Social Work; Essays on the Meeting Ground of Doctor and Social Worker. Cabot Richard Clarke
his school environment, for evidence that others have been exposed to the same contagion and possibly already infected. This sort of duty cannot be abandoned merely because there is no health officer at hand. It is a crying need and must be attended to at once.
Now in a minor degree this is true of many other diseases as well as smallpox. We are beginning to realize that it is true of tuberculosis, so that when one case of advanced and therefore contagious tuberculosis is seen at the dispensary, machinery should automatically and invariably be set in motion to search out possible paths of contagion from that patient to others, just as if he had smallpox.
This principle which is well established in the case of dangerous contagious diseases like smallpox and diphtheria, and is beginning to be established in relation to tuberculosis, is even more important in dealing with syphilis. Every case of syphilis means more cases of syphilis, and the danger of still more each day that the contagious patient is at large. No physician has done his duty unless, after seeing a case of syphilis, he attempts, through a social worker or otherwise, to get knowledge of others from whom this disease has been acquired, or to whom it may be freshly spread. At the Massachusetts General Hospital each patient with syphilis is asked to bring to the clinic for treatment the person who infected him. The method sounds impossible but in fact it works, and many cases are thus brought under treatment and prevented from infecting others.
With contagious skin diseases such as scabies or impetigo, the principle is obviously the same, though the dangers of disregarding it are not so great. With typhoid fever, which not very infrequently shows itself even at a dispensary, the duty of the social worker is not so much to search for other persons through whom it may have been contracted or to whom it may be spread, as to investigate the water-supply and the milk-supply of the patient and of others in his environment. One case of typhoid always means more cases, usually more cases acquired, not by contact with one another, but through their share in a contaminated water-supply or milk-supply. The social worker, therefore, should know how to search out contaminated water-supplies, or at least to put in motion such machinery of public health investigation in the city or town where the case arises as may lead to good detective work in the attempt to track down the source of the trouble. It has been well said that every case of typhoid is some one's fault. It has even been asserted that for every case of typhoid some one should be punished. Certainly there are some grounds for such an assertion.
Commoner and not less important than the contagious diseases that I have just mentioned are industrial diseases, or diseases aggravated by the conditions of industry. A physician may serve for many months in a dispensary without seeing a case of smallpox, of trichiniasis, or of typhoid fever, or feeling it his duty to set in motion the forces that I have just mentioned for rooting out the sources of contagion and preventing their further spread. But he cannot serve a month in any well-attended dispensary without seeing cases of industrial disease in the narrow sense, such as lead poisoning, or of independent disease aggravated by the conditions of industry, such as the functional neuroses of cigar-makers or of telephone operators. With such diseases, as with the infectious and contagious diseases, the presence of one case in the clinic should lead straight to the inference that there are others elsewhere, out of sight but no less important from the point of view of public good. This conclusion should lead in turn to the search through a social worker for the cases of disease which do not present themselves to any physician, which may be totally unknown even to the patient himself, yet which are important to the health of the nation.
Difficult though this field of industrial disease has shown itself to be, difficult though it is to separate out that portion of the patients' complaints which can justly be referred to the conditions of his work, and to distinguish it from the portions which are due to the way he lives, to his inheritance, to his habits or to diseases like tuberculosis and syphilis which may have been acquired without any connection with his work, – nevertheless we must try to disentangle and to recognize the elements in this knotty problem. And we can hardly fail to see that the social worker is an essential and logical assistant in the processes of investigation which we must carry out. If we can ever unravel the tangled skein of causes and effects whereby the hours of work, the strain of work, the patients' heredity and his home conditions, all combine to produce the symptoms of disease, it will be through such intimate, prolonged, detailed studies as the social worker can carry out, especially if she becomes a friend of the family. The doctor in his hours of consultation at the dispensary certainly can never do it. The official agent of the Board of Health, perhaps feared, certainly not a natural confidant for the family, may easily miss the truth which the social worker unearths, provided always she succeeds in differentiating herself altogether from the impersonal and professional investigator, and gradually becomes in the mind of the family and in truth their friend.
I said above that the social worker should try to find out what disease, how much disease, and why this disease is present. The answers to these three questions cannot be kept separate. If one knows how much importance to attribute to a given symptom and whether it is as bad as it seems or worse than it seems in the dispensary interview, one may be steered straight to a correct diagnosis. To know how much disease may thus mean knowing what disease is present. Furthermore, the understanding of these questions, even though it be only partial and unsatisfactory, leads us a considerable distance towards understanding why the disease has arisen. The search for sources for contagion is an example of a search for a why in disease. The search for psychical factors – groundless fears, misleading newspaper advertisements, distracting rumors – all this is also a search for the cause as well as for the nature of disease.
The social worker's investigations into the cause of disease may perhaps be still further exemplified. I once sent a social worker to my patient's home with the request that she try to find out what I had failed to find out, namely, why a young girl could not sleep. Physical examination of the girl had revealed no cause; the exploration of such parts of her mind as she would reveal to me had thrown no light upon the trouble. I was at a loss and asked for help through the more intimate knowledge of the patient sometimes to be gained through a social worker's studies. Such a search might easily have been fruitless – it often has been fruitless in my own experience. But in this case it was almost comically swift in reaching its goal. The visitor found that this girl was sleeping with two other girls of about her own age, in a bed hardly more than a metre wide. It needed only that she should acquire a separate bed for herself, which she was able to do without any financial assistance. She then regained her power to sleep. How often have such cases been treated with drugs or perhaps with more complicated physio-therapeutic or psycho-therapeutic procedures, when some simple fact like the size of the bed, the temperature of the sleeping-room, or the mental activities of the evening immediately preceding bedtime, are really responsible for the whole trouble.
In order to carry out the particular procedures of diagnosis and treatment which belong within the province of the social worker, a certain amount of medical knowledge is needed. Because this is true, it has often been assumed that the social worker must be a trained nurse, prepared by months or years of experience in a hospital. But experience has shown that much of the knowledge possessed by nurses who have had this training cannot be used by the home visitor. On the other hand, the information which the social worker needs is often quite lacking even in well-trained nurses. Furthermore, it may be said with truth that the training of a nurse, as we know it in America at any rate, really unfits a woman in some respects for the work of a social worker, since it accustoms her to habitual obedience and subordination. These habits are very useful in their proper place, but they are antagonistic upon the whole to the temper and mental activity which is important in the social worker. I mean the temper of aggression in relation to disease, and the mental attitude of the teacher and leader in relation to the patient. But of this point it will be more in place to speak when I come to consider the functions of the social worker as a teacher.
Let us return, then, to the question, What knowledge should the social worker possess in order to do her part in the "team-work" of the medical-social dispensary? Her knowledge should approximate that of the public health officer. Like him she should be, above all, familiar with what is known to medical science about the causes of disease. This is of great importance because it is especially in this field of medical science and medical ignorance that the public,