Social Work; Essays on the Meeting Ground of Doctor and Social Worker

Hotbeds of industrial disease

Commoner and not less important than the contagious diseases that I have just mentioned are industrial diseases, or diseases aggravated by the conditions of industry. A physician may serve for many months in a dispensary without seeing a case of smallpox, of trichiniasis, or of typhoid fever, or feeling it his duty to set in motion the forces that I have just mentioned for rooting out the sources of contagion and preventing their further spread. But he cannot serve a month in any well-attended dispensary without seeing cases of industrial disease in the narrow sense, such as lead poisoning, or of independent disease aggravated by the conditions of industry, such as the functional neuroses of cigar-makers or of telephone operators. With such diseases, as with the infectious and contagious diseases, the presence of one case in the clinic should lead straight to the inference that there are others elsewhere, out of sight but no less important from the point of view of public good. This conclusion should lead in turn to the search through a social worker for the cases of disease which do not present themselves to any physician, which may be totally unknown even to the patient himself, yet which are important to the health of the nation.

Difficult though this field of industrial disease has shown itself to be, difficult though it is to separate out that portion of the patients' complaints which can justly be referred to the conditions of his work, and to distinguish it from the portions which are due to the way he lives, to his inheritance, to his habits or to diseases like tuberculosis and syphilis which may have been acquired without any connection with his work, – nevertheless we must try to disentangle and to recognize the elements in this knotty problem. And we can hardly fail to see that the social worker is an essential and logical assistant in the processes of investigation which we must carry out. If we can ever unravel the tangled skein of causes and effects whereby the hours of work, the strain of work, the patients' heredity and his home conditions, all combine to produce the symptoms of disease, it will be through such intimate, prolonged, detailed studies as the social worker can carry out, especially if she becomes a friend of the family. The doctor in his hours of consultation at the dispensary certainly can never do it. The official agent of the Board of Health, perhaps feared, certainly not a natural confidant for the family, may easily miss the truth which the social worker unearths, provided always she succeeds in differentiating herself altogether from the impersonal and professional investigator, and gradually becomes in the mind of the family and in truth their friend.

I said above that the social worker should try to find out what disease, how much disease, and why this disease is present. The answers to these three questions cannot be kept separate. If one knows how much importance to attribute to a given symptom and whether it is as bad as it seems or worse than it seems in the dispensary interview, one may be steered straight to a correct diagnosis. To know how much disease may thus mean knowing what disease is present. Furthermore, the understanding of these questions, even though it be only partial and unsatisfactory, leads us a considerable distance towards understanding why the disease has arisen. The search for sources for contagion is an example of a search for a why in disease. The search for psychical factors – groundless fears, misleading newspaper advertisements, distracting rumors – all this is also a search for the cause as well as for the nature of disease.

The social worker's investigations into the cause of disease may perhaps be still further exemplified. I once sent a social worker to my patient's home with the request that she try to find out what I had failed to find out, namely, why a young girl could not sleep. Physical examination of the girl had revealed no cause; the exploration of such parts of her mind as she would reveal to me had thrown no light upon the trouble. I was at a loss and asked for help through the more intimate knowledge of the patient sometimes to be gained through a social worker's studies. Such a search might easily have been fruitless – it often has been fruitless in my own experience. But in this case it was almost comically swift in reaching its goal. The visitor found that this girl was sleeping with two other girls of about her own age, in a bed hardly more than a metre wide. It needed only that she should acquire a separate bed for herself, which she was able to do without any financial assistance. She then regained her power to sleep. How often have such cases been treated with drugs or perhaps with more complicated physio-therapeutic or psycho-therapeutic procedures, when some simple fact like the size of the bed, the temperature of the sleeping-room, or the mental activities of the evening immediately preceding bedtime, are really responsible for the whole trouble.

Medical outfit of the social worker

In order to carry out the particular procedures of diagnosis and treatment which belong within the province of the social worker, a certain amount of medical knowledge is needed. Because this is true, it has often been assumed that the social worker must be a trained nurse, prepared by months or years of experience in a hospital. But experience has shown that much of the knowledge possessed by nurses who have had this training cannot be used by the home visitor. On the other hand, the information which the social worker needs is often quite lacking even in well-trained nurses. Furthermore, it may be said with truth that the training of a nurse, as we know it in America at any rate, really unfits a woman in some respects for the work of a social worker, since it accustoms her to habitual obedience and subordination. These habits are very useful in their proper place, but they are antagonistic upon the whole to the temper and mental activity which is important in the social worker. I mean the temper of aggression in relation to disease, and the mental attitude of the teacher and leader in relation to the patient. But of this point it will be more in place to speak when I come to consider the functions of the social worker as a teacher.

Let us return, then, to the question, What knowledge should the social worker possess in order to do her part in the "team-work" of the medical-social dispensary? Her knowledge should approximate that of the public health officer. Like him she should be, above all, familiar with what is known to medical science about the causes of disease. This is of great importance because it is especially in this field of medical science and medical ignorance that the public, the patients among whom the social worker will work, is most in need both of new knowledge and of the uprooting of old error and superstition. Medical science knows very little of the causes of many diseases. But our patients, especially the more ignorant of them, are very glib and confident in their assertions as to what has caused the particular disease from which they just now suffer. They tell us about their "torpid livers," their "congestive chills," their "ptomaine poisonings" and the like. Their supposed but unreal knowledge is extensive and detailed. Indeed, so stubborn are their beliefs upon such matters that they often present a firm wall of resistance which must be broken down by the social worker before any truth upon these matters can be introduced into their minds.

The social worker, then, should share such knowledge as the medical profession possesses about the causation of infectious disease, about direct personal contagion, and also about the indirect methods by which disease is conveyed from person to person through insects or through instruments and utensils, such as the barber's razor, the family towel, or the public drinking-cup. She should be familiar with the small body of knowledge which we possess upon the transmission of disease by drinking-water, by milk, and other kinds of food. She should appreciate our still smaller body of knowledge about the relation of disease to climate, to weather, and to other physical agents such as the extreme heat and cold produced by some industrial processes, and the action of X-rays.

In addition to this definite and specific knowledge of causes, she should know the generally accepted views of the medical profession on the subject of bodily resistance, immunity, inheritance, the diseases and perversions of metabolism, and the other non-bacterial factors in the production of disease. Above all, she should realize the multiplicity of causes which science more and more clearly recognizes in their single result. She should learn both by precept and by experience that for a single fact such as disease or health there are always many causes, so that any one who points confidently to a single cause, such as cold, fatigue, bacteria, or worry as a sufficient explanation of a person's disease, is almost certain to be wrong. Obviously, this truth bears a close relation to what is to be said on the "historic and catastrophic points of view." Chapter III.

The importance of teaching the social worker all that is known about the transmission and causation of disease is due to the following fact: whatever we succeed in accomplishing in our efforts at preventive medicine, whatever we do to nip disease in the bud or to check the spread of epidemics, is due to our knowledge of the causes of disease. The instructions of the doctor at the dispensary can accomplish but little in this field when compared with the detailed teaching of the social worker in the patient's house, in his workshop, in the schools and factories where disease is spread so much more frequently than in the dispensaries. If we hope to show people how they can avoid the disasters of illness, our teaching should be given in the very place where these disasters most often occur. There we can illustrate and demonstrate with the objects in sight what is to be done and to be avoided.

It is for this reason that the social worker is above all others the person who can convey life-saving information to the public in an effective way. A considerable amount of this precious knowledge is now possessed by the medical profession; but it is shut away useless, unavailable, in medical libraries and in doctors' minds. The social worker can fight disease by spreading the contagion of medical truth. She can multiply the foci from which truth can spread still more after she is gone, just as disease is redistributed again and again from new nests of infection.

The prognosis of disease, like its causation, is a subject on which the social worker should know almost as much as the doctor. This is possible because medical knowledge on this subject is still so very limited. For the purposes of one who has to combat the poverty, sorrow, idleness, and corroding fears which disease produces, knowledge of prognosis is a most useful tool. For example: if one is to make plans for the care of a group of children during their mother's illness, one must have some idea how long that illness is going to last. If it affects the bread-winner of the family, how long will he or she be disabled, and how completely; what are the hopes of ultimate and complete recovery; will chronic invalidism follow; is it worth while in this particular disease to spend a great deal of money and time in trying to achieve a complete cure, or is cure so improbable and at best so incomplete that our resources can be expended more wisely in other directions?

A knowledge of prognosis will help the home visitor greatly in the solution of such problems. But it must be added that such knowledge as she already possesses about the prognosis of a disease, such as tuberculosis or heart trouble or kidney trouble, must always be supplemented by all the information that she can gain from the doctor as to the present prognosis in the case of the particular patient with whom the social worker has to deal. For the general prognosis of a disease is greatly modified by the particular circumstances in each individual case.

Physicians are not at all eager to impart their knowledge about prognosis, because this knowledge is so limited and so faulty. No scientific man likes to make definite statements upon so indefinite and hazy a matter as prognosis. Nevertheless, it is essential for the patient's good that the doctor should be asked to give her as clear and definite a statement as is possible for him to make with the facts that he possesses. For it is only upon the basis of such a statement that an intelligent plan of social treatment can be constructed.

Besides acquiring all that she can learn of the causes and prognosis of disease, the social worker should be familiar with the symptoms of the more important and common types of disease. There are now several books written particularly with the object of conveying to social workers and others such knowledge as I have referred to, yet without any pretence of equipping the person either for nursing or for the practice of medicine. I will mention here a book by Dr. Roger I. Lee, Professor of Hygiene in Harvard University, "Health and Disease: Their Determining Factors" (Little, Brown & Co., Boston, 1917), and my own book, "The Layman's Handbook of Medicine" (Houghton Mifflin Co., Boston, 1916).

In order to understand such books, and to arrange her knowledge of disease in such form that it may be easily handled, the social worker must have a slight knowledge of anatomy and physiology, so that she can arrange the symptoms of disease in connection with the different systems of organs: circulatory, digestive, respiratory, urinary, nervous, and locomotive.

Finally, the social worker must know the principles of hygiene, in order that she may effectively combat medical quackery and the prevalent medical superstitions of the people. That portion of hygiene which is both securely founded upon scientific evidence and useful in the preservation of health, makes up only a very small body of knowledge, so that it can be easily mastered by any intelligent person. Our knowledge upon such matters as diet, exercise, bathing, sleep, ventilation, when such knowledge is both scientific and practically useful, could be written upon a very few pages. It consists largely of negatives which contradict the current superstitions.

In my own work in this field I have found it essential that there should be no mystery and concealment, no obscurantism and mediæval Latin in the methods of treatment which the social worker explains or carries out under the doctor's directions. She must be able to deal with the patients frankly, openly, without concealment or prevarication. Otherwise she will not have moral force enough behind her statements to bring them home to the patient so as to secure any reform in his hygienic habits. Such reforms are difficult enough in any case. They are usually impossible unless they can be initiated by one rendered eloquent and convincing by the consciousness that she leans upon the truth and has nothing to conceal. If she has mental reservations, if she is trying to protect the authority of the physician in a statement which she does not believe to be wholly true, the force of her appeal will be so weakened that it will probably be ineffective.

Technical methods

There are some technical processes of diagnosis and treatment which are usually carried out by the visiting nurse, but which may well be performed after a brief training by the social worker who is not a nurse. Among these are:

(1) The accurate reading of the patient's temperature, pulse, and respiration, which she must often teach the patient to do for himself and to record accurately and clearly. This is of especial importance in tuberculosis, for in suspected cases of this disease one often needs daily measurements of the temperature as an aid in determining the diagnosis or in estimating the severity of the case and the fitness of the patient for work.

(2) The arrangement of a window tent or some other device for insuring the maximum of fresh air for the tuberculous patient both day and night. This device is also useful in pneumonia, typhoid fever, and other diseases, in case they are to be cared for at home and not in a hospital.

(3) The application of simple dressings to wounds, abscesses, and common skin diseases such as eczema, and impetigo.

(4) The care of the skin in bedridden patients. Our primary object here is the prevention of bedsores, those ulcerations which occur in very emaciated patients at the points where their weight presses a bone against the bedclothes.

(5) The simpler procedures for the preparation of milk for sick children and of other foods commonly advised for patients who are confined to bed.

(6) The methods of emptying the lower bowel by means of an enema.

Into the details of these procedures this is not the place to enter, but I wish specially to assert that all of them may be learned within a few weeks by persons who have not studied medicine or had the full course for the training of a nurse. Any one who possesses these simple bits of skill can do all that is necessary for the physical care of the sick poor in their homes, unless continuous attendance upon the patient is necessary. Such attendance is not within the province of the social worker. But in the technical procedures just described it is all the more important that she be expert, because such skill makes her a welcome visitor and a trusted adviser outside the field of medicine. Because she has given relief by dressing a wound, curing a skin disease, or applying a poultice, she will be listened to with liking and with confidence when, later, she comes to give advice in economic, educational, or moral difficulties.

CHAPTER II

HISTORY-TAKING BY THE SOCIAL ASSISTANT

History-taking concerns the social assistant especially because history-taking is one of the things one does, if one is wise, in any matter in which one is trying to help a human being. Even if you were concerned to help not a stranger, but a member of your own family, still you would need a story or history of the person's life whether you wrote it down or not.

History and catastrophe

In our attempts to be of use to people in their misfortunes, there are two very common and quite opposite points of view (roughly the right and the wrong), which I call (a) the "historic" and (b) the "catastrophic," the accidental, or the emergency point of view.

Confronted with people's troubles, whether physical or mental or spiritual, we are tempted, and above all they are tempted to regard the sickness, the poverty, or the sorrow in the light of an emergency, an accident, and therefore as something to be treated at once and by means which have little to do with the past and the future. On the other hand, the standpoint of science and philosophy, and of any one who has labored long in the field of social work with or without science or philosophy, is the point of view of history. This is the habit of mind which makes us believe that a supposed "accident" belongs in a long sequence, a long chain of events, so that it is impossible to understand or to help it without knowledge, as extensive as our time and our wisdom will allow, of that whole chain.

Consider a few examples which contrast these two points of view. When a boy is brought into court for stealing, it is almost always his attempt, and the attempt of those who defend him, to show that such a thing has never happened in his life before; he "just happened to steal." But as we inquire more closely into the facts, we almost always find that this is a fundamentally untrue statement of the case. For the offence which brought him into court is almost never the first offence. He has always stolen before. On the present occasion he was a member of a boy's gang; it was not in the least accidental that he got into that group of boys. As we search back in his history, and perhaps into his father's history, we find reasons why he is what he is now. Again, we are trying to help some wayward girl who has taken an immoral step. We are told what a wholly unforeseeable accident it was that got her into her trouble. But if we can get a good picture of her past, we find that we could have traced the tendency to weakness of this kind from the time she was born.

So it is in medical matters. Emergencies are rare. I remember being called out of a sound sleep one night to go "as quickly as possible" to see a man who had discovered a lump upon his breast bone. He was quite sure that the swelling had appeared since the time when he went to bed. It was then one o'clock in the morning, and he had gone to bed at eleven. Well, I found a slight bony irregularity in his breast bone which doubtless had been there about forty-five years, as he was forty-six years old. He did not pretend that it hurt him, and did not undertake to show that he was ill in any other way. But this lump had come and naturally he wanted help at once.

The great importance of the contrast between the historic and the catastrophic points of view is, in the first place, that one way is on the whole right and the other on the whole wrong; but still more, that the patients whom we are going to deal with, and all the unfortunate or needy people whom the social assistant tries to help, are very fond of the wrong point of view and hang to it extraordinarily. It is the natural first impression of any untrained person that his troubles "simply happen" without any explanation that he knows. So that we have to start at once to tear down a structure of innocent and lifelong belief on the part of the patient, that troubles come suddenly and by accident. We have to disillusion him, a process which naturally he does not take to particularly pleasantly.

Our task in a dispensary is the same. The patient almost always starts with the catastrophic point of view, and can only be very gradually engineered into the other. And yet our work in relation to public health is largely to be summed up as finding out how, – that is by what history, through what chain of events, people come to be sick. Repetition and extension of disease can be checked only in case we succeed in finding such clues. Hence our labors to change people's point of view in this particular respect are as worth while as anything we can do, and we must not be discouraged by the fact that, week after week and year after year, we come up against the same difficulties, the same conviction, that troubles "just come" and have no cause.

I have said that the historic prejudice is essentially right and the catastrophic prejudice essentially wrong. Of course, there are exceptions. A man may be run over in the street for reasons that we cannot discover to be connected in any possible way with his previous history; a man gets a burn, gets a broken leg, is hit by a missile in an air raid over London or Paris, in ways that are essentially catastrophic. And yet even in the field of accidents, industrial accidents for instance, the more we study, the more we find that injuries are not wholly accidental. The whole of science is the attempt to prove that nothing is an accident, that everything comes out of previous causes. The percentage of accident in the so-called "accidental" injuries decreases as we study industrial accidents. (a) They happen at certain hours of the day more than at other hours of the day: if they were really accidental this would not be so. (b) They happen on certain days of the week, especially Mondays, for obvious reasons. (c) They happen especially to greenhorns, to the newcomers, who have not learned how to avoid them. One of the expenses incidental to hiring new help is the expense of accidents. Thus these events turn out to have a good deal of law and reason, a good deal in the history of the individual (alcoholism?), and the nature of the industrial process (speeding up?) which helps to explain them. By eliminating such causative factors, we may prevent some accidents.

The remedies that we apply fit the type of trouble; in so far as the trouble is accidental or catastrophic, the remedy is mechanical; in so far as the thing is historical and continuous, the remedy cannot be mechanical. When a man breaks his leg we put on a splint; that is mechanical. But if he is in a low state of health and the fracture won't unite, we have to do something non-mechanical, physiological, psychological. We may have to get him into a different state of nutrition or even into a better state of mind before his tissues will heal.