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XVIII

COMMUNITY ORGANIZATION

If one needed to be convinced of the seriousness of the immigrant health problem in this country, a glance at available sickness and death rates would be sufficient. The general terms of the situation are as follows. The physical and social environment in which the average immigrant finds himself in America contains elements that seriously menace his health. Unsanitary housing almost automatically falls to his lot. The balance of his dietary is upset by inability to secure familiar foodstuffs. His occupation is changed without a corresponding change in his way of living. His medical service is in large part supplied by the midwife and the quack. His comparative ignorance and his comparative poverty often make it impossible for him not only to secure the best in our complicated society, but even to use the advantages that come under his hand.

The immigrants themselves have made an effort to meet the burden of sickness by organizing benefit societies, but their measures are inadequate to the situation.

American agencies and methods of work with the foreign born are gradually being developed. The nurse, the hospital, the dispensary, the employer, and

the health officer have each contributed something, either in plan or practice, to the large problem of the health of the immigrant. Although relatively little serious attention has been given to special methods of work with the immigrant, by most health departments and hospitals, certain promising lines of work have been developed, chiefly in health centers, and a certain amount of technique has been worked out by visiting nurses and social-service workers.

But has there been in any instance a comprehensive plan for the whole situation? Can any one, or all of these organizations, working independently, be said to be adequate? Throughout our considerations of these agencies in their work with the foreign born, an attempt has been made to keep in mind the way the individual immigrant views things. From his point of view has health service been satisfactory? If it has not been adequate or satisfactory, what has stood in its way?

There are four limitations upon the extent and quality of medical care which this part of our population receives. They are economic, psychological, professional, and social. A study of these will give the basis for a more comprehensive plan.

THE ECONOMIC LIMITATION

The immigrant has not enough income to pay for what he and his family need in case of sickness. Recent studies of the United States Bureau of Labor Statistics have shown that in 1918-19, among a large

1 Monthly Labor Review, United States Bureau of Labor Statistics, November, 1919, p. 19.

number of families in thirty representative cities, the yearly expenditure per family for health ranged from $31.27 to $92.77, averaging $58. This sum included expenditure for doctor, dentist, oculist, hospital, and medicines. Unfortunately these data do not separate the native from the foreign-born families, so that it is not possible to compare their expenditures.

Previous to the war the incomes of most of our wage-earning population did not exceed $100 per month per family, and many had less than $1,000 per year. There must be thousands of cases where expenditure for medical care in ordinary illness is out of the question, and the cost of a grave emergency involves the sacrifice of small savings or actual debt. Unfortunately, it is in this class that a great many immigrant families fall.

It is, however, true that the economic limitation is not wholly a question of income. All immigrants are not poor in the technical sense of dependency. It is a question of income in relation to the standard of living. Families with two or three generations of American ancestry and with incomes, let us say, of $1,800 or $2,500 a year, usually include in their conception of life many activities and requirements with which the immigrant is unfamiliar.

In ordinary terms we say that this American standard of living is higher than that of the immigrant. Among other things, the American family is accustomed to provide the service of a private doctor for its members during illness. They allow for this as far as they can in making up their annual budget or in planning the expenditure of their income.

The combination of a so-called low standard of

living, with considerable financial reserve in emergency, is a characteristic frequently noted by workers among the immigrants. A doctor tells of an obstetrical case in which the free services of an institution were at first sought, but, owing to difficulty and delay at the critical moment, $60 was finally paid in cash to a private physician to deliver the woman.

It has not always been appreciated that savings are part of the standard of living in many immigrant families. They pursue a standard of life more or less like that to which they have been accustomed in Europe, with certain adaptations to the American environment. They receive more money wages than ever before, and sometimes put much by. A native family with the same income but a different standard would spend more and save less, because they would be unwilling to sacrifice present comfort, health, or self-development. The immigrant does not appreciate that he is making a sacrifice.

It is only gradually, as he becomes accustomed to American wage scales, American living conditions, American opportunities, that he begins to adjust his spending and his saving to what we call the American standard. Before this happens there is a tendency to cut down the use of the more expensive forms of medical care until the critical stages of disease, usually too late for the best medical efforts to yield full results.

THE PSYCHOLOGICAL LIMITATION

People have inadequate, false, or foolish conceptions about their own bodies and about the influences which make for health or disease. Different levels of

understanding are admirably illustrated among immigrants.

To the primitive mind, healing seems a form of witchery or magic. An advertisement, clipped from a Polish newspaper, read as follows:

If you have love troubles, write me. I have something that never fails. Mrs. Blank... Street.

A complaint was actually received by one of the staff of this study through the editor of the paper in which this advertisement appeared. A trusting Pole had read the advertisement, and, feeling that his wife's affection for him was on the wane, wrote to Mrs. Blank. He learned that for $12 she would send him a love potion in the form of a powder, which, put into his wife's tea, would certainly restore his happiness immediately. He sent the $12. Unfortunately, the package arrived in the absence of the man of the house, and was opened by his wife. She threw it away, and what she said to her husband he failed to repeat to the editor. He did not lose hope, however, but again wrote to Mrs. Blank, telling her that the powder had been lost through accident and asking her to send him another. She refused, but after more correspondence agreed to send a second package for an additional $6. By this time, however, the man had become disgusted and complained to the editor of the paper in which he had seen the advertisement. The editor seemed to feel rather helpless about the matter, but turned the correspondence over to us.

Somewhat less primitive is the reliance on medicine. Upon still another level is the conception of medical treatment as a "system," according to which each

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