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groups. In one State, 1 baby out of 10 dies; in another, 1 out of 30. The death rate for Negro infants is 72 percent higher than that for white infants.

Many babies, perhaps half of those who die today, might have lived if adequate medical and hospital care were available.

Like the infant death rate, the maternal death rate varies greatly from State to State and by racial and language groups. In some States it is five times as high as in others. The mortality rate for Negro mothers is two and a half times that for white mothers.

Although the maternal death rate has been reduced more than half in the last decade, still 7,000 mothers die each year from causes associated with childbirth.

Despite the gain already made, it is estimated that still another 50 percent of the deaths of mothers in childbirth, might be prevented if all mothers had the care this country knows how to give.

More than 200,000 babies annually are born without a doctor in attendance.

In 1942, approximately three-fourths of the rural counties were still without maternity clinic centers, and it is not likely that the situation has changed for the better in the war period.

In the large cities, health and medical services for young children are usually available, but of the small cities (10,000 to 25,000 po tion), one-fourth have no child-health conferences.

Two-thirds of the rural counties in this country still have no regularly conducted child-health conferences under the administration of public-health agencies.

A public-health-nursing program adequate to bring skilled care to all families in the community, it is estimated, requires one nurse to every 2,000 of the population. The best ratio in any State is 1 to 3,400. The poorest record is 1 to 25,500.

Forty-eight thousand additional public health nurses, the Children's Bureau estimates, are needed.

"These figures,” says Dr. Martha M. Eliot, Associate Chief of the Children's Bureau, "give at least some insight into the huge problem facing this country if good medical and nursing care is to be made available to all mothers and children in the United States."

WHAT IS PROPOSED

1

The National Commission on Children in Wartime, which is made up of outstanding men and women interested in child-health and child-welfare, made a year's study of what was being done under these maternal and child-health programs in comparison with the need.

As a result, the Commission proposes that an additional $50,000,000 be appropriated immediately from Federal funds under the Social Security Act for an extension of the maternal and child-health programs in the States, with more funds to be granted later as the program expands. Such an appropriation would be expended as follows:

Twenty-five million dollars for maternity care and care for infants and preschool children.

Fifteen million dollars for preventive and curative health service for schoolage children.

Ten million dollars for dental care of young school children. In such a major expansion of the program as the Commission recommends, the objective is to make available good maternity and infant care to all mothers and children who choose to make use of such services. This is to be done without discrimination because of race, color, national origin, or residence. The health of children, the Commission states, no less than their education, is a public responsibility and services should be made avalable as a matter of right.

HOW THE STORY CAN BE LOCALIZED

Each State has its own story of what has been accomplished under the social security program. In many, for instance, the decline in maternal and infant mortality rates is even more striking than it is for the Nation.

In almost any State the program can be seen operating through prenatal clinics, well-child conferences, classes for mothers, and in the round of visits made by the public-health nurse.

1 The report of the Commission, which is entitled “Building the Future for Children and Youth" can be obtained from the Children's Bureau, U. S. Department of Labor, Washington 25, D. C.

In each State a story can be had of how the maternal and child-health divisions have taken on the job of providing medical, hospital, and nursing care for servicemen's wives and infants under the emergency maternity and infant-care program. A magazine of national circulation, describing the work being done in the States under this program, calls it the "biggest public health experiment ever conducted in this country.”

Besides the programs that are common to all the States, there are those adapted to the particular needs and resources of the State or community.

The range is wide: for instance, in Anne Arundel County (Annapolis), Md., a demonstration project is in operation that gives as complete a maternal and infant and child-health service as is to be found anywhere in the country; and in San Mateo, Calif., to cite another instance of a significant step forward in the public health field, child guidance, including psychiatric consultation, is now being included in health services provided on a community-wide basis. In both instances, the work being carried on is in the nature of a demonstration project.

Elsewhere in the country, to illustrate the adaptation of these programs to local needs, a great deal of the health department's effort goes into improving the care given by midwives, upon whom thousands of women in this country, Negro mothers for the most part, are still dependent.

Another example illustrating how the work done under these programs reaches the people for whom little has heretofore been available is in Tuskegee, Ala. Federal funds are used to maintain in part a training center for nurse midwives. These women serve the women in the surrounding rural area.

In Alaska, to cite still another instance of the program's adaptability, a boat, acquired from the United States Army, has been outfitted as a clinic and serves the island people of southeastern Alaska who heretofore have had little or no public-health or medical service.

As an example of how social-security funds are used to provide health services in "areas of special need,” to quote the act, Federal funds are being used to maintain in part the Slossfield Health Center, in Birmingham, Ala. This center serves the Negro population of a wide area.

These examples are cited only as an indication of the work being done that is out of the ordinary under the maternal and child-health program. Each State has its own special projects that are no less newsworthy.

Information about these programs can be obtained from State health departments, from county health officers, and from public health nurses, including nurse-midwives, and others participating in these undertakings.

PART II-SERVICES FOR CRIPPLED CHILDREN

This summary of the work done in providing care and treatment for physicallyhandicapped children during the first 10 years of the social-security program is one of a series of three covering those activities in which the Children's Bureau, United States Department of Labor, has a special responsibility. Part I of this summary deals with the work done toward the betterment of the health of mothers and children; part III deals with the aid given in establishing and extending child-welfare services. These programs are all administered by State agencies under plans approved by the Children's Bureau.

This report is intended for use as background material by newspaper editors and feature writers; radio program directors; and by organizations interested in the welfare of children. The national story, in each instance, can be related to the work done in the States and the localities. :

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SERVICES FOR CRIPPLED CHILDREN UNDER THE SOCIAL SECURITY ACT, 1935-45

"FIND THE CRIPPLED CHILDREN AND GIVE THEM CARE”—THE CONGRESS OF THE

UNITED STATES

THE AUTHORITY

Title V, part 2, section 511 of the Social Security Act, as amended, reads: "For the purpose of enabling each State to extend and improve (especially in rural areas and in areas suffering from severe economic distress), as far as practicable under the conditions in such State, services for locating crippled, and for providing medical, surgical, corrective, and other services and care, and facilities for diagnosis, hospitalization and aftercare, for children who are crippled or who

*

*

are suffering from conditions which lead to crippling, there is hereby authorized to be appropriated for each fiscal year

the sum of $3,870,000. The sums made available under this section shall be used for making payments to States which have submitted, and had approved by the Chief of the Children's Bureau, State plans for such services."

Although 35 States were providing for the care of crippled children with State funds at the time the Social Security Act was passed, in only a relatively few was a State-wide program conducted providing diagnosis, medical and surgical care, hospitalization, and after-care services for any substantial number of crip pled children. In some of those 35 States only a very small number of children were cared for, because appropriations were so limited.

Within 18 months after social security funds were made available, all the States, the District of Columbia, Alaska, and Hawaii, had designated a State agency to carry on a program for the care of crippled children. Subsequently Puerto Rico was added to the list. Thus, because of the Social Security Act, and the support it gave to the States in their efforts to reach crippled children, care has been made possible for thousands of children who otherwise might have grown up needlessly handicapped.

THE BENEFICIARIES

Today, over a third of a million crippled children, boys and girls under 21 years of age, are listed on State registers.

Some of these children and young people have already been aided; some are now getting care; and others are known to be in need of care.

Last year alone, more than 100,000 children received care under these State programs of service to crippled children.

These 100,000 children are children who were born with a harelip, or a cleft palate, or a clubfoot, or some other congenital malformation; children with bent backs and twisted bodies; children with tuberculosis of the bone, arthritis, osteomyelitis, or poliomyelitis; children with cerebral palsy; children with rheumatic fever and heart disease; children with diabetes; children with eyes that are crossed, or eye conditions that require surgery—all of them children who because of the care given through the State crippled children's agencies may hope to lead happy and useful lives.

HOW CARE IS BROUGHT TO THESE BOYS AND GIRLS

In each of the States, and in the District of Columbia, Alaska, Hawaii, and Puerto Rico, there is a crippled children's agency.

Sometimes it is a part of the State health or welfare department; sometimes it is under the board of education; sometimes it is a separate agency or commission.

Each year these agencies submit to the Children's Bureau, United States Department of Labor, plans of operation within the over-all objectives of the program set by Congress. Upon approval of the plan by the Children's Bureau, socialsecurity funds are allotted to the State.

The programs vary greatly from Siate to State. All provide certain services, as for instance, diagnosis for all children brought to the agency's attention, and treatment and care for specific groups, such as those suffering from orthopedic and plastic conditions. Each State, however, adapts its program to the special needs within the State, within the limitations of funds and personnel available.

For instance in an area of scattered population with few facilities for specialized medical care, as in Wyoming, provision often has to be made for bringing the children to the treatment center and for their boarding care while in attendance. The Alaska agency sends many children to Seattle, Wash., for care that is not to be had in the Territory.

A number of the States have rheumatic-fever control programs. These programs are being operated in California, Connecticut, District of Columbia, Iowa, Maine, Maryland, Michigan, Minnesota, Missouri, Montana, Nebraska, Oklahoma, Rhode Island, South Carolina, Utah, Virginia, Washington, and Wisconsin.

One State, Iowa, is caring for children with diabetes. Maryland and Connecticut are undertaking the care of children with hearing defects.

All of the State agencies are on the alert in times of poliomyelitis epidemics, not only taking special measures at the time of the epidemic, but also in providing services to the young victims for long periods afterward. This work is done with the help of other agencies and organizations engaged in the fight against infantile paralysis.

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The State agencies all provide a variety of services and care, including diagnosis, medical, surgical, and hospital care, care in a convalescent or foster home when necessary, and after care to see that a satisfactory adjustment is made. Education and needed vocational training are also arranged for by the crippled children's agency.

Medical services are given by qualified orthopedic surgeons, pediatricians, and other consultants. Public-health nursing and social services, so necessary for the rehabilitation of a child who is crippled or has been crippled, are usually given by local workers with advice and help from nursing and medicalsocial consultants on the staff of the crippled children's agency.

Many persons, institutions, and agencies may be concerned in one or another aspects of the child's care. It is the job of the State agency to make sure that a coordinated plan is being followed for the child's care and to prevent interrupted and contradictory types of treatment.

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The first step in the operation of this program, as set forth by Congress, is to find the children. The injunction is unusual: The Federal Government is saying in effect, do not wait for these children who need care to be brought to you; find them—wherever they may be—and bring them in.

Sometimes it is the parent or friend of the child who reports his case to the agency; or a physician, public health nurse, social worker, or school official may direct the agency's attention to the crippled child. Other individuals and groups likewise help in locating these crippled children.

Then, a diagnosis of the case is arranged for at a crippled children's clinic. Some of these clinics are so-called “permanenta clinics held in the same placea hospital or health center-at regular intervals. Other clinics are “itinerant"the clinic staff goes into rural areas. If a child is acutely ill, say with rheumatic fever or infantile paralysis, the physician may go into the child's home.

In all instances the diagnosis is made without charge and without regard to the family's financial circumstances.

After it is known what care is needed and what it is likely to cost, then, as the program is operated by the State, consideration may be given to the ability of the family to pay for the recommended treatment. No child is denied care because of inability of the family to meet any part of the cost of treatment.

HOW WELL IS THE NEED MET ?

The Chief of the Children's Bureau, at a recent hearing before a congressional committee, stated that “fewer than 10 percent of the Nation's physically handicapped children are receiving care through services de eloped under the socialsecurity program.”

The care now given is largely to those with orthopedic or plastic conditions, yet State crippled children's agencies a year ago had on their registers some 15,000 children for whom care could not be provided because funds were not available.

Others do not get the care they need because they live where hospital facilities are not available. In all States convalescent facilities are inadequate, but the lack is particularly serious as far as Negro children are concerned, and serious, too, for adolescent boys and girls.

Besides these thousands of children with orthopedic or plastic conditions who are not getting care, an even larger group are neglected. They are to be found among the half million with rheumatic fever; the thousands with cerebral palsy, or diabetes, or epilepsy ; the millions with visual or hearing defects; the approximately half million with tuberculosis; the nearly a million with congenital syphilis; and the more than a million with asthma. Not all, of course, are without care, but a large proportion are, particularly those in rural areas and small towns, and those in certain racial or language groups.

These figures, when placed alongside the findings of Selective Service, become even more tragic in their implications, for the handicaps of childhood are the handicaps of young manhood, and often needlessly so. Among 18- and 19-year-old registrants examined, 1 out of 10 had defective eyesight; 3 out of 100 had defective hearing; approximately 1 out of 20 had a musculoskeletal deformity, and an equal number relatively had defective feet; and 3 out of 100 had a heart condition, undoubtedly traceable in many instances to rheumatic fever. These young men were in an age group that might have been reached by the crippled children's program had it been able these last 10 years to bring to all physically handicapped children the care it is authorized by law to provide.

The record for those who are cared for is in bright contrast to those cited in the previous paragraph. In Kansas, for instance, a survey showed that a large proportion of the boys and girls cared for under its program are now self-supporting young men and women, and some of the group were in the armed forces.

NEXT STEPS The National Commission on Children in Wartime' recommends that an additional $25,000,000 be appropriated immediately to be used as follows:

$5,000,000 for orthopedically crippled children including those with cerebral

palsy. $5,00,000 for children with other physically handicapping conditions includ

ing defects of vision and hearing, diabetes, allergy, epilepsy, etc. $15,000,000 for children with rheumatic fever and heart disease—the greatest

killer of school-age children. Programs for their care, under services for crippled children, are operated in only 17 States and the District of

Columbia, and even in these States in only a few counties. The objective of those administering these programs—and of those who support them—is not only to get care, but to get the best care possible to all crippled children in need of it.

*

Information can be obtained from the State crippled children's agency, or from the State or local health departments, about what is being done and what is planned for crippled children under the social security program.

PART III-CHILD-WELFARE SERVICES

This summary of the work done in establishing and extending child-welfare services during the first 10 years of the social-security program is one of a series of three covering those activities in which the Children's Bureau, United States Department of Labor, has a special responsibility. Part I of this summary deals with the work done toward the betterment of the health of mothers and children; part II deals with the work done on behalf of crippled children. These programs are all administered by State agencies under plans approved by the Children's Bureau.

This report is intended for use as background material by newspaper editors and feature writers; radio program directors; and by organizations interested in the welfare of children. The national story, in each instance, can be related to the work done in the States and the localities.

CHILD-WELFARE SERVICES UNDER THE SOCIAL SECURITY ACT, 1935–45

“For every child his fair chance in the world”—Julia Lathrop, first Chief of the Children's Bureau.

THE AUTHORITY

Section 521 (a) of the Social Security Act, as amended, reads: "For the purpose of enabling the United States, through the Children's Bureau, to cooperate with State public-welfare agencies in establishing, extending, and strengthening, especially in predominantly rural areas, public-welfare services (hereinafter

referred to as 'child-welfare services') for the protection and care of homeless, dependent, and neglected children, and children in danger of becoming delinquent, there is hereby authorized to be appropriated for each fiscal year

the sum of $1,510,000. Such amount shall be allotted by the Secretary of Labor, for use by cooperating State public-welfare agencies on the basis of plans developed jointly by the State agency and the Children's Bureau. *

* Copies of the report of the Commission, which is entitled “Building the Future for Children and Youth,' are available free upon request to the Children's Bureau, U. S. Department of Labor, Washington 25, D. C.

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