Health and Commonwealth

By Wilbur C. Phillips, Secretary, National Social Unit Organization, Cincinnati, Ohio

A Presentation at the National Conference Of Social Work,  Forty-Fourth Annual Session Held In Pittsburgh, Pennsylvania June 6-13, 1917

Ed. Note: The social unit plan concept was designed and promoted by Wilbur and Elsie Cole Phillips, who shared the management and fund raising responsibilities necessary to advance the project and demonstrate its feasibility.  When the social unit plan had been concreted, they organized a national group to finance and conduct it in some American city.  Having secured $135,000 for a three years’ demonstration, they set up a competition among cities and Cincinnati, Ohio, was finally chosen. The first and only demonstration of the social unit plan was in Cincinnati, Ohio. The project’s working hypothesis was that economic and social unity must be based on a spiritual and moral law and achieved through people organizing democratically in such fashion as to integrate their complimentary functions as consumers and workers – doing so under no compulsion other than the dictates of their reason and conscience.

This presentation by Wilbur C. Phillips at the 1917 conference of the National Conference of Social Work describes the social unit plan as it was being formulated for demonstration in Cincinnati, Ohio in 1918.  Despite its contributions, when the three-year project ended, the City of Cincinnati elected not to continue the demonstration.

I have chosen as my subject Health and Commonwealth, because of my belief that the health of each individual is inseparably bound up with the health of the whole community and that the health of the whole community cannot be conserved and enhanced to its fullest degree without concerted action by the whole community-that is, by the state, the commonwealth. Sickness arises from the fact that the vital and essential needs of people are not satisfied. The individual who lacks air, sunshine, space, good food and sufficient in quantity, a clean, sanitary home, freedom from the anxieties and harassment attendant upon an insufficient income, a place in the community and a feeling that life is worth while because it affords him a chance to function happily and effectively towards an end that is bigger than himself-such an individual cannot be healthy and the community around him is affected by his presence in it exactly as are apples in a barrel when rot has touched one of their number.

An ideal health program must be a community program. Its aim must be to plan in the wisest possible way methods by which the needs of all people for all the things essential to life and happiness may eventually be satisfied. Such an objective is, of course, no other than the end and aim of government itself, the purpose of whose existence is, or should be, solely to meet through organized action on the part of all, needs which the individual cannot satisfy through private effort. Secure democracy-build up a co-operative commonwealth-and health will at the same time have been achieved.

What then is democracy? We call America a democracy, but is this in accord with the facts? Does not the widespread existence of sickness, disease, poverty and unhappiness indicate clearly that as yet we have democracy merely in name, that the people have not yet banded together as a social union and come into their own? Genuinely democratic government, the kind that will ensure sound health for everyone has yet to be realized. Even so-called democracies have always been oligarchal, because the bulk of the citizens have had no adequate understanding either of their own needs or of ways in which to meet them.

The social unit plan aims to bring about a genuine and efficient democracy by showing the rank and file how to secure for themselves a clear idea of their own needs and by helping them to organize for the satisfaction of those needs the best skill and the wisest advice available. Practical health work is the point of attack because it is one of the sorest immediate needs and the one of which people are most conscious.

The laboratory chosen for the working out of this new concept of democracy is a typical district of Cincinnati containing approximately fifteen thousand people. In this district, under the control of the citizens who reside in it and with the co-operation of citizens throughout the entire city as well as of the city government, it is planned to develop an organization which, if successful, may later, with minor modifications, be capable of application in other sections of the city and in cities throughout the country. The work is under the charge of the National Social Unit Organization, created on April 11, 1916, in New York City, for the purpose of aiding the program financially, securing advice of national experts in the conduct of the experiment and disseminating the lessons learned.

At the time of the creation of the national body, announcement of its purpose was made through the newspapers of the country. It was clearly stated at this time that, because of the democratic character of the plan contemplated, the enthusiastic co-operation of the leading citizens in the city to be selected was essential to its success. For that reason, the committee explained, it would not arbitrarily select a city, but would wait for the community forces in various places to come forward and apply for the aid of the national organization. This announcement aroused an unusual and remarkably widespread interest. Within a few weeks letters were received, in some cases from public officials, in others from social workers and private individuals, from sixteen cities, asking on what conditions they could secure the work.

In Cincinnati considerable interest had already been aroused in a health center plan, advanced by the Cincinnati Anti-Tuberculosis League, as a central feature of a program to be adopted by the Municipal Tuberculosis Committee. A special committee had been created, of which Dr. J. H. Landis, Executive Officer of the Board of Health, was chairman, and Mr. Courtenay Dinwiddie, secretary. The publicity given to this local project had opened the minds of physicians, social workers and the public in general to the health center features of the unit plan, so that when a campaign to secure this plan for Cincinnati was pushed by the Anti-Tuberculosis League the response was immediate and widespread. The interest and initiative shown by these local enthusiasts was, indeed, one of the principal things which weighed with the national body in determining upon the Queen City as the field for its experiment. Other arguments lay in the fact that Cincinnati lies in the center of the most thickly populated section of the United States; that it has, to a very unusual degree, developed co-operation and good feeling among the members of important groups and that it voluntarily pledged $15,000 for three years to supplement the $90,000 which the National Social Unit Organization had raised for the same period.

Actual work began in Cincinnati on January 2, 1917. A little more than two and a half months later a citywide organization was created to select a neighborhood for the work. The purpose of this preliminary campaign and its resulting organization was to get the whole city of Cincinnati interested in the plan and to impress upon it the fact that the social unit was to be a municipal laboratory for the development of an idea which had significance, value and importance to the entire citizenship. The enthusiastic support of the various citywide groups, whose co-operation was essential to its success, was secured easily. Leading business men and women are now associated with the movement; the labor unions have been interested and are officially represented; the chief social agencies have pledged their support, even to the point of agreeing to relinquish their work in the experimental area; the medical profession has endorsed the plan through the Academy of Medicine and through the West End Medical Society, the most important medical organizations in the city; prominent Catholics, Jews and Protestants are associated with the movement; and the city government has given its official sanction to the idea through the acceptance by the mayor of the honorary headship of the organization, by his appointment of a representative of the city departments on the Social Unit Organization; by the election of a representative of the City Council of Cincinnati to serve on the same board, and by the fact that each group committee has a city official on its membership. Following the precedent set in the choosing of Cincinnati by the national body, the various neighborhoods within the city were given an opportunity to express their interest in the movement. A citywide referendum was taken through the distribution of fifty-five thousand circulars and ballots by children in the public schools to determine the sentiment of people living in them. Six of them entered into competition with each other to secure the plan and on Thursday evening, June 7th, at a public hearing in Exchange Hall, Chamber of Commerce, the Mohawk-Brighton district was selected as the field for the work. This district for two months had carried on a vigorous campaign towards this end. An organizing committee of 145 leading men and women had been created; the district had been canvassed from house to house; petitions signed by nearly two thousand families had been forwarded to the city organization; ballots returned through the schools from this district numbered 1,400; circulars printed at the expense of the local people had been distributed, and letters pledging co-operation had been written by 26 of the leading agencies and organizations having their headquarters in the neighborhood.

Now that the district has been found, the next step will be to create within its limits a democratic organization which can accomplish the purpose defined at the beginning of this paper. This organization will consist of two types of members; first, representatives of committees representing population units, and second, representatives of occupational groups at work within the neighborhood. The members chosen on a population basis will form a sort of House of Representatives and the members chosen on the group basis a sort of Senate, the two bodies together constituting a Congress for the area.

As a means of securing the population representatives the Mohawk-Brighton district will be subdivided into smaller units of perhaps five or six hundred people, by blocks possibly, or possibly on some other basis. In each of these units a Citizens’ Committee of men and women will be selected, making a corps of potential social workers drawn straight from the neighborhood itself.

The first task assigned them will be a simple one, merely that of finding all the mothers in their blocks who have babies under one year of age, securing friendly acquaintance and persuading them of the value of supervisory care by doctors and nurses which can be had at the “baby clinic”-the first department of social service which will be opened at headquarters, In order that the block organizers may be intelligent in their preachment of the value of this preventive oversight they will be called together at the station and the doctor (a baby specialist) in charge of the work will tell them in simple terms the reasons for its importance, how thousands of baby lives are being saved by it, and why. This general knowledge they will carry back to the mothers in their blocks-to all of them, for their task is to establish, as far as possible, 100 per cent contact with those mothers.

When this field has been cultivated intensively and results show in the high percentage of the mothers who not only welcome the nurses’ home visits, but bring their babies regularly to the station for medical examination, another task will await the block organizers-that of carrying the story of the prenatal work, now opened, to all expectant mothers in their blocks. In preparation for this work they will again take instruction at the station-this time from the specialist at the head of the prenatal clinic. Here is a more difficult and delicate task and ample time will be allowed for it. -By the time it has been completed each of these neighborhood workers will have established acquaintance with some twenty-five to thirty families, that is, with 125 to 150 people. Adding those previously known to her, she will have gone a good way towards knowledge of her block. From this point on her first task will be that of pursuing acquaintance until she knows in a really friendly way every man, woman and child in her five hundred. She will then do two things. First, she will carry to approximately all of those who should hear it the general educational propaganda of each of the services, medical and social, which will be gradually set up at the station. Such educational work is essential to the reduction of infant mortality, the prevention of tuberculosis and the curing of other social ills. Before she undertakes it, she will, of course, receive instruction from the expert in charge at headquarters which, in this way, will become a school for the workers as well as a social service agency. Second, she will gather the social data needed from the district-keeping 100 per cent before her as an ideal. If she is in touch with the whole population in her small area she can, it is believed, keep the census and keep it up to date. She can achieve a complete birth registration (at present the average American community is lucky if 75 per cent to 90 per cent of its infants are registered). She can report all cases of unemployment and secure detailed facts in connection therewith. Surveys and social studies can be made through her. In short, this one staff can carry to the people of the area and can also get from them, on an approximately complete basis, just the facts that many social agencies wish to teach or to gather, but are unable to gather completely, because they lack the necessary contact.

The fact that the women selected for this staff may not all be acceptable to their blocks or small units has been kept clearly in mind. For that reason each woman organizer will be regarded merely as a temporary appointee. As such she will as soon as possible gather about her a citizens’ committee, made up of leading men and women in her unit. This committee when it is created will have the privilege of selecting its own executive or representative, who may be the original organizer or another person. Eventually, and at as early a point as proves practical, the people within the unit will be asked to take the matter into their own hands and elect their own citizens’ committee, whose head will there upon become the social worker for the unit.

Through this method of organization three desiderata are aimed at so far as.this one district is concerned: (a) The reaching of a much higher percentage of those to whom social information is now disseminated; (b) the collection of more complete facts, and those facts corrected up to date; and (c) the doing away with “multiple visiting” in the sense of the unasked intrusion into families of a series of unrelated agents.

By the last we do not mean that the neighborhood worker will in any sense replace the nurse or the social technician. Specialized ability is as essential in social as it is in medical diagnosis. But the general diagnosis is needed, too, and this the neighborhood worker will supply, implanting in the minds of the people a sense of their need for special service where it is necessary and persuading them to seek the specialist instead of, as is the case at present having the specialist seek them. More important still is the fact that all this work of education and service will be done by the people for themselves and not to them by some one else.

As soon as the block organizers are actually chosen by the people of the area, there will have been created a council of social representatives, in closest touch with their social constituents, under the direct control of those constituents and trained for their work by the best skill the community affords. At the same time the district station will gradually become, not merely a health center or school in social service, but a sort of branch city hall, with complete records of local social conditions and needs, which will be open to a neighborhood taught to realize their importance. Here, in other words, will be a truly democratic machinery, offering the people of the district a genuine chance to discover what their needs are and to formulate their own ideas as to what should be done to meet them.

The other half of the program, that of making’skill available for the effective fulfilling of the desires of the people, is exemplified in the organization of the medical work. There is only one group in the community that knows anything about medicine-and that is the doctors themselves. A community must, therefore, depend upon its physicians when it wishes advice on these matters. It lets-it is compelled to letthe doctors do its medical thinking for it. No one else is available. In other words, the. medical group constitutes a mind of the public in its particular field.

The unit program aims to organize this group intelligence-the best of it-and concentrate it on the formulation of a plan for medical work within the district. First, the official medical organization of the city will be asked to elect a council of physicians made up of city committees on pediatrics, obstetrics, etc., with the secretary of the board of health as a member. These committees will be related to the medical work carried on by the neighborhood through what has been called an hour-glass connection. To illustrate, the city committee on pediatrics, or child care, will be made up of the doctors whom the medical profession regard as the best fitted of any in the city to conduct the baby work in the district. Direction’ of the post-natal work will be given over to this committee. The doctors in the district will also be organized, however, and will appoint a staff from their own numbers to hold the baby clinics at the station. This staff will be paid. It will select its own supervisor. It may select one of the specialists on the city committee. If not, the man who is selected will become ex-officio a member of that committee. Thus a channel will be created through which the best of the knowledge, skill and experience of the whole medical profession, can sift down to the work in the unit, yet the medical service in the neighborhood will be carried on by the medical agents already and naturally located there.

This same method of organization will be utilized for each other medical service set up-pre-natal, tuberculosis and so on. Simultaneously, the knowledge and experience gained through the neighborhood work can be rendered available for the whole profession. Thus there will gradually be built up a health center, run by the medical profession, each clinic manned by local men working under the best medical intelligence in the city.

In addition to planning and supervising the medical work at district headquarters, the city medical council, through its various committees, will study this work in relation to hospitals and dispensaries throughout the city; ascertain the extent and adequacy of these institutions and their relation to medical education in the community, and gradually work out a city plan for an inter-related system of hospitals, dispensaries, prophylactic health centers and institutions for instruction in medicine.

The same principle of group organization will be applied to the social work, the nursing, the statistical work, etc., as well as to the gradual building up of an advisory council composed of representative, socially-minded and interested men and women from other occupational groups in the community. For example, in social work, formulation of plans and directions of policies will rest in city committees of social experts, elected by their fellow members and united through their heads in a social council, of which the superintendent of public welfare will be a member. Special agents already at work within the district will meet as local committees, with representation on the higher committees on city planning. As time goes on, individual agencies now at work in the district will be asked to turn over their work there to the central organization, which will assume financial responsibility for it. This will not mean that these agencies will cease to exist, for 90 per cent or more of the city will be unaffected and still be left them as a field in which to operate. It will mean only this-that they will join in an experiment, in the conduct of which they will have a voice, to ascertain experimentally whether, as many people believe, it is more efficient and economical to conduct certain forms of social work through a single organization democratically managed by all of the social experts in the community, rather than through individual organizations, each with its own office, directors, secretary, overhead charges and appeal.

In summary, then, the unit plan aims at three things: To organize the people of a limited district democratically, so that they can get a clear idea of what their needs are and what they think ought to be done about them; to organize democratically the specialists from the neighborhood of the city, so that the highest skill and experience can be applied to meeting needs disclosed; and to bind the people and the technically skilled groups together in such a way that the people can tell the specialists what they want done and the specialists how to do it, submitting plans, programs and policies to the people for approval.

To put it another way, the aim is to bring efficiency to democracy, or, to get back to the beginning of this paper, to conserve and enhance the health of the people living in the social unit by building up therein a model commonwealth.

Some of the points on which the plan differs from older conceptions of social work are as follows: (1) The work will be under the direct democratic control of the people who will be affected by it, and not of an absentee board of directors. (2) The aim will be to do 100 per cent work in the district by securing a report of every instance of need in each social field which is entered and endeavoring to connect each case. with adequate treatment. (3) The plan aims at the elimination of duplicate investigations by co-ordinating all of the social endeavor carried on within the unit. (4) A broader scope in preventive work is contemplated, not only in medical but in social fields.