NCSW Part 4: A Century of Concern 1873-1973: Social Aspects of HealthA Century of Concern [View Image]
A Century of Concern
Social Aspects of Health
by Ralph E. Pumphrey, Professor George Warren Brown School of Social Work Washington University, St. Louis, Missouri
Social Aspects of Health, 1873 – 1973
Health has been an area of concern in the deliberations of the National Conference throughout its history. The topics discussed have reflected in a general way the broadening conceptions of health and ways to promote it which have been abroad during the past century. And yet it was only occasionally that health matters seemed to be in priority positions, or that crucial issues were being debated.
There were probably many reasons for this. The immediate occupational concerns of most participants were elsewhere. The social implications of ill-health were long subsumed under the general heading of “pauperism,” a more or less helpless condition for which the least expensive care was to be sought. When the importance of social factors in the incidence and recovery from illness drew the attention of Richard Cabot and Ida Cannon, their basic relationship of physician and nurse meant that social work was subordinate to medical work. Over the years medical social work discussions became heavily focused on work with individuals, a tendency encouraged by Freudian concepts emphasizing internal and familial rather than more broadly social influences. Exciting environmental studies in which early medical social workers took leading parts became the preserve of the public health movement.
Physicians frequently have had important parts in National Conferences, but seldom as physicians and almost never as bridging persons between medicine and social welfare. For instance, in the 1932 Conference Dr. ‘Richard Cabot gave the presidential address and Dr. Ray Lyman Wilbur was one of the principal speakers. However, Dr. Cabot, who was somewhat out of step with some of his medical colleagues, spoke more as the founder of medical social work than as a representative of the medical profession, while Dr. Wilbur, past president of the American Medical Association, formerly dean of one of the leading medical schools in the country, and at the time chairman of the precedent-setting Committee on the Costs of Medical Care, spoke in his capacity as Secretary of the Interior, a political appointment under President Hoover, and only mentioned medical concerns in passing in his address on the United States Children’s Bureau.
Such limited participation may indicate that the often-stated disdain of the medical profession for social work and the manifestly superior political clout of the American Medical Association could not be modified by isolated speeches and discussions at annual meetings. To attempt serious discussion of health policies must have seemed an exercise in frustration.
Keeping in mind this peripheral involvement in the social issues related to health, it is interesting to look at Conference programming at four different periods to see the changing emphases revealed in the Indexes.
During the first decade of the Conference the care and treatment of the insane was the principal health topic, not surprisingly in view of the responsibilities for state and local institutions carried by most of the delegates. Such attention as was given to other “medical charities” seems to have been dominated by a fear that they were being “abused” by persons who were not eligible for the help given and reflected a narrow conception of responsibility and a lack of appreciation of the financial burden of illness.
A generation later, during the Progressive era immediately preceding World War I, insanity, together with feeblemindedness, was still a major concern, though the new mental hygiene movement had injected a somewhat more positive tone into the discussion. Equal or greater attention went to public health activities, both preventive and remedial, although the early push for health insurance had not yet taken shape following the success of the movement for workmen’s compensation legislation. Such major scourges as tuberculosis and syphillis, and the physical and economic handicaps coming from industrial accidents and disease were discussed extensively. Medical social service took its place as a recognized aspect of medical treatment. Considerable negative attention was directed towards the evils associated with commercial recreation (prostitution, venereal disease, etc.) which was partially balanced by attention to the salutary effects of outdoor recreation.
As another generation passed, the Great Depression and World War II dominated the Conference agenda for a. decade and a half. Health interests in Conference programs reflected the report of the Committee on the Costs of Medical Care, the fight over the inclusion of a health insurance title in the Social Security Act, and the succession of Wagner-Murray-Dingell bills. In the minds of the promoters of these measures, they were closely related to public health work, and it was public health and other medical services which were most prominent in conference programs. Positive mental hygiene programs tied in with this approach. Handicaps and specific diseases were less prominent than in the past.
In the most recent period, since 1965, Conference interest in health has shown three model areas of emphasis – on mental illness and retardation, on alcoholism and drug abuse, and on various sex-related subjects such as illegitimacy, family planning, abortion, and venereal disease. In all of these and many other places in the programs the role of social work in facilitating adjustment and recovery from illness was played up extensively. Abused children, the chronically ill and the handicapped received scattering attention along with new developments in medical care, preventive medicine and health insurance, while the world population problem was treated at one isolated session.
In sum, while participants pay more attention at the Conference now than a century ago to prevention and remedial treatment, they are still focused on the problems created by disease and handicaps. For the most part we react to that which we find wrong. In the future might we assume a more central position and ask: “Are our standards good enough? How can we improve them?”
A Spectrum of Social Concerns About Health
What should we be concerned about today and in the next decade? There is a bewildering range of possible topics which might be brought up. Some grouping of them may help to focus attention.
Care of the Ill and Incapacitated. In American culture this residual function is mandatory. Basically citizens have always regarded this as a responsibility of family and neighbors. From earliest colonial times, however, such voluntary activities have been supported and supplemented by community effort. As the number of persons and institutions with specialized expertise has increased, they have tended to supplant voluntary efforts, often to the relief, but sometimes to the distress, of the would-be helpers. Two intervening forces can be mentioned here.
Professional specialization has all but ruled out the casual helper. Nursing as a profession got its start in this country about a century ago. Specialization according to the illness, the kind of patient dealt with, and the function performed has brought not only obstetric, psychiatric and geriatric nurses, but also nurses aides, licensed practical nurses, registered nurses, visiting nurses and a variety of highly skilled dual professionals such as nurse-anesthetists. Comparable degrees of specialization can be found in most other fields.
Increasing technology has also entered in. The search for analagesics spawned pharmacy as a profession and as an industry. The industry has expanded into the production on a giant scale of the bandages and equipment which are used in the care of the ill and injured. Two decades ago the manager of a pharmaceutical factory was heard to comment that all the bandages which were produced by all the volunteer efforts in the country during a full year of World War II could have been produced in his factory in a single day. The care of illness has come to be BIG business, not the least part of which is institutional care. We have had hospitals for centuries. During the past several decades their increasing numbers, size, and complexity whether under voluntary or governmental auspices, have made them major economic entities. Now institutionalized nursing care has burgeoned to the point of becoming another substantial business as well as philanthropic activity.
So long as illness and injury occur, care of the victim can be expected to have an overriding claim on individual and social resources. The golden rule takes on a very personal meaning in this context and they are hard-hearted indeed who deny care. Furthermore, it provides employment for thousands of wage earners which might be extend ed to thousands more. Yet we have long since ceased to think that just any kind of care is all that is needed.
Social welfare’s concerns in this area are pretty well defined in several directions:
a. The quality of care provided – are the facilities, staff, food, and amenities kept up to standards everywhere and not merely in showcase institutions?
b. The distribution of care – are some persons in need of care neglected while others are cared for in luxury?
c. The development of necessary manpower – does this kind of personal care afford an opportunity for the employment of people who are presently marginal in the labor market? Can such employment be both socially useful and personally satisfying?
d. Are we keeping a proper balance between care on the one hand and the prevention of illness and handicaps on the other? Are we adequately providing for the financial needs of individuals and families so that the drain caused by care will not bring on secondary breakdowns?
Care of Illness. Alongside care there has always been the goal of curing the sick. Almost universally healers, medicine men and doctors have held respected, not to say mystical, authority among their fellows..The search for causes and cures has led to drawing with increasing .self-assurance on the whole range of natural and physical sciences and their derived applications, from physiology and chemistry to computers and laser beams, to intervene against challenges to the health of the individual which in the not too distant past would have been fatal. With each new invention or discovery, medicine and surgery push further back the threats to survival to which mankind has been subject.
This phenomenal development depends not merely on specialized knowledge but, even more than in the case of care, on the availability of tremendously complex technology. Typically this is to be found in hospitals. While patients may obtain some of the more common technological services such as X-rays, electrocardiographs and various laboratory tests from specialized service groups in the community, or even from individual physicians, the more complicated diagnostic processes and nearly all surgical procedures require facilities and equipment which are made available by society through capital investment in hospitals.
Quite apart from the hospitals and other service arrangements themselves, this complex of curative efforts is the base for major economic activities. Research for the development and production of new “wonder drugs” draws on important scientific know ledge and supports both professionals and the industries by which they are employed. Similarly, the wide range of equipment utilized draws on the engineering professions and supports important segments of industry.
As social welfare contemplates this necessary function in a never-ending effort, it may wish to focus on such topics as these:
a. As care and cure become commercialized, what protections does the public have against their misdirection? A wide range of explorations is suggested by recent allegations that over-commercialization of legitimate medications is encouraging a “drug culture.”
b. How accessible is medical technology to those who need it? Do the development of air ambulance systems to transport accident victims to hospitals suggest the need for fresh looks at the problem of distribution and accessibility of medical services?
c. Are we keeping a proper balance between the curing function and other parts of the spectrum?
Alleviation of Financial Stress. It has long been pointed out that illness is costly to the victim in two ways. There is the direct cost involved in securing medical care, and the indirect cost in lost wages if the victim or members of his family have to stay away from work. There are more remote indirect costs to the employer in lost productive capacity; to merchants and others in reduced purchasing capacity; and to the public sector in the loss of tax revenues. Such costs are relatively minor and bearable in many illnesses where the family income is reasonably secure, but may become disastrous for the individual and troublesome for the community in so-called “catastrophic illness.”
During the past sixty years in this country, much has been done to deal with this complex of problems: The devastating losses by victims of industrial accidents were reduced by the introduction of workmen’s compensation – later extended to cover occupational illnesses. Wage loss insurance has become available through commercial channels but to date meets only a fraction of actual losses. Other provisions for the financial needs of the disabled have been made in the form of Aid to the Permanently and Totally Disabled and Disability Insurance. Both were approached with caution, not to say reluctance, by Congress which demonstrated an almost pathological fear of malingering. Eligibility requirements have .been rigid and benefits limited, but they represent major advances in one aspect of provision during the past quarter century.
Additional measures have been projected and debated in what has come to be a major area of unfinished social and political business. As we move into a second century of the National Conference, health minded persons may well raise the same questions that have been raised in one form or another during half of the century which is now ending:
a. Do the existing methods of dealing with the financial stress of illness reach the persons they are designed to help and, taken together, do they provide adequate coverage for the total population?
b. Are the benefits under these programs sufficient to meet the needs of those covered?
c. Do other income maintenance programs provide sufficient financial support to enable those who are dependent on them to maintain their health?
d. How can the cost of any increased benefits be met without bankrupting the country?
Reduction of the volume of illness. The discovery of causes for illnesses, which permits the formulation of curative measures, carries the implication that, in some cases at least, the causes may be removed before an illness occurs at all. Gross preventive measures may even be undertaken before exact causes ate known. The importance of a pure water supply and other sanitary measures was recognized long before the specific cause of typhoid fever was determined. Nevertheless, it has been after specific causes have been discovered and steps have been taken to intercept or destroy them that phenomenal successes have occurred. Smallpox, yellow fever and tuberculosis are classic examples of this approach.
It is a fact of some importance that both the cure of illness and its prevention became broad areas of specialization as the practice of medicine and public health work, respectively, with relatively little interchange of personnel and with a considerable amount of misunderstanding and suspicion attached to those who did seek to tie the two together. As various disease entities for which environmental control measures were most appropriate were overcome in large measure the public health people began to emphasize early diagnosis and treatment of illness as important factors in improving the general level of health. They sought ways in which the most advanced medical knowledge and services could be made available to all people, not merely a privileged few. In so doing, they proposed changes in the system of delivery of curative medical services.
As a result of their efforts the neglected segment of the population between the “haves” who could pay for whatever medical care was needed and the “have nots” who received free care because they could afford to pay nothing was somewhat better served by making clinical and hospital services available at reduced rates for those who could afford to pay something. Also, for increasing numbers of people it became possible to distribute the direct costs of illness through a variety of pre-payment or post-payment plans and medical expense insurance, including medicare for the elderly, thus improving · their access to medical care.
These and other developments and proposals distressed many and enraged some medical practitioners with the result that rational discussion of the proposals became virtually impossible. During the past half century those devoted to medical practice have exerted pressures to confine public health efforts to the maintenance of the kinds of sanitary, epidemiological and other preventive measures which had already been demonstrated and to the development of mass health education programs, specially in the realm of personal hygiene, separated from the direct practice of medicine and the treatment of illness. Meantime, in the practice of medicine an important place is now given to preventive work with patients through periodical health examinations and health consultations. Some of the newer experimental community health programs give further indication that the long-standing cleavage between the two fields is being eased.
It should be noted that while public health has not been permitted to move far into the direct treatment of illness, by its involvement in such activities as supervision of water supply, in the enforcement of regulations to insure pure food supplies and the installation and operation of sewage and other environmental disposal and protection systems it is involved in major public programs and expenditures which, in turn, contribute both to the tax burden and to the economy. It depends not only on staff with medical training, but also on people with a wide variety of professional or occupational training, including engineers, biological and physiological scientists, nurses, social workers, and statisticians.
The current rash of proposals for new delivery systems has become entangled as others before them in issues related to methods of payment for service. At one pole are individually billed and paid fees for service. At another are services provided by salaried professionals with no form of individualized fees. Both extremes are found readily in the United States today. Between them are a wide variety of plans and proposals designed to accommodate traditional concepts of doctor-patient relationships to modern economic and social realities. Labels are inexact and confusing, but many insurance plans serve essentially as financial intermediaries between the patient and the service deliverer. Others, whether called “insurance” or not, include both a prepayment arrangement and a service delivery component, including in some cases, payment for services outside the system, for instance for the use of a hospital. The range of proposals currently before Congress raises the possibility that four decades after the first serious consideration and a decade after the passage of the first aspect, Medicare, some form of general health insurance will come into being on a national, compulsory basis.
Obviously, the professional, political and economic problems centering in this area continue to produce some of the most hotly debated issues of our time. The effects of their resolution will be felt by the entire society, and will have repercussions on a wide variety of other problems and services. It follows that all of social welfare has a stake in the ramifications as well as the central issues in such questions as:
a. Are there ways to organize the delivery of health services which will insure that medical care and treatment will be accessible to every person who needs them?
b. What are the means of financing the delivery of health services which will most effectively support the accessibility of the services to all?
c. What are the legitimate professional and economic considerations which must be recognized in the arrangements for delivery and financing of health services?
d. Are excessive professional or economic pretensions and pressures interfering with maximum use of all the available, appropriate resources which would contribute to reducing the volume of illness and incapacity?
e. Are we giving an appropriate amount of attention and support to this segment of the spectrum of health concerns?
Adaptation to conditions imposed by illness. The victim of illness is dependent on other persons to provide him the services needed for cure. He and his family, however, must make most of the adjustments to the new conditions which are forced on him during and after his incapacity. His freedom of movement is limited; he may not engage in certain activities; he may have to fore go short range, or even long range, goals. Not to do so would involve risks whose import he needs to understand. His condition may inspire a variety of reactions·among relatives, friends, and associates. Some conditions are temporary; some can be overcome or compensated for; still others are permanent and essentially irreversible.
Around these conditions and reactions have developed a network of services more or less closely related to medicine. The manufacture of appliances, from wheel chairs to prostheses to pacemakers, is perhaps a minor but nevertheless significant part of the general economy. The training and retraining of individuals in new or lost skills is important not only in hospitals, rehabilitation centers and sheltered workshops, but in industry . But many people also need help in observing prescribed medical regimes, in evaluating a situation and accepting in a realistic way the limitations which it imposes, and in arriving at a constructive attitude in which to move forward. The professional roles of both nurses and medical social workers have been shaped in large measure by the expectation that they will carry primary responsibilities in this general area. Such services are of great importance to the individual and to society. There is a crying need for more of them in our present state of ill health.
Those interested in the social aspects of health and the health aspects of social welfare may well raise such questions as:
a. What changes in demand for this kind of service may be expected with developing programs aimed at reducing the volume of illness? Specifically, does the developing concept of health maintenance organizations (HMOs) include this aspect of health services, or are they exclusively medical?
b. What changes in professional education are needed to keep pace with developments in this aspect of the health field? Is there need for cooperative programs of education between nursing, social work, medicine and perhaps other professions and/or occupations to secure increased effectiveness of services?
c. As the level of health improves, should we look forward to much of the need for this type of services being related to the aging population, and gear our educational and vocational counseling efforts in that direction?
d. To what extent is this type of service especially needed in relation to health pro grams in poverty areas where use of modern medical resources has heretofore been minimal? Orchestration of Efforts. To a limited degree we have developed multifunctional delivery units for some of the steps so far outlined. In particular, hospitals provide care, cure, and, in varying degrees, adaptive services. The traditional pattern, however, has been to develop activities singly, apparently completely independent of, or even in competition with, each other. The overall result has been that we have inherited a hodge-podge of activities and programs which we euphemistically call a “health delivery system.”
From the standpoint of the recipient of service, the effectiveness varies with the circumstances. Sometimes it is judged to be good to excellent. In many instances the outcome is less than desired but is accepted by the victim and society with the fatalistic judgment that it is the best that can be expected under the circumstances. Some apparent stupidities, such as calling an ambulance to transport the dying victim of an auto accident
26 blocks from the threshold of a general hospital to another hospital, bring the “system” into disrepute. In other cases, a few of which receive feature treatment in the news media, the gap between that which has been established as good procedure (as in kidney trans plants or cardiac seizures) and the ability of the system to deliver that procedure to all who would benefit from it stands as a challenge to the prevailing ethical standards in society. ·
Rationalization of this complex structure has been the subject of increasing attention and effort over the past two generations. The concept of the hospital as the nexus in a network of medical, rehabilitative and preventive services was being discussed prior to World War I. It received official impetus in the Hill-Burton Act and in the National Mental Health Act at the end of World War II. Flowing from these have come regional hospital planning and programming for comprehensive community health and mental health services.
If enacted, it seems probable that national health insurance legislation will substantially encourage the development of comprehensive health maintenance services, including not only care and cure, but also rehabilitation and, to an extent not heretofore seen, prevention on both the individual and community basis. It will thus promote the corning together of the “practice of medicine” and public health work. Taken together with the more vigorous supervision of the planning of facilities which is now going on, these developments may substantially enhance the orchestration of activities in the health field, although it is hard to envision any sudden transformation.
However, none of these health insurance or health main terrace plans deals with the alleviation of financial stress. Wage losses and peripheral expenses still are to be dealt with under another category of needs and provision, income maintenance. Logical and administratively sound as this may be, it means that an important part of the total problems and services in relation to health is being orchestrated in a different concerto and the result up to now has not been harmonious. Intensified public discussion of the interrelatedness of health and social welfare activities would be eminently appropriate in National Conference programming. Much of the rest of this paper will elaborate themes for this discussion.
Enhancement of Health. This is the natural culmination of this series of social concerns about health. As we have seen, by and large, we are dealing now as in the past with actual or anticipated illness and disability and the resulting individual and social dis locations. In a world of mortals there is no prospect that we can avoid this entirely, but we have noted a shift in emphasis away from a merely residual approach towards prevention and now towards the more positive concept of health maintenance. This suggests that the time may come when we will include in our array of emphases the enhancement of health.
If this should occur, is it possible that a major portion of the thrust will occur outside the health field as now defined? Could it even be that many of the activities and services which would enhance health would not be labeled, or even recognized, as health services? Such a prediction might be made on the basis of institutional and professional investments and inertia such as have been illustrated in the struggles within the field of medical care during the past half century. Furthermore, the problem of financial stress due to wage losses from illness and disability is, and probably will be, dealt with in the income maintenance system rather than in the health system. This indicates the need for all of us in social welfare to extend our thinking and our programming in many fields, particularly economic, in such a way that we relate them to a positive, enhancing concept of health. Some health questions which might be brought into the discussion of general social policy issues are here suggested.
Health Considerations in Broad Social Issues
Income Policy. A great deal of political heat is being emitted over welfare proposals. Although there is some relevant research data, almost no attention has been given to the health implications of various proposals in the popular debate. These implications need to be identified and evaluative data developed and made available in popular as well as scientific form.
What does it mean in terms of ill-health that more than ten million AFDC recipients are living on average grants of less than $52.00 per month? That in no state is the average grant up to the so-called “poverty level” and in only two states is this level approximated? That in thirty-two states, Puerto Rico, Guam and the Virgin Islands, having a total of more than 4.5 million recipients, the average grants are below the national average? What would be the effect on the nation’s health statistics if we could establish a minimum income at the arbitrary figure we call the “poverty level”?
How far are we ready to go in formulating and implementing a general incomes policy? What would such a policy mean for the maintenance and for the enhancement of health?
Employment Policy. Closely related to this is the whole range of questions about employment. Is a minimum income to be tied to a compulsory work requirement? If so, who is to provide the employment? Are minimum wage laws to be observed? What will be the health implications of such a policy – for the wage earner and for his/her dependents? What will be the bases of exemption from the work requirement? What policy will be followed with respect to handicapped persons? Should we greatly expand public and voluntary sheltered employment?
Aging. Outstanding medical and public health successes have brought great numbers of persons to or beyond the Biblical limits of life, while employment and social security policies have created an arbitrary cut-off period for most employment at between 62 and 68 years. Improved social security and private retirement provisions have not made up the lost income and normally increased medical costs at advanced ages become a double burden.
Medicare and medicaid are partial answers to this specific problem, but leave many health involvements of aged people still unresolved. Would individual and community health be improved by encouraging either independent living or institutional care? If institutional care is deemed preferable, who is to pay for it, since even domicillary care exceeds in cost most social security payments? Would health benefits result from finding ways to use constructively the talents of older people whose accustomed activities have been interrupted?
Such questions raise more general issues: Do we have a policy toward the aging beyond giving them something every time an election is pending, so they will vote right? Are we committed to a policy of minimum sustenance so they will not die of starvation, or do we see in the elderly a national resource to be conserved and promoted? What is the relation of meaningful activity and employment to the maintenance of health? Do our employment and retirement policies contribute to or detract from the health of the aging?
Children. Do we have a policy with respect to children? With the increasing proportion of mothers who are employed out of the home do we have any policy with respect to responsibility for the well-being of the child? Day care centers? The schools? Are we moving towards a Kibbutz system? Or might the mother be expected to take more responsibility if we had a different income policy? Under which circumstances would the physical, educational and emotional development of the child be most favor able – for what?
What do we see as the place of the child in society? Potential manpower – do we need it? Potential cannon fodder – do we need that? Potential social dropouts – do we need them? Potentially self-determining, self-activating individuals – do we need them? What difference does it make what we visualize our children to be in the future? Are there health implications here?
Population policy. The two extremes of the age scale forcefully pose the issue of population policy. The success of medical and public health measures long ago distorted the operation of natural survival factors. The unprecedented “baby boom” of the forties and fifties can be expected to produce “waves” in the population for another half century. Widespread use of contraceptives is tending to modify this. Legalization of abortions carries this modification still further. The provision of contraceptive information and supplies for welfare recipients removes an apparent inequality of access due to economic and educational factors. But does it unfairly interfere with freedom of choice? What are the implications for the maintenance and enhancement of health in our attitudes and practices with regard to birth control and the rate of population growth?
Leisure Time. The relationship between physical activity, especially in the outdoors, and the maintenance of health has long been recognized. So also are the psychological and physical value of changes of activity and exposure to new experiences. Yet in our present-day concern for health maintenance and health insurance have we left the whole leisure time and recreational field out of our consideration as a factor in health? Do we need to reexamine these relationships and if they are still valid take a more active part in the promotion of adequate programs in the leisure time area as an important part of health promotion?
The Role of the Professions. In the diagnosis and treatment of illness the medical profession is essentially unchallenged. There are divergent groups which are not accepted by organized medicine and there are some healers who are completely non-medical, but these exceptions simply emphasize the overall recognition and acceptance o(medical competence in this area.
In the public health field, with its emphasis on prevention of disease, the diagnostic skill of the physician is essential, but, given the gulf between prevention and treatment which has developed, most of the other functions call for non-medical expertise such as sanitary engineering, bio-chemical, statistical, to name a few. As one looks at other bands of . the health spectrum, other occupations, professions and disciplines come into prominence: nursing, economics, psychology , management social work, law, mechanical engineering, and the like.
Progress has been made in establishing working relationships among the occupation groups, but Whether they are always for the best interests of health or are sometimes the outcomes of territorial tests of strength between groups is not clear. What appears to be needed is a much more positive promotion of the overall concept of health, to which all parties can relate, rather than continued almost exclusive emphasis on the component functional responses to aspects of ill-health.
What we are suggesting here may mean that the National Conference, representative of a forward-looking segment of society, will need to provide a forum for the further clarification of certain basic issues which underlie the other aspects of health which have been raised. The outcomes will depend in part on hard research which can be presented to and understood by the general public. Beyond that perhaps an even more important element will be the prevailing political attitudes and the extent to which social welfare is able to contribute constructively to their formation, especially along two lines.
First, that health as a concept relates to the whole person. This requires that health considerations be kept in mind as policies and programs are worked out in the whole range of human concerns, from income maintenance to the environment. This does not mean that support of specifically health-oriented activities needs to be dropped but that such activities be seen in a broader context and that those persons who are directly involved in health work accept responsibilities for inputs in the development of policies and programs in the broader field of social welfare.
Second, that our present-day society and its health problems be perceived as a complex so intricate that only the fullest cooperation of all appropriate persons and organizations can result in substantial improvements. So long as the focus of attention was on individual instances of ill-health, their care and cure, it was possible to deal with them on a more or less individualistic basis. Even so, hospitals and dispensaries early brought in a cooperative element. By now a strictly one-to-one relationship anywhere in the health field is a vestigial carry-over. Cooperative arrangements extend from practice partnerships to visiting nurse associations to sanitary districts to hospital planning councils to the United States Public Health Service and the World Health Organization. The kinds of developments suggested in this paper would call for a substantial increase in cooperative efforts at all levels of social organization, from the local community to the nation and beyond.
This brings to the fore the need for continuing review of the rights and responsibilities of both voluntary and governmental organizations. What is the role of the local unit, whether governmental or voluntary, in the shaping of the implementation of broad policies set at the state, national, or even international level? What degrees of governmental stimulus, prodding or compulsion will be required to achieve broad general goals, and at what levels of government? What can voluntarism contribute to the provision of services, to the formulation of policy, to the building of public understanding?
The ongoing discussion of such issues as these need not be specifically directed to health topics to contribute significantly to the furtherance of the social aspects of health.
Ralph E. Pumphrey is Professor of Social Work at the George Warren Brown School of Social Work, Washington University. He received his AB from Miami University, Oxford, Ohio (1928), Ph.D. in History from Yale University (1934), and graduated from the New York School of Social Work (1940). His practice experience includes: Exec. Sec., Council of Social Agencies, Syracuse, New York (1944-1946); Exec, Dir., Health and Welfare Council, Indianapolis, Indiana (1946-1951), Field representative and public relations director, United Community Defense Services (1951-1956). He was Associate Professor of Social Work at New York University (1956-1959) before going to Washington University. He has served as consultant to the Upper Great Plains Committee on Social Work Education and as a member of the Task Force on Exits from Poverty appointed by the Secretary of HEW. With Muriel W. Pumphrey, he edited The Heritage of American Social Work (1961) and he is currently preparing a biography of Michael M. Davis, pioneer social worker and medical economist, who had answers for most present-day questions about social aspects of health decades ago.