Immigrant health and the community

Front matter

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K5 HEALTH SCIENCES S^ANOAPO ^^

BS3

Foreword

This volume is the result of studies in methods of Americanization prepared through funds furnished by the Carnegie Corporation of New York. It arose out of the fact that constant applications were being made to the Corporation for contributions to the work of numerous agencies engaged in various forms of social activity intended to extend among the people of the United States the knowledge of their government and their obligations to it. The trustees felt that a study which should set forth, not theories of social betterment, but a description of the methods of the various agencies engaged in such work, would be of distinct value to the cause itself and to the public.

The outcome of the study is contained in eleven volumes on the following subjects: Schooling of the Immigrant; The Press; Adjustment of Homes and Family Life; Legal Protection and Correction; Health Standards and Care; Naturalization and Political Life; Industrial and Economic Amalgamation; Treatment of Immigrant Heritages; Neighborhood Agencies and Organization; Rural Developments; and Summary. The ei^ire study has been carried out under the

ix

FOREWORD

general direction of Mr. Allen T. Burns. Each volume appears in the name of the author who had immediate charge of the particular field it is intended to cover.

Upon the invitation of the Carnegie Corporation a committee consisting of the late Theodore Roosevelt, Prof. John Graham Brooks, Dr. John M. Glenn, and Mr. John A. Voll has acted in an advisory capacity to the director. An editorial committee consisting of Dr. Talcott Williams, Dr. Raymond B. Fosdick, and Dr. Edwin F. Gay has read and criticized the manuscripts. To both of these committees the trustees of the Carnegie Corporation are much indebted.

The purpose of the report is to give as clear a notion as possible of the methods of the agencies actually at work in this field and not to propose theories for dealing with the complicated questions involved.

Table Of Contents

PAGB

Publisher's Note vii

Foreword *^

Introduction

The purpose of this book is to help interrelate the so-called Americanization movement in the United States with the many efforts toward the betterment of health conditions and the improvement of facilities for the care and prevention of disease. Americanization should include interplay between native and foreign born in all the important aspects of life, including the care and promotion of health. Therefore, the physicians, nurses, social workers, and administrators who are professionally concerned with medical and health work need to study people as well as technique, and adapt the policies and methods of their work to psychological as well as technical conditions.

The larger part of the book has been written by the undersigned, as chief of that division of the Americanization Study entitled Health Standards and Care. The writer accepts general responsibility for the book as a whole, due credit being given in this preface to the members of the staff or to co-operating specialists for the responsible parts which they have taken in collecting and summarizing material for particular parts of the book.

Miss Linda James was general assistant to the chief of this division of this study during the year and a half of its course. She is especially responsible for gathering the material on industrial medicine in relation to the foreign born, and for the statistical

XXV

INTRODUCTION

material in Chapters II and III. Dr. Walter H. Brown, Health Officer for Bridgeport, Connecticut, was responsible for the general survey of health departments; Miss Bertha M. Wood, head of the food clinic of the Boston Dispensary, for the valuable study of the dietary problems of a number of races; Miss Elizabeth C. Watson of New York for the midwife material, and Mr. Samuel M. Auerbach and Mrs. Janet Hayes Davis for the facts about the medical quacks.

The co-operation of several associations dealing with particular sections of our field proved of the greatest assistance. The National Organization for Public Health Nursing generously permitted one of its executive secretaries, Mrs. Bessie Ammerman Haasis, to devote a portion of her time as a member of the staff of this division to a survey of the policies and methods of visiting nursing organizations in relation to the foreign born. The American Association of Hospital Social Workers similarly allowed its executive secretary. Miss M. Antoinette Cannon, to give a portion of her time to a survey of the working methods of social-service departments with immigrant patients.

The helpful co-operation of the United States Public Health Service and the Bureau of Labor Statistics is cordially acknowledged. Dr. Harry E. Mock, president of the AmericanAssociation of Industrial Physicians and Surgeons, generously gave much time in an advisory way to that part of the study concerned with industrial medicine. The number of individuals and of organizations who have assisted, by permitting us to analyze data which they had collected or by fur-

xxvi

INTRODUCTION

nishing us original or published material of their own, has been too considerable to mention here, but an effort has been made to give credit and express appreciation in the text.

The compilation of material for this book was completed December, 1919, and this date should be borne in mind in considering the statistics and the discussion in general.

We are under deep indebtedness to the Harvard Medical School for generously furnishing comfortable office rooms for the staff of this division without charge for rent. The nature of this study has required visits to many parts of the country on the part of certain members of the staff, and hundreds of interviews with physicians in private practice, public-health officers, hospital superintendents, nurses, dietitians, social workers, officials and leaders in immigrant organizations, the priests and ministers of the churches, and, above all, with many immigrants themselves, medical or lay workers among their own race, or simply mothers or fathers or people who gave us something of themselves, their characteristics, their views, and their needs. The belief that America ought to see to it that its newcomers have facilities for better medical care and for more and better public-health work has been given a foundation which cannot be transferred to the reader by pages of statistics or of argument.

Much is said just now in criticism of the alien, particularly of the temporary residents in this country. But most of the immigrant men and women whom we have seen are raising their families here, and, though

not losing their affection for the land of their birth,

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INTRODUCTION

have burned their bridges against return. Interviews with them have left us with a sense of gratitude for the patience, the sympathy, the real understanding with which they have endured and responded to our questioning, and for the larger knowledge of human nature and human needs which they have given to us in much fuller measure than anything we have been able to return to them. The professional desire for better medical and health service to these foreign-born fellow citizens has thus been warmed and uplifted by the wish that they and their children shall share more fully than heretofore in the heritage of health and happiness of the New World.

Michael M. Davis, Jr.

Cambridge, Massachusetts, July, 1920.

IMMIGRANT HEALTH AND THE COMMUNITY

Part I AMERICANIZATION AND HEALTH IMMIGRANT HEALTH AND THE COMMUNITY

"The healthy know not of their health, but only the sick." With the advance of medical science this saying of the nineteenth century should be changed by the twentieth century to, "The healthy learn to promote their health; the sick wish they had." If a town is stricken with typhoid fever it must no longer blame Providence, but itself. Health can no longer be regarded as a negative or passive state, the mere absence of disease. Health is a positive quantity, an ideal of individual or community life, capable of being reaUzed by methods which are more or less known.

This spread of knowledge has led in recent years to aggressive, organized movements for the care of illness and the promotion of health. The medical investigator, the executive officer of the health department, the hospital, the dispensary, the public-health nurse, the social worker, are all concerned with the study of medical methods and the application to the care and prevention of disease. Much of this study has to do with technique, such as periods and modes of quarantine, organization of hospitals, clinics, or sanatoriums, methods of prenatal care or of babyfeeding. A large part of medical and health work depends for its effectiveness upon the careful, continuous study of just such impersonal matters of technique. Without underestimating the value and necessity of technique, it must, nevertheless, be pointed out that effective medical and health work must take into account yet another element. The aim of medical and health work is to secure practical results in curing disease, reducing morbidity and mortality, promoting wholesome and efficient living. Work for these aims involves two fields of human knowledge. One is physiology, taken in the broad sense of that word. Medicine and its related sciences, such as bacteriology and chemistry, aim to ascertain the reactions of the human organism to various conditions of activity, climate, infection, and so forth. This constitutes what may be called the physiological field.

PSYCHOLOGICAL FACTORS IN HEALTH WORK

The other field is psychological or social. Medical and health work involves the application of science, or a group of sciences, to groups of human beings in both their individual and collective relationships. It deals with people and is administered by people. What the executives and field workers, what their patients and their public, think and feel about such work is fundamental in determining its extent and effectiveness at any given period.

The study of people is as important a factor in its success as are the noiihuman elements of technique. The health officer, the hospital superintendent, the public-health nurse, and the social worker, all being members of the human family, consider this human element in a more or less conscious way during their daily work. The extent to which they do this is a measure of what we commonly call their wisdom and tact. But beyond these individual considerations of personality, the sciences of psychology, economics, and sociology have a definite application to medical and health work. Inexact as these sciences are called, they yet bear lessons of importance for the physician or health worker. Conscious and deliberate research in this direction is urgently needed and will repay serious attention.

There are thirteen million foreign-born persons in the United States, and about twenty million more of foreign-born or mixed parentage. These people, because of their racial inheritance and their position as immigrants, have developed a psychology and live under social and economic conditions very different from those of the native born. For these reasons the problem of the human factor is intensified in medical and health work with the foreign element in our population. Also, they suffer more than the native bom from failure to consider this factor, for American medical and health methods grew out of native conditions and so fit them at least approximately. The study of health problems among the foreign born here in the United States is, therefore, a necessary part of the investigation of Americanization methods, as well as a method of approaching the study of the

2 5

DIAGRAM I. — COMPARISON FOR EACH MOTHER TONGUE OF FOREIGN BORN IN THE UNITED STATES IN 1910 AND THE NET INCREASE TO JULY, 1919, ACCORDING TO THE U. S. BUREAU OF IMMIGRATION REPORTS

ENGUSH, SCOTCH AND IRISH

SCANDINAVIAN

HEBREW & YIDDISH

POUSH

SPANISH AND MEXICAN

MAGYAR

BOHEMIAN AND MORAVIAN

DUTCH AND FLEMISH

UTHUANIAN

PORTUGUESE

JAPANESE

CHINESE ROUMANIAN

SYRIAN RUTHENIAN ARMENIAN

TURKISH

....

1 '

i

1^

■ 1

^HM

H

DecreoBo Detmam

C

OMPARISON OF THE NET INCREASE

SINCE 1910 OF THE IMMIGRANTS

OF THE OLD AND NEW RACES

OLO^^

1 1,009,674

-

TOTAL] NETADI

)moNs

1911*19

human element in health technique within a field sufficiently definite and limited to be practicable. Obviously the Italian, the Jew, the Scandinavian, the Pole, and the Syrian are not all alike. They differ in various physical characteristics, in language and traditions. They are human varieties, we may say. But is not health a problem of the human species.'^ Have these human varieties, along with their admitted differences, any characteristically different problems of health or disease? In health matters, do they as a group differ from that other human variety known as native-born Americans?

These questions are partly answered by comparative statistical studies of sickness or mortality among different peoples here and abroad. In large part, however, they are answered by other kinds of data. Psychological and social differences between "races" or national groups, as contrasted with one another and with the native-born American, may be found to create the need for different methods of medical or health work.

This is the general problem. We deal with the specific situation in America. We seek to discover how far the foreign born present distinctive problems of health and disease and how our methods of medical and health work need to be adapted to the foreign bom in order to secure the best results.

The characteristic qualities of different groups of our foreign born, and their condition in the United States, must be briefly reviewed, so that we may have a background of customs and traditions to which to relate matters of health and disease. The conditions and problems which are faced by those interested in medical and health work must be illustrated by field studies. Health departments, antituberculosis associations, industrial or commercial establishments doing medical or health work among their employees, must be considered from a technical point of view, to see how their methods have been adapted to the foreign bom, or have failed to be so adapted. Examples of effective methods which might be of practical service if generally known, should be presented in some detail wherever possible. This is the case with problems of diet for the foreign born, a matter of great practical importance to hospitals and to health workers in the homes. So also with the urgent and picturesque subject of the medical quack and his all-too-effective methods among the foreign born.

The war forced Americanization upon the public attention. Some developed a definite conception of Americanization without much serious thinking. To them it meant teaching English and civics. It meant getting the immigrant naturalized. It meant making people Americans by putting them through certain instructions, crowned by the laying on of hands.

But the war made many others think about this matter. It brought them to see that Americanization implies more than mere instruction and more than naturalization. The assimilation of ten, twenty, or thirty million people into a nation of over one hundred million should mean mutual understanding, not the swallowing of one by the other. A common language must be achieved, but also mutually respected habits and standards of life. Full Americanization is impossible without an all-round transfusion of all the important elements in human life.

Health matters, as one of the important aspects of life, have an integral part in the process of Americanization. The numberless habits, customs, standards, upon which personal and family hygiene are based are of importance to the physician, and the health department, in relation to the care and prevention of disease. They are also everyday elements in determining the extent to which people are developing as Americans, members-in-full of an American community.

Have people such habits and standards of household life that if good housing is available facilities will be used and not misused .^^ This question involves health and Americanization at the same time. Do people know how to use the facilities for the care of disease, such as, hospitals, sanitariums, clinics, well-trained private doctors? Or are people too ill informed to make the best use of what is available? This is not only a question of health. It involves the extent to which the people are intelligent participants in the American community. Are people intelligently co-operative with the school nurse, with the department of health, the infant welfare or antituberculosis agencies, public or private? Are people subject to the exploitations of medical quacks because of ignorance of good medical facilities combined with inability to read English? These, again, are matters of both health and Americanization.

Perhaps the chief difficulty in such a study as this

is that of starting with a clean slate. Too many people

have made up their minds concerning Americanization

before thinking about it. It is easy to be led into a

certain policy perhaps unconsciously, because of an a

priori theory. We may hold in the backs of our heads

cherished ideas about Americanization or about the

differences between races. Consciously, or even unconsciously, we may have prejudices against certain kinds of people. Our attitude toward Americanization may be deeply injQuenced also by a fear of Bolshevism. Our selection and interpretation of facts, and our final conclusions, must not be determined by such preconceptions.

It is all too easy to let race prejudice or antagonism to foreign language be a controlling element in our judgments. This is particularly true when we are hardly conscious of our prejudices. It is well, therefore, to discuss, at the beginning, the three prevailing groups of preconceptions or "theories" about Americanization activities from the point of view of medical and health work especially. Such a review will render ,,us conscious of the place and limitations of each theory, and we shall be less likely to be led astray without knowing it.

THE BIG-STICK THEORY

" Sorry to say it, but most of them must be scared into doing things." Thus tne executive of a Western health organization sums up his policy of dealing with them — the foreign born. The health officer of a large city writes:

In most cases of contagion among foreigners, especially those who will not observe quarantine, we keep a quarantine officer in the neighborhood, who does not hesitate to arrest any o£Pender, and generally after the first arrest we have no further trouble. This is a drastic measure, but it is the only efficient one we know.

A surgeon connected with a large industrial establishment says:

What we need to deal with the health problems of the foreign born is adequate health laws and power to enforce them.

A health officer of a Middle Western city of moderate size says:

The foreign element in our city are most difficult to deal with because they are generally inclined to help themselves rather than accept skilled medical assistance and advice.

The same theory as that expressed in the previous quotations appears here by implication. It stands out still more plainly in the following, from a child-welfare bureau in a large Eastern city:

We have never modified the type of work to suit any special groups of people. We have always attempted to mold the groups to our way, so that our work would be uniform. We do, however, teU our workers never to encroach upon customs of different nationalities, if those customs do not conflict with our regulations or teaching.

An official from another large city writes:

In hospitals they [the foreign born] cannot be made to understand the treatment, and do not seem to improve under unfamiliar conditions.

A devoted worker, himseK of foreign extraction, who has spent years of his life wrestling with this problem in great hospitals, illustrates his experience as follows:

Internes, as a rule, wonder how Polish mothers can be for ten years in America without knowing the language of the country. My answer was that those Polish mothers were exempted by the United States government by having brought forth and educated ten to twelve strong and healthy sons and daughters that are able to speak two languages.

But our social workers are more severe in their judgment. In their fervor they would like to call upon the United States army and navy to do away with all those foreign languages.

What may be called the big-stick theory shows its head more or less frankly in these citations. This theory has taken on new vigor because of the war. Through its influence the continuance of foreign customs and ideas among people who have come to this country has been made to appear un-American or anti- American, and compulsion has been recommended as the remedy. These ideas find almost classic expression in the comic paper's recommendation to the worried mother when she wished to know how her children should take the necessary but disagreeable pills prescribed by the doctor:

How should they take 'em?

You hold their noses.

And step on their toeses.

And thus — you make 'em.

Analyzed more seriously, the big-stick theory seems to imply:

Americanism as a dogma.

Inferiority (of the foreign born) as a datum.

Uniformity as a social goal.

Compulsion as a method.

Undoubtedly a large number of persons feel that America is the best place in the world — ^Americanism the best thing — and they then proceed to the conclusion that Americans are persons like themselves, and that people who come to this country from elsewhere ought as quickly as possible to make themselves, or else be made, like Americans.

In health work the application of the big-stick theory means reliance upon police power, the enforcement of sanitary regulations by punishing people who violate them. It means trying to educate a community toward better sanitary standards by telling people w^hat they must do and the penalties for not doing it. There are those who consider it un-American to use foreign languages in educational or health work, regarding this as a concession to the foreign born which is unwarranted, if not un-American.

Many big-stickers would protest that they do not hold the foreign born to be "inferior." Often a belief in inferiority is subconscious, but no less real. Sometimes it appears in the statement that the immigrant has no right to retain habits, customs, or traditions which he brought with him to this country. Oftener it is apparent when men are called "wops" or "hunkies," or in the mere tone in which immigrants are referred to. How does such a theory bear comparison with the Declaration of Independence?

Every important social group believes in itself. The conviction that "We are the people " is perhaps more characteristic of Americans than of others. The wish to make other people like this desirable model is a natural result. It takes time and effort to perceive that our true goal is not uniformity, but unity; not one vast note of blaring sound, but a harmony of many tones.

No sane man questions the necessity of authority

and of its use under certain conditions. The strong hand of the law must and should deal with the careless consumptive who endangers his wife and children by promiscuo us spitting about his home ; the infectious syphilitic, recalcitrant to treatment and persistent in evil courses; or the family which maintains a gross sanitary nuisance. In such extreme cases the course of policy is clear. But, as a rule, it is important to determine the degree of authority which proves effective in securing results.

Is it best to teach by compulsion? When? How? Or do we get better results by some other method? The question at issue is not the presence or absence of the principle of authority from the armamentarium of medical or health work, but the manner and extent in which this instrument proves effective as compared with other means.

The use of compulsion as a method is one of those questions of degree which amount, in practice, to questions of principle. No sensible man objects to the proclamation of martial law under certain conditions. Martial law has its place among the instruments which a wise society will have at its command for use when necessary. But under what conditions is it necessary? How often? How much? Would we wish to live in a society in which martial law was the habitual method of administration? If not, let us seek to define its place, so that we shall know where and when to employ it, and when and where to avoid it.

If we proceed in medical or health work with the

big-stick theory under our caps, we are likely to adopt

policies and methods because we think they ought to

work, without constantly testing them to see how

they do work. Doubtless we all wish to attain a unified, harmonious community, with high standards of persocal and public hygiene. What is the best method of attainment? The test of method in medical or health work is the same as in any other field of practical endeavor. Policies and methods must be tested by results.

The big-stick theory ought to be applied just as far as it will work — in a democratic society. And how far it will work is to be determined not by our preconceptions of policy, not by an a priori theory of Americanization, but by the dispassionate study of principles and the practical test of facts.

THE LAISSEZ-FAIRE THEORY

The traditional American, when not under pressure of war or the dread of some social upheaval, is an energetic individualist. He sees a chance to push himself ahead, and he admits the other fellow's right to the same opportunity. He follows the principle, live and let live, which in application to health work can best be expressed by the reverse, die and let die. The laissez-faire theory is based partly on the optimism of ignorance. The belief is briefly as follows. The immigrants who have "the stuff" in them take care of themselves and become "Americans" without any great diflSculty. The incapable must be taken care of anyway. America is the world's melting pot. All varieties of the human species have come here. The melting pot transforms all into Americans, like us who were born here. A piece of the philosopher's stone is always somewhere in the crucible, and turns

every good bit of alloy into American gold.

Frequent as are contemporary expressions of the big-stick theory of Americanization among medical and health workers, still more frequent expressions indicate the attitude of laissez faire.

**I hardly think it desirable to work out special diets for foreigners," writes the chief of dietetics in a large city hospital, "for I am told by the nurse that they do not complain of the meals served."

"This state has a large number of immigrants of all nationalities. We are not making any special effort to reach these people other than publishing certain literature in their native language," says the head of a state department of health.

The limitation in some cases of this kind is lack of funds rather than lack of desire, but many evidently feel with the health department of a large Middle Western city, that "Our foreign population is not a problem in any sense."

In application to health work the laissez-faire theory is illustrated by the health department, which provides various facilities, which is ever seeking larger funds, but which expects people to seek out what is provided. Investigations to determine what needs exist are rarely undertaken where this point of view dominates, nor are districts surveyed to discover what groups of people have or have not been reached by antituberculosis or infant- welfare campaigns. Neither is it likely that those imbued with this easy point of view will consider the foreign born as a special problem, the study of which is necessary in order to determine effective policies and methods.

"We object," said a health officer of a large city

department, "to giving any special consideration to the health problems of the foreign born. This would be discrimination. Our aim is to treat everybody alike."

In almost the same words the superintendent of a large hospital stated his policy. These people remind one of the Dutch judge who said that it always troubled him to hear both sides of a case. It is easy to proceed upon the supposition that everybody is alike or near enough alike for practical purposes. Have in mind a standard. Consequently, have your scheme of sanitation or education or medical care. Maintain your standard. Offer your scheme. Let those who come to be benefited by the work profit by its blessings.

The laissez-faire theory, as applied to the field of medical or health work, means the assumption that the foreign born have no special health problems and that methods of health work need not be specially adapted to immigrant characteristics or needs.

No sensible person will question the value of throwing the responsibility for a man's success upon himself, or of expecting that those who wish to be blessed should seek the places of blessing. But here again the test of theory must be by results. The danger is that we mingle our prejudices with our practice instead of guiding our practice and controlling our prejudices by constant tests of efficiency in getting results.

In the descriptive portions of this book evidence

will be presented to show that the presupposition of

uniformity on which the laissez-faire theory is based

is not correct. We shall endeavor to demonstrate that

differences in health problems between native and

foreign born exist, sufficient to warrant practical consideration; and that there are even wider differences in psychological and social reactions between native and foreign born which necessitate careful adaptation of methods to each group in order to secure the best results in medical or health work.

The laissez-faire theory is a useful corrective to the overeagerness of some reformers, but it is too simple to be true. As the Yankee who did not like French, translated it, the laissez-faire theory is a lazy theory, and not fair.

THE DEMOCRATIC THEORY

A new conception has taken practical shape in health work during recent years which we may call the 100-per-cent Idea. Suppose one thousand babies a year are born in a certain community. Suppose there is a bureau of child hygiene of the local department of health, or a private association doing infant-welfare work. Suppose the baby clinic or infant- welfare station had an attendance of one hundred and fifty different babies during the course of a year. How then shall the bureau of child hygiene or the infant- welfare association measure its results.?