherwise it couldn't accomplish.

I didn't finish my first point regarding the personnel of this new board. The bill also provides for a public health nurse as a member. The majority of the public health nurses who are employed in States, are employed under boards of health, so that really the balance of power on this new board would be representative of the board of health, with a physician from the board of health and a public health nurse employed by them. I feel that the State boards of health were given very generous recognition in the formation of this new maternity board. The other member is to be a teacher from the State college or agricultural college. In many States it has been shown that appropriations are much more easily obtained where a State college is represented. I can not in any way see how this bill can be considered as retarding child welfare work. I am a little surprised to find myself a member of an association-American Child Hygiene Association-which feels that a bill such as the proposed one could possibly effect retardation of welfare work among children.

Dr. BAKER. May I use a personal privilege, if I may, in the record for the stenographer. If he will read the things I stated, that I appeared for the executive committee of the American Child Welfare Association, that is stated there; nor am I opposed in any way to the purpose of the bill. We have gone on record heartily in favor of the bill.

Dr. RUDE. Kansas is quoted as one of the States doing excellent work and was one of the original States having a child hygiene division. That division at the present time consists of a director, who is a physician, and three stenographers. They have been able to do some educational extension work but not the type of Statewide work such as this bill provides for.

Those are my points. Have you any questions?

Mr. ROBINSON. Is there any reason why this work should not be carried on through the recognized boards of health? I am inclined to favor the purpose of this bill, and think I do, but is there any good reason why this work should not be carried on through the established boards of health where they have them, and where they have not provide that it be carried on through boards of health of the several States, and let them establish a board of health before they can get the benefits of the provisions of this bill.

Dr. RUDE. As I think I stated before, this bill is intended to be a much broader bill than a purely health bill; its real purpose is for educational extension work and that is the reason for having it under a separate board. It is true that now all of our States have boards of health, but some of them are rather feebly organized. Many of them have not a full-time health officer, which is a very great handicap, and for that reason they are not as efficient as they might be otherwise.

The United States Public Health Service in a recent report states: "Two other basic problems, tuberculosis and infant welfare, are unfortunately beyond the direct reach of the one-man health officer, although it is possible and essential to stress these subjects in an educational way from every possible angle. ”

Mr. Zihlman. It would be a Federal appropriation intended to stimulate health work?

Dr. RUDE. Yes.

Mr. McLEMORE. Didn't you make a statement to take one from each board of health it really gives them the balance of power?

Dr. RUDE. One member of each maternity and infancy board would be a physician representing the State Board of Health, and another member would be a public health nurse, and I have tried to make it clear here that the majority of the public health nurses at the present time are employed by State boards of health, so that the balance of power would still rest in that board.

Mr. HERSEY. If they have the balance of power, why should not they have all the power?

Dr. RUDE. A person representing a State college or an agricultural college will be one very valuable means of cooperation. There you have the machinery through which to extend teaching. This bill is really broader than a simple health measure.



Dr. MENDENHALL. I think Dr. Rude has proved that in ninetenths of our States, at least, there is no machinery this bill would supersede. There is

There is no well organized child welfare work done under the State boards of health, except in a few Eastern States. I also take exception to the assertion that the State boards of health have done heretofore in the majority of our States the best child welfare work—that is, work to promote right conditions for maternity and early infancy; that the medical profession, as represented by the State boards of health, is necessarily the best profession to administer this bill or to administer it alone, and that it would not be better to have a broader administration representing three professions, for such a bill.

I shall only touch on the point of the child hygiene divisions hitherto organized. With the exception of Kansas, where there has been State-wide distribution of educational material, but where there has been no work for the teaching of mothers in the care of themselves and their babies, except through correspondence, so far as I know the child hygiene divisions of Massachusetts, New York, New Jersey, and Pennsylvania have been the only contribution to child welfare


of the State boards of health. There is practically no child welfare work of any moment being done except in this eastern locality. The great West and South have developed no child hygiene work under State boards of health or are just beginning to start such divisions in five or six States. I am sure we are therefore not superseding any machinery.

Now, there have been other agencies doing splendid work in many of the Western States to promote health in rural communities. I am referring to the work of the extension divisions of our State universities, through which demonstrations, lectures, and actual welfare conferences are held throughout the rural districts, especially in Wisconsin, Utah, Oregon, and Indiana, and to a lesser extent in Michigan, Minnesota, and Kansas. This work in Wisconsin has been going on for over five years, and also agricultural extension work in health has been started in our State. I do not know whether you understand what extension work is. We go out to little towns, even in Wisconsin, 25 miles or 40 miles from the railroad, and there hold institutes or farmers' meetings for both men and women, and also women's meetings, where we take up among other things the health of the mothers, the question of prenatal care, the need of good obstetrical care, and the feeding of infants and older children. In the evening, at general meetings, talks are given on the health of the community and contagious diseases. Usually, in Wisconsin, we have health conferences at the end of the day, where we actually examine children, and give advice to mothers in regard to their own health problems and those of their child. Very often this is the only chance that the mother has to consult a physician. These families will come 10 to 40 miles to these conferences, because there is no other opportunity for them to consult a children's specialist. This work has been developed in many of our Western States, and I wish to say, for the sake of the other people in this work, that this is actual service for humanity, for the community. It necessitates hard and arduous traveling out into remote places, five or six days in the week, exposure to bad weather, and the danger of getting snowed up or caught all night in a stalled train. It is indeed hard, wearing work, and unless you have a real love of humanity you will not stay very long in extension work of any sort, for the salaries are quite small, practically the ordinary teacher's salary.

Appropriations to further_this work have been easily obtained from the State legislatures. For instance, Utah, in 1917, was granted $5,000 by the State legislature for the child hygiene work of the extension division of the State university. The legislatures, I think, on the whole, in the Western States, the ones I know about, are glad to give funds for this extension work of the universities, while they have been less generous to State boards of health. I do not say the State board of health projects should not be forwarded, but in the West it is university extension projects that have been favored. In Iowa there is a Child Research Division for studying the conditions related to child welfare and the promotion of better health conditions for children, especially in rural districts. The State legislature, in 1917, appropriated $25,000 to start this at the State university-a very unusual example of State generosity. So much for extension work.

I am a physician, a member of both the associations which Dr. Baker and Mr. Frankel represent. It is unfortunately true in the medical profession, as in many other professions, that you rarely find the modern, scientific equipment necessary for a fine physician or surgeon coupled with a broad social knowledge, a disinterested love of humanity, and the common sense point of view, such as we used to have in the old-time practitioner. The medical profession is so exacting in its training that to be expert in branches of medicine and surgery so much time has to be devoted to professional training that the social point of view is apt to be lost. I think there are exceptions where one gets disinterested love of humanity plus that scientific medical knowledge, but I am sorry to say that in many of the States where I have worked you are not apt to find it, in rural communities or in county health officers. The State boards of health in the past have been very largely interested in combating disease, and they have not been willing or anxious to take an aggressive in attacking the fundamental causes which injure the health of the community.

I believe the reason why they have not been willing to take this aggressive action and sometimes they have been asked to do it and, have refused, is because they are afraid of the small practitioner in the locality where they wish to undertake or start some health project. There are physicians, unfortunately, who consider their profession a money-making business and are not willing to see started in their community a project that may injure their pocketbooks. have been told by health officers that they could not undertake work in certain places because the local practitioners would object and would go to the State medical association, which was backing the State board of health, and make trouble for them. I think that this has undoubtedly happened in some instances. I do not think any one profession is apt to see outside of their own particular field; a board composed of any one profession would not therefore be as broad minded or have as wide a vision as a board made up of several different professions.

I want to say a word about the nursing profession. It is a very practical profession. These women will very largely carry out the measures of this bill.

The nurse will go into the homes and teach the mother how to care for herself and for her child and will start the centers and conferences for mothers and children and largely carry on this important part of the work. The nursing profession, as I am sure we all realize, is a profession peculiarly disinterested, with a great desire for general public service. Nursing is also a profession of women, and I think that it is only right that women should be represented in the administration of this bill, which has to do with the instruction of mothers in regard to their care and the care of their children. For another reason, I think it is an excellent thing because the nursing profession always cooperates with the medical profession, and naturally the physicians and nurses in the State board of health would work together in the administration of this bill. The nursing profession, the public health nurse, should be represented in this board.

For two reasons it seems to me that it is very much better to have the administration of this bill left as it is. One of them is that the first object of the bill is that of instruction. It is educational exten


sion work to promote proper hygiene of maternity and infancy. Then, the carrying out of this bill involves nursing work, under the direction of physicians. Since the bill involves the use of three professions, the extension teacher, the nurse, and the doctor, and is a social and not a purely medical bill, these three professions a teacher from the State university or agricultural college, a physician representing the State board of health, "and a member of the nursing profession-should administer the bill. I can not see that this will not be a better plan than putting the administration of this bill in the hands of the medical profession alone. It is not a medical bill, but an educational extension bill. It is a social bill. It is not best for any one profession to have the administration of it. I am here to answer questions if there are any.

Dr. FRANKEL. May I correct the minutes as to the animadversions against the medical profession. Possibly I ought to consider myself fortunate in not belonging thereto. I am not a physician.

Dr. BAKER. I am a practical hygiene administrator myself and have a very extensive piece of child work under my jurisdiction in New York City. I am not speaking as an individual here, but as a practical administrator. I have been firmly impressed with the work that the public health work was doing, and that all functions of the municipality or of any part of the Government that relate to a detailed piece of work should be submitted to the part of the Government which is created to deal with that work. Crime necessarily belongs to the police department, fire prevention to the fire department, and education to the education department; the health is a function of the health department. There has been nothing said here that the public health is not eminently social in its nature. There is nothing said here that brings out the contradistinction that the bill is itself a public health bill. Its provisions are themselves recognized as public health work. The statement that was made that the nurses in this bill would be the public health nurses is not borne out by the bill itself. The bill simply says a nurse. The statement that the medical representative would be a member of the board of health is not borne out by the bill. It simply says a physician who shall be a representative of the board of health, and that means the Governor might appoint the lowliest medical inspector without administrative authority or anything else except political preference. There is no reason to believe, nor as far as I have been able to hear, have any arguments been advanced which would show wherein this work would be better carried out by that separate board than the already created health boards.

When one speaks of the delinquencies of the medical profession and the fact about a love of humanity, who are you going to use except the same ones. You will have to use through a separate board the same doctors, and nurses or health department employees. They are merely citizens of the States and with all their faults or virtues they would have to enter into any other board created. I do not see how you can possibly separete infant and child welfare work from the legal and authorized functions of any department. If you

should in New York State take that part of our work away from us we would feel that we were negligent in allowing anyone to take it away from us. It is a truism that infant mortality is the sanitary index of any vicinity. The basis of welfare work and the

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