The Place Of Social Work In Public Health

Harry L. Hopkins, Director, New York Tuberculosis Association, New York

A Presentation at the National Conference Of Social Work (Formerly National Conference of Charities and Correction) At The Fifty-Third Annual Session Held In Cleveland, Ohio May 26-June 2, 1926

This paper is an attempt to present a brief outline of the influence of social work upon the public health movement in this country. The two fields, it seems to me, have been artificially divided until now we erroneously speak of social work and public health in two distinct classifications.

The public health workers as a group resent being classified as social workers because the average health administrator thinks of social work as being synonymous with case work-a rather natural deduction in view of the development and emphasis which communities all over the country have placed on this single phase of social work.

The influence of social work on public health administration is found in the development of every branch of that service in the past fifty years. The recreation movement, the child welfare movement, and such special developments as workingmen’s compensation in the industrial field have all been influenced by the humanitarian interests of the forces interested in social work, and each of these has had a direct bearing upon the health of the several communities in this country.

In considering this problem I do not wish to minimize the effect of individual physicians working apart from any organization and exercising a tremendous influence on the public health movement through their own efforts-men like Park, in the laboratory; Biggs, in public health administration; Trudeau, in tuberculosis; and a host of others who gave years of their lives to awakening the consciousness of the public to an interest in public health. Single-handed they have braved the antagonism of powerful groups in the slow and patient progress of community health service. While modern public health found its greatest impetus in the brilliant discoveries of Pasteur and his successors, its widespread application is found, to a very large extent, in the humanitarian impulses developed into action by modern social work.

Apart from the development of sanitation, the modern public health movement finds its genesis in the dramatic discoveries of the nineteenth century. Pasteur then lifted the veil of obscurity for all time from the plagues and pestilences which for centuries had destroyed millions and at times wiped out whole communities. He proved that communicable disease was caused by specific micro-organisms that live and grow in the bodies of men and animals, and that the secretions coming from the bodies of the sick, and sometimes the well, were the real carriers of these minute messengers of death. He and his successors not only showed the world how microbes could be isolated, but followed this up with the equally brilliant discovery of the artificial production of active immunization. His discovery of vaccine against rabies was followed in quick succession by the discovery and isolation of the germs of anthrax, leprosy, typhoid, the tubercle bacillus, cholera, diphtheria, and yellow fever.

Pasteur and his followers developed the knowledge and the means to avoid disease. Without these the modern public health movement never could have made the tremendous advances that have been accomplished in the past sixty years. The history of this glorious period in preventive medicine is marked with the sacrifice of a score of scientists who gave their lives in pursuit of a complete and scientific knowledge of the methods and habits of the treacherous microbes. These adventurers in public health died, as has been said, “with more than the courage of soldiers. They risked and lost their lives to show how fearful pests are communicated, and how their ravages may be prevented.” No page in modern history is replete with more heroic service in the interests of mankind. In considering the problem that we have before us, none of us should forget that it is these men who have made modern public health possible, and no one can know how many tens of thousands of lives have been saved by their discoveries.

But in spite of the brilliant discovery of the causative organism of most of the common diseases and of the rapid dissemination of knowledge about bacteria, the results for a long time had little effect in the practice of public health in this country. Indeed, the ever recurrent deaths from smallpox, typhoid, and diphtheria give evidence enough that we are still a long way from applying the knowledge given to us by Pasteur and his successors. It was only when the humanitarian impulses of the community attacked the problem that these discoveries began to be applied in this country. Indeed, the development of modern sanitation which preceded Pasteur found its support in a public aroused because of the miserable living conditions in the slums of England. Industrial accidents decreased tremendously when social groups secured the enactment of workmen’s compensation legislation. The filth-born diseases of the slums were partially eradicated when the miserable housing conditions of our great cities were attacked by socially minded people. The appalling infant death rate began to fall when social agencies developed facilities for the care of the babies of the sick poor, and insisted upon communities putting into practice the discoveries of the scientists. The development of every phase of public health work can be traced in part to the influence of private voluntary social groups demanding the attention of a passive public.

Because of the limitation of time I shall attempt to trace briefly the influence of social work on but three special fields of public health-housing, infant mortality, and tuberculosis.

Housing: In the report of the Metropolitan Board of Health for I866 we read the following:

The first, and at all times the most prolific, cause of disease was found to be the very insalubrious condition of most of the tenement houses in the cities of New York and Brooklyn. These houses were built without any reference to the health and comfort of the occupants. The provision for ventilation and light is very insufficient, and the arrangement of water closets or privies could hardly be worse if actually intended to produce disease. These houses were almost invariably crowded and ill-ventilated to such a degree as to render the air within them constantly impure and offensive.

The cellars were made the receptacle of garbage and refuse matter of every description. The halls and stairways were usually filthy and dark, while the floors were not infrequently used as privies from lack of other provision. Many of the sleeping-rooms were without light or ventilation. The yards were piled with garbage and filth.

The rate of mortality in children is greater than in any city with which this Board of Health has correspondence, and the cause of this excess will best be sought in the miserable housing of the laboring classes. In no other place in the civilized world is there to be found half a million people so unhealthily housed as the tenement house population of New York.

This was the condition of the slums of New York sixty years ago. Linked as it is with the public health movement, and concerned with ventilation, sewerage, disposal of garbage, water supply, insect-born diseases, and the spread of communicable diseases, it was attacked for the first time by social groups, first, because it was an intolerable injustice for any community to permit its working classes to live under such miserable conditions, and second, because they believed that there was a direct relation between bad housing and the health of the community. As a direct result of the work of the Council of Hygiene, the Tenement House Committee of the Charity Organization Society, and other agencies, tremendous advances have been made in this one field of public health.

For instance, as late as 1872 it was the practice to build houses-especially the houses intended for the working classes-in which most of the rooms were entirely unventilated, securing their air and light only from adjoining rooms. The first tenement house law under which such unventilated rooms were outlawed was secured by the social agencies of New York City. At that time one-half to two-thirds of the rooms were totally dark, until, in I879, the legislation was secured providing for the light shaft, and twenty years later a bill was presented and passed, over the strenuous objection of the landlords, providing for the admission of light in every room in the tenement.

Probably the greatest advance in sanitary science in the housing field for the past half-century is a direct result of the work of the housing agencies in New York. The modern disposal of waste, the provision for draining, the whole development for sanitary plumbing can be traced directly to those courageous and highly unpopular crusaders for decent housing for the poor in New York City. To be sure, it is true that the homes of the tenement dwellers of New York City are still a disgraceful blot upon modern civilization, but it is nevertheless a far cry from the unspeakable and miserable conditions of those tenements sixty years ago.

Infant Mortality: Sixty years ago there was literally a slaughter of the innocents in New York City. Out of 2,500 children born alive, death took nearly one-third of the total number before their first birthday. In I925 we had an infant death-rate of 65 per 1,000 births, as compared with the infant death-rate of 333 in 1866. If the death rate of 1866 had continued we would have had 42,390 deaths, as against 8,315 which actually occurred. Fifty years ago there was no child health work in New York City; in fact, the Society for the Prevention of Cruelty to Animals was organized many years prior to the Society for the Prevention of Cruelty to Children.

While it is impossible to give a chronological account of the development of infant welfare work, we do know that the impetus for this work came largely from private social groups. In 1873 the New York Diet Kitchen Association was founded to distribute nourishing food to the sick among the very poor. Twenty years later Mr. Nathan Straus founded his famous pasteurized milk laboratories, where any baby who needed milk could obtain a daily supply. This was followed by similar stations established by social agencies in every part of the city, and finally by the organization of the division of child hygiene in the department of health itself. Social agencies have ever insisted upon the direct relationship of poverty to infant mortality, and through the exhaustive studies of the federal Children’s Bureau, in a number of cities, proved this point conclusively. We know now that for a variety of reasons the babies of the poor die in greater numbers than the babies of the well-to-do. Mothers living in miserable tenements with inadequate medical and nursing facilities lose children for no other reason than their poverty. In no field, perhaps, has as much pressure been brought to bear upon public authorities by social workers to give adequate health service to any single group as has been the influence on the care of infants. They have demanded the establishment of facilities for the prevention of infant mortality, and no little credit is due them for the winning fight now carried on in every city in the country for the lives of babies.

Tuberculosis: The tuberculosis movement, too, is a shining example of the influence of social work on public health. In this field particularly we find outstanding individuals like the Bowditches, Trudeau, Biggs, and Loomis, who were the real pioneers and whose ideas were capitalized by social groups. With this movement there has developed a technique and phase of public health which provides a wholly new chapter in preventive medicine. There has developed the dominant motive in the present-day public health program, namely, the education of the individual in the practices of personal hygiene. The discovery and application of the use of popular health education was made by the pioneers of the tuberculosis movement, who were aided from the beginning by the social agencies of this country. The actual provision for adequate sanatorium clinical and nursing care has come about very largely through the interests of social agencies in the care of tuberculosis families under their control.

The history of tuberculosis is one of the social agencies interest in, and the fostering of, facilities for the care and prevention of tuberculosis. The history of public health and the influence of social work upon it cannot be related adequately in terms of agencies, because it has been written by individuals through whom social movements of this or any other character are largely influenced. The first approach to sanitation in the modern public health movement was urged by the aggressive and pugnacious secretary of the Poor Law Commission of England, who from the first saw the connection between poverty and disease, as well as the preventability of much of this disease. The famous report of the sanitary condition of the laboring population in Great Britain was Chadwick’s outstanding work, which resulted in the appointment of special commissions on health for all the large towns in England. There directly resulted from this the first intelligent handling of water supply and sewage disposal throughout the modern world.

Homer Folks, attracted from his pleasant studies of the Romance languages at Harvard into the field of social work, has become probably the most influential single individual in the promotion of adequate health facilities in New York State. As secretary of the State Charities Aid Association he has taken the leadership in the promotion of public health in New York since I893. He was instrumental in founding the Craig Colony for Epileptics, the establishment of the first state hospital for consumptives, and for the reorganization of the state health department into one of the most effective units in this country. He helped reorganize the health machinery of Cuba. In I902 he organized the first municipal hospital for consumptives in the United States, and under his leadership has developed the whole machinery for tuberculosis prevention in New York State. Lee Frankel, trained in the family casework field, has, as director of the welfare department of the Metropolitan Life Insurance Company, inaugurated a health educational campaign among policyholders that leads the world in health education. Through his influence was organized one of the finest tuberculosis sanatoria in America for the care of employees of the Metropolitan Life Insurance Company. He conceived the idea of the now famous Framingham Health and Tuberculosis Demonstration. He has been active in the development of the social hygiene movement, and has been president of, and for many years active in, the American Public Health Association. These and many others have been the champions of public health in the field of social work. They have helped to organize the forces of the community to fight disease, and to them and to hundreds of social workers in as many communities the public health movement owes much for its tremendous advances.

Haven Emerson has recently drawn some invidious comparisons between some branches of social work and public health on the score of the latter’s willingness to measure their results in terms of careful research and statistical analysis. Nearly a million dollars will be spent this year in experimental work in health demonstrations in half a dozen communities for the specific purpose of determining the values of various administrative practices. With no preconceived idea of methods to be followed in the several fields of health, they will test their value on the basis of criteria worked out by the best statisticians in the country. Why should there not be organized “social welfare demonstrations,” the purpose of which would be not only to analyze the social work of a community, but to set up adequate experimental machinery to try out on a scientific basis the theories expounded for years by social workers?

In still another field it seems to me public health has far outstripped most of the fields of social service, and that is in the technical standards of administration. Precise and well-recognized standards have been developed in prenatal and infant welfare work, in the medical inspection of school children, in tuberculosis, venereal disease, and other fields. Many of the activities of social work might well examine the history and procedure by which these technical standards have been attained.

But the burden of this paper is to explain again that the fields of social work and public health are inseparable, and no artificial boundaries can separate them. Social work is interwoven in the whole fabric of the public health movement, and has directly influenced it at every point. No phase of community effort has made such remarkable progress. It has probably had more direct influence on the decrease in poverty than all the other forces of social work combined. Made possible by the scientists, it has been put into practice in every community in the land, largely through the humanitarian impulses organized and directed by the social agencies of the nation.

Source: Proceedings of The National Conference of Social Work (Formerly National Conference of Charities and Correction) At The Fifty-Third Annual Session Held In Cleveland, Ohio May 26-June 2, 1926 — www.hti.umich.edu/n/ncosw/