curative. Preventive medicine is free from the commercial element and applies to all individuals in a community, native and foreign born alike. For this reason it is very suitably a public function.

There is a great psychological obstacle, however, to preventive work with the foreign born. When an immigrant is suffering, he is ready to seek care. But to approach a well man or woman with excellently intended hygienic advice is a difficult proposition. It is a sound principle, borne out again and again by this study of the foreign born, that curative medicine provides an approach to preventive. Our goal is to teach people how not to get sick, "how to be healthy and well." But we generally find that the best way to get this instruction accepted and put into practice by the recipient is to give it when the recipient or some member of his family is sick or threatened with sickness.

When we are dealing with people of such advanced education and consequent openness and flexibility of mind that they will receive from any competent authority instructions in hygiene, in the care of children, in the prevention of infection, and put them into practice without prejudice or hesitation, then our method of approach can be neglected, and the pure light of science need be the only guide of the publichealth worker. But in dealing with our immigrants or other persons whose previously formed habits or prejudices are strong and definite, and whose circumstances may not permit an easy conformity to ideal hygienic conditions, then our method of approach is of fundamental importance if we are to expect practical results from our efforts toward prevention.

That curative work furnishes the best approach to preventive has been fully recognized in the practice of most organizations carrying on extensive field work. This is notably true in visiting nursing. The original work of the nurse was at the bedside. What she brings in womanly sympathy and in professional skill are two offerings which it requires no interpreter to make clear to the crudest intelligence when acute sickness is in the home. The recent influenza epidemic brought this out in a dramatic way. Much testimony was secured from immigrants, from physicians, and from nurses during the winter following the 1918 epidemic that the nurse who went into the homes during those desperate weeks to give sorely needed service, had an approach to the family and won a sympathy which furnished a splendid basis for purely educational work.

In the field of preventive medical and health work, therefore, we see that there is particular need for emphasizing our initial principle that the study of people must run parallel to the study of technique. As a corollary to this, curative work must be connected with preventive work, so that the service which the people seek of their own initiative can be supplemented by the service which we believe the larger interests of all require. Give a man what he wants when he wants it, and he will be ready to take what he needs when you offer to give it.

A SMALL COMMUNITY PROGRAM

The objection is often raised that community programs for health are too often adapted only to the

large city, where there are many health agencies and abundant financial resources, while it is often the small community that is most in need of a comprehensive health program. Since half of our population live in villages or rural districts, and more than 70 per cent in communities of 50,000 or less, too much thought cannot be spent in considering the small community's health problem. The large city has been the experiment station for technique, where methods in school work, health work, recreation, and countless other human activities have been initiated and tried out. The small community is the place where these policies and methods must be applied if they are to reach the mass of the people.

The foreign born, too, are frequently regarded as a problem of the large city exclusively. It is true that New York, the great port of entry for immigrants, has gathered its millions of foreign born and their children, and that other cities receive them in large numbers.

But some important race groups, notably the Scandinavians, have settled primarily in rural areas and small towns. An increasing number of the Italians, Poles, and other Slavic peoples have moved to the country, where the agricultural life to which they have been accustomed abroad can be resumed.

It is even more common to find the immigrant in the industrial community of moderate size. For most of the heavier and less skilled kinds of work in manufacturing and mining, we have come to depend so largely upon immigrant labor that an enormous emigration of the foreign born to these middle-sized communities has taken place.

There is no inherent reason why the principles discussed here cannot apply to a community of any size. As a matter of fact, it is in a small place that the most comprehensive plan yet made has been tried out. "A program of clinical activities for towns of approximately 20,000 population" was worked out in 1918 for the Committee on Dispensary Work of the American Hospital Association, by Dr. Donald B. Armstrong, the executive officer of the Framingham Community Health and Tuberculosis Demonstration.1 Step by step he has put it into actual practice in Framingham. A portion of the plan is reprinted here:

ESSENTIAL OBJECTS

The essential objects in the development of any clinic program in such a community would include encouraging the town to recognize its medical and health clinic needs and to try, through public and private channels, to meet these needs. This would probably involve the definitizing of opportunities for community service. The hospitals and other existing treatment agencies should be encouraged to see the community as a whole and not to deal exclusively with individual cases. It is essential to protect the hospital and therapeutic facilities by a bulwark of clinical agencies, thereby heading off many potential patients from hospital treatment by means of education, preventive advice, and early treatment of incipient conditions. These clinics should serve primarily to decrease the need for hospital treatment, and not primarily as an avenue into the hospital.

The clinic service should be put on a self-respecting, selfsupporting basis, thereby encouraging adequate medical attention to the class of individuals who fall between the very poor and the very wealthy. The result would be a

1 Donald B. Armstrong, M.D., "Program for Clinical Activities for Towns of Approximately Twenty Thousand Population," The Modern Hospital, vol. xii, no. 3, March, 1919.

consequent improvement of medical practice in general, with its elevation and standardization.

COMMUNITY NEEDS

The clinic needs of a community of this size are in general as follows: (1) preventive, educative, health creative; (2) disease detective, eliminative, suppressive; (3) curative, therapeutic.

PROGRAM FOR MEETING THESE NEEDS

The hospitals of a small community are, together with the health department, its chief centers of organized service for health. The provision of clinics for a community should be based upon, or at least closely connected with, its hospital or hospitals. The hospitals have medical equipment and often have space which can be used for clinics with great advantage.

The practical clinic needs of a community fall into two classes: (1) clinics for public health work, and (2) clinics for diagnosis and treatment. The two groups, however, overlap considerably in their practical operation, both as to machinery and field.

The public health clinics grow out of the demand upon the health department to meet the medical needs of a community. The clinics for diagnosis and treatment grow out of the demand upon the hospital to meet the same needs. By co-operation of the hospitals with the health department, or such voluntary agencies as tuberculosis committees, and by co-ordination of the actual work done by all these agencies, the most efficient service will be secured with the greatest economy.

I. PUBLIC HEALTH CLINICS

1. Prenatal and Infant Work.-In the establishment of infant clinics in a small city the essential considerations are at least in part as follows:

The work should be designed to reach both sick and well babies, should be partly therapeutic (in co-operation with local physicians and institutions), and should be largely