596 NATIONAL MUNICIPAL REVIEW [November

The citizens’ referendum league, during the sixty days legally allotted to it, obtained the necessary quota of signatures to require a submission of the franchise ordinance a t an election. On the night before the day that these signatures were to have been presented to the election com- missioners, the safe containing the petitions was opened by an electric drill and over 11,000 signatures stolen. In two days’ time, however, the league succeeded in obtaining 19,000 additional signatures-enough to insure a vote on the subject a t the coming November election. Several of those implicated in the burglary have been apprehended, and as a result of their revelations the company’s superintendent of transpor- tation has been indicted. A consequent impetus has been given the referendum movement; imperilled again for the moment, however, by an opinion of the attorney-general’s oTce that a mimicipal issue of this kind cannot be voted on at a general state election. Independent stock- holders have also renewed the receivership suit.

The whole St. Louis situation points strongly to the necessity of the public acquisition of public utilities. By such action an end will be put to the eternal conflict between the demands of the public for service and the efforts of the private corporation for profh-as Dr. Wilcox has re- peatedly pointed out-and the chief obstacle to satisfactory municipal government will be done away with. The hope of St. Louis, as of all other .large cities similarly situated, is the institution of such constitu- tional changes-particularly in regard to indebtedness limitations-as will make possible the early acquisition of all utility properties. The federal loan made to the United Railways Company in June may be the means by which a governmental control leading to ownership will finally be affected.

THE UNIT PLAN OF HEALTH ADMINIS- TRATION

AS IT IS BEING TRIED OUT I N THE MOHAWK-BRIGHTON DISTRICT OF CINCINNATI

BY DOROTHY THOMPSON

URING the convention of the American surgical association, recently held in Cincinnati, a group of local physicians met D with Dr. William H. Mayo, its president, and with Dr. Frank-

lin P. Martin, chairman of the Medical Division of the Council of Na- tional Defense, to discuss with them the progress of a unique venture. in health administration, now being tried out experimentally in a limited area in Cincinnati. At this meeting, Dr. Martin and Dr. Mayo did not

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hesitate to characterize the experiment as “one of the most significant movements of the day in modern medicine.” And still more recently, Dr. RenC Sand, professor of social medicine in the University of Brussels on a mission in this country is reported to have said: “I consider its value from the point of view of reconstruction to be inestimable, and I shall carry back to my people no more interesting suggestion.”

WHAT IS THIS EXPERIMENT?

It is one branch of the work of a unique community organization called “The Social Unit,” which has as its basic ideas the mobilization of all available social skill into groups the elected representatives of which form an occupational council for the community, which as one part of the local organization shall diagnose the community’s needs, and form- ulate a-program for meeting these needs, this program to be affirmed and rendered effective through the other part of the organization- representatives elected from the citizenry, by bloclrs, and forming a citizens’ council. It is operating in an area of Cincinnati comprising a population of 15,000, under the direction of Mr. and Mrs. Wilbur C. Phillips, originators of the plan, and with the guidance and backing of a national committee, made up of experts in various social fields.

The medical administration, which is so far the most highly developed branch of the work of this organization, and which illustrates the manner in which any group of the occupational council-ministers, teachers, business men, or social workers-might function, was formed in Septem- ber, 1917, from the thirty-six physicians resident or practicing in the district. These physicians elected from their group a council of nine, with an executive responsible to them. A t the same time a council of nurses was formed, consisting of the representatives of the various health agencies operating in the district. The formation of this council was made possible through the co-operation of these agencies.

The two councils and their executives, working in close co-operation, have formulated a health program for the district consisting of specific services, the program being elastic and open to constant expansion. At present these services are six-a general nursing service, for home care of sick patients, a pre-natal service for expectant mothers, a maternity service, a tuberculosis service, and an infant welfare and pre-school service.

The establishment of services has necessarily meant the establishment of sub-committees of the medical administration,-a committee on pedi- atrics, obstetrics, etc. These committees have been responsible for standardizing work in these departments, and to assist them at their re- quest at arriving at the best modern standards, advisory councils have been formed from the City Academy of Medicine, these men in turn seek- ng the advice of national committees. Exactly the same policy of city

598 NATIONAL MUNICIPAL REVIEW [November

and national organization has been followed in regard to the nurses’ work.

POINTS O F ADVANTAGE

The points in this administration which are particularly noteworthy are, perhaps, five:

1. The Democratic Form of the Organization.-Programs for socializing medicine have, in the past, been formulated by social workers and re- formers rather than by physicians, often meeting with strenuous opposi- tion from the medical profession, though in the long run the physicians must by nature of their skill be responsible for the effectiveness of such programs. In this community, the responsibility for planning and carry- ing out the health program is put up to the physicians and nurses, their program being subject to the approval of the rest of the occupational council of which they form a part and of the citizens’ council representing the entire lay citizenry. All of the practitioners being included in the medical group the standardization of clinic methods is carried down into the private practice of every physician in the district, and so socializes standards to the last degree.

2. The Intensiveness with Which Each Detail of the Program Can Be Carried Out.-Through the block workers of the citizens’ council, i t is possible to reach every person for whom a service is designed, easily, the approach in each case being made by a neighbor. For instance, infant welfare and pre-school services are designed to give every child in the district up to six years of age a complete medical examination, this serv- ice to include a consultation with the mother, follow up work done in the home by the nurses, and the organization of classes for mothers in each nursing district, the information given in these classes to be based on the needs of the district as they manifest themselves. In an ordinary unco- ordinated community such a task would be stupendous. But in this district the block workers took a census of all children, made appoint- ments for them at the station, reported on epidemic cases, and persuaded obstructive mothers so effectively that in three months 80 per cent of all the children have been examined and Dr. Kreidler, executive of the medical council, reports expectations of reaching 95 per cent with these services. The Nursing Council already has 100% of the children under supervision.

3. The Educative Effect on the Medical Profession.-Responsibility for the health of the district and the daily clinics presided over by the phy- sicians of the district have developed standards of medical practice far above what they were seven months ago when the medical work started. 4. The Greater Responsibility in the Nursing Service.-The nurses in this

district are a self-governing body. They formulate their own programs for public health nursing. One of the first things which they did was to do away with specialized nursing in large areas-in favor of general

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nursing in small areas, putting the emphasis on preventive rather than curative measures, and making the nurse responsible, not only for the care of individual patients but for encouraging the maintenance of high health standards for an entire household, and a t the same time doing away with duplication of effort in the same household, and saving time in going from place to place.

5. The Possibility of Extending the Unit Oqanization throughout the City until It Covers the Total Population Supplying an Efective Mechanism for the Administration of the City’s Health Work.-Such an administration would be centered in the general hospital and the medical college of the City University and should be able to give a 100 per cent health super- vision to every man, woman, and child. This may seem far away but it is worth considering. If a given area in a city can develop a health center with a department for every branch of medicine tied up to the corresponding departments of the city medical college and general hos- pital, each department in the health center run democratically by a local staff, yet each staff related to a central committee of the best experts in the field, why would it not be possible to extend that plan dividing the entire city into such units, and eventually bringing in every physician as part of a community system for reducing sickness and death to the lowest possible point? Some of the leading physicians of the country believe that it is possible, and that now is the time when such an experiment might be tried. The press reported Dr. Martin to have said when he was in Cincinnati: “The tremendous advances in professional skill made during the war must be put at the services of a larger and larger per cent of the people, in order to conserve every atom of the nation’s vital resources from which the war takes so costly toll. It is unthinkable that after the war is won we should allow ourselves to drift back to old methods, which the international crisis has proved to be outworn. If the Social Unit can build up, as I believe it is doing, a model system of medical administra- tion, we shall be ready, when the war is over, to take it, adjust it to various environments, and apply i t generally.”

ENLISTMENT OF WORKINGMEN IN THE CAUSE OF BETTER GOVERNMENT

BY WILLIAM P. LOVETT’ Delroil

HAT factory workers in numbers can be enlisted for active service in municipal reform, without the entangling alliances incident to city politics or the problems which arise when capital and labor

try to co-operate, has been proved by the Detroit citizens’ league, a volunteer organization now six years old.

1 Executive secretary, Detroit Citizens’ league.

T