PUB RA 982. N49 D38 1927 1,042,572 N EW CLINICS FOR OLD BY MlICHAEL M. DAVIS, Plt.D. AND ANNA MANN RICHARDsoN, M.D. N / NEW CLINICS FOR OLD A STUDY OF CLINICS UNATTACHED TO HOSPITALS IN NEW YORK CITY: THE PASSING OF THE OLD "DISPENSARY" AND THE RISE OF HEALTH CENTERS AND OF OTHER CLINICS RENDERING HEALTH SERVICES By MICHAEL M. DAVIS, Ph.D. and ANNA MANN RICHARDSON, M.D. Published by THE COMMITTEE ON DISPENSARY DEVELOPMENT OF THE UNITED HOSPITAL FUND OF NEW YORK FEBRUARY, 1927 k~a~ HLKI1 THE COMMITTEE ON DISPENSARY DEVELOPMENT OF THE UNITED HOSPITAL FUND OF NEW YORK HENRY J. FISHER, Chairman JOHN SHERMAN HOYT, Treasure MRs. WILLIAM K. DRAPER S. S. GOLDWATER, M.D. JoHN A. HARTWELL, M.D. RANsoM S. HOOKER, M.D. MICnHAEL M. DAVIS, ADRIAN V. S. LAMBERT, M.D. 3r WILLrAM FELLOWES MORGAN MRS. JOHN S. SHEPPARD FRANCIS SMYTH ISABEL M. STEWART, R.N. LINSLY R. WILLMAMs, M.D. Executive Secretary 5-c53 FOREWORD THE COMMITTEE on Dispensary Development in its original program adopted in the autumn of 1920 recognized that some attention should be given to clinics unattached to hospitals and a practical experiment or "demonstration" in a selected clinic of this type was authorized. The inquiries leading to the selection of a suitable clinic for this purpose and other data accumulated during the first few years of the Committee's work made it apparent that clinics unattached to hospitals were much more significant than had been anticipated, particularly from the standpoint of public health. Hence there were undertaken the studies, conferences, and field work leading to this publication; and also another group of investigations into the preventive and health services which can appropriately be rendered in clinics unconnected with hospitals. The latter group of studies are incorporated in Doctor Richardson's Health Services in Clinics, which must be taken as a companion booklet to this, dealing as it does with the content and method of service, whereas this is concerned with organization and relationships. iii CONTENTS CHAPTERS PAGE FOREWORD................................ 1iii I. INTRODUCTION............................. II. THE OLD DISPENSARIES AND THEIR SURVIVAL... 5 Dispensary Service In 1862. Importance Of The Early Dispensaries. Typical Dispensary Service In 1876. The Commercial Dispensary. How Specialization In Medicine Affected Clinic Work. The Old Dispensaries In 1921. Changes Since 1921. III. THE NEWLY ESTABLISHED CLINICS EMPHASIZING PREVENTION.............................20 Establishment Of New Types Of Medical Service. Baby-Welfare Clinics. Prenatal Clinics. Dental Service. Unattached Treatment Clinics. Tuberculosis Clinics. VenerealDisease And Cardiac Clinics. Industrial Clinics. Clinics Under Private Auspices. IV. PROBLEMS OF THE NEW CLINICS.............. 41 Difficulties In Carrying Out Standards. Limitations Of Non-Medical Agency. Lack Of Supervision. Lack Of Properly Trained Personnel. Lack Of Statistical Data. Charging Fees For Preventive Work. Definition Of Policy In Establishing Clinics. V. T iEi HEALTH CENTER....................... 51 Co6rdination Of Medical And Health Services. Health Demonstrations. JudsonHealth Center. Judson Health Center Schedule. Clinton Neighborhood Conference. East iv CONTENTS Harlem Health Center. The Place Of The Clinic In The Health Center. Health Center Policies. Record Keeping In Health Centers. VI. THE PLACE OF THE UNATTACHED CLINIC IN HEALTH SERVICE......................... 69 Importance Of The Small Clinics. Why Clinics Unattached To Hospitals Are Needed. Types Of Service. Organization. How Unattached Clinics May Be Aided And Developed. Financial Aspects. Questions For The Future. APPENDIX................................ 90 _ __ NEW CLINICS FOR OLD CHART I CHAPTER I INTRODUCTION CLINICS OLD AND NEW ONE HUNDRED and thirty-six years ago the 33,000 people in the Town of New York included, as the great city does today, persons who were unfortunate enough to be both sick and poor. Those who were confined to bed and could not be cared for at home had recourse to the poorhouse, which was then slowly beginning to assume the characteristics of a hospital, while those not sick enough to go to a hospital, but without the money for necessary medicine or special food, might go to the New York Dispensary, which had been established shortly after the Revolutionary War. Early in the history of this institution the original plan of sending doctors to the homes and supplying drugs, wine, and special foods was extended so that doctors also could see at the dispensary such patients as were able to go there. Within the next two generations six more such "dispensaries" were established. The way of the sick poor was much harder a century ago than it is today, for the sufferer could not then go directly to one of these dispensaries and see the doctor. First, he had to seek out one of the donors to the dispensary and convince this charitable person that he was not only poor and sick, but also "worthy." For at that period it was the privilege of the "donors," or those who, contributed five dollars or more to the maintenance of the dispensary, to designate persons they considered eligible for treatment. For each five dollars contributed,, one or two persons might be cared for. If the donor had not already reached his quota of "worthy poor" when our sick man applied, he might be given a card of recom [1] NEW CLINICS FOR OLD mendation, and be admitted to the dispensary. There he had to join a slowly moving line and eventually found himself before a bearded and bespectacled doctor seated at a desk behind a large ledger. After the doctor had inspected the permit from the contributor, he entered the name, address, age, sex, and complaint on one line in his ledger. He inspected the sufferer's tongue, felt his pulse, probably inquired about his appetite, sleep, and bowels, and then wrote a diagnosis in his book, with several numbers indicating medications. These numbers were copied on a slip and handed to the patient, who was told to report back if not cured when the medicine was gone. The patient next passed to the pharmacy where the numbers were interpreted into prescriptions. If the medication consisted of herbs to be steeped at home, he usually carried it away in his hat, or, if a salve were indicated, was expected to produce a clam shell or other container to receive it. There was little attention to physical examination and little respect for the patient's privacy. The doctor felt obligated to name the condition, however, so that he could enter a diagnosis in his ledger. This need of a name made it to his advantage not to individualize his cases lest he could not define the condition by a single term. The old case books and the annual reports are full of such "diagnoses" as rheumatism, plethora, ague, and so on, which are only symptoms and not diseases. False ideas as to the causes of disease resulted in needless suffering for the patients by such practices as bloodletting, withholding water, and cauterization. From these original little prescription mills, which were called "dispensaries," the institutions furnishing medical service to the sick who are not confined to bed have extended their work in the two ways suggested in Chart I. [2] INTRODUCTION (1) Into hospitals. Almost every hospital in the city now possesses an out-patient department where patients not confined to bed receive diagnosis and treatment. Thus the modern hospital is able not only to serve a vastly greater number of persons, but is also capable of rendering a far more complete and adequate medical service for many diseases and many stages of diseases beyond those requiring hospital beds. About 1800 hospitals in the United States now have out-patient departments. The number has practically trebled in the past decade. (2) Into the crowded neighborhoods of the city, the byways and corners where numerous small clinics have been set up in recent years. Like the original "dispensaries" these are unattached to hospitals, but unlike the original dispensaries, their purpose has generally been to provide not medicines, but medical advice and preventive medical service. In 1926 the clinics unattached to hospitals numbered about 240 in New York City. Fifteen years ago there were less than twenty. Chart II (page 20) illustrates this development graphically. A study of the history, scope, and efficacy of these clinics unattached to hospitals shows that while the old original type of dispensary has survived in certain instances, its number has not increased for half a century. Should institutions of this old type survive? Are they needed under present-day conditions? How, if at all, should they be transformed in order that their endowments and goodwill might be better adjusted to presentday needs? On the other hand, we find that a great variety of clinics unattached to hospitals have been founded during the past fifteen years. They serve chiefly as the arms of public-health movements and as agents of churches, settlements, and charitable societies in their warfare against poverty, malnutrition, and associated diseases. Our [3] NEW CLINICS FOR OLD studies show that the growth of these many small but significant clinics is intimately related to important movements in preventive medicine, and that some of the most puzzling problems of the organization of modern health work are involved in their policies and maintenance. What should be the future of these unattached clinics? What kinds of medical service, curative or preventive, are most appropriate and useful for them to render? How should they be organized and supported? Should they be moved into association with hospitals, or do we need neighborhood health stations and district health centers? In the next two chapters, the history of the old "dispensaries" and of the recent growth of clinics emphasizing preventive medicine will provide background for the discussion of these questions, and for the conclusions to which we are led by further consideration of the subject. [4] CHAPTER II THE OLD DISPENSARIES AND THEIR SURVIVAL IN 1862 the City of New York had a population of approximately 830,000. Manhattan Island, or rather the lower portion of it, in which practically all of the city's population then resided, was divided into seven districts, in each of which a "dispensary" was located to provide medical aid to the sick poor. In the wellpreserved records of the Northern Dispensary is found a large sheet compiled by some laborious lover of his kind to show the "leading statistics of the seven dispensaries of New York for the year 1862. Compiled from their annually published returns and their general statistics from the dates of their organization respectively to December 31st, 1862." Table I gives a number of the items shown on this old sheet: date of origin, number and sex of patients, and where treated. DISPENSARY SERVICE IN 1862 It should be said that the number of "patients " treated according to these figures undoubtedly means what is now called "visits." The records were not so kept that the individual patient who came more than once to the dispensary during the year or was seen more than once in his home by the doctor was recorded without duplication. It is interesting to know that the proportion of visits to the total population of the city was then approximately one visit to 5.5 persons, whereas at the present time the number of visits made by New York City's [5] NEW CLINICS FOR OLD population to all of the 300 and more clinics is over 5,700,000 (1), or nearly one visit per head per year. The ratio has increased about five times. TABLE I-NEW YORK DISPENSARIES IN 1862 PATIENTS Sex Where Treated Name Founded Male Female At Dis- At Home Total pensary New York................. 1790 15,761 26,002 34,364 7,399 41,763 Northern.................. 1827 8,263 14,179 18,215 4,227 22,442 Eastern (Good Samaritan).. 1834 15,142 17,963 26,604 6,501 33,105 Demilt................... 1851 12,411 17,965 24,545 5,561 30,106 Northwestern.............. 1852 5,274 7,488 10,415 2,347 12,762 Northeastern.............. 1862 2,550 2,613 4,042 1,121 5,163 Manhattan.............. 1862 112 145 224 33 257 Total.............. 59,513 86,085 118,409 27,189 145,598 From other columns of the original table, which are too detailed to reproduce here, we note that 81,000 of the 145,000 visits were recorded as from patients of foreign birth, the remaining minority, 64,000, being from the American born. The form of medical care originally provided by these dispensaries had been the visitation of the sick in their homes by physicians sent by the institutions. By the year 1862 this was still an important portion of the work, though relatively much smaller than that with the ambulatory patients who came to the dis(1) The figures given in the Annual Report of the State Board of Charities are much smaller than this as they do not include a considerable number of clinics, mostly among those unattached to hospitals, which because of the scope or nature of their work are not regarded as coming within the definition of "dispensary" laid down in the New York law passed in 1899. Hence they are not required to be licensed nor to report their statistics to the Board. [6] THE OLD DISPENSARIES pensary to see the doctor. An interesting commentary upon the character of medical practice at the time this table was prepared is brought out in the figures showing that an average of two and one-sixth prescriptions for medicine were given to each patient at each visit. In modern clinic practice, the proportion of prescriptions has sunk to a quarter of this, or less. The table also shows that excluding the two institutions founded in 1862, which were just getting under way, the average cost per visit was 131/ cents, a figure which, even allowing for the change in the purchasing power of money, is only a fraction of the expense of well-organized clinic service at the present day. A large proportion of the expenditure in 1862 was for the purchase and dispensing of the medicines. IMPORTANCE OF THE EARLY DISPENSARIES These seven dispensaries, during the first half of the nineteenth century, were relatively conspicuous institutions among the charities of the city, as shown by the names of the prominent families constituting their boards of directors. In those days, which antedated official public-health work or the establishment of federal quarantine in the port, the public was shaken by periodic scares of epidemics such as cholera, typhoid, typhus, and small-pox. The table of 1862 shows that a substantial proportion (about one-eighth) of all the activities of the dispensaries was vaccination. Indeed, it is reported with apparent pride that the whole number of persons vaccinated by all the dispensaries since the year 1804, or since "the era of the protective power of vaccine," totaled 275,844. In some years, when small-pox seemed especially menacing, appropriations were made by the city and state governments to the extent of a thousand or fifteen hundred dollars to several dispensaries toward the cost of vaccination. This branch of their work in [7] NEW CLINICS FOR OLD some years constituted as much as one third of the entire activities of some of the dispensaries. They were in this sense health stations as well as medical "soup kitchens." An intimate connection between these old dispensaries and the vital advancement of the city came shortly after the table of 1862 had been prepared. The law establishing the health department of New York City, enacted by the State Legislature of 1866 through the persistent efforts of Dr. Stephen Smith, Mr. Peter Cooper, Mr. Dorman B. Eaton, and other leading citizens of the day, was passed by the Legislature against political opposition, owing largely to facts assembled by the dispensary physicians. These doctors, familiar through regular visitation in the homes with sanitary and health conditions in the city, were enlisted by the committee proposing the law in a systematic sanitary and health survey in order to reveal the menaces of insanitation and the necessity for a legally constituted authority to deal with them. Dr. Stephen Smith's famous little book, The City That Was, quotes from the reports of these dispensary physicians the convincing evidence which placed on the statute books a law that was the model for every public health department in the United States. Most of the institutions established before the Civil War have lived on to the present time, accumulating age and endowments. Few of the same type were established in the city after that period. The Harlem Dispensary was established in 1867 to serve the northern colony on the Island, and in 1883 the Stuyvesant Polyclinic was started by and for the German population. Across the river, the "Brooklyn City Dispensary" had been founded in 1846 and in 1872 and 1878 respectively the Brooklyn Eastern District and Homeopathic Dispensary and the Bushwick and East Brooklyn Dispensary were established. At the close of the nineteenth century and in the early years of the twentieth, a very few additional dis [8] THE OLD DISPENSARIES pensaries of similar type were set up chiefly as the outgrowth of church activities, as by Trinity Church (Trinity Dispensary), St. Michael's Church (Bloomingdale Clinic), and the Reformed Church of Harlem. The great increase in the number of unattached clinics since 1910 has been almost entirely due to new motives leading to a different type of work, as described in the next chapter. At just about the period when the old type of dispensary practically ceased to increase in number, the development of out-patient departments of hospitals and of teaching clinics associated with medical schools began, together with the remarkable advances in the science and art of medicine which have transformed medical practice and medical institutions. An account of a case in one of the leading dispensaries in 1876, told by Dr. Ignatz L. Nascher, is illustrative of some of the characteristics of institutional medical practice of that period. TYPICAL DISPENSARY SERVICE IN 1876 On July fourth of that year a small boy shot himself in the finger with a toy pistol and hurried to the dispensary. The house physician held the boy's finger under the faucet and while the water was running probed for the bullet which had gone through. He then applied balsam of fir to the wound, covered it with lint and sent the boy home. Next day the boy went to the dispensary again, and the physician removed the bandage to see if the pus that had formed was "laudable" or "sanious." "Laudable pus" was considered necessary for healing wounds. The following paragraphs give his remembrance of the dispensary and the methods employed. He entered the large dimly-lighted waiting room in the corner of the building and was taken into the "'surgery, " as one of the four small examining rooms with windows facing the street was called. In this room was a long [9] NEW CLINICS FOR OLD examining table with one end so cnt that two narrow projections with holes near the ends served as stirrups when women were examined. This table, a flat-topped desk, two chairs, an instrument case, and a small table on which were bottles, basins, lint, bandages, and some instruments, completed the furniture of the room, except f or a washstand in one corner. White paint on the window glass prevented curious neighbors from looking into the room. No antiseptic precautions were taken. When an instrument that the surgeon was using fell on the floor, he picked it up, wiped it on his sleeve if the towel he was using was too bloody and a clean one was not at hand, and continued to use the instrument. Immediate auscultation was the general practice in heart and lung examinations, some doctors placing the ear on the bare chest or back, while others first placed a towel over the part to be examined. A few physicians used the simple monoanral stethoscope, but the binaural stethoscope was not in general use. There were no trained nurses in dispensaries in those days, but a woman was usually engaged to keep the place clean during clinic hours and incidentally, to serve as matron or attendant in the woman's clinic. THE COMMERCIA-LDISPENSARY With the growth. of the city, certain forms of undesirable dispensaries developed, as illustrated by the record of a visit made by a physician of our acquaintance to a certain unattached "dispensary" in 1885. At that time this dispensary occupied the front room in the basement of an old dwelling house. The dark hallway was the waiting room, a bench and a couple of chairs furnished the seating accommodations. The dispensary itself contained a table, a chair, and a sof a which also served as [ 10]1 THE OLD DISPENSARIES an examination table. It was run by an old homeopathic physician who used the rear room and the floor above as his living quarters and private office. At the time of our friend's visit there were on the table a simple, monoaural stethoscope and a couple of tubulat vaginal specule, also a few numbered bottles containing pellets and a pin file on which hung a number of slips each containing a number, the name and address of a patient, and a notation or letter indicating what tablets the doctor had given that patient. Patients said he seldom made an examination, but told them that if they wanted a more thorough examination they could go to his office upstairs, where a charge of fifty cents a visit was made. A patient going to the dispensary for the first time received a numbered card and after telling the doctor her complaint, received a number of pills, generally 25 at the first visit, one to be taken every hour. A charge of a cent a pellet was made. The patient was also told to send the card the next day for more pellets at one cent a pellet. This dispensary, which has since gone out of existence, was virtually a money-making scheme, although it was recorded for several years as a philanthropic institution "supported by contributions from a generous public." The growth of the city had at this time given occasion for the development of a number of so-calied "dispensaries" connected with drug stores. The doctor might be consulted in a back room, without charge, but the prescription, written in code, could be made up only in that store, at a stated price. If the drug store was not owned by a physician, a physician might be hired on a commission basis to examine and treat patients. One of the incentives to the passage of the New York State Dispensary Law in 1899 was the existence of these and some other types of undesirable dispensaries. This drug-store type was practically put out of existence by the Law, although the legislation, as passed and as still on our [11] NEW CLINICS FOR OLD statute books, failed to provide for the future development of new, and then unforeseen, types of out-patient service. How SPECIALIZATION IN MEDICINE AFFECTED CLINIC WORK During that period, and in the succeeding generation, specialization in medicine was developing rapidly. Surgery especially was advancing, and with the subsequent introduction of laboratory methods, the x-ray and numberless scientific and mechanical devices and instruments, diagnosis and treatment were coming to involve more and more equipment of both a mechanical and professional nature, and trained personnel of various kinds to assist the physician. A more or less elaborate organization became necessary in hospitals and clinics to make this equipment and personnel effective and to promote the increasingly necessary cobperative work among different professional groups. In out-patient service these advances began to be noticeable in some,, of the teaching clinics associated with medical schools during the last quarter of the nineteenth century and much progress has been made since then. By the time of the Civil War, recommendations of patients as "poor and worthy" by a contributor to the dispensary had long been dispensed with. Patients applied directly to the institution, where the admitting official, frequently the pharmacist, determined their eligibility for care. THE OLD DISPENSARIES IN 1921 At the close of the first quarter of the twentieth century, the old-established dispensaries of New York City remained, with some important individual exceptions mentioned below, much the same as they were a genera [12 1 THE OLD DISPENSARIES tion and more ago-and this despite the sweeping advances in medicine and in other institutions for outpatient service. A member of the staff of the Committee on Dispensary Development who visited one of these dispensaries not long ago reported as follows: "A doctor with hat on, coat off, and feet on desk, sits back in his swivel chair smoking a cigar. As each patient enters his small office he reaches over to the file boxes on his desk and pulls out the 5 x 8 card corresponding to the number on the patient's ticket. He reads the brief notes on the card and either gives the patient a scrap of paper with a number on it and the name of a clinic or he asks a few questions and renews a prescription by number, or he takes down the name and address and promises a home visit." Within the past five years, the trustees of another dispensary were informed, as a result of their own requests for information concerning their institution, that the woman attendant in a surgical clinic, and not infrequently the physician, was going from one patient to another without washing the hands, and in some instances without sterilizing or even cleaning the instruments, and that the attendant-when this failure to adopt reasonable precautions was called to her attentionreplied that there were so many patients that she had no time for sterilization. The fact that a large number of patients continued to come daily to the clinic seemed to these trustees a sufficient answer to this criticism. Within the same period, determined opposition was shown by a considerable proportion of the board of another institution to the employment of a nurse, no such person then being on the staff of the dispensary, on the ground that a professionally trained person was an unnecessary expense, and "made more work." It is pleasant to report that ultimately the opposition was success [13] TABLE II-TEN OLD UNATTACHED 'DISPENSARIES" IN NEW YORK CITY, 1921 Name of the Institution Date Established Visits in 1921 (a) Average Visits per day Current Expenses (b) Cost per Visit Total Current Income (c) Per Cent from Endowment Per Cent Income from Fees from Patients 1. Brooklyn City................. 2. Brooklyn Eastern District and Homeopathic................. 3. Bushwick & East Brooklyn........ 4. Harlem...................... 5. Northeastern..................... 6. Northern..................... S 7. Northwestern................... 8. Stuyvesant Polyclinic........... I I* I -------1-- -I- 'I---- [-I-[ 1846 1872 1878 1868 1861 1828 1852 1883 3,914 5,899 8,047 2,711 18,677 10,675 2,887 36,752 13 19 27 9 62 36 10 122 $5,850.42 2,041.29 6,429.48 3,759.54 8,946.92 10,451.52 5,331.01 14,024.41 $1.49 +.34~.79+ 1.38+.47+.81+ 1.84+.81+ $4S,647.12 1,256.45 4,870.96 7,160.25 13,224.66 12,871.47 1,279.38 17,478.86 -I 37 16 8 43 58 26 -I 50 52 47 17 17 70 -I Per Cent Contributions 13 844 48 10 25 57 30 L- j Total.............................. 89,562 298 $56,834.59 $.63+ $62,789.15 25 49 26 9. New York.......................1794 149,382 498 48,032.20.33+ 51,237.19 21 43 36 lO.Good Samaritan.................1832 117,964 393 39,391.29.24+ 44,725.66 21 79 Total............................. 267,346 891 $87,423.49 8.32+ $95,962.85 21 60 19 Grand Total........................356,908 1189 $144,258.08 A40 $158,752.00 23 56 21 (a) In the case of institutions Nos. 6, 9 & 10, a small proportion of these visits are to patients in the homes, (b) Expenditures for reinvestment of securities and for buildings are excluded, (c) Cash in hand from preceding year; loans; and income in. the form of principal (maturing bonds, etc.) are excluded. 0 0 THE OLD DISPENSARIES fully overcome by the modern-minded members of this board. Table II displays the situation of the old dispensaries in 1921. The figures are taken from annual reports. As a practical classification, these ten institutions obviously fall into two groups. All but two are comparatively small, and can hardly be compared with the New York or the Good Samaritan, as either of these receives more visits a year from patients than do the eight small ones put together. A glance at column five in the table shows that the cost per visit varied within wide limits, but was remarkably high at nearly all of the eight small dispensaries. A cost of more than a dollar per visit is out of all proportion to the kind and quality of service rendered in these institutions. At the present time adequate, high grade service in well-organized out-patient departments of hospitals, including all the chief specialties of medicine and surgery, can be furnished for about one dollar a visit, with physicians unpaid. These small dispensaries generally paid a small sum to their physicians, as it would have been impossible otherwise for them to secure medical service. This, however, at the rates paid, adds not more than 25 or 30 per cent to the cost. The high cost per visit is primarily due, in most if not all instances, to the limited amount of work done in proportion to the size of plant and the staff carried. These small "dispensaries" were costing much because they were doing little. Actual inspection of these institutions when this table was prepared in 1921 led to the conclusion that in most instances the service was below standard, although this proved impossible to demonstrate to the satisfaction of some boards of trustees. Further study of the table shows that these institutions were to an unusual extent supported by income from invested funds. Of the eight small institutions, the amount of income derived from investments runs in several in [15] NEW CLINICS FOR OLD stances to over 50 per cent of the expenses. The annual reports of a number of these institutions showed in 1921, and have shown in other years, a surplus of total receipts over current expenses. The surplus has usually been invested. The endowments of the eight small institutions totaled about $300,000 in 1921 and the value of real estate owned was judged to be $200,000 or over. This survey of the institutions in 1921, as apparent from the figures presented in the table, supplemented by personal inspection, led to the following conclusions: Most of these old-established charities were being conducted at a low level of service; they were declining rather than advancing in relation to the community needs for which they were founded; their trustees were unable or unwilling to alter antiquated charitable policies or out-of-date medical methods. CHANGES SINCE 1921 Developments since 1920 leave this gloomy view unchanged in regard to a number of these institutions, but introduce several bright spots of hope. A comparison of the 1921 list with the list of 1862 shows the addition of several institutions, but the omission of one important dispensary, the Demilt. A 1926 list would further reduce the number below that of 1921, through the elimination of three Brooklyn institutions: the Brooklyn City Dispensary, the Bushwick and East Brooklyn, and the Brooklyn Eastern District and Homeopathic. The Demilt Dispensary went out of existence in 1918, the invested funds of the corporation being combined with those of two other organizations to found and maintain the Reconstruction Hospital and Out-Patient Department. This desirable consummation was brought about through the Public Health Committee of the New York Academy of Medicine, which brought members of the consulting med [16] THE OLD DISPENSARIES ical board of the Demilt Dispensary to a realization of the inferior character of the service to which they were lending their names, and later led the board of trustees to put their property and funds to a use appropriate to present-day needs. The Brooklyn City Dispensary was combined in 1923 with the Brooklyn Hospital and served as the nucleus of certain extensions of service in the out-patient department of that institution, particularly along dental linesa service peculiarly needed at the present time. The other two institutions named are in process of termination during the present period. It should be mentioned that during the same five-year period the Dispensary of the Reformed Church of Harlem has also gone out of existence. This institution was not named in the list, as data concerning it were not available in detail. During these five years, progress has thus been made by the method of demise. By another method, that of internal transformation, certain institutions have also moved forward. Both the New York Dispensary and the Good Samaritan, the two large institutions on the list, have made distinct advances. The Northern Dispensary, among the remaining smaller institutions, has reconstituted itself in many ways, both by providing additional services locally needed, such as a dental clinic and examinations for the clients of social agencies, and by qualitative improvement in its medical work. The fact that some aid from the Committee on Dispensary Development was furnished the Northern Dispensary during the earlier stages of its advance does not detract from the credit due its managing authorities for their responsiveness. Efforts directed towards the trustees of some other institutions in the list have not yielded similar results. It is evident that the reason for the decline of this type of unattached clinic is not to be found in insufficiency of [ 17] NEW CLINICS FOR OLD funds, but that it is suggested by their history and the psychology of their governing boards. Apparently the most fundamental reason is that the advance of the science and art of medicine now demands equipment and personnel for the satisfactory treatment of many kinds of disease which cannot be provided within any reasonable limits of expense except in association with a hospital. The unattached clinic which undertakes to diagnose and treat disease can rarely attract physicians of the type who are glad to serve in the out-patient department of a hospital. The laboratory facilities and trained technical personnel of a hospital can with little additional expense serve the out-patient department also. It is true that there are a considerable number of diseases and conditions, the diagnosis and treatment of which may not require specialized medical services or extensive laboratory facilities. On the other hand, the diagnosis and treatment of many ambulatory conditions, general and special, do require equipment, staff, and organization which cannot be furnished economically, if at all, except in the out-patient department of a hospital. The development of out-patient departments of hospitals has largely removed the reasons for the existence of those unattached clinics, whose primary aim is to furnish diagnosis and treatment for disease. It should be mentioned at this point that the clinic unattached to a hospital but associated with a medical school is, for practical purposes, the out-patient department of a hospital since, through the medical affiliations of the school faculty, hospital service is available and laboratory and other professional facilities are necessarily provided for the clinic for the educational and research purposes of the school. The tendency, which has been manifested throughout the United States as well as in New York City, is for the teaching clinics of medical schools to become physically and administra [ 18 THE OLD DISPENSARIES tively out-patient departments of hospitals and not merely to depend for hospital service upon their medical staff affiliations. In general then it has become more and more true, because of the progress of the science and the art of medicine, that only through the association of an outpatient clinic with a hospital can the clinic deal adequately, or without undue expense, with the diagnosis and treatment of the more complex and obscure general diseases and conditions and with many of the special conditions and diseases. On the other hand, the succeeding chapters will show it is far from true that there is no place left for the unattached clinic, provided those clinics take up forms of medical work particularly along preventive lines, which can be effectively carried on without connection with a hospital. It is to be hoped that the remainder will realize that the intention of the founders was to meet the needs of the sick poor. The kind of service which too many of these old dispensaries now render compares with a modern service as the bloodletting and leeches applied at barber shops a century ago compared with the medical care given at the dispensaries during the same period. To continue to maintain an antiquated medical standard can hardly be carrying out the intent of the founders and is as wasteful as it would be for a private doctor to make his calls today on horseback, trying to carry all his medical equipment along with him. If the sick poor need service they need service that is not an anachronism. The doctor can no longer be expected to face disease with the resources of his saddle bags. [19] CHAPTER III THE NEWLY ESTABLISHED CLINICS EMPHASIZING PREVENTION HE CHANGING trends of medical service are shown in Chart II. This depicts in a striking way the relative growth in New York City in twenty years of the two types of clinics unattached to hospitals. In 1904, the handful of old-established "dispensaries" were the only clinics in the city outside of hospitals. By 1924, they had not increased in number, but 230 unattached clinics had been established, and, in addition, a considerable number had also been started by industrial or commercial establishments for the benefit of their employees. The larger part of this growth has been during the past ten years. 15 YEARS AGO (191 ) 19 TODAY (1926) 241 Old-fashioned Dispensary F77 UnRtattached Clinics Established by the Health Department or under Private Auspices CHART II. UNATTACHED CLINICS IN NEW YORK CITY FIFTEEN YEARS AGO AND TODAY [20] THE NEW CLINICS In 1924, 146 of these unattached clinics, excluding industrial clinics, were in Manhattan, 52 in Brooklyn, 20 in the Bronx, 15 in Queens, and 8 in Richmond. ESTABLISHMENT OF NEW TYPES OF MEDICAL SERVICE This growth does not represent the sudden addition of new units of the same type as the old, but the establishment of a new type of medical service formerly unknown in clinics. This contrast is brought out in Chart III, which gives the cross section at five-year periods for the Borough of Manhattan alone. The city during recent years has been dotted with unattached clinics which are little stations in most instances, but which, because of their number, variety, and the significance for public health of the types of work which many represent, bulk together into a significant total. The whole group of 230 received about 1,300,000 visits from patients in the year 1924. This is an average of only 20 per day per clinic, but they range from a health center which admits 75 to 100 patients a day to a small church clinic holding two sessions a week with an average of 10 to 15 patients at a session. The visiting nurse and social services, usually combined with these clinics, furnish an important part of the work which does not appear at all in the records of visits made by patients at these clinics. To measure this, no accurate data are at present obtainable since it is often impossible to separate the visits made by public-health nurses in connection with clinic work from the visits made to the homes for other reasons. The home visits of the Department of Health nurses in connection with the baby-welfare clinics alone were over 200,000 in 1924. A comparison of the number of visits by patients to the old-fashioned dispensaries in Manhattan with the [21] NEW CLINICS FOR OLD Old-fashioned Dispensary SUnattached Clinics Established by the Health Depardment J Unattached Clinics Established under Private Auspices 1900 1904 1909 1914 1919 1924 CHART III. GROWTH OF UNATTACHED CLINICS IN MANHATTAN SINCE 1900 attendance at the newly established clinics emphasizing prevention also shows the decline of the one and the growth of the other. To the old-fashioned treatment clinics, the number of visits in 1914 in Manhattan was recorded as 547,327. In 1919, it had shrunk to 378,123, and in 1924, to 314,381. On the other hand, the number of visits to the newly established clinics emphasizing prevention was in 1914, 427,402; in 1919, 471,907; and in 1924, 562,138.* It is probably not true that much of the wTork done in the old-fashioned treatment clinics has been transferred to these newer types of clinics emphasizing prevention, but rather, that the out-patient departments of the hospitals have received the work which formerly went to the old-fashioned dispensaries. The newly established types of clinics are, on the whole, meeting needs * This figure includes only those in Manhattan, which reported a definite number. For others, the number of visits had to be estimated to make up the greater city total stated above. [ 22 1 THE NEW CLINICS for kinds of medical and health service which in former years were unrecognized, or which existing resources did not permit of being met. The advance of this new preventive service should in the long run reduce the burden of the treatment clinics. The forces which have led to the establishment of these numerous clinics in New York City and elsewhere throughout this country have been, in the first place, the development of organized militant public-health movements, and, in the second place, a growing recognition by the larger business establishments and by philanthropic and educational agencies of the needs of their employees or clientele, which private physicians could not meet because the approach today must be militant, which is inconsistent with existing medical ethics. Nor can these needs be taken care of by already established medical institutions, organized as they usually are to deal with the problems and emergencies of sickness already incurred. Reference may be made to seven public-health movements, active during recent years, as illustrating the first of these two sets of forces. (1) Tuberculosis Clinics. Earliest chronologically was the movement for the prevention and control of tuberculosis, which was organized nationally in 1905, and is now represented by a network of official and voluntary agencies throughout the United States. From the first, one of the important points within the program of the anti-tuberculosis campaign has been the establishment or encouragement of tuberculosis clinics, clinics which offered a chance for early diagnosis, for the education of patient and family and for continued observation. (2) Baby-Welfare Clinics. The characteristic American interest in children, turned to the field of health, had its earliest expression in school-medical inspection, which [23] NEW CLINICS FOR OLD has now become accepted throughout the country. Concern for children first expressed itself in militant form as a "public health movement" in organizations to study and reduce infant mortality. Baby-welfare clinics, or infant-welfare stations, as they are variously called, were established by private organizations on an experimental basis, in this city and elsewhere, before 1910, and so demonstrated their effectiveness that, during the second decade of the century, they were rapidly incorporated into official public-health work here and throughout the country. They represent the most numerous form of unattached clinic in this city. In 1924, 70 were maintained by the Department of Health, and 22 by private agencies -a total of 92. In 1926, the number had slightly increased, there being 69 Department of Health stations and probably 25 under private auspices. The incursion of private agencies into this field has been notable of late years. In 1914, there were 56 Department of Health stations receiving 964,000 visits; in 1924, the number of stations was 70 but the number of visits had sunk to 750,000. The number of home visits by nurses had risen slightly, 185,000 to 202,000. (3) Prenatal Clinics. The closely related movement to reduce maternal mortality, pushed especially by the Federal Children's Bureau, as well as by private organizations, has led to the development of the prenatal clinic. In 1924, in New York City, 77 of these were on our lists. The part played by the municipality in this important form of work was small, only eight of the clinics being under public auspices, while 69 were privately controlled. (4) Preschool Clinics. The general interest in child health, taking national and local form in recent associations representing combinations of several originally specialized bodies, has through its educational propaganda as well as research furthered the general physical [24] THE NEW CLINICS examination of school children and more lately laid emphasis on children of preschool age. Some twenty unattached clinics have been established with special reference to the needs of this group. They generally devote particular attention to malnutrition. As in the baby-health station, so in preschool clinics, doctors examine the children, nurses instruct the mothers in diet, and follow each child up urging the correction of defects or demonstrating the preparation of diets. Theoretically, this plan should provide for the correction of such defects as dental caries, infected tonsils, defects of vision and hearing, and underweight. In practice, however, the plan has proved unsatisfactory, largely because of difficulty in getting mothers to bring their preschool children to clinic with regularity. Problems of policy and technique exist here which will be discussed somewhat in the next chapter. The establishment of a small number of eye clinics unattached to hospitals, six under the Health Department, has likewise been a result of the general child-health program, since concern for individual health and efficiency has brought to light many visual defects among school children. Because of the expense of competent private attention and the crowded condition of eye clinics in the out-patient departments of the best known special hospitals, the establishment of special clinics seemed necessary. (5) Venereal-Disease Clinics. The movement to control venereal disease received great impetus and assumed large national proportions during the war. The national and local organizations concerned with this program have laid great stress on the establishment of venerealdisease clinics where necessary, or on the enlargement or improvement of existing clinics in the out-patient departments of hospitals. In New York City, the movement [25] NEW CLINICS FOR OLD has taken chiefly the latter direction. In three unattached Health Department Clinics patients may receive treatment for venereal conditions. (6) Mental Clinics. The control or prevention of mental disease, and the promotion of mental hygiene, has recently become an impressive national movement and is responsible for a considerable number of clinics unattached to hospitals. At present there are about seventeen such in New York City and about an equal number in out-patient departments. (7) Health Clinics. The tendency of late years for the specialized health movements to realize their mutual relationships, and consequently for the specialized organizations to affiliate or to cooperate in a common program, has led among other results to more public attention to the general medical examination, or "periodic health examination" of supposedly well persons. A small number of clinics have been established for this purpose, as in the out-patient departments of PostGraduate Hospital, in the Cornell Clinic, and in the East Harlem Health Center. An important practical distinction is to be drawn between the types of the clinics which have been established as a result of these organized health movements. In one type the persons dealt with are not sick, and the work is primarily that of examination, advice, and education. In another type the ultimate purpose is the same-that of control and prevention-but because of the presence of a disease or defect this fundamental purpose must be realized through, or in conjunction with, a process involving diagnosis and treatment. BABY-WELFARE CLINICS The infant-welfare stations and the prenatal clinics are the best examples of the former type. At the typical [26] THE NEW CLINICS baby-welfare clinic the doctor is present at a few specified hours weekly, when mothers bring their babies for examination. Sick babies are not treated, but are assigned to private physicians or to children's clinics, usually in the out-patient departments of hospitals. The essential features of the service are examination and advice, the encouragement of mothers to nurse their infants, the prescribing of feeding formulas when breast nursing is impracticable, and the advice to mothers on other problems in which they may need help from a doctor or a nurse. A minor function in the New York City stations is the provision of high-grade milk through a milk company which sells Grade A milk at the station for three cents per quart less than the retail price for Grade B. The nurses are a vital element of the service. They are, of course, present during the sessions with the doctor, and may also be consulted at the station at other hours. The remainder of their time is spent in the essential work of home visiting in the district covered by the clinic. Through follow-up on birth registrations the nurses are able to get in touch with the mothers of newly-born babies and to interest them in bringing their babies to the station nearest their homes. For the first two years, or for as long as the family lives in the district, the baby is usually brought for weekly or monthly weighing. Following a careful preliminary examination, the baby is shown to the doctor if it is not doing well, or if the mother wishes advice on some special point. In addition to this clinic service, and the occasional home visits from the nurse, the regular presence of the nurse in the station at a certain time each day serves as a constant source of counsel for mothers in the neighborhood. The nurse's advice is sought on all kinds of problems from such simple questions as when to put the baby into short clothes to complicated and delicate problems [27] NEW CLINICS FOR OLD of family relations. The value of this incidental service is impossible to measure, especially when a nurse has become identified with a district through years of welcome service. The baby-health clinics throughout the country are generally similar to those just described. They have undoubtedly been one of the important factors, though not the only one, in the marked reduction that has taken place in infant mortality. During the fifteen years that the infant-welfare stations have been intensively developed in New York City, the infant-mortality rate has diminished from about one baby in ten during the first year nearly to one in twenty. It has been noted that the Department of Health stations have not been increased much in recent years, and that private organizations have found it wise, or necessary, to supplement the service by stations of their own. It is a question whether an established health service of this kind, the general responsibility for which has been assumed by the City, is a fair burden upon private endeavor, and whether the whole situation of infantwelfare work, which has remained little changed of late years, and possibly become somewhat routinized, would not benefit by careful study and some recasting, both with reference to the relative parts to be played by public and private organizations, and as to the relations of the infant-welfare stations to prenatal work on the one side, and to certain activities for children over two years of age on the other. To be successful in this field, the doctor must examine, not only to detect physical defects or diseases but with an eye to improving the baby's adjustment to his environment. In the course of his examination he inquires into the baby's habits, and brings into his diagnosis an estimate of nutrition, muscle tone, coordination, and, roughly, mentality. His plan includes, besides the feed [28s] THE NEW CLINICS ing formula, suggestions as to sleep, clothing, and discipline. The nurse must observe not only the baby's weight but also the development of his coordination, his teeth, and fontanels as well as whether he has fresh air, a quiet sleeping room, and suitable bathing and clothing. This breadth of content in both the doctors' and the nurses' work requires special preparation to know what is significant and how to interest the mothers. This ideal, clear and obvious in theory, has not been so easy to put into practice. Among other reasons for this is the assumption that health guidance was simple because no serious disease existed, and that any medical or nursing training prepared one to do it. As a result, doctors who had spare time or nurses who wanted regular hours of work have undertaken to render the service irrespective of their special fitness for it. Then, too, this broader content has not been included in the preparation for the medical or nursing professions, so that it must either be picked up, which is difficult because the material is not coordinated; or neglected, simply emphasizing the parts of the service already familiar to doctor and nurse. In the crowded city communities doctors usually do the latter and nurses follow suit. To overcome this temptation, the work must have alert and creative supervision with a continuous check-up on results and progress of various methods. In certain of the clinics under private auspices the doctors have limited the number of babies they see to sixteen in a two-and-a half-hour session. Only eight of the sixteen should be new cases. Under these circumstances doctors find they can make more detailed and careful recommendations which will carry the baby over a longer period without return to clinic, the nurse seeing and weighing the child weekly meanwhile. Where this practice has been introduced, the doctors take much more individual responsibility. [29] NEW CLINICS FOR OLD The majority of clinics, however, like the Department of Health Clinics in New York City, have every baby present seen by the doctor on clinic day if the mother wishes it. Thus doctors see thirty to one hundred babies in their three-hour sessions. While this makes it possible for the doctor to give each mother something, he cannot hope to give her just the next step needed. He can detect the obvious troubles, but cannot guide her in developing healthy habits for her baby. When his directions are given on the spur of the moment, they lack distant vision so that the baby must be brought back at frequent intervals when problems arise that might have been forestalled by careful examination and thoughtful consideration. This means that the doctor sees the health client so frequently he cannot observe the necessarily slow changes, with the result that the mother loses interest before her baby has made gains. Comparative statistics are not available on the end results of these two methods, but the physicians who are limiting their members find far more satisfaction in their service-a satisfaction that can hardly fail to be reflected in their results. Nurses who serve in stations where the number of babies seen by the doctor is limited, find the responsibility placed on them to select the cases wisely very stimulating. Each case comes to them with a careful plan after the first examination so that they develop resourcefulness in carrying out the recommendations. PRENATAL CLINICS Prenatal clinics, like the infant-welfare stations, center their service upon the examination and advice of the client-in this case, the expectant mother-by a doctor who comes to the clinic at specified intervals, and upon the work of the nurse in advising and instructing the mother in the clinic or in the home. In New York City [30 ] THE NEW CLINICS these clinics have been developed chiefly through the Maternity Center Association, which has studied the need for this kind of work, developed policies and standards, and rendered actual service by the maintenance of clinics. Beginning in 1917, the Association aimed to cover Manhattan through 37 local units. It has been gradually stimulating other permanent organizations to take over the service. The Association today retains a demonstration and training district, and supplies doctors and nurses to 11 clinics throughout Manhattan. In these 11 clinics, such organizations as the Department of Health or the Visiting Nurse Service of the Henry Street Settlement manage the clinics and do the follow-up work. When a woman is delivered at home, the Maternity Center Association will, if the physician so desires, send in a nurse to give the post-partum bedside care, provided the woman was known to the clinic before her confinement. Bedside nursing at confinement is also included under certain circumstances. One gauge of the acceptance of this service by the community is the fact that in 1917 when the service was being established 80 per cent of the cases were recruited by door-to-door canvass, an expensive and tiresome job. In 1925 this canvassing was unnecessary, women came voluntarily as a result of satisfactory previous experience, or through doctors or maternity hospitals. In introducing the service in a new locality, recruiting for the clinic is usually necessary, but if the need for it does not diminish steadily the service is in some way not fitted to the needs of the community. Dr. S. Josephine Baker has set as a goal for adequate prenatal service, the instruction and care of fifty per cent of the women confined each year. In making this estimate, care must be taken to include stillbirths, for experience is demonstrating the marked reduction in this [311 NEW CLINICS FOR OLD annual loss possible through wise prenatal guidance. In New York City, there are approximately 130,000 living births a year, and 6,000 stillbirths. Among these 136,000 births, only 16,500 cases, or 12 per cent, received prenatal service in 1925. 5,186 of these received care through the Department of Health clinics, 11,314 through private agencies. We generally find prenatal clinics in connection with the out-patient departments of maternity hospitals, and occasionally in the out-patient department of a general hospital having an obstetrical service. The most highly developed types of prenatal clinics, from the technical standpoint, are those in connection with hospitals, where the prenatal service, the care and delivery in the hospital or in the patient's home, and the postpartum care, can be worked out together as part of one coordinated plan. As a matter of general policy, it would seem desirable to build up the prenatal clinics of a community in affiliation with hospitals. Unfortunately, the location of maternity hospitals or of general hospitals with obstetrical services, in New York City and elsewhere, has rarely been planned with reference to the distribution of population. With the growing general knowledge of the value and importance of prenatal and infant-welfare service, the need for localizing clinics providing these services may perhaps be less in the future than it has in the past. The need is probably less for the prenatal clinic than for the infantwelfare station. It appears, nevertheless, impractical to expect to build up the prenatal work of a communitystill less the infant-welfare service-in a few large centralized units. Hence, a certain number of prenatal clinics must be physically detached from hospitals. Medical affiliation and supervision by the hospital, with or without administrative control and support, is, however, practicable even if the clinic is located at a long distance from the parent hospital. The whole prenatal service of [32] THE NEW CLINICS some large cities, Cleveland and Toronto for instance, has been developed along these lines. In New York, where responsibility cannot be centered upon a single hospital, but must be divided among many, it is much less easy to bring about a systematic and harmonious development of this sort. Everything possible should be done by public and private health agencies to encourage hospitals to feel their responsibility in this direction and gradually to work out an ordered system of prenatal clinics affiliated with hospitals and so situated as to cover all districts of the city needing the service. To bring about an affiliation between an unattached prenatal clinic and the hospital requires receptivity on the part of the medical and administrative authorities of the hospital towards this phase of their community responsibility, and also some pledge or outlook for financial support for the new obligation which the hospital would thus assume. Medical affiliation between the unattached prenatal clinic and the hospital service, combined with administrative and financial maintenance of the clinic by an official or a voluntary health agency, would bridge this gap. DENTAL SERVICE A form of service primarily preventive which also requires localization in many detached units is dental prophylaxis for children, i.e., the cleaning of teeth and instruction in oral hygiene. In those cities where this service has assumed large proportions, it has been best developed through the school system, and largely through unattached or traveling clinics, preferably associated with and professionally supervised by a central institution. In New York this public-health measure is but slightly developed in comparison with Boston, Rochester, Detroit, and Toronto. The number of children's clinics [33] NEW CLINICS FOR OLD under municipal control is only about the same as in Detroit, which has one-fifth the population. In addition to the two large dental clinics ("infirmaries") conducted by the two dental colleges of New York, there were in 1924 approximately 65 dental clinics unattached to hospitals, excluding those maintained by industries. These clinics might, from the present point of view, be classified as follows: For children, 33 located in school buildings, of these 19 were maintained by the Department of Health in public schools and the remaining 14 by private organizations in public or special schools. Twenty established by health organizations, settlements, churches or charitable societies. These dental clinics are sometimes by themselves, sometimes in conjunction with other unattached clinics in the same building. These clinics generally confine themselves largely, but not as a rule wholly, to children, and emphasize preventive work, although the urgency of the demand for many forms of curative work renders a rigid policy in this respect difficult. The ten additional unattached dental clinics are mostly in the old-fashioned treatment dispensaries, or in the teaching clinics of the medical schools, and are similar in their scope of work, as a rule, to the forty-odd dental clinics which are in the out-patient departments of hospitals. Their work is primarily reparative and curative in nature. The broad line of demarcation of function between the emphasis on treatment in the clinics connected with hospitals and the emphasis on prevention in the unattached clinics is quite clearly defined in the dental field. On the other hand, the fact that prevention and cure must often intermingle in the same service is likewise well brought out. [341 THE NEW CLINICS UNATTACHED TREATMENT CLINICS We thus pass to a discussion of the other type of service rendered by the newly established unattached clinics, especially illustrated by clinics dealing with tuberculosis, venereal disease or heart disease. These clinics face the problem of determining through examination and diagnosis the presence or absence of a certain disease or defect, and if the disease exists, of furnishing or referring to appropriate treatment; and also of taking the educational or social measures necessary to help the sufferer to adjust himself to the handicaps, temporary or permanent, of a disease like tuberculosis, or of a heart lesion. Steps necessary to protect others from infection may also be called for. Educational and preventive aspects intermingle thus intimately with curative work. In such clinics there is often a diagnostic problem involving the use of laboratories, x-rays and consultation services, which as a rule can be most adequately or economically provided in the out-patient department of a hospital. The patient may also require periods of bed care or diagnostic observation which should be under the same medical guidance as the clinic treatment. An example of these relationships appeared in the work of the "after-care committee," organized following the infantile paralysis epidemic in 1916. Through this committee there were established local services (clinics) which were affiliated with out-patient departments of hospitals especially equipped for caring for such cases. The orthopedic hospitals were, of course, primarily concerned. The local stations or clinics served as neighborhood recruiting centers, in which cases needing only massage might be treated, from which nurses followed up cases, and to which neighborhood cases came for preliminary examination or diagnosis and for assignment to the nearest or most appropriate clinic in the out-patient [35] NEW CLINICS FOR OLD department of a hospital. There the facilities were provided for making the final diagnosis and for treating specialized cases needing therapeutic resources not available in the local stations. TUBERCULOSIS CLINICS In the case of tuberculosis clinics, diagnostic and therapeutic factors intermingle with these of education, prevention, and sanitary control. There are in New York City 21 unattached to hospitals, all of these but two being under the Department of Health. Ten tuberculosis clinics are in the out-patient departments of hospitals, four under the auspices of Bellevue and its allied institutions, and the remaining six in privately supported institutions. All are affiliated through the long-established Association of Tuberculosis Clinics, now a part of the New York Tuberculosis and Health Association, which has exercised a highly beneficial influence in establishing standards and in securing a body of statistics of great value in guiding the work. The relative advantages of the tuberculosis clinic in the out-patient department of the hospital and that unattached to a hospital has been the subject of some recent study as to internal efficiency and also as to community relationships. The statistics of the Association of Tuberculosis Clinics indicate that the advantages of the connection of a tuberculosis clinic with a hospital are not merely theoretical, but are real. Community relationships and neighborhood conditions must be considered as well as considerations of internal efficiency in diagnosis, care, and preventive effort so that any decision to transfer unattached tuberculosis clinics to the out-patient departments of hospitals should only be made after individual consideration of each clinic and of the several areas involved. [36] THE NEW CLINICS VENEREAL-DISEASE AND CARDIAC CLINICS The advantages of the association with the laboratories, consultation, and therapeutic resources of an outpatient department of a hospital in the case of clinics which have a public-health purpose but which must deal with disease, is well brought out in the case of venereal and cardiac clinics. In 1926 there were 118 clinics treating syphilis or gonorrhea in New York City, located in 58 different institutions. All but eight institutions are the out-patient departments of hospitals or the teaching clinics of the medical schools. Elsewhere in the United States a considerable number of unattached clinics dealing with venereal disease were established during the war period unconnected with hospitals, usually directly under the auspices of an official or voluntary health organization. The number of these unattached venereal clinics has decreased since the war, as the work has been taken over into the out-patient departments of hospitals. A slowly, but still actually, increasing receptivity on the part of the hospitals to the public-health point of view, and also a clearer recognition of the medical and economic value of the hospital connection to clinics of this type are probably responsible for this development. It is further and especially well illustrated by the cardiac clinics, which have sprung from the very recent and very important movement for the study and control of heart disease. Of 44 cardiac clinics in New York City all but two are in the out-patient departments of hospitals. INDUSTRIAL CLINICS The second main reason, indicated on page three, for the recent development of unattached clinics is the special demand of organizations to meet the needs of their employees or clientele. Largest and most important [37] NEW CLINICS FOR OLD among this group are the industrial clinics maintained by many of the larger business enterprises, such as insurance, transit, telephone, and manufacturing companies, and by department stores for providing various health, and sometimes also treatment, services for their employees. The special interests and problems of the industrial clinics lie outside the scope of this monograph, and the industrial clinics have therefore not been included in the statistics of the number of clinics and attendance. CLINICS UNDER PRIVATE AUSPICES In smaller or newer communities, the voluntary health organization has often found the establishment and maintenance of clinics an important, and sometimes a continuing, activity. In New York City clinics have more frequently been established as an indirect result of the activities of the voluntary health organizations, which have stimulated other organizations to a realization of health needs formerly unrecognized and to the establishment of various clinics to meet these needs. Charitable societies, social settlements, and churches have, together with other institutions and with the general public, been aroused of late years to greater interest in health, have considered the needs of their district or their clientele from this point of view, and the establishment or the encouragement of clinics has been one of the results. Some of these efforts have taken the form of treatment clinics akin to, though more modern in type than, the oldfashioned treatment dispensaries. The great majority have taken their color from one or another of the publichealth movements above referred to. In addition to the city health authorities, a variety of private welfare agencies has been thus stimulated. [38] THE NEW CLINICS Forty-seven different agencies were involved in the 93 unattached clinics maintained by private organizations in 1924. Thus, a church maintains dental, nutritional, and general examination clinics having particularly in mind service to their Sunday School group. Another church initiates a health center with some therapeutic as well as preventive services, for the benefit of a considerable specified district in its vicinity. A settlement starts infant-welfare, preschool and prenatal services, leading into a more general health program for its district, adding among other activities a mental-hygiene clinic. In 1924 nine settlements and ten churches were maintaining clinics. In the same year, 14 different charitable organizations were maintaining 31 clinics. For the charitable agency, the problem of securing examinations and advice for their clients is an important one, not at present met adequately by the out-patient department of the hospital.* Hence, some of the charitable agencies doing family-welfare work have established clinics for general examinations or for certain specialized examinations, particularly psychiatric, for their clients. Some societies, notably the Association for Improving The Condition of The Poor, have undertaken an extensive systematic health program with a number of clinics. Forty-two of the 93 unattached clinics mentioned above were in 1924 maintained by 14 different organizations whose work was primarily within the medical field. These organizations have set up clinics partly as supplements to the activities of the municipal authorities, as in some of the baby-welfare stations on Staten Island maintained by the New York Tuberculosis and Health Association, partly as the outgrowth of their special purpose to develop some particular forms of health service, as in * Seereferences in Appendix. [39 1 NEW CLINICS FOR OLD the case of the Maternity Center Association with its prenatal clinics. A keen feeling for the needs of families in various districts has led the Visiting Nurse Service of the Henry Street Settlement to maintain a number of baby-welfare, preschool, and prenatal services. Somewhat less than half of the 93 unattached clinics maintained by private organizations in 1924 were under the auspices of purely local organizations like settlements, churches, or charitable societies, which carried on a clinic in one locality only. The remaining clinics, constituting the majority, were under the auspices of city-wide organizations such as those just mentioned, together with the New York Diet Kitchen, with its eight stations serving babies and preschool children, and the Children's Aid Society's clinics for its special school population. The significance of this distinction between the purely local unattached clinics and those maintained as part of a general scheme by a city-wide organization will be discussed later. Thus it will be seen that, within the past fifteen years, there have grown up a variety of clinics, unattached to hospitals, performing services very different from those of the old-fashioned dispensaries, linked up with public health movements on the one hand, and with a great variety of public and private organizations on the other. [401 CHAPTER IV PROBLEMS OF THE NEW CLINICS HE PROBLEMS and difficulties associated with the unattached clinics are to be considered in this chapter, and begin with those connected with standards of service. The characteristic activities of these unattached clinics emphasizing health and preventive work rather than the diagnosis and treatment of illness have placed them in a field in which standards and technique are far less developed than in the longer established areas of clinical medicine. National and local organizations have gone a long way towards working out standards for tuberculosis, infant-welfare, and prenatal service, both in those aspects which concern the doctor's and the nurse's technique and those of the set-up, administration, and relationships of the clinics. A similar process is now going on in relation to clinics for heart disease, and a notable beginning has been made by the American Medical Association and some industrial and health bodies to work out standards and methods for the general health examination.* Much less progress has yet been made in agreement as to standards for the scope and kinds of work which are most appropriate to local dental clinics, though a hopeful start in this direction may be recorded. Standards of policies and methods in mental-hygiene clinics will, it is hoped, be greatly advanced by important demonstrations now under way in the child-guidance field. Least standardized of all, perhaps, are the services to children of preschool age. Clinics dealing with this group are found to provide a wide variety of differing services, * See references in Appendix. [41] NEW CLINICS FOR OLD and the work must be regarded as yet as experimental, feeling its way towards agreement upon the kinds of service- which prove effective in bringing results not merely in the correction of defects but in the best development of little children. The services offered today depend for their methods and results largely on the personalities of the doctors and the nurses administering the services. They are excellent in spots and faulty and mi~sdirected in other places. The practical difficulty is illustrated by the f act that it is reported to be hard to keep the mothers interested and their children in sufficiently regular attendance. Few health workers appear to be f acing the f act that there is little off ered in most preschool clinics to make the service really important to the mother. It does not help her in her everyday perplexities. The problems of feeding or of correction of defects, which have dominated infant and school work are too specialized f or this age. Health guidance f or the preschool child must include advice as to nutrition, muscle coordination and control, and especially habit training. Nutrition instruction, f or example, which has become a fairly exact science for infants, is vastly more complicated f or preschool children, but when this service is well done, it contributes to the health of the entire family group. These items merely suggest some of the f actors w~hich need study before work with the preschool child can be effective or standardized. (1) DIFFICULTIES IN CARRYING OUT STANDARDS The carrying out of standards, so far as they do exist, however, is another -matter from the standards themselves. The unattached clinic providing services along (1) Discussed also in Chapter V of Health Services in Clinics by Anna M. Richardson, M.D. (New York, The Committee on Dispensary Development of the United Hospital Fund, 1927). [I 42]1 PROBLEMS OF THE CLINICS preventive lines suffers not only from the lack of standards in various fields, or the lack of sufficient understanding of what standards do exist, but still more from the practical difficulties of carrying out these standards under working conditions. These difficulties may be summarized under four heads: (1) Limitations of Nonmedical Agency; (2) Lack of Supervision; (3) Lack of Properly Trained Personnel; (4) Lack of Statistical Data. LIMITATIONS OF NONMEDICAL AGENCY The settlement, the church, and the charitable agency, established as they have been for other than medical or public-health purposes, often lack in their.directing boards and staffs the background, understanding, or connections to secure the right professional personnel for the clinic, or to conceive and carry forward its policy clearly and consistently. The city-wide agency in this respect is likely to be in a much better position than the purely local agency, partly because the city-wide agency, through more varied connections and greater resources, can more readily secure the advice, direction, and when necessary, the special staff required. Among the local clinics established by isolated agencies, examples have been noted, such as the following: a clinic was maintained with enthusiasm for some time, but when a certain individual left the staff of the organization the service was abandoned because there was no one competent or interested to carry it forward and secure support; in another organization, the one person employed, being the only individual with a medical background in a nonmedical organization, dominated the situation completely, producing a one-sided and uncooperative development; in another instance a local organization had under way a program certain to arouse active opposition from the [ 43 1 NEW CLINICS FOR OLD practising physicians of the district, but because of lack of experience in health work, and lack of contact with those familiar with it, plans had been made without any consideration of this factor. LACK OF SUPERVISION This leads to the second difficulty-that of providing supervision of the personnel. The physicians, dentists, nurses, social workers, and others engaged in a small isolated unit need, even when qualifications and character are of the best, contact with other workers, and a certain degree of supervision in order to maintain standards, and to preserve that sense of cooperative professional work which is essential to the best morale. An even more serious problem is the intimate cooperation that must exist between the doctor rendering the technical service and the nurses or social workers doing the field work. The place and responsibilities of each have a slightly different emphasis from that found in the treatment of disease. Therefore many misunderstandings arise if there is not a type of supervision which understands both and can enter into the service in enough detail to see that personnel relationships are sound. The out-patient department of a hospital, or the public or private health organization covering the city or a borough, can provide this supervision and stimulus through department heads, bureau chiefs, supervisory or advisory medical boards or committees, and through staff conferences. The purely local agency rarely finds it possible to furnish any of these forms of constructive supervision. A few have medical advisory committees secured through the influence of the members of their boards of trustees, but while such committees are occasionally useful in advising the board on some questions of general policy, they are hardly ever capable, as a body or through their [44] PROBLEMS OF THE CLINICS individual members, of meeting the need for supervision of the regular work of the clinic or the other health activities of the local organization. The tuberculosis clinics long ago attacked the problem of standardization through the Association of Tuberculosis Clinics mentioned in the last chapter, and the conferences and other activities of this Association have furnished much the same kind of stimulus as do certain forms of administrative supervision. The Associated Out-Patient Clinics have worked out clinic standards* in 'a number of branches, and have provided, less intensively than the tuberculosis group, some stimuli of a similar nature, but these do not amount to supervision, and they have not affected to any extent the clinics unattached to hospitals. Of course, the need for systematic supervision and stimulation of the physicians and other personnel engaged in clinic work exists in the out-patient department of the hospital also. Within the scope of this report, however, we must confine ourselves to pointing out the special need for supervision in, the unattached clinics, and the special difficulties of providing it f or them. The studies of the Committee on Community Dental Service have led to the conclusion that the isolated dental clinic is in need of systematic professional supervision f or the maintenance of adequate technical standards,* as well as f or the establishment and carrying out of sound policies in the selection of cases and in the kinds of dental work to be done. Attention has been directed toward the possibility of a central committee, furnishing by request of local organizations certain forms of supervision, but the difficulties are considerable and only experimental beginnings have yet been made. It is obviously difficult to draw the line between the furnishing of super*See references to Standards iin Appendix. [ 45]1 NEW CLINICS FOR OLD vision and the assumption of responsibility for the professional standards and the quality of the service provided in the local organization which is "supervised." Other obstacles in the way are the expense of supervisory service, which must necessarily require a highly skilled personnel, and the difficulty of securing from the local organizations a payment equivalent to what the service costs. LACK OF PROPERLY TRAINED PERSONNEL A need closely related to that for supervision is in connection with securing professional personnel. Few physicians have had training in preventive medicine as applied to individuals. The personality of some physicians renders them naturally effective in such work, yet such personalities are seldom appreciative of the inherent problems of the work and are impatient of necessary standards and of the need for research. Personalities of this type often do not easily benefit by the experiences of others. Then, too, it is difficult to secure and retain such types. A sufficient supply of adequately trained public-health nurses and social workers is also a problem. The unattached clinics maintained by agencies not especially formed for medical or public-health purposes rarely have any systematic method or established connections which would enable them to secure the physicians, dentists, or nurses who are qualified for the particular work to be done. At the time the clinic is started, it not infrequently happens that the initial professional service is secured through some member of the governing board of the agency, whose family physician suggests or obtains a doctor as a personal favor, or some members may be associated with leading physicians or with a medical committee of some kind, through whom the clinic positions are filled. This method obviously does not always secure [46] PROBLEMS OF THE CLINICS a professional man who is especially qualified for the kind of work required, and the local organization is unlikely to have any advisor, committee, or other machinery to select personnel at times when additional physicians or dentists are needed, or to judge the qualifications of candidates. No request has been more frequent to us from the local organizations maintaining clinics than the plea to suggest professional personnel to man a clinic of one kind or another or to pass on the qualifications of physicians or dentists who have been suggested. In providing supervision or securing personnel, the city-wide organization is obviously in a better position than the purely local agency. Even if the work of a citywide organization is not primarily in the medical or health field, it is usually of larger size, has or can obtain connections with organized medical bodies, can form a medical advisory committee, or in some other way secure an agent to serve these purposes. Organizations formed specifically for medical or public-health purposes usually have automatically the needed professional contacts. LACK OF STATISTICAL DATA Closely connected with the three difficulties above named, which stand in the way of carrying out standards in the unattached clinics, is lack of facts from which the work done can be judged. There are inadequate medical records in some instances. There is frequent deficiency in the elementary current statistics of the numbers of patients, visits, and other elementary facts showing the bulk of work each month and year. Comparatively adequate medical records not infrequently exist, even in local unattached clinics, but it is exceptional that these will have been utilized by the administration for the pur [47] NEW CLINICS FOR OLD pose of securing the administrative statistics, which show the bulk of service and which sometimes suggest important points regarding its scope and quality. This again is a phase of deficient standardization; in this case a lack on the administrative, rather than on the professional side. The individual local organizations maintaining unattached clinics have more especially illustrated this defect, partly because the clinic is usually an undertaking aside from their main purpose and partly because of detachment from the sources of knowledge regarding the technique of administering medical services. Supreme good will in managing a clinic is an important element in successful work, but is not a substitute for facts by which the service can be intelligently guided. A special law of New York State places all "dispensaries" under the supervision of the State Board of Charities, which must license each such institution, and which has the power and duty of inspection. This law was passed in 1899, before the modern public-health movements had developed, and when the only unattached clinics in existence were the old-fashioned "dispensaries." A considerable proportion of the unattached clinics representing the new attempts to work along preventive lines are not therefore regarded as coming within the purview of the law or under the supervision of the State Board. Whether a revision of the law or a broadening of its interpretation to include these new types of clinics would be practicable and desirable, will be discussed briefly in the final chapter. CHARGING FEES FOR PREVENTIVE WORK Since the purpose of these new clinics has been to educate people to use the service, and they have had the motive of health promotion rather than of charity, their [48] PROBLEMS OF THE CLINICS situation has been held to be quite different from that of' clinics treating disease, and, as a rule, whether under private or public auspices, they have not charged fees. Most of the dental clinics, however, even those confined to prophylactic work, have done so. Some experiments in well-baby clinics, serving persons of moderate means at a fee covering cost, have been successful, as have clinics furnishing health examinations for a fee of about five dollars. These experiments serve to educate the public in a practical way as to the value of preventive services, but as yet most persons seem to be unwilling to pay either private physicians or organizations for individual services of a preventive character. DEFINITION OF POLICY IN ESTABLISHING CLINICS The problems and difficulties thus far discussed may be called internal, since they concern the professional or administrative standards of the unattached clinic. Another type of problem, of broader scope, is the policy under which such clinics are, or should be, established and the mutual relations of the clinics serving a given district. The number and variety of organizations concerned in the comparatively sudden expansion of unattached clinics in recent years suggests the impression,. which more intimate study has confirmed, that clinics have often been started without full consideration of all the factors involved. It is one thing to feel convinced as a matter of intimate neighborhood experience that a certain kind of curative or health service is insufficiently provided in a district; it is another thing to decide that this particular form of service can and should be furnished by a particular agency. It is not always true that the organization which has come to realize the need is the, best organization for providing the service to meet this; need. [49 ] NEW CLINICS FOR OLD On the other hand, there is a wholesome side to this stream of little independent activities that have taken the form of varied local clinics, nursing, educational, and recreational services. It is a good thing that local organizations should feel needs and should define them sufficiently to make concrete efforts to meet them, and in so doing experiment with ways and means of making modern city life more wholesome and healthy, particularly for the children, towards whom most of this effort has been directed. The experimental individualistic period has now perhaps continued far enough to make a review of the situation desirable, to have provided enough material for such a review, and to make it worth while to go behind technical standards of clinics and to formulate even in a tentative way the principles which should underlie the whole development. Such principles should touch on one side the functions of various types of organizations, and the kinds of service which they can render effectively, if at all, in the clinic field. On the other side, the principles should also touch the problem of organization which revolves about the much-discussed "health center." The development of the health center should be reviewed before this final summary is attempted. [50] CHAPTER V THE HEALTH CENTER (1) THE TERM "Health Center" has been given many different meanings. Its broadest application has been to a community organization for both preventive and curative medicine, centering around a hospital as its institutional expression, and around an organization of medical men, health authorities, and laymen, as the means whereby the institutional facilities might serve the whole local population. A comprehensive "health center program" of this sort was proposed for England a few years ago by the Ministry of Health. In a somewhat modified form, but under the same name, a similar program for New York has been proposed to the Legislature by the State Health Department, but not yet enacted. The much discussed "community hospital" for small towns and rural areas is often referred to as a health center. This broad meaning of the term may become generally accepted when such plans are fully realized in practice. But at present this is not the case. Even in its more usual and restricted meaning, the term "health center" needs analysis before definition. The kinds of clinics and educational activities which the term designates are so varied in different communities, and even within New York City, that some historical review and examination of common characteristics are necessary. As methods in any field of service are gradually tested and standardized, the emphasis shifts from experiment (1) The material in this chapter has been taken from Chapter XXIII of Clinics, Hospitals and Health Centers by Michael M. Davis, published by Harper & Bros., New York, to whose courtesy the privilege of utilizing it is due. S51. 1 NEW CLINICS FOR OLD and research to extended application. As soon as certain methods of controlling tuberculosis or infant mortality had proved effective, the primary question facing the promoters of these movements became, how shall the methods be applied so as to reach the greatest possible number, and ideally, the whole population? This states in an interrogative way the first of the two essential ideas 'behind the health center, namely, the aim to serve intensively or effectively the people of a defined area. Service to the people of a specified district is one health center slogan. COORDINATION OF MEDICAL AND HEALTH SERVICES A second root idea in the history of health centers in this country is that of the co6rdination of medical and health services. The organized health movements which have spread like waves over the United States during the last twenty years have each begun as a specialized activity dealing with tuberculosis, infant or maternal mortality, venereal disease, mental disease, or child health, and each has tended toward having its own specialized staff. To a certain extent this has been wholesome and necessary, but after the experimental stage the application to a small local area of several specialized medical and health programs becomes confusing and self-defeating. Coordination of clinic services and home visiting services in given areas was an outstanding problem before the war, to which the health center idea frequently seemed to offer a solution. During the formative period, from 1910 to 1915, the effort to relate services to a definite population or district began to take practical shape. In Pittsburgh the tuberculosis workers, under the leadership of Dr. William Charles White, started significant activities and began to formulate their philosophy. In Cincinnati, a [52] THE HEALTH CENTER health-center program was likewise begun by the tuberculosis workers; in New York, in the child-health field, by the New York Milk Committee; in Milwaukee, in the same field by the city administration under Wilbur C. Phillips; in Philadelphia, also by child-health workers, directed by Dr. Samuel M. Hamill. The coordination idea began to have local expression during the same period. In Boston during 1912-15 the Maverick Dispensary developed gradually into a co6rdinating center for a number of health activities in East Boston, without, however, any coherent central organization. Toward the close of this period the Health Department of the same city initiated the "Blossom Street Health Unit" by providing common headquarters for a number of health agencies of the West End district. Buffalo began in 1914 the most extensive development in this country of a hospital and health-center program for a large community. The year following, Dr. S. S. Goldwater, then Health Commissioner of New York City, initiated an important health-center project serving a district of the lower East Side with all the facilities of the Health Department, through a localized administrative unit. The plan was extended experimentally by the organization of similar health districts in the Borough of Queens. Political conditions prevented the continuance of this project. In this field, as in others, enterprise was held back during most of the war years, but near their close great impetus was given to certain forms of health work. The American Red Cross advertised the health-center idea and especially the dissemination of health information, throughout the country. The term "health center" was thus popularized, but there was considerable opposition to the movement from the medical profession, usually because its nature was not properly understood. Several [53] NEW CLINICS FOR OLD hundred "health centers" were established during this period. They varied in scope from extensive enterprises to mere offices giving general health information. HEALTH DEMONSTRATIONS During the post-war period, the chief development has been the so-called "demonstrations," intending to work out methods of applying certain programs to a community or district. These projects have generally been financed by foundations, or by some single specially interested group, rather than by the general public. Notable among them have been the Framingham Tuberculosis and Health Demonstration supported by the Metropolitan Life Insurance Company; the series by the American Child Health Association in cities of moderate size; the demonstrations of the Milbank Memorial Fund in Cattaraugus County, in Syracuse, and in the BellevueYorkville District, New York City; and the East Harlem Nursing and Health Demonstration, also in New York, operated in conjunction with the East Harlem Health Center described later. All such demonstrations have involved the establishment of clinics and the formulation of a health-center idea to a greater or less degree. A review of the activities actually conducted in organizations known as health centers in New York City and elsewhere in the United States and Canada, and of the forms of their organization, shows plainly that a health center cannot be defined in terms of any specific list of activities or by the form of its organization or by its physical plant. We find health centers, as in Cleveland, Buffalo, or New Haven, offering new forms of health service, chiefly or wholly preventive in nature. On the other hand, we find in Des Moines, Halifax, Alameda [54 1 THE HEALTH CENTER County, California, and New York City, health centers which offer a wide variety of preventive and curative services. On the basis of observation and experience, labels such as "preventive," "curative," "health," " medical," and the like, should not be applied to services as arguments either for or against their inclusion within the program of a health center. The sound basic considerations are the needs of a district and the availability of various services rendered by other already existing agencies and by private medical practice. It is likewise impossible to specify a particular form of organization for a health center-administrative or federative. A review of the situation shows again that organization must conform to local conditions, and cannot be prescribed a priori. The extent to which a federate form of organization, pooling the interests of a number of existing agencies for the common service of an agreed area; and the degree to which welfare agencies not in the health field shall participate in the organization and activities of the health center, are examples of questions of this type, which for the present at least should be worked out on a pragmatic basis. A definition of a health center might, however, be stated in terms of the two factors which all health centers that have been studied appear to present: first, the selection of a definite population or district unit, with the aim of serving all therein who need the services offered; second, coordination of services within this area, embracing both the facilities furnished by the health center itself and those provided by other agencies. The definition might be stated as follows: A health center is an organization which provides, promotes, and co6rdinates needed medical service and related social service for a specified district. In New York City we have a number of illustrations of the health center in its various forms. The Bowling [55] NEW CLINICS FOR OLD Green Neighborhood Association, established since 1914 on the lower West Side, and recently installed in its new building, exemplifies as to form of organization the health center managed under one administrative control, and as to range of work, both curative and preventive service combined with various social and recreational activities. The Mulberry Community House, or Mulberry Health Center, of the A. I. C. P., has exemplified the service and demonstration aspects of the health center without, for obvious reasons, illustrating to any great extent the coordinating factor. It has demonstrated various methods of meeting district needs, of stimulating and improving existing agencies and of checking up progress and results. The Red Hook Center of the Brooklyn Bureau of Charities has illustrated a small unit providing a limited range of services (for tuberculosis and for children). It may be of service to describe in more detail the activities of one health center of a nonfederate type as a basis for certain subsequent discussion. JUDSON HEALTH CENTER The Judson Health Center was initiated in 1920 by a church. It is an independently administered unit with its own board of directors. It undertakes to serve a definite area, with a population of over 40,000 persons, predominantly Italian. The stated aim of this Center is threefold: (1) The encouragement of the people of the district to undergo thorough physical examination at stated periods. (2) Through the use of curative measures to correct such physical defects as the examinations disclose, and to make such curative measures the media through which preventive health lessons may be taught. [ 56] THE HEALTH CENTER (3) The education of the people of the district in proper habits of diet, exercise, rest, cleanliness, and general hygiene. The accompanying schedule shows the clinics with the number of weekly sessions as indicated. JUDSON HEALTH CENTER CLINIC SCHEDULE SESSIONS 'General Clinic (Adult Medical, Surgical, Gynecological)..... 6 Daily 9-11 Physiotherapy................ 6 Daily 10- 3 Child Health................. 5 Ex. Sat 1- 3 Child Medical................ 3 Mon., Wed., Fri. 1- 3 Ear, Nose and Throat......... 2 Tues., Thurs. 1- 3 Eye........................ 2 Tues., Thurs. 1- 3 Dental....................... 6 Daily 9-11 In 1925 about 25,000 clinic visits were received and almost 17,000 home visits made. Over 5,000 persons, exclusive of school children, were served. The field staff consisted of a director of family-health service, a supervisor of nursing, a supervisor of nutrition, seven or eight staff nurses, four nutrition workers, and four trained Italian workers acting as visitors and interpreters. The staff divided its time between clinics and home visiting. Day nurseries were conducted taking specially difficult feeding cases among infants not actually sick, but have recently been given up as too expensive. There is no organized federated relation with other agencies but several cooperative programs have been undertaken, notably the provision of a health service in a neighboring public school, supplementing that furnished by the city; and, in a special school conducted by the Children's Aid Society, a program of dental health service, which is gradually being taken over by that organization. The problem of coordination has thus only [57 ] NEW CLINICS FOR OLD been touched. About 12 per cent of the total population of the district is reached, but this includes about a fifth of the babies and preschool children, and more than a quarter of the school children. CLINTON NEIGHBORHOOD CONFERENCE The coordinate aim of the health center naturally takes form when a number of different agencies serving the district are brought into some federate type of organization. This is illustrated in a very interesting way in New York City by the Clinton Neighboorhood Conference, organized in 1918 by a group of agencies on the middle West Side of Manhattan. It is essentially a federation of 46 existing agencies for the purpose of joint planning to study or to meet needs of the district, and to co6perate when possible in securing or providing service to meet unmet needs. The participating agencies include hospitals, public schools, public libraries, health centers, social centers, and representatives of the charitable organizations, the churches, the Young Men's and Young Women's Christian Associations, and the Society of St. Vincent de Paul. Several of these agencies are providing certain health services through clinics, visiting nurses, and social workers. The Neighborhood Conference has assisted in interrelating these services more effectively. In the Greenwich, Chelsea, and Lower East Side districts of Manhattan there exist local councils of social agencies which have much the same purposes in view. The Clinton Conference has gone further than the others in one respect, namely that the Conference itself has provided, for the benefit of its members and the district, a dental clinic, because of the urgent need for this felt by all members. The Clinton Neighborhood Conference might thus be described as a federate health-center organization [58] THE HEALTH CENTER without the physical expression of a health center in a building. The widely known East Harlem Health Center is an example of the federate type of organization which also possesses a building. EAST HARLEM HEALTH CENTER In accordance with the announced program of the American Red Cross, a special health service committee of the New York County Chapter initiated a plan for the East Harlem Health Center near the close of 1919. This was to be of the federate type, serving approximately 112,000 persons in the upper East Side of Manhattan. It was organized in January, 1921, and opened for active service in September of that year. The organizations and services included in 1926 are shown in the accompanying list. As may be seen, the services are chiefly of the preventive type, as there are a number of hospitals and clinics for treatment purposes, easily accessible. There is a council of representatives from the 23 agencies with an executive committee of 11 members, to which the executive officer is responsible. The council and its executive committee directly control the operation of the building itself, owned by the American Red Cross, and a few central services, but have no administrative authority over the work of the constituent agencies. The total budget for the work of the health-center organization alone for the year beginning September 1, 1924, was less than $21,000, but about $300,000 was expended by the 23 constituent agencies. During the three-year period the amount expended by all the agencies in the district increased from $1.70 to $2.79 per capita for the 112,000 population. It is estimated that the actual services were more than doubled. It is notable that the City Health Department took an important part in the cooperative activities as well as in providing services. [59] NEW CLINICS FOR OLD Tuberculos: General M( Baby-Heall Eye Clinic Vaccinatior Cardiac Cl EAST HARLEM HEALTH CENTER SERVICES 1. Services Within the Center AGENCY RESPONSIBLE is Clinic Bureau of Preventable Diseases, edical Examinations New York Health Department th Station Bureau of Child Hygiene, New York Health Department n and Schick Tests inic Prenatal Clinic Psychiatric Clinic "Health Shop" (Community Health Education) Health Information Bureau Home Visiting Nursing Service Social and Family Welfare Aid to CrippledIChildren Heart Committee of the New York Tuberculosis and Health Association Maternity Center Association State Charities Aid Association New York Tuberculosis and Health Association American Red Cross Visiting Nurse Service of the Henry Street Settlement (a) Association for Improving the Condition of the Poor (b) Charity Organization Society (c) Jewish Social Service Association Association for the Aid of Crippled Children 2. Affiliated Services in Neighboring Buildings Dental Service Children's Examination Clinic Jefferson Clinic Auxiliary Nutrition Classes (Health Department and A. I. C. P.) Social and Educational Service Infant and Child Welfare Substations New York Diet Kitchen Association Infant and Preschool Clinics Prenatal Clinic East Harlem Nursing and Health DemNutrition Classes onstration Home Visiting Nursing Service American Social Hygiene Association 3. Additional Advisory Agencies Catholic Charities of the Archdiocese Haarlem House of New York Committee on Dispensary Develop- Harlem Council for Women ment St. Timothy's Community Center, Inc. Federation Settlement Union Settlement [60] THE HEALTH CENTER THE PLACE OF THE CLINIC IN THE HEALTHE CENTER From the point of view of this report, a health center obviously represents a combination of a number of unattached clinics with one another, and with other public health and social services of or for the district. The unattached clinic, whether therapeutic or preventive, when located in the health center, obviously loses some of the disadvantages discussed in the preceding chapter. When clinics are located in the same building, they are of mutual assistance. A combination under one roof, for example, of baby-welfare and prenatal clinics, with perhaps also some services to preschool or school children, enables the medical and nonmedical personnel of the clinics to coo-perate with one another to mutual advantage, and also saves time of patients and increases the weight and influence of the clinics in the district. If there are also in the same building, for instance, a tuberculosis, a cardiac, and a dental clinic, still larger opportunities are opened up for the mutual interplay between the clinics in their medical aspects and the mutual stimu.lation of their working personnel. Various cobrdinations in the medical and social case work with patients come about naturally through the personal contacts among the specialized personnel of different clinics, even when these clinics are under separate organizations. The opportunity to provide needed supervision on the professional side is much greater than if the clinics are in isolated units in independent buildings and under independent Bronx might be mentioned as examples of areas not thus jurisdiction. In Halifax, the main health center is physically associated with the out-patient department of a hospital and with an important medical teaching center, so that the whole range of institutional medical practice is provided. But in a city already as well provided with hospitals and out-patient departments as most sections [ 61] NEW CLINICS FOR OLD of New York (the Borough of Queens and parts of the Bronx might be mentioned as examples of areas thus served), the health center would ordinarily not need, and the New York health centers have ordinarily not provided, therapeutic services beyond those which seem urgently called for by neighborhood needs. The problems of standardization, supervision, and personnel brought about among the unattached clinics by their rapid growth under a great variety of independent and mostly small local organizations would thus seem to be largely solvable through the grouping of such clinics into district health centers. Merely grouping them in this way would not, of itself, solve the problems, but would tend to make their solution much easier. Complete solution, however, is not quite so simple, since the clientele of local organizations such as settlements, special schools, churches, and charitable societies have certain needs for health service which may have to be dealt with by, and often within, these organizations themselves. This matter will be referred to in the final chapter. From a broader point of view, the health-center idea in its aspect of codrdination represents the means through which may be solved the problem of planning for adequate and economical health service on a district basis. The growth of unattached clinics and their related nursing and social services under the auspices of numerous local organizations represents the effort to meet this need on an uncodrdinated basis. The health-center idea has, in some other cities, been developed in this direction as a broad community scheme. Buffalo, Halifax, Alameda County, California, and Boston stand out as examples of this. HEALTH CENTER POLICIES Health centers are still in the experimental stage, and numerous problems in policy, organization, and internal [62] THE HEALTH CENTER technique need continued study and experiment. The time has not come for dogmatic statements. How far, for example, is organization of the people of a district a practicable means of promoting the services at the center, and of advancing health education throughout the district? Experience shows great value in a loose local organization of agencies interested in medical or health work, in education, especially public and parochial schools, neighborhood and recreational bodies. On the other hand, the attempt to organize the people of a district themselves into a local council, with or without block workers, has generally yielded little result in proportion to the effort expended. The reasons for this difficulty lie deep in the characteristics of American neighborhood life, whether among native or foreign-born. Health work is also a highly technical service, still in the experimental stage and cannot be carried forward by individuals without specialized knowledge and training. The primary question with the federate type of organization is how far the federate scope and authority should go, as distinguished from the administrative authority of the constituent agencies. As yet this question cannot be answered on the basis of experience. The answer is clearer with respect to program making than with respect to administration. There can be no difference of opinion as to the desirability of a unified program of work for the district. Undoubtedly it is desirable to set up machinery and procedures whereby no one agency will develop its policy and activities without reference to a district program, constructed by all interested groups. RECORD KEEPING IN HEALTH CENTERS* Those interested in health centers will do well to learn all possible in matters of internal technique from the ex* See references in Appendix. [63] NEW CLINICS FOR OLD perience of the longer established hospitals and outpatient departments. In the matter of records, for instance, it would seem unfortunate if health centers should have to muddle through a series of mistakes, repeating the evolution of hospitals and out-patient departments, instead of profiting by their experience. The principle of a unified record system, now generally accepted as desirable in the hospital world, cannot be applied in detail to the health center in exactly the same fashion as to the hospital and the out-patient department; but the fundamental principle that the records concerning a given patient or family should be filed together, and should be centrally indexed, has application to any organization or group of organizations which has various departments dealing with medical and health problems of the same individuals. Although the usual records of a federate type of health center present a technical problem similar to that of the different clinical and social services of an out-patient department, the situation is complicated administratively by the fact that many of the records may be under diverse agencies whose interrelations are far looser than those of the clinics in an out-patient department. The best service to the client, however, would render it desirable to concentrate all the records of the different clinics and to associate as closely as possible with these the nursing or social records pertaining to the same person. Economy and convenience would be promoted by having all the files in a single room from which records could be distributed to the agencies as needed. This would insure much more expert filing and better statistical control. Combination in a single room is, of course, possible without putting all the records of a given individualin a single folder. It is strongly urged, first, that a central record room be specified in planning new centers; [64] THE HEALTH CENTER second, that physical centralization, at least of all medical records, be effected. It may be mentioned that a decimal system of numbering has been devised and proven practicable in some health centers (including Judson in New York), whereby the records of all members of a family are given a certain number, and the individual members of the family are indicated by a number to the right of the decimal point, after the family number. Thus, the family number for Jones may be 1247, and Mr. Jones is 1247.1, Mrs. Jones, 1247.2, and so forth. This makes practicable the correlation between family and individual records, which in the health center has presented special difficulties. The records of all the members of the family will thus be filed contiguously. Thus the social data, which are alike for all members of the family, may be written out only once, rendering it unnecessary to duplicate this information about the family as a whole on the record of every individual member who may receive service in the center. Whatever the record system, a central alphabetical index is essential if the relation of the services rendered to the population of a district are to be known, as well as the interrelations of services to individuals. The central alphabetical index must, of course, be maintained by one organization, usually the federate group of the health center. Each card will show, as in the out-patient department, the identifying information regarding the patient. This will be filed under his name, and will indicate all the clinics, agencies, or departments he has attended, with the date of his first admission. The entire range of services to any client will thus be available through the index, and his complete record can readily be assembled at any time. The alphabetical index is also essential in determining the number of individuals reached by each service and by the center as a whole; in comparing these numbers with the population of the [65] NEW CLINICS FOR OLD district or any subdivision, and in analyzing the number and types of services rendered to persons in various age, sex, or race classifications. Without a good central index, a health center is seriously handicapped in securing knowledge regarding its own work. HEALTH CENTER STATISTICS So far as its technique is concerned, the establishment and maintenance of such an index has been fully described in hospital literature. In federate types of health centers all of the constituent agencies should recognize the importance of the index. Some mechanism must be devised whereby daily reports shall be made by each unit to the central office, showing the individuals admitted and the services rendered them. This is readily done if the building is so arranged that all persons must pass a single point, at which the identifying information can be taken and recorded, or the index card immediately looked up and the appropriate entry made thereon. A daily tally of individuals served, classified according to departments and in other ways, can be made and "pyramided" to the monthly and yearly totals. Quantitative facts regarding the work of the health center depend largely upon a good central index as heretofore described. The center must also derive from its constituent agencies individual reports of their work in their own terms. The cost of the statistical service in a federate type of health center should, of course, be considered in relation to the cost of service by the clinic and field agencies, not in its ratio to the much smaller budget of the central federate body itself. A good central statistical service should aid every constituent agency in policy-making and in administration. The center also needs quantitative data of another kind -namely, vital statistics concerning the area served. [66] THE HEALTH CENTER Health departments do not always report mortality, morbidity, births, and so forth, according to local areas, but the tendency in health work is strongly toward this. In using such data, care should be taken that the figures in the subclassifications are sufficiently large to furnish a satisfactory statistical foundation. Little is yet known how far statistics of mortality and morbidity for districts within a city can be reliably used as yardsticks of progress. The shifting of varying age and race groups, for instance, in and out of the area may defeat the statistical tests. What other footrules can be devised? CORRELATION OF SERVICES The correlation of the medical service with the social service rendered in connection with the center presents a variety of problems. The fact that social agencies often keep their records on a family basis creates technical problems of comparisons between their work and that of the clinics whose records are kept on an individual basis. Another problem is the correlation of the field work done by nurses or social workers with the work done in the clinics. In the typical out-patient department or unattached clinic all of the home nursing or social service is directly related to the medical work of the clinic, and is under the same administrative direction as the clinic itself. Even in this case the correlation of the home work with the work of the clinic is not always easy. When, however, one agency is in charge of the clinic and another of the field work, complications are increased and home service may not bear a sufficiently intimate relation to the medical problems revealed in the clinic. On the other hand, the clinic work may be conducted without proper utilization of the information about the patient's personality and home conditions secured in the home contacts by nurse or social worker. [67] NEW CLINICS FOR OLD It is to be regretted that thus far no one of the federate types of health center, even East Harlem in New York, has worked out these fundamental problems of technique connected with records, the provision of the basal statistical data on which the quantity and efficiency of the work is to be judged. Health centers have especial obligations to foster the experimental attitude toward their own technique, not only as to statistics or records, but as to methods of service to clients. More should be expended on sound fact-gathering and self-analytical service than on publicity, particularly at this stage where the work is new and needs to establish firm foundations. It may be hoped that in the Bellevue-Yorkville Demonstration in New York, with its large resources, a systematic attempt will be made to solve, and to demonstrate the solution of, the important problems of technique and administration of health centers. This Demonstration will also illustrate the need of adapting health-center objectives as well as methods to the peculiar needs of the district. Such questions arise as: With a diminishing resident population, will service limited to this population be an adequate aim for the Demonstration? An increasing day-time population which sleeps all over the greater city being characteristic of this section, how far is service to this large group a legitimate and perhaps necessary aim of a Demonstration which has advisedly selected such a metropolitan area; and by what tests could the results of such service be measured? Since in this area there are at work over 70 health and welfare agencies, many of which serve the whole city, how far is the stimulation and co6rdination of their activities an appropriate aim of the Demonstration, transcending though such an aim does the interests of the district itself 7 Determining objectives which fit the local situation and devising tests of accomplishment will be as challenging as any work of this Demonstration. [ 68 ] CHAPTER VI THE PLACE OF THE UNATTACHED CLINIC IN HEALTH SERVICE T HE, CONCLUSION has been reached that the old " dispensaries"I are a declining and unnecessary type of institution in New York City '. It is a f air question whether the unattached clinics that have sprung up so numerously of late years are a mushroom growth, or whether they have a permanent and distinctive place in the scheme of twentieth-century medical service. The review in Chapter IV of their problems and limitations almost suggests the former conclusion but a study of all sides of their activities leads to a much more favorable view. There can hardly be question regarding the desirability of the inf ant-welf are stations, prenatal clinics and health services to school children under the Departments of Health and Education. The questions here are those of quantity and quality of service. The issue centers, if anywhere, about the unattached clinics maintained by private agencies. In Manhattan, the number of unattached clinics maintained by private organizations exceeds those carried by the Department of Health, although the number of visits to the municipal stations is larger. IMPORTANCE OF THE SMALL CLINICS The size of the individual units is small, often so small as to raise the query whether such tiny clinics are worth serious attention, but their importance cannot be measured in terms of attendance. The real significance of the recent rapid growth of the unattached clinic is that it has been a service station, and still more an experiment station, in health service, or in other words, in the appli [691 NEW CLINICS FOR OLD cation of preventive medicine to the individual. This is the field in which the leaders of public health now generally believe the great future of both official and voluntary health work to lie. The problems and technique of dealing with the material environment for the purpose of sanitation have been largely mastered and reduced to administrative routine. The problems ahead in constructive health work are those which involve the hygienic guidance, instruction, education, or reiducation of the individual. The reduction of infant and maternal mortality, the healthy and wholesome development of children in body and mind, the application of existing knowledge to control of tuberculosis, venereal disease, heart disease, cancer, and the degenerative diseases and chronic illnesses of middle and later life, involve the community as well as individual factors, but will depend primarily upon success in rendering health service to individuals. The unattached clinic in New York City and throughout the country has been the chief institution in or through which the methods, technique, and policies of this health service have been, and still are being, worked out. They have provided the centers in which the physicians have worked upon the problems, and the centers from which the public-health nurse and the social worker have found their point of departure and their door of approach to the people. It is obvious from the discussion in Chapter IV that many of the unattached clinics under local and even under city-wide organization have been equipped neither in personnel nor resources to contribute effectively as experiment stations to our knowledge of policies and technique in health service. Yet, in the main it is in just such stations that significant contributions, taken by and large, have been and are being made, and it would be a serious blow to one of the important developments in modern health work, as well as to the immediate service [70] THE UNATTACHED CLINIC needs of many persons in this city, to hamper agencies in developing clinics. It is wise and desirable, however, to stimulate and guide this development, so far as possible, in directions which will mean the best utilization of limited resources and the best co6rdination of the clinics that may be established. WHY CLINICS UNATTACHED TO HOSPITALS ARE NEEDED It is obvious that these forms of health service could not in the past and, even at the present time, cannot usually develop in conjunction with the hospital. The emphasis upon curative work in the hospital and the outpatient department is inevitable. While much preventive medicine can be applied to the individual in the early stages of disease in the out-patient department, and during the convalescent period in both out-patient department and hospital, and while the tendency to introduce educational and preventive methods into these aspects of curative medicine is increasing, it remains true that the temper of the medical and other personnel in the hospital and the out-patient department and the character of its organization and procedure are adapted primarily to dealing with sick persons. It is well to encourage the establishment in out-patient departments of special clinics for children or adults in those branches of health service, particularly tuberculosis, venereal, or cardiac clinics, in which the health services must be rendered via the diagnosis, treatment, or supervision of a disease. The hospital and its out-patient department thus have their place, and probably a growing place, in the scheme of health service. But we must still look to the unattached clinic as the special field for the advancement of health service to the individual, in so far as this is not taken over into private medical practice. The need of localization is another reason for the un [71] NEW CLINICS FOR OLD attached clinic. Proximity to a neighborhood is essential in order to reach its population intensively for some forms of health service. Districting is desirable for the maximum economy of time and energy both of clients and of clinic personnel, primarily the nursing and social work. The location of hospitals and the out-patient departments immediately connected with them must be determined by other considerations than those of local health service; hence in any districting plan certain areas may often require some clinics or health centers, located apart from hospitals. There are many reasons why it is desirable for hospitals to be away from the more congested, noisy and smoky sections of the city. Branch out-patient departments are practicable, though not as yet in favor, and these will probably play a future part in conjunction with the growth of district health centers, but that lies in the future. The unattached clinic, in one form or another, must be utilized as an agent through which organized health service can be brought to all the sections of a community which need it. TYPES OF SERVICE It may be well to restate, in summary form, the types of service which our observations and experiments have indicated are suited to unattached clinics: (1) Infant welfare work, examination and supervision of "well babies": Because of the simple equipment required, the desirability of proximity to the neighborhood served, and the freedom from contact with the sick which the unattached clinic provides. (2) Prenatal examination and health supervision of the expectant mother: The same reasons as for the infantwelfare work, although more emphasis should be laid on [721 THE UNATTACHED CLINIC the desirability of affiliation between the unattached prenatal clinic and a hospital service. (3) Health examinations (for adults): The unattached clinic can provide all needed equipment, and because of the small local volume of work that usually appears, can easily do it by appointment and give it a very personal character. There are a number of disadvantages, however, in the health examination of adults in an unattached clinic when the types of persons examined are those that have many diseases or defects requiring treatment. The necessity of referring to other clinics all such cases who cannot pay a private physician renders the unattached clinic much less advantageous for such groups than a health examination service in the out-patient department of a hospital. This is particularly true of the clients of relief agencies, among whom a very large proportion have immediate treatment needs. (4) Health examinations (for children): The slight equipment and the advantages of localization render the unattached clinic useful for this purpose. The treatment needs of children are generally not so numerous as those of adults, so the disadvantage mentioned in the preceding paragraph is, while existent, not so weighty in this case. (5) Dental prophylaxis (mouth hygiene and related reparative service): Because of the widespread need for the work, the impracticability of securing sufficient of it through out-patient departments or dental infirmaries, or, at present, through school clinics in New York, the advantages of localization, saving time and promoting the convenience of the children, and the convenience of follow-up and coordination with the local schools. (6) Nutrition clinics: A special study by one of the writers, made in conjunction with the New York Nutrition Council, led to the following conclusions, defining [ 73 1 NEW CLINICS FOR OLD the respective functions of out-patient departments and unattached clinics in nutrition work. (a) The special function of the out-patient department or "dispensary," whose main activity is the care of disease, is in dealing with nutrition problems of specialized conditions, such as obesity, diabetes, rickets, tuberculosis, and in serving as a diagnostic agent for outside centers of nutrition work. The appropriate method is that of individual work with these patients. (b) Such institutions as schools, settlements and health centers are fitted to deal primarily with the educational aspects of nutrition service to those not suffering from developed disease. The fact that such institutions are free in the minds of the general public from the compulsions necessary in the treatment of disease renders them especially appropriate for this phase of the work. While work with individuals is necessary to some extent, the class method proves effective and economical in dealing with the types of cases which are appropriate to the health center, the school, and the settlement. (7) Habit clinics: Assuming that the diagnosis of obscure or problem cases can be made in a specially equipped institution or clinic, the local unattached clinic can conduct a behavior or habit clinic for children advantageously. The long period of supervision renders localization convenient, and the absence of contact with groups of sick persons is advantageous. (8) Posture clinics: Appropriate in the unattached clinic, provided the diagnosis of problem cases be made in a fully developed orthopedic clinic. For the carrying of the educational aspect of posture work the unattached posture clinic has advantages. Affiliation with an orthopedic clinic in an out-patient department is desirable. We have observed the following services, primarily therapeutic, working satisfactorily in unattached clinics, which were careful to keep within certain limits: (9) Minor surgery, simple dressings, and the like: Advantageous because of the conservation of working time of patients when the clinic is located in proximity to their place of residence or place of work. Most such clinics are industrial. [74] THE UNATTACHED CLINIC (10) Medical cases, treatment of minor medical conditions: Advisable only when all cases are observed with sufficient care to refer those needing diagnosis and study to a fully equipped clinic (out-patient department). (11) Eye-refraction: When eye clinics in the outpatient departments are crowded, unattached clinics for refraction may be advisable in certain districts, because of their convenience to the patients served, and the ease of supervising the follow-up to assure the actual securing and wearing of the glasses prescribed. (12) Certain forms of therapy: Electrical and light therapy and massage are practicable in the unattached clinic when adequate medical supervision is obtainable. The frequency of the treatments required renders the proximity to patient's residence or place of work very advantageous. ORGANIZATION What forms should unattached clinics take, as to manner of organization? In the preceding chapters four kinds of organization of the unattached clinics have been shown to exist. (1) Local individual units, such as those established by industries, settlements, churches, schools and some charitable organizations. (2) Similar service rendered in individual units under the auspices of city-wide organizations, such as those established by the Department of Health, the Maternity Center Association, the Visiting Nurse Service of the Henry Street Settlement, the New York Diet Kitchen, the Association for Improving the Condition of the Poor, the New York Tuberculosis and Health Association. [75] NEW CLINICS FOR OLD (3) Local federations of agencies, not in a building, but with certain mutual understandings and cooperative machinery, and possibly certain common services rendered by the federate group itself. Examples have been mentioned in the Chelsea and Greenwich districts of Manhattan, and, more distinctively, in the Clinton district, under the Clinton Neighborhood Conference. (4) The health center. Various clinic and other services rendered in a single building under unified administration, or under the administration of a federate body. Each of these four types has its place, provided the policy and characteristics of the clinic service are adjusted within the limitations or possibilities of the organization or organizations concerned. (1) For the first group, it has been apparent that there are insuperable difficulties in the way of satisfactory development of unattached clinics under the auspices of independent, purely local organizations. It is inconceivable that systematic covering of the city could thus take place, or any systematic coordination of the differing types of clinic service with one another on the medical side, or in relation to the extramural activities of the nurses and social workers. On the other hand, the study of the needs of various local organizations, settlements, churches, and charitable societies, has made clear that there do exist specific needs and opportunities for service, which may require clinics to be established by these organizations, but that these clinics should usually be limited to serving the clientele of the organization itself, that is, those persons who come to the settlement, church, day nursery, or charitable agency for the other work of that agency. The settle [ 76 THE UNATTACHED CLINIC ment gymnasium work, for example, and the recreational activities connected with its athletics and summer vacations, provide need for health examinations and health supervision of children and young persons, and this need can best be met by securing service on the spot from qualified personnel. Similarly, special schools have need for the supervision of the health and hygiene of their pupils; likewise with the day nurseries. The settlements or the day nurseries might, through their city organizations, arrange for joint action in securing the desirable medical personnel and medical supervision for health examinations and hygienic services. What has been accomplished through co6perative action in country-care examinations may suggest possibilities in this field also. (See Chapter IV of Health Services in Clinics, by Anna Mann Richardson, M. D.) Theoretically, therefore, the local individual units should establish clinics primarily, or perhaps solely, for intramural service, or intraorganization service, as it might be called. (2) The city-wide organization is in a different position. Some such organizations, like the Children's Aid Society, have a chain of special schools, which need the intramural service just referred to. The city-wide organization interested in various special health programsprenatal, nutrition, tuberculosis, and so, forth-must necessarily encourage, and in some instances establish unattached clinics in some districts, but ought to do so, as far as possible, as part of a general health-center program, co6perating, with local or with other city-wide agencies, in so locating and federating the clinics that they constitute the health center of a districct. (3 and 4) The health center is clearly indicated as the goal of the development of unattached clinics. Towards the ideal of a city which is districted, and which has in [77]1 NEW CLINICS FOR OLD each district a health center, many are working at the present time. The local federation of agencies, as in Clinton and other districts, is a step in this direction which ought to be encouraged, since with little expense it helps to coordinate the unattached clinics of an area. It is also a step in the direction of a health center, having its physical expression in a building and a definite organization for continuous common services. How UNATTACHED CLINICS MAY BE AIDED AND DEVELOPED In what manner can assistance be given in some of the present problems of existing unattached clinics, and how can their development be aided in the direction just indicated? (1) Official Supervision. A revision of the dispensary law, or a broadening of its interpretation, might place the State Board of Charities in a position to license and inspect, and thus to influence the development of unattached clinics. Any such broadening of the scope of the Board's activities would be pf questionable value unless the State appropriations were enlarged to make possible an addition to the force of inspectors of the Board. In 1924 there were 152 unlicensed clinics in New York City, not counting the industrial clinics. Less than half of these were under the municipality, the remainder, more than half, under private agencies. To license and inspect all these would be a considerable task. The unlicensed clinics are those which confine their work to preventive service, or to the clientele of an industry or agency, being thus not open to the public. It is doubtful whether the regulative powers of the Board are needed in connection with this type of clinic, which is not likely to be abused for commercial purposes, and which was clearly not included within the scope of the "dispensary law" as originally designed. It is equally questionable whether it [78] THE UNATTACHED CLINIC would be practicable for the Board to exercise official influence toward coordination or standardization of these small, numerous, and diverse units. On the whole an extension of the Board's work to license and inspect these clinics seems hardly to be urged. The existing powers of the Health Department are adequate to deal with sanitary or other conditions in clinics which might be a menace to health. (2) Fostering Research. It is greatly to be hoped that through the medium of the unattached clinic all possible will be done to facilitate the continuous study of standards and methods of health service to individuals. There are certain fields, particularly in dealing with preschool children (see Chapter IV), in which there is special need for better understanding of policies and methods, and in which special appropriations for research and demonstration in technical matters would be worth while from central organizations to enable the problems to be adequately studied in the field laboratory of the clinic. A still broader problem, which greatly needs systematic attention, is the study of methods of health education and the testing of their effectiveness. All sorts of experiments are being made today in the use of literature, talks, individual conferences, group conferences, conferences in the clinic, conferences in the patient's home, moving pictures, radio, class and club work, and even gold stars, borrowed from the methods of the Sunday School. What is needed are a few stations properly equipped in personnel and other resources to give systematic and critical study to the effectiveness of these various methods and their comparative cost. The problem goes deeper than merely judging the relative values of literature, movies, and gold stars. If we are to apply preventive medicine effectively to the individual, it is necessary that we know [ 79 ] NEW CLINICS FOR OLD more about the psychological incentives which are effective for the various sex and age groups and for the various personality types, in order to stimulate the individual into willingness to change habits. Effective health education, without waste effort, waits upon the clarification of these incentives by patient experiment and observation. The study of methods of health education would also aid in clearing up the not infrequent confusion between the health education of an individual or a family and the help given for needed social readjustments. The case work of the social worker deals primarily with the latter, while the typical activities of the public-health nurse in association with a clinic deal primarily with health education. The two needs may, and often do, coexist in the same family, and a single agent with adequate training can serve both needs. Today, however, in a large city we generally find many specialized agencies, and the tasks of health education and of social case work are frequently separated between different staffs, and their respective boundaries are often not clearly defined. Anything which will help to define the broad, somewhat vague field of health education will aid in clarifying its relations and in determining the best organization and the best qualifications of the personnel for doing it and the related social case work. In addition to such investigations into methods of health service, administrative research should be encouraged, particularly in developing methods for securing, tabulating, correlating and utilizing the current statistics of health centers. (See Chapter V.) (3) Promotion of Standards and Co6rdination by Central Agencies. As a means of studying out ways in which the standardization and coordination of unattached clinics might be practicable, the authors and their associ [80 ] THE UNATTACHED CLINIC ates held a number of conferences during 1923 and 1924, bringing together the representatives of a number of unattached clinics, a comparatively few at a time, to talk over problems. It became evident that as to the standardization of the internal technique of the clinics, there were and are in existence agencies which have outlined or are in process of developing standards* in almost all the branches in which unattached clinics are maintained. The practical problem is to bring the local unattached clinic maintained by isolated agencies into touch with these sources of information, and (a problem much more difficult) to provide, or assist the supporting agencies in providing, the personnel and supervision without which standards become a mere form. With the public or private city-wide agencies the same needs exist in different form for standardization and coordination. The problem of the unattached clinics thus reduces itself to two main points: first, the provision of personnel and of supervision; and, second, the promotion of coordination and the ultimate coalescence of local clinics into district health centers, with the exception of such unattached clinics as are maintained for special purposes, such as the intramural service to the clients of an agency. The question was raised, and has since been carefully considered, whether a cooperative organization of the unattached clinics on a city or borough basis would be a useful means of supplying the personnel and supervision required and of promoting co6rdination. The intimate study of the situation through observation of many individual clinics as well as through the conferences referred to, has led to the conclusion that a general organization of the unattached clinics themselves would not be valuable for these purposes. The individual units are widely different in the kinds of medical service furnished, in the * See references in Appendix. [81] NEW CLINICS FOR OLD background of the organizations maintaining them, and in the immediate problems with which they are wrestling, since these vary greatly with the clientele served, or with the neighborhood. There would be very little in common were representatives of such a heterogeneous group brought together, and slight possibility of an effective federate organization. It is believed worth while and practicable to provide for the professional personnel of the unattached clinics -physicians, dentists, nurses, and others-the same kind of stimuli, standards, meetings, and other well-intended helps which the Association of Tuberculosis Clinics or the various sections of the Associated Out-Patient Clinics have furnished. On this plan, the professional personnel are gathered together in each specialty or type of service represented, so that a common interest exists as a basis for the activity of the sectional organization. Bringing together from time to time the physicians interested in preschool work, the dentists at the various dental clinics, the nurses serving clinics of various types, each in their several gatherings, or in joint meetings on common problems, would be beneficial to professional standards but cannot be expected to have much effect on organization or coordination. The conferences in 1923 led also to the conclusion that useful groupings of the unattached clinics might be formed along neighborhood or district lines. Whether the clinics of a given district are individually providing baby-welfare, prenatal, dental, mental hygiene, or other special services, their representatives have a common interest in the problems of the district with which all are acquainted, and local conferences or local organizations directly promote common planning and lead towards coordination of services. A spontaneous development has actually taken place along these lines, as described, in the Clinton, Chelsea, Greenwich, and other districts. It will [82] THE UNATTACHED CLINIC be desirable for some appropriate city-wide organization to promote and foster local conferences, and, whenever possible, definite local co6perative organizations of this type. Only through such means can it be expected that existing clinics can be brought together into federations, and ultimately into health centers with a building. Agencies must be brought to work together sufficiently to be ready, as the means become available, to make a health center affiliation. It is much to be hoped that the city-wide agencies establishing unattached clinics will consider their policies carefully and will either (1) establish only such unattached clinics as give the intramural service to the clients of the agency itself, or of one of its districts, or (2) combine with a local agency, such as a settlement, which will provide the plant and certain neighborhood connections, the city-wide agency furnishing the personnel and the professional supervision. In this way, many of the difficulties of the local unattached clinic will be overcome, and there will be economy on both sides. Cooperative effort in any given district on the part of several citywide agencies with one or more of the local agencies of the district would create almost or quite a health center for that area. Something approaching this has taken place at Greenwich House, although a more federate form for the direction of the service and ampler quarters would be necessary in order to render it a health center for the district rather than a part of the activities of this particular settlement itself. In a health-center organization of the federate type, it is not well that any one of the constituent members, even one of overshadowing relative importance, such as the health department, should dominate the group, unless it is in a position to assume the responsibility for conducting and financing all of the health activities needed in the center. In such a case the other agencies would be [83] NEW CLINICS FOR OLD merely advisory, thus being enabled to release funds and attention to other districts. FINANCIAL ASPECTS The financial aspect must, of course, be considered. The cost of the unattached clinics is often difficult to evaluate. They are largely in buildings established for other purposes and it is impossible to ascertain the elements of overhead, such as the provision and maintenance of the quarters and the general supervision. We have few exact cost figures for unattached clinics. The elements of direct outlay for salaries and supplies are known in many instances, but even here it is impossible to allocate to the clinics their due share of the time of personnelwho devote some attention to other activities. The cost of health services is comparatively high, both because of the intrinsic nature of preventive work which requires skilled personnel and much time per patient. Moreover, in many instances the physicians are necessarily salaried. As a guess, rather than as an estimate, the statement may be hazarded that the million or so visits made annually to the unattached clinics in this city for mainly preventive purposes cost between $1,250,000 and $1,750,000, counting in this expense the visits to the homes made directly in connection with the clinic work. The clinics maintained by nonmunicipal agencies probably cost $500,000 to $750,000 annually. An additional and larger sum is spent for other health and social services, like visiting nursing, gymnasium work, some school health work, or some of the case work of family welfare agencies, which, while not part of the work of clinics, are intimately related to it. The expenditures for the unattached clinics are not distributed evenly throughout the city in proportion to the population, but are concentrated largely in Manhat [84] THE UNATTACHED CLINIC tan and, indeed, within certain districts of that borough. From the point of view of a program for coordination of clinics and the creation of health centers, the problem is easier financially when the expenditures of agencies for health services in a district are already so considerable that the creation of a health center involves the coordination or combination of existing services rather than the establishment of many new ones. In districts where there exists already a considerable amount of health service in the forms of clinics and public-health nursing, the creation of a health center means merely the transfer of these activities to the center, and only certain relatively small additional expenses for central administration and common services. New services are likely to be demanded when or shortly after the center is formed. So far as the experience at East Harlem indicates, a central budget of $20,000 would be sufficient, in a district with a good supply of services already maintained by constituent agencies, to maintain a health center with fairly adequate health service for a population of over 100,000. In districts of the city which are but slightly provided with existing health services, so favorable a showing could not be expected. Even when all these conditions are admitted, the financial side of a program for the coordination of existing services on a district basis and the establishment of health centers throughout the city is large enough to be formidable. But it is not impossible. What has been done in Boston by a combination of public and private endeavor may well stimulate our larger and wealthier city. The immediate obstacles are psychological. These must be overcome by promoting the idea of co6rdination, the existing need for it, and its practicability and economy. Both for the purpose of improving the standards of unattached clinics and for promoting their coordination and ultimate development into a system of district [ 85] NEW CLINICS FOR OLD health centers, the immediate and permanent need is for continuous attention to the problem by a voluntary citywide organization. It should not be thought that the need is primarily for buildings. In fact, in some rapidly changing districts the erection of health-center buildings is questionable. There are very divergent problems in different parts of this city. In most of the Borough of Manhattan the outstanding problems are: (1) the organization of existing facilities on a district basis either with, or in some cases without, a central building. The shifting of population from some districts would render unwise any considerable local investment of capital; (2) the improvement of existing health centers in their technique and methods, as for example, the strengthening of the federate organization, the development of sound and economical statistical technique and of more effectively functioning relations between clinic services and the health and general welfare work done in the homes; (3) dealing with the problems of health service in sections of Manhattan possessing a large day-time population and a great number of agencies which serve the city as a whole and only in small part the district in which they are located. The objectives of a health center in such a metropolitan area must be very different from those in the ordinary neighborhood, as the Bellevue-Yorkville Demonstration will illustrate. In Brooklyn, Bronx, Queens, and Richmond existing health service facilities are so limited that a health-center program must begin with the study of needs and proceed cautiously to the promotion of new facilities. In these boroughs, study of population trends and of consequent future health needs is fundamental to the development of health centers. It is essential that both local and citywide interest in the needs of these areas be aroused, and only through the efforts of a city-wide organization can [86 1 THE UNATTACHED CLINIC this be accomplished. Financial support of local health service from private funds contributed by the residents of the locality is in most districts impossible. Neither from public nor private funds can adequate support for local health activities be secured except as the overcentralization of interest in Manhattan is combatted and there is developed a consciousness of the interdependence of all portions of this metropolis, with a sharper visualization of the outlying districts. The organization which thus undertakes a health-center program must deal with both the research and the promotive sides. It should assume the operation of local activities, if at all, only for limited periods, and on a demonstration basis. It must aid in the definition of needs and standards and must steadily promote higher standards among the professional personnel. As compared with the sums now lavished on the building of hospitals, the money required to equip New York with a chain of health-center buildings is a bagatelle. It may be hoped that as some of the remaining old-fashioned treatment dispensaries become aware of their own decline, their endowments and plants will be made the nuclei of health centers for their districts. As to the sums required for maintenance, one need not look as far back as twenty years to see how the practical application of preventive medicine to the individual, in clinics and in other forms of health service, has drawn funds from taxes and from private individuals and foundations at a rate which is indeed astonishing considering the newness and the relatively abstract nature of the appeal, as contrasted with the more direct stimulus to the sympathies and the sentiments made by the older forms of work dealing with sickness and poverty. [ 87 NEW CLINICS FOR OLD QUESTIONS FOR THE FUTURE In furthering these health services, the lesson from the history of the old "dispensaries" should not be forgotten. Services should be established to meet existing needs and be adapted as time goes on in accordance with changing social needs and with advances in the science and art of health work. Who can safely predict what health services will be regarded as most important twenty-five years hence? How long will it take before knowledge and habits now laboriously inculcated by the baby-welfare station and the prenatal clinic are part of the education of every girl? To what extent, and how rapidly, will the medical profession grasp the opportunity to render effective health service to individuals, including periodic health examinations, and how far and how soon will the public be mentally prepared and be financially able to pay for this service as a part of private practice? Much of the future need for organized health services in clinics depends upon the answer to this question. The development of health service to the individual has thus far come almost entirely through organized services, in clinics and through health education and public-health nursing largely in connection with clinics. It seems clear that for the immediate future, at least, such organized health services must be continued, be developed, and be better organized and coordinated. The great desiderata are a critical attitude on the part of those professionally engaged in the work towards their own standards and accomplishment; an interest on the part of financing agencies in research and experiment in new methods and- new services; and an open-mindedness on the part of governing boards towards changes in either policies or methods as indicated by advancing standards or altered needs. [ 88] THE UNATTACHED CLINIC Public funds may be expected to carry an increasing share of the maintenance of health service to individuals in health centers and elsewhere, but cannot be expected to grow rapidly enough, for years to come, without the leadership and example of voluntary activities. The appeals for funds by local institutions or even by cooperative organizations dealing with only a single district can with difficulty touch a sufficiently wide public, or the imagination of large givers. A city-wide plan and citywide leadership by a voluntary organization of high standing is required also on the financial side, not so much for the purpose of direct appeal as for building up public understanding of a program so that municipal appropriating bodies and private givers will appreciate the weight of local appeals or special requests. Is it too much to expect that what George R. White has done for Boston, one or more New Yorkers will do for New York? [89] UNIVERSITY OF MICHIGAN 3 9015 02984 4704 APPENDIX LIST OF TEXT REFERENCES American Medical Association, A Manual of Suggestions for the Conduct of Periodic Examinations of Apparently Healthy People, Chicago, Press of the American Medical Association, 1925. Baker, S. Josephine, M.D., Child Hygiene, Harper's Public Health Series, New York, Harper & Brothers, 1925. Bryant, Louise Stevens, Ph.D., Better Doctoring-Less Dependency, New York, the Committee on Dispensary Development of the United Hospital Fund, 1927. Davis, Michael M., Ph.D., Clinics, Hospitals and Health Centers, Harper's Public Health Series, New York, Harper & Brothers, 1927. Especially Chapters XVIII, Records; XIX Statistics, XXIII, The Health Center: Its History and Types; XXIV, Health Service in Clinics. Goodale, Walter S., M.D., Blazing the Trail for Municipal Hospitals and Health Centers, Buffalo, New York, Department of Hospitals and Dispensaries, July, 1920. Lobenstine, Ralph Waldo, M.D., "Meeting the Baby Welfare Needs of the Community," The Modern Hospital, June, 1926, p. 548. Richardson, Anna Mann, M.D., Health Services in Clinics, New York, The Committee on Dispensary Development of the United Hospital Fund, 1927. Smith, Stephen, M.D., The City That Was, New York, Frank Allaben, 1911. Widdemer, Kenneth, D., The House That Health Built, New York, The East Harlem Health Center, 1925. Wilinsky, Charles F., M.D., "The Blossom Street Health Unit," The Nation's Health, June, 1924, p. 397. Standards Associated Out-Patient Clinics, Follow-up System in the Syphilis Clinic, New York, Associated Out-Patient Clinics, September, 1926. Associated Out-Patient Clinics, "Standards for Out-Patient Service in Ophthalmology," American Journal of Ophthalmology, April, 1923, p. 320. Associated Out-Patient Clinics, "Standards for Out-Patient Service in Pediatrics," Archives of Pediatrics, March, 1923, p. 208. Association of Tuberculosis Clinics, Annual Reports, New York. Committee on Dispensary Development, "Tentative Standards for Dental Clinics," prepared by a professional committee, Journal of the American Dental Association, November, 1925, p. 1375. Reprinted for the Committee on Dispensary Development under the title, "Dental Service in Hospitals and Clinics." Federal Children's Bureau, Publication No. 153, Standards of Prenatal Care, Washington, D. C. (Also other publications of the Federal Children's Bureau). Heart Committee of the New York Tuberculosis and Health Association, "Requirements for an Ideal Cardiac Clinic," The Modern Hospital, October, 1926, p. 136. [901 COMMITTEE ON DISPENSARY DEVELOPMENT LIST OF PUBLICATIONS Books Based on Material Collected under the Auspices. of the Committee NICS, HOSPITALS AND HEALTH CENTERS. Published by Harper & Brothers, New York, 1927. Harper's Public Health Series. THE BURDEN OF SICKNESS (in preparation). Monographs Published by the Committee THE CORNELL CLINIC, 1921-1924. Medical Service on a Self-Supporting Basis for Persons of Moderate Means. By the Committee on Dispensary Development. WHAT CONSTITUTES ADEQUATE MEDICAL SERVICE? A Study of Methods and Results in Caring for Two Hundred Cases of Chronic Illness in Ambulatory Patients. By Samuel Bradbury, M.D., with an Introduction by Richard C. Cabot, M.D. HUMAN FACTORS IN CLINIC MANAGEMENT. A Study Made in the Minor Surgical and Fracture Clinics of the Out-Patient Department of the Presbyterian Hospital, New York. By Mary K. Taylor, with a Foreword by David C. Bull, M.D. NEw CLINICS FOR OLD. A Study of Clinics Unattached to Hospitals in New York City: The Passing of the Old "Dispensary" and the Rise of Health Centers and of Other Clinics Rendering Health Services. By Michael M. Davis, Ph.D., and Anna Mann Richardson, M.D. HEALTH SERVICES IN CLINICS. Suggestions as to Content and Method of Clinic Services for the Promotion of Health Based on Work with Various Agencies and Types of Problems. By Anna Mann Richardson, M. D. BETTER DOCTORING--LESS DEPENDENCY. Study of the -Relations between Medical and Non-Medical Agencies with Special Reference to Clinic and Family Welfare Service. By Louise Stevens Bryant, Ph.D., with a Foreword by John A. Lapp, LL.D. A MEDICAL SOCIAL TERMINOLOGY. Preliminary Report of a Study in Classification and Terminology for Case Work in Hospitals and Clinics. By Gordon Hamilton, with a Foreword by Hugh Auchincloss, M.D. COMMUNITY DENTAL SERVICE IN NEW YORK CITY. A Survey of Dental Clinics and Other Organized Facilities. By Michael M. Davis, Ph.D., and Clare Terwilliger, R.N. GROUP CLINICS. A Study in Organized Medical Practice. By Walter C. Klotz, M.D. WORK OF THE COMMITTEE ON DISPENSARY DEVELoPMENT. Six-Year Report, 1920-1926. Articles and Reports A considerable number of articles and reports by members of the Committee staff and others on out-patient work and related subjects have been published or reprinted by the Committee for distribution. The monographs, reports, and reprints may be obtained from the Associated Out-Patient Clinies Committee, 244 Madison Avenue, New York.