Inquiries were made as to methods of reaching the foreign born. Very few, if any, of the health officials in the country have any special program laid out for the foreign born. It is true that we find a great many clinics, public-health nurses, health centers, and welfare centers established in the foreign quarters, but investigation shows that these centers are established to provide general medical care for the poor, and the solution of the problems of the foreign born is of secondary importance.

These methods have been discussed as such in earlier chapters. The point of view of various health officers toward them is significant. The following testimonies are typical. A Middle-Western health officer says:

Force them to use the "American language." We have Welfare Stations with Americans in charge. I will not employ any who talks to them in a foreign language. It is up to them to learn English-not us to learn their languages. I have no patience with less strenuous methods. With this can be contrasted the statement of the health officer of one of our modern Eastern departments (Newark, New Jersey), who says:

We believe until such time as English is universally spoken we should endeavor to reach the foreigner by all possible

means.

He backs this opinion by providing, in every part of his department, a line of communication to the foreign born in their own languages.

Intensive study of certain outstanding experiments in community health work brings out more suggestive evidence than did correspondence. With the exception of a few middle-sized communities, such as Erie,

Pennsylvania, and Bridgeport, Connecticut, the items of interest are chiefly from cities of the first class. In these the health departments have been of sufficient magnitude to develop full-time expert personnel along various special lines of medical and health work, as well as in their general administrative staffs. The large cities have thus naturally served as experiment stations and leaders in professional development. Voluntary organizations supported by private funds have also conducted a number of pieces of work in large cities which are of almost equal interest with the undertakings of health departments.

The most important single step made by health departments toward effective methods of work with the immigrant has been the employment of visiting nurses to do infant-welfare or tuberculosis work, school nursing, prenatal work, or general public-health nursing, including these and sometimes other lines. Formerly, the only point of contact between the health department and the average family was a distant central office, with a formal, if not political, atmosphere, to which people rarely resorted except at the summons of the police or to lodge their complaints. The visiting nurse has taken health work to the people. She has put it into terms of daily personal life.

The same methods which make nursing service under private associations effective in dealing with the immigrant will be successful in state and municipal health departments. Since this technique has already been considered, our present interest in surveying notable developments by health departments and voluntary associations in the same field is in their

organization and their relations to other community agencies.

The use of visiting nurses naturally promotes localization. Districting is an obvious means to efficiency in administering visiting-nursing service in any large city. Experience has shown that the tuberculosis, baby, and other health clinics that have developed simultaneously with visiting nursing, are also most effective when brought close to the people. For example, large centrally located clinics for diagnosis and treatment of sick babies are essential, but to do infantwelfare work along preventive lines on any extensive scale it has everywhere been found necessary to have a number of "infant-welfare stations," or local baby clinics, each serving a small, definite area. The visiting nurses have naturally been attached to the clinics.

The developments studied here relate chiefly to methods of intensive localized medical or health work, and to the co-ordination of intensively organized local health districts one with another and with the medical and health work of the city as a whole. It has recently become the fashion to call this the health-center movement, but this term lacks exact definition and is being used to cover a variety of undertakings. It will not, therefore, be employed here except in an illustrative way. The history of its development can be found elsewhere.1

EXPERIMENTS IN NEW YORK

A certain number of organizations have consciously sought to develop neighborhood co-operation in the 1 Michael M. Davis, Jr., Public Health Nurse Quarterly, January, 1916.

district receiving the health service. One of the earliest, if not the earliest attempt in this direction, was made by the New York Milk Committee in 1913, in establishing a health center on the lower West Side of Manhattan.

The section selected was largely populated by Syrians, with a proportion of Irish-Americans and native born. It was a district with comparatively poor housing conditions and limited medical resources. A thorough canvass of the residents was made during the first two years of the health center. The Bowling Green Neighborhood Association, composed of residents and of friends and specialists from outside, was formed to administer the activities of the center. These were chiefly infant welfare and prenatal work, but the program ran beyond the health field, and illustrated the wisdom of expanding the interests of a neighborhood group beyond a single specialized activity. As an experiment in practical Americanization, the "Bowling Green" undertaking is well worth careful study.

It has been characteristic of almost all these endeavors that they have been conducted in districts predominantly inhabited by comparatively recent immigrants and their children. Thus the most ambitious attempt to apply the principle of localization in the administration of health work was made by the Health Department of New York City in 1915 in a district on the lower East Side of Manhattan, almost entirely populated by Jewish people. The scheme can be most readily shown by the tabulation on the following page.

The health officer of the district was a Jewish physi

cian who understood the people, their language, backgrounds, and characteristics. The three nurses and the nurses' assistant, as will be seen from the tabulation, were each performing several functions, instead of one. Thus, under ordinary conditions, no home would have

more than one nurse as a visitor. The contacts between the people of the district and the health department were simplified and strengthened in three

ways:

1. By visibly localizing the health department's work in an office in the center of the twenty-one