The Problem of Giving Relief—The Giver of Relief—Co-operation between
Agent and Nurse—General Rules for Nurses and Agents—Conditions of
Asking for Relief—Wrong Conditions of Relief-Giving—Incidental
Assistance—Withdrawal of Relief—Supplying Milk and Eggs.
=The Problem of Relief-Giving.= Giving financial assistance or relief to
patients on or below the poverty line is a question which sooner or
later confronts the nurse who undertakes social work. Long hours,
overwork, and low wages produce a class of people who offer little or no
resistance to disease, and when tuberculosis once gets a foothold
amongst them, it is passed on from one devitalized individual to
another. This is why it is necessary to remove a disease-distributor
from among a group of highly susceptible individuals. For example: let
us take a family consisting of father, mother, and four children. The
father contracts tuberculosis and stops work—his income also stops. Even
at best, it was a pitifully inadequate income, and in consequence the
entire family is undernourished, anæmic, and generally run down. With
the income gone, their resistance is still further lowered, and their
chances of infection are correspondingly increased. The result is a
patient surrounded by a group of people able to offer but slight
opposition to this insidious disease. The environment, bad as it was
originally, grows worse. The family moves into smaller, fewer, cheaper
rooms, and food, heat, clothing are all reduced to a minimum. This
increasing poverty means diminished vitality, and heightened
susceptibility to the threatening danger. In attempting to relieve this
situation we are dealing not with a simple, but with a twofold
problem—poverty, plus an infectious disease.
Because of its complex nature, the question of giving assistance is a
difficult and delicate matter. In our efforts to relieve distress and
want, we must be careful to do nothing which will result in spreading
tuberculosis. The paramount consideration is the prevention of
infection, and for this reason, relief should be made conditional upon
the removal or reduction of the danger. If we keep this idea firmly
before us, the problem will be much simplified.
In Baltimore, from one third to one half of the families under
supervision are on or below the poverty line. This means that they are
registered on the books of some charitable association, and are, or at
times have been, dependent upon these organizations for food, rent,
fuel, clothing, or other assistance. In other words, the gap between the
income and the cost of living has needed to be bridged over by outside
aid. In a new community when the nurse’s first patients are the “poor
people” of the locality, she will find that nearly a hundred per cent.
of her cases are on the poverty line. This was our experience in
Baltimore, when the work was first organized, but now that it is well
established the percentage is much reduced. The nurses are now working
in homes where economic conditions are not acute, hence the number of
those receiving or rather of those needing relief (the terms are not
always synonymous) is less than a few years ago. Still, distressing
poverty is found in from one half to one third of the families, which
means that the problem of fighting tuberculosis is gravely complicated.
=The Relief-Giver.= When people need financial assistance, the question
arises, by whom shall it be given? a point which provokes much
discussion. Many people think that the nurse should give this relief,
because of her intimate knowledge of the home conditions of the families
under her charge—a knowledge far more extensive than that gained in any
other way. Some think if she is socially trained, _i.e._, supplements
her hospital training by a course in a school of philanthropy, that she
can combine the duties of both nurse and charity organization agent, and
become in this way a most effective social worker. By this combination,
the family will be spared the infliction of two visitors, nurse and
agent, a desirable result, since the advice given by these two workers
is often flatly contradictory. Other people think that instead of having
a nurse, it would be better to have a graduate from a school of
philanthropy, with a training supplemented by a six months’ hospital
course. The superficial nature of this course is sufficient commentary
on its value. Moreover, more than one half of the patients with
tuberculosis do not come within the reach of a relief-giving agency.
These two people, nurse and agent, are both specialists in their own
lines, and they are equally needed. They have had a different training
and are equally valuable in the field of social service. Even if it were
possible, we should not like to see these two offices combined in one
person—somewhere there would be a loss. It is difficult enough to get a
first-class tuberculosis nurse, and it is equally difficult to find a
first-class charity organization agent. How much more difficult to find
these combined in one person. There is full warrant for saying that
under no circumstances whatever should the nurse become a relief-giver,
or even remotely identified as such. In the foregoing pages we have
learned something of the extent and responsibility of her work, and if
she concentrates her attention upon bringing it to the highest degree of
efficiency, she will find time for nothing else. Moreover, if she
becomes known as one able to give material assistance, her value as a
public health nurse will decline. That she can give or withhold relief
will become known to her patients, who will follow or reject advice
according to what they receive from her. Her prestige as impartial,
disinterested adviser will at once diminish, and the force and authority
of her opinion be lost. Never, even by the gift of a five-cent piece,
should she jeopardize her unique position. The well-to-do patients will
scorn her services, and resent the implication of her visits, while the
others will follow advice when they are bribed, so to speak, and do as
they like when for any reason this bribe is withdrawn. And other
patients will be disobedient or resentful if they cannot obtain what
their neighbours have, or what they believe themselves entitled to.
=Co-operation not Interference.= To concentrate on one’s specialty is
all we should ask of anyone. Any social agency which scatters instead of
concentrates, produces superficial work, which is open to well-deserved
criticism. As well expect a nurse to become a kindergarten teacher,
because she sees the need for kindergartens, or to become a playground
teacher or settlement worker, as to take upon herself the rôle of
charity-organization agent. _And the reverse of this is true._ We should
not expect a relief-giver to undertake a nurse’s duties. It is not the
combination of various effective qualities in one person, but the
co-operation of various effective persons or specialists, which counts
in social service. Furthermore, each set of workers should recognize its
own limitations. The line of demarcation should be sharply drawn between
the work of one agency and that of another.
One sometimes encounters an intense zeal which causes one social worker
to try to do her own, and everyone else’s work as well; or even worse
than this, to neglect her own work in order to do that of another
person. All social workers should learn where to stop—where to transfer
the case to someone else better fitted to deal with another phase of it.
We sometimes hesitate to call in other agencies, because they do not
recognize their boundaries. Co-operation should be substituted for
rivalry and interference; when this is brought about, petty bickerings
and jealousies among the social agencies will cease.
To become an effective co-operator, instead of a critical interferer,
the public health nurse must familiarize herself with all the agencies
in the wide field of social service. She should try to understand the
object and method of their work, and to know where her own work
interlocks with theirs. In a way, they are all interdependent, one upon
the other, and have the same object in view—to relieve distress and
raise the sum total of human happiness. Whether their work is effective
or superficial is not our concern. The nurse should understand what each
of them has to offer, and by picking here and there among them, secure
valuable assistance for the families under her charge. She can thus
reinforce her own efforts, and supplement her own work in behalf of
their well-being and security.
Since nurses come in almost daily contact with the Charity Organization
Societies it should be part of their duties to attend the local district
meetings of these associations, for during the discussions which take
place, the nurses are able to give most helpful information concerning
their own cases, while in regard to other cases, not complicated by a
communicable disease, they learn much as to the methods and theory of
relief-giving. For this reason, these district meetings are useful to
both nurse and agent alike; the interchange of opinion enlarges the
outlook of both workers, and each gains an insight into the difficulties
of the other’s work. This interest and understanding promotes good
feeling, tolerance, and personal friendliness—the basis of successful
team work.
=General Rules for Nurses and Agents.= In a small community in which
there is but one nurse and no Charity Organization Society or its
equivalent, it is well to form a Relief Committee, to whom the nurse may
refer such of her cases as need assistance. In cities where
relief-giving organizations are already established, a few general rules
should govern the relation between nurse and agent; the observance of
these will prevent much trouble and misunderstanding. Under no
circumstances should the nurse give material assistance—neither money,
food, clothing, nor anything of the sort. When these things are needed,
the agent should be asked for them, and no case is so acute but that it
may wait until this consultation takes place. In a city where there is
no emergency or night bureau, it may be necessary to make an occasional
exception to this rule, in which case the nurse may tide the patient
over till the following morning, when the agent may be conferred with.
Such instances will be so rare, however, that they are merely noted as
exceptions to the general rule—under no consideration whatever should
the nurse give any material relief.
It sometimes happens that the nurse has been given a small sum to buy
food, clothing, or special articles for some of her patients. This fund
was perhaps intended for a specified case, or to be used at discretion.
It is wiser to give this money to the agent, with the request that it be
spent (if circumstances warrant) as the nurse suggests. This course may
involve additional trouble, a little extra work for both nurse and
agent, but it is necessary to be extremely punctilious in order to avoid
serious misunderstandings.
When a nurse has been in the work a long time, and is dealing with
agents whom she knows and understands, a feeling of mutual trust and
dependence will arise. Under such circumstances, both may take far more
leeway than should be granted a new worker—but unfortunately this happy
and comfortable state is not always reached. The safest plan is that
each should follow her own line with utmost precision, being rigidly
careful not to overstep the boundaries between her own and another’s
duties.
For example: a benevolent individual may give the nurse an overcoat, to
be used for any patient who needs it. The nurse knows a patient who is
expecting to enter a sanatorium in a few days. Her first inclination
would be to give him the coat and say nothing. Apparently it concerns no
one but herself and her patient. In adherence to the rules laid down,
however, she must first consult the agent before giving away the coat.
This consultation may reveal the fact that the family (new to the nurse)
is well known to the Federated Charities, and that but a short time ago
this patient was given an overcoat which he sold for drink. At this
time, be it said, he was not known to be tuberculous. Of course, this
constitutes no argument against giving him another chance, inasmuch as
he depends upon it to enter the sanatorium, but it gives the nurse a
side light on her patient’s character. She should make sure that he will
not play fast and loose again; also upon entering the sanatorium the
physician must be informed that the man is addicted to alcohol—a
tendency to be considered in his treatment.
Tuberculosis, like poverty, is a chronic condition, and the delay
required for wholesome co-operation will seldom prove fatal.
The agents, likewise, should be governed by one very simple rule, which
will obviate all misunderstandings and ill feeling. This rule should
be—no advice, suggestions, or interference in regard to medical
attention, nursing, or treatment. All this lies strictly within the
nurse’s province and should be left absolutely to her. For example: if
an agent enters a house and finds a consumptive, she should make no
suggestions as to changing doctors, going to this or that dispensary, or
to such and such an institution. If the case is already known to the
nurse, the agent may consult her, and find out what plans and
arrangements have been made and then aid in bringing them about. If the
case is unknown to the nurse, the agent should report it at once,
leaving the nurse to take all necessary steps as to diagnosis and
treatment. Grave results often follow the abuse of this one simple rule.
For example: an agent enters a patient’s home, and finds him in charge
of a certain doctor. Without knowing anything of the circumstances, she
may advise him to change doctors, go to a dispensary, or even to a
sanatorium. She does not know that the patient is in charge of a
physician with a large private practice, and that this is the first time
he has called upon the tuberculosis nurse. His co-operation and help in
the tuberculosis campaign depends upon the way this first case is
handled. His indignation at finding the nurse has played him false (for
it is apt to be the nurse who is credited with these objectionable
things) may be so great that months of explanation cannot wipe it out.
As we have said before, tuberculosis is like poverty—a chronic
complaint—and the delay needed for co-operation will not prove fatal.
If nurses and agents will follow strictly this one simple rule—the
former to give no material assistance, the latter to offer no advice
concerning the patient’s treatment—the chief cause of friction between
these two sets of workers will be eliminated.
=Conditions under which Relief is Asked.= The nurse who visits a family
every week or two is in a position to know when they have come to the
end of their resources and need relief. When this point is reached, she
should report the case to the agent of the Federated Charities. She must
always bear in mind that her chief work is the prevention of
tuberculosis; it is not necessarily the prolongation of human life,
although the two are sometimes coincident. Relief should be asked for if
it brings about the prevention of tuberculosis, but under no
circumstances if it means increased opportunities for scattering the
disease. Under the latter conditions, assistance should be withheld or
withdrawn as the case may be.
For example: we have a family consisting of father, mother, and several
children. The income ceased when the father, the wage-earner, became too
ill to work. The family is in great need of fuel, rent, and groceries.
The giving of this assistance should be made conditional upon the
removal of the danger—that is, upon the patient’s going to an
institution where he will be better cared for than in the home. By
insisting upon this removal, the Federated Charities can play an
important part in the suppression of tuberculosis.
Suppose there are no hospital facilities, and it is necessary to keep
the patient at home. In this case, the most susceptible members of the
household, namely, the children, should be removed. To place out
children is a difficult matter, since it is hard to get the parents’
consent; this can be done, however, with time.
If this turns out to be impossible, relief may be given on condition
that the strictest precautions are observed. This assistance may be
given as long as both patient and family follow rigidly all directions
given by the nurse; failure to do so should be a signal for the
withdrawal of all aid. To assist the patient who has no choice but to
remain at home, means to give relief under the least favourable
conditions, but it must answer when there are no hospital facilities.
When such facilities exist, no alternative should be permitted. When a
family reaches the point where outside interference—social
interference—is needed, we think it not unreasonable that this
assistance should be given upon terms which tend to promote, rather than
diminish the welfare of its members.
=Wrong Conditions of Relief-Giving.= Relief is sometimes given in a way
that makes it defeat preventive work, and tends to create new sources of
infection. For example: we recall a case in which the father of a family
was in the last stages of consumption. His wife took in washing, and was
general drudge for the patient and five small children. This man refused
to go to a hospital, and also refused to use his sputum cup, or take any
other precautions. Most of his time was spent in bed, and beside him in
the bed were his two small children, whose presence gave him pleasure.
Neither doctor, nurse, nor agent could bring about a better state of
things, yet the family was desperately poor and in great need of help.
In consequence, assistance was given upon the patient’s own terms of
being allowed to carry out his right to infect his family. Groceries
were given in large amounts, and the patient himself was supplied with
abundant milk and eggs, which kept him alive for weeks beyond the point
where his own manner of living would have ended the matter. Soon after
his death, one of the children died of tubercular meningitis, while his
wife developed a pulmonary lesion. All the family are now public
charges.
We recall another case: The family consisted of the patient, his wife,
and eight children. The patient was grossly careless, declining to
observe the slightest precautions, and flatly refused to enter a
hospital. After his death, his wife and five of the eight children were
found to have tuberculosis. During the last six months of his life, a
certain agency had poured in unceasing relief, thereby subsidizing a
centre of infection.
Still a third case is that of a widow, with two small children. She
would not part from these children, and refused to go to a hospital, or
to let them go to the country. A separate bed was provided, so that for
part of the time at least the children might be away from her, but she
declined to let them occupy it. She kept them in bed with her. Neither
would she use a sputum cup nor follow advice in any way. All this time,
some benevolent old ladies kept her well supplied with groceries, milk,
eggs, coal, rent, and so forth, by means of which assistance she was
able to drag out a moribund existence for eight or ten months. Pitiful
as this case was, the utter selfishness and immorality of this sort of
“mother love” is something which should repel rather than attract the
sympathies of thinking people.
These are perhaps extreme instances, yet in a lesser degree this is what
usually happens unless relief is made conditional upon removal of the
danger. Charitable associations should be careful not to act as
accessories in the spread of tuberculosis, and should not prolong
conditions under which this is practically inevitable. If centres of
infection are thus perpetuated, through sources over which the
associations in question have no control, nurse and agent, at least,
should not countenance such “benevolence.”
=Incidental Assistance.= There are many occasions when the nurse should
ask for relief, and when this should be freely and generously given.
When a patient enters an institution, it may be necessary to pension his
family during his absence; assurance of their welfare will enable him to
leave with an easy mind. Unless such provision is made, we are
threatened with the alternative of seeing him sit at home, unable to
work, but engaged in the minor though highly dangerous occupation of
caring for the children while his wife goes out to service.
Relief may also be of a temporary nature. While a patient waits for
admission to a hospital he may be too sick to remain alone at home. This
may mean that his wife, the breadwinner, is forced to give up work in
order to care for him. Assistance should be given during this waiting
period, after which time the wife will return to her employment and the
family affairs readjust themselves.
Again, we may have a family in which the patient himself is the only one
who needs help, the income sufficing for all ordinary demands, but not
for the extraordinary demands of illness. While awaiting admission to an
institution, it may be necessary to give him extra food, extra clothing
or bed clothing, an overcoat, railway fare, or something of like nature,
either to make him comfortable, or to facilitate his removal when the
time comes. The patient must not be allowed to suffer during this
enforced wait, but this assistance must not be interpreted as
encouragement to remain at home.
In the foregoing instances, relief has been conditional upon removal. We
must sometimes give assistance under other circumstances. If there are
no hospital facilities, or if he will not avail himself of them, we are
doing good preventive work if we give the patient an extra bed, since
this may result in his partial separation from the children or other
members of the household. Extra clothing may also be given under like
conditions. On the other hand, if we gave milk and eggs to the patient,
we should be supplying food which would maintain indefinitely a centre
of infection. (Good preventive work may be accomplished by ample feeding
of the other members of the household, thus increasing their resistance.
In this case we should be sure that this food is taken by the children,
or by those for whom it was intended, since otherwise it would be
wasted.) Let us put the matter very frankly: it is wrong to prolong a
patient’s life, unless at the same time we can make him harmless to
those about him. If the two are coincident, well and good. If not, then
the shorter the exposure, the better for all those who must submit to
it. We repeat what was said at the beginning of the chapter: the patient
on the poverty line is surrounded by a group of individuals whose
vitality is at a very low ebb. Our first duty is to protect these
individuals.
=Withdrawal of Relief.= When relief is given with the understanding that
certain conditions be complied with, it should be withdrawn if this
compact be violated. The nurse is in a position to know of any breach of
faith, and should notify the agent accordingly. The objection is
sometimes raised that assistance given in this way is a bribe, or a
threat, or a means of coercion, and is therefore wrong. This rather
overstates the case. Let us say, rather, that under these circumstances
we have in our hands a powerful lever, by which mountains of ignorance
and prejudice may be removed. By the use of this lever, we can work
quickly and well for the best interests of the family and the community.
We constantly see families who are not on the poverty line, and over
whom we have no control, yet who are equally obstinate, ignorant, and
dangerous, and regret infinitely that we have no such lever as in the
case of patients who are below the poverty line.
When asking for relief, the nurse must be sure that her patients will
take advantage of it, and that she is not sending the agent on
wild-goose chases. Patients have sometimes been supplied with cots,
window-tents, reclining chairs, and other similar and expensive
articles, which they subsequently declined to use. An indifferent,
careless patient, unwilling to co-operate in any way, is not one for
whom to demand such an outlay.
=Milk and Eggs.= Ten years ago, milk and eggs for consumptives was an
integral part of the tuberculosis campaign. In those early days, they
were considered as necessary as was fresh air itself. They were
prescribed as a matter of routine, and if the patient could not afford
to buy them, they were at once supplied by some charitable association.
We have come a long way since then.
Attention has already been called to the fact that, in the past few
years, medical opinion has undergone a great change as to the value of
milk and eggs. This rich and highly concentrated food is considered far
less advantageous than was at first supposed. By reason of their fat
content (especially the case with eggs), they tend to cause indigestion,
always a serious complication in pulmonary tuberculosis. For this
reason, the old idea of living on enormous quantities of milk and eggs
has been largely abandoned. Some sanatoriums do not give them at
all—other food is substituted, equally nourishing but less apt to upset
the stomach. Yet the idea that they are necessary for consumptives dies
hard.
In Baltimore, there is now no question of providing them. During the
past year, nearly five thousand consumptives passed under the
supervision of the Tuberculosis Division; we asked that milk and eggs be
given to only thirty-eight of this number. Of these thirty-eight cases,
thirteen were advanced, waiting admission to a hospital; two were early
cases, waiting admission to a sanatorium; nine were suspects, and extra
nourishment was needed in order to facilitate diagnosis; and fourteen
were chronic cases, to whom this diet was given as a valuable tonic.
Quite apart from their value, the real reason that we have ceased to
give milk and eggs is because of our policy of removing the patient to
an institution. The furnishing of this diet, or of anything else which
tends to keep him at home, is something we do not endorse. We do not
wish to place any premium upon the home, or to offer any inducements to
remain in it. If our patient wants milk and eggs, we can send him where
they may be had.
If there is no hospital for the tuberculous patient in a community which
is able to furnish one, the maintenance of the patient by charity as a
centre of infection, makes little difference, one way or the other. In
this case, the absence of a hospital means that the community is merely
sentimentalizing and pottering over the tuberculosis problem.