were used to establish the services. In 1942, however, a State appropriation was made for child welfare, and similar appropriations have been continued. In Delaware, to cite another example, State funds for child-welfare services were increased threefold from 1938 to 1944.

The greatest stimulus from the use of Federal moneys has been experienced in the rural areas, where, for the first time, in many instances, the services of a trained child-welfare worker have been made available. Federal funds are being used to pay the salaries of 651 child-welfare workers, all except a few of whom were working in rural counties. In addition to this aid, Federal money is also being used to provide child-welfare workers in areas of special need, or specifically, in places where children are living under extremely unfavorable conditions.

So, what was done in the first decade of the social-security program, as far as child welfare was concerned, was to establish and set in motion the governmental machinery by which the greater resources of the Federal Government were brought to the assistance of the States, with whom the responsibility rests for the welfare of the children.

THE BENEFICIARIES

There is no way of counting the children who benefit from what is done under the child-welfare programs under the Social Security Act, for many whom the child-welfare worker never sees are directly affected through advisory and consultative work with State and local welfare departments. For instance, a consultant may be asked to make a study of a home for deliquent girls, and the recommendations made may be far reaching in their consequences. The child-welfare worker may succeed in arousing community concern over disgraceful conditions in jails in which children are being held.

Or less dramatically, the child-welfare worker may bring the community's attention to the need for a summer day camp or for a recreation hall for children in an underprivileged neighborhood.

In short, one large part of the child-welfare worker's task is to develop community interest in what is happening to the children, for with that interest once aroused, much can be done for their protection and care.

As for those who are served directly by child-welfare workers each year under the State-Federal programs, they are, by and large, a hapless lot of youngsters. Some are boys and girls for whom a foster home has to be found and the childwelfare worker's responsibility is not only to find the home but to see that a satisfactory adjustment is made in it.

Some of the children are in difficulty in their own homes or in the neighborhood. Some are children in jails, and children are in jails almost everywhere in the country, for few States have as yet provided adequate detention facilities for children. In many instances, they are quartered with adult offenders for days, and sometimes for weeks. For these children the child-welfare worker is the spokesman, arousing communities to the need for making other provision for their care. Sometimes, and more and more frequently it happens, the childwelfare worker is called to the jail, to make some other arrangement, when possible, for the child's detention.

Others whom the child-welfare worker aids are children who are in institutions for the care of delinquents. Some others are not yet in the jails or the training schools, but in the opinion of the community "they are headed there." For these boys and girls, too, the child-welfare worker serves as a friendly advocate.

Some who are cared for are the mentally deficient for whom institutional or foster-family care must be found.

An important group being aided by child-welfare workers are unmarried mothers and their babies. Often the mothers are so young themselves as to come within the legal definition of a child. The child-welfare worker is one to whom these girls can turn in confidence, and they do, and with the help of the child-welfare worker a plan is made for the care of the girl during pregnancy and childbirth and for such time after as she still needs professional counsel. Should she decide to relinquish her baby for adoption, again the childwelfare worker helps in getting the child settled in a home where he will get the affectionate care his mother wants for him. In other adoptions, too, the child-welfare worker's services are used.

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So the work goes on in its day-by-day routine, unobtrusively but courageously, with a gain here and a gain there for children-children whose need, at least, has been made known, children to whom the way is opened a little wider for their fair chance in the world.

HOW THE PROGRAM OPERATES

Each year the State public welfare agency submits to the Children's Bureau a plan describing how the Federal money will be used in developing child-welfare services for children within the State. Upon approval of that plan by the Children's Bureau, money is allotted to the State.

Federal money, in large part, is used to pay the salaries of child-welfare workers, and a high proportion of the total number of child-welfare workers employed by certain States are so paid.

Federal funds are used, too, to pay the salaries of consultants working in and through the State offices.

Some money is used for the training of personnel, one of the great needs. None of the money is used for actual board and care; it is all used, in one way or the other, to provide services to children.

Significantly, in 70 percent of the cases, the child involved is cared for in his own home, as would not have been true, in many instances, if the services of a child-welfare worker had not been available.

HOW WELL IS THE NEED MET

The need for those social services that would aid in assuring to "each child his fair chance" is not being met, and for many reasons, in addition to the lack of funds. Lack of skilled personnel is one of the most important of those reasons. The public's unawareness of that need is another.

The situation today is not what it was in 1935, neither so far as services are concerned, for a good beginning has been made in providing them, nor so far as the children themselves are concerned. But a supposition that, because economic tension has been lifted for many families who were living in terrifying insecurity 10 years ago, all children are appreciably better off is contrary to the facts.

Today's children, in great numbers, are an uprooted lot-children of families that were first on the move in the depression years, then, in the war years, on the move once more. Homes have been broken and reestablished and broken again, in many, many instances. Thousands of children, too, have had family relationships threatened, and in some cases broken with the call of men to the armed services. The insecurity of the times has in its hold not only the children living in urban areas but also those living in the small towns and over the countryside, and ahead of them is a new adjustment, Nation-wide. Families will need help, and children will need help if they are to have "their fair chance" in the days to come.

To be measured against that need are these facts:

Federal funds are being used today to provide child-welfare workers in only one out of seven counties in the United States. The number of full-time workers paid from Federal funds is an appreciable part-one out of five of the whole number employed by State or local agencies.

Less than 1,000 child-welfare workers under public auspices are working outside the metropolitan centers, i. e., counties that have cities of 100,000 or more population. Yet most children live in the smaller cities and in towns and the rural areas.

More than half of the child-welfare workers employed by public-welfare agencies are working in eight States-New York, Massachusetts, Minnesota, Indiana, Washington, Illinois, Ohio, and Connecticut.

Not only are they concentrated in a few States, but, they tend to be further concentrated in counties in those States that have large urban populations. In many of those counties, moreover, the services are limited, wholly or in large measure, to provision of foster care, with little or no service provided under public auspices to children in their own homes (exclusive of the provision of general relief and special types of public assistance). Relatively few places have wellrounded child-welfare services.

Thirty-two States have fewer than 25 full-time child-welfare workers on their staffs, and sometimes of necessity, their services are "spread thin."

The figures have even more meaning when given, not in a State, but in a county tabulation. For example, this is the kind of picture obtained:

Of the 102 counties in one State, only 7 have child-welfare workers; of the 114 in another, only 6 have child-welfare workers; of 100 counties in still another State, only 15; and so on. Some other specialized services to children may be available in these counties, but it is not likely.

Programs everywhere are admittedly operating under great handicaps. The field is relatively new. Funds are limited, and a major difficulty mentioned previously-men and women with the necessary professional skills are nowhere near adequate in number to meet even a considerable part of the need. A training program has to go hand in hand with an expansion of services.

On the positive side it can be said that the files of State and local publicwelfare offices contain the stories of thousands of children and families who have been helped to help themselves because a worker was near at hand to "do something" when their own social and economic resources were not enough to carry them through the stress of a particular situation. And, as the need of the individual child is met, communities become aware of the need of the hundreds and the thousands of children in similar circumstances, the children who are being denied "their fair chance in the world."

NEXT STEPS

Stating that "today hundreds of thousands of children are living under conditions that deprive them of the opportunities and privileges contributing to good citizenship," the National Commission on Children in Wartime,1 in its recent prospectus, calls for an expansion of social services to help meet the special needs of children whose "well-being cannot be fully assured by their families and by those community services that are intended for all children." The commission also states that the war has shown clearly that State and local public and private welfare agencies do not have the necessary services and facilities to meet the social needs of children.

To meet the needs more fully, the commission proposes an expansion of child-welfare services under the social-security program, over a 10-year period, that would make coverage State-wide, so that individual guidance and service would be available to every child in special need.

The commission would have Federal funds available to the States for the following purposes:

(a) An extension of foster care for children, primarily in foster-family homes. (b) Provision for temporary care of dependent, neglected, and delinquent children in areas where they might otherwise be without adequate protection and shelter, or would be detained in jail.

(c) An improvement of institutional care for children.

(d) Day-care services for children whose mothers are employed or whose home conditions require such services.

Recognizing that a basic need is for well-trained personnel the commission also asks that Federal funds should be made available to the States to assist in training such personnel.

Child-welfare services provided under such Federal-State programs, furthermore, would be available without discrimination because of color, race, creed, national origin, or residence.

Federal funds, under the commission's proposal, would be allotted to the States, not on their ability to match the fund in whole or in part, but on the basis of State and community needs and the resources available to meet those needs.

HOW THE STORY CAN BE TOLD

What is being done in providing specialized services to children in your State? What change has taken place since social security funds were made available? How many counties have child-welfare workers?

Are children being held in jails in your community?

What does the child-welfare worker actually do for children in your community? The answers to these and other questions that will localize the national story can be had from the State department of public welfare, or from the county health office.

1 Copies of this report-Building the Future-are available free upon request to the Children's Bureau, U. S. Department of Labor, Washington 25, D. C.

EXHIBIT 75

[Reprinted from Medical Care, 1790 Broadway, New York, Vol. 4, No. 3, August 1944] THE EMERGENCY CARE PROGRAM FOR THE WIVES AND BABIES OF OUR ENLISTED MEN

(By Allan M. Butler, M. D., Boston)

During the 15 months ending June 30, more than 400,000 wives and babies of enlisted men in the four lowest pay grades received maternity, pediatric, or hospital care provided under the emergency maternity and infant care program by the Nation which their husbands are serving. During 1945 it is estimated that approximately 500,000 will be cared for, more than 1 in 6 of the probable number of births in the United States next year. For this program Congress appropriated a total of $29,700,000 in the fiscal year 1944, parcelling it out in three separate appropriations as need was demonstrated. By appropriating one lump sum of $42,800,000 for the fiscal year 1945, the Congress has expressed its wholehearted support for the program and confidence in the way it is being administered by the Children's Bureau of the United States Department of Labor and by the health agencies of every State.

Thus from an awareness by the United States Public Health Service, the Office of Civilian Defense, and the Children's Bureau of the need for medical care in the areas of expanding war work in the summer of 1941, there has gradually emerged a medical care program reaching out into the homes of men in the armed forces in practically every county in the land. The program provides for all maternity care and for all medical needs during the infant's first year. As the availability of this care has become more widely known, the number of applications has increased month by month reaching 47,000 in June 1944. The actual counts from April 1943 through June 30, 1944, are: mothers and infants given maternity and newborn infant care, 380,775; sick infants given medical, nursing, and hospital care during the first year of life, 21,553.

EMERGENCY NEED

The primary purpose of this public policy, as stated by Congress, is to relieve enlisted men of uncertainty as to the availability of the maternity and infant care needed by their families and of worry as to how the cost of care will be met. No wonder it is received with eagerness and satisfaction by the servicemen and their wives. The Surgeons General of the Army and Navy have enthusiastically endorsed it as an aid to the morale of the men overseas. The representatives of so-called organized medicine, however, though cognizant of this need offered little constructive assistance in the development and operation of any program. Instead they elected to play the selfish and easy role of objector. This lack of constructive interest is most unfortunate because the scarcity of physicians, of public health administrative personnel, and of hospital and clinic facilities renders the need for the program greater but makes its operational problems exceptionally difficult. Success probably can be achieved only by the most effective cooperative effort of all those who are qualified to give a helping hand. A spirit of cooperative endeavor to make the program work is desirable not only to support the intent of Congress in the provision of this emergency care to the wives and infants of our soldiers and sailors, but also to take advantage of a fortuitous opportunity to increase our knowledge concerning the provision of medical care. At almost the moment of a possible expansion of Government medical care through a national health program which at one stride may embrace 100,000,000 people at an annual cost of $3,000,000,000, we are presented with a small clearly defined problem in the provision of Federally financed medical care, limited in size, type of medical service, and duration. The opportunity to learn how best to operate such a program of group prepaid medical care is unique. The occasion should arouse the spirit of objective study not of obstructive fear. Will the medical profession put its shoulder to the wheel of this war opportunity and see how constructive knowledge can be derived from it? Or will it obstruct the program, lest its successful operation should provide an experiment in medical care that would suggest the desirability of modifying our existing individualistic medical prac tice?

The attack of “organized medicine" started with a series of resolutions by the American Medical Association and State and county medical societies. Practi

cally all these resolutions give ample evidence of great interest in and sympathy for the desire of Congress to provide for the wives and infants of the men who are fighting this war for us. It is the way it is set up by Congress and administered by the Children's Bureau that draws their fire.

"FREE CHOICE"

The opponents assert that the emergency maternity and infant care program violates the right of the patient for free choice of doctors. Obviously when certain physicians refuse to cooperate under the program, the free choice of the wives is limited. But such a possible restriction of free choice pertains to ordinary medical practice where doctors cannot or do not wish to care for certain patients. It may also be limited by the qualification standards set by State health agencies or by State licensing laws as to what persons may participate in the care of maternity patients or as consultants or specialists. But surely standards are essential if the public's money is to be spent economically and effectively in the provision of medical care to these wives and infants. With these exceptions, free choice is in fact made a reality for these soldiers' and sailors' wives by the removal of the economic barrier between them and a doctor. Because she knows the physician and hospital will be paid, any wife may select a physician instead of feeling compelled to go to a midwife; she may choose the safety and comfort of a hospital delivery rather than one at home; and she may go freely and promptly to a physician when her baby shows the earliest signs of illness, instead of waiting in the hope that a doctor's bill will not be necessary.

"THIRD PARTY" BOGIE

The representatives of "organized medicine" repeatedly express the fear that the doctor-patient relationship is being jeopardized. The old bogie of a "third party" coming between the doctor and his patient is again given a leading role. Sometimes this third party is described as the State health agency which under the law administers the program locally, sets standards, and pays bills; sometimes it is the Children's Bureau in Washington. These representatives resent that the doctor cannot negotiate with his patient as to how much she will pay him, because the State health agency has fixed the amount to be paid within a national maximum and because the Children's Bureau has said the doctor may not charge, nor the wife pay, an amount above that paid by the State. They say physicians should be allowed to negotiate with the wives of servicemen as to how much they can afford to pay over and above the amounts paid by the State health agency or the wife should be permitted to offer, and the physician to accept, a "gift" or additional payment. The refusal of the Children's Bureau to allow such dickering is considered to be a threat to the established tradition of the "sliding scale" of fees.

CASH GRANTS

Fundamentally, it is this ruling that has caused "organized medicine" to rise up and demand cash grants to the wife on the pretext that this method alone would not disturb the existing doctor-patient relationship. With cash grants in operation, the physician would apply his own "means test" and could negotiate his fee with all wives, including those whose only income is their husband's allotment and the Government maintenance allowance. Such grants would also remove from the program any control over quality of medical care, as no agency would know how much or what kind of medicine was purchased with the grants. They would permit the expenditure of public monies without any assurance that they be used for the purpose for which Congress had voted them. The advocacy of such grants by physicians reflects an unbelievable disregard of responsibility and economy in Government spending, and a shocking lack of concern for standards of medical care.

Surely it is unthinkable that a physician would allow the consideration of a supplemental fee to interfere with the basic relationship between him and his patient in the matter of the kind of care he will give or the confidence that the patient has in him. So far as the attitude of the wife of a serviceman goes, the fact that she knows the physician and hospital are to be paid by the Government would tend to make her more willing to seek advice early and more receptive to it. She will not be restrained by an inability to meet the physician's bill; she will not have to accept charity if she cannot pay at all. She knows that the care is provided by the Government as her right, just as is her allowance for maintenance, because her husband is in the armed forces.