S REPORTS Milwaukee County Survey of Social Welfare and Health Service, Inc. Prepared by JOEL D. HUNTER July, 1949 Suntmany of the REPORTS of the MILWAUKEE COUNTY / t I SURVEY OF SOCIAL WELFARE AND HEALTH SERVICES, INC. 'Piejiarcd JOEL D. HUNTER TABLE OF CONTENTS Letter of Transmittal 3 Survey Staff 5 Members of Corporation 6 Organizations Included in Survey 7 Foreword 9 A. Objectives, Organizations, Financing, and Scope of Survey 9 B. Method and Procedure of the Milwaukee Survey 9 C. Some Over-all Facts About Health and Welfare Services Which are not Covered in the Summary Report 10 TABLE 1 — Expenditures for Health and Welfare Services by Field of Service and Source of Funds — Milwaukee Coun- ty _ 1946 11 TABLE 2 — Expenditures for Health and Welfare Services by Field of Service and Public and Private Funds — 1948. . 12 TABLE 3 — Comparison of Expendi- tures Per Capita For 1946 and 1948 13 TABLE 4 — Payments by Persons Re- ceiving Services of Milwaukee County Health, Welfare, and Recreation Agen- cies for 1940, 1942, 1946, and 1948 by Type of Service, Percent Change 1940- 1948, and Payments as Percent of Total Private Expenditure by Service Field . . . 13 TABLE 5 — Disbursements of Chest Agencies by Service Field and Chest Al- locations, 1940, 1942, 1946, 1947, and 1948 and Percent Change 1940 to 1948 — Mil- waukee County 14 TABLE 6 — Percentage of Total Private and Public Funds Received From Local Governments in Fifteen Urban Areas — 1946 15 TABLE 7 — Percentage of Total Public and Private Funds Received From State Governments in Fifteen Urban Areas •—- 1946 15 TABLE 8 — Percentage of Total Private and Public Funds Received From Fed- eral Government in Fifteen Urban Areas — 1946 15 TABLE 9 — Total Public and Private Expenditures in Milwaukee County by Field of Service for 1940 and 1948 and Percentage Change From 1940 to 1948.. 16 I. FAMILY SERVICES 17 A. Economic Security 17 B. Public Assistance Programs 20 TABLE 10 —1949 Budget of Milwaukee County’s Social Security Aids 21 TABLE 11 — Number of Recipients, Av- erage Monthly Payment, and Annual Ex- penditure for Public Assistance, Milwau- kee County, 1940-1947 22 C. Voluntary Family Case Work 25 TABLE 12 — Total Cases and Average Monthly Figures for Eight Voluntary Family and Adult Case Work Agencies in Milwaukee County — 1948 27 TABLE 13 — Number of Men Served by Two Shelters in Milwaukee County and Number of Meals and Lodgings Provided 27 TABLE 14 — Total Expenditures, Source of Income, and Relief Expenditures for Nine Voluntary Family and Adult Case Work Agencies in Milwaukee County — 1948 28 D. Homemaker Services 29 II. CHILD WELFARE SERVICES 31 TABLE 15 — Number of Dependent and Neglected Children Under Direct Care of Child Caring Agencies and Institutions in 1948 32 TABLE 16 — Average Number of Chil- dren Under Care on the Last Day of the Month by Public and Private Child Care Agencies in Milwaukee County, 1940-1948 32 TABLE 17 — Whereabouts of Children Under Care in Six Urban Areas 33 TABLE 18 — Foster Care Facilities Pro- viding 24 Hour Care in Milwaukee Coun- ty, December, 1948 33 TABLE 19 — Day Care Facilities for Less Than 24 Hour Periods, Milwaukee County, December, 1948 34 HI. RECREATION, INFORMAL EDUCATION, AND GROUP WORK 36 A. Dept, of Municipal Recreation and Adult Education, City of Milwaukee School Board 36 B. Public Recreation Programs — Munici- palities Outside of Milwaukee 37 C. Private Group Work Agencies 37 2 TABLE OF CONTENTS D. County Park Commission 39 E. Camping 42 F. Other Organizations 42 Natatoria of the City of Milwaukee. . . 42 Milwaukee Police Department Youth Aid Bureau 42 Milwaukee Public Library 43 Milwaukee Public Museum 43 4-H Clubs 43 IV. SPECIAL SERVICES 44 A. Veterans’ Services 44 B. Court Services 45 C. Services to the Aged 47 D. Welfare of Negroes and the Urban League 48 TABLE 20 — City of Milwaukee’s Negro Population 48 V. PLANNING, FINANCING, AND CENTRAL SERVICES 50 A. Community Welfare Council 50 CHART A. — Staff Assignments .... 51 B. Community Chest Campaign Methods . . 54 C. Milwaukee Jewish Welfare Fund 54 D. City-Wide Financial Campaigns 55 VI. THE HEALTH SECTION — GENERAL COMMENTS 57 VII. BRIEF HISTORY OF HEALTH ACTIVITIES IN MILWAUKEE 57 VIII. THE OVER-ALL PICTURE — BIO STA- TISTICS FOR THE CITY AND COUNTY.. 58 IX. PREVENTIVE MEDICINE 58 A. Public Health Education 58 B. Milwaukee City Health Department ... 60 CHART B. — Proposed Organization Chart for City Health Department of Milwaukee, Wis 60 C. Suburban Health Departments 61 D. Recording and Processing of Vital Sta- tistics 62 E. Public Health Laboratory Facilities .... 62 F. Child Welfare Bureau 63 G. School Hygiene 63 H. Communicable Disease Control 64 I. Venereal Disease Control 65 J. Dental Care 66 TABLE 21 — Dental Service Facilities in Milwaukee City and County Available in 1949, Classified According to Adminis- trative Control 66 K. Mental Health 67 L. Chronic Alcoholism 69 M. The Medical Clinic 69 N. Public Health Nursing 70 O. Medical Social Service 71 P. Voluntary Agencies 72 Q. Industrial Health 73 X. MEDICAL CARE 75 A. General and Special Hospitals in Milwaukee County 75 B. Services for the Chronically 111 76 C. Tuberculosis 77 D. Rehabilitation 78 CHART C. — Hospitals 80 CHART D. — Agencies 81 XL ENVIRONMENTAL SANITATION 82 A. Introduction to Environmental Sanitation 82 B. Public Water Supplies 83 C. Ground Water Supplies 84 D. Deep Wells — Non Public 85 E. Swimming Pools and Bathing Beaches.. 85 F. Sewage Collection and Disposal and Water Pollution 85 G. Refuse Disposal 86 H. General Sanitation , 87 I. Atmospheric Pollution 87 J. Rat Infestation and Rodent Control .... 88 K. Housing 88 L. Trailer Camps 89 M. Lake and Stream Building Sites 89 N. Milk Sanitation 89 O. Recommendations 90 3 MILWAUKEE COUNTY SURVEY OF SOCIAL WELFARE AND HEALTH SERVICES, INC. CO-SPONSORS: CIVIC ALLIANCE OF MILWAUKEE AND COMMUNITY WELFARE COUNCIL OF MILWAUKEE COUNTY. INC. PHONE MARQUETTE 8-4946 610 NORTH JACKSON STREET MILWAUKEE 2. WISCONSIN ELMER H, GROOTEMAAT PRESIDENT WYETH ALLEN Vice president RALPH A. UIHLEIN SECRETARY ALBERT S. PUELICHER Treasurer ROBERT W. BAIRD Chrmn. Exec. Comm. SYDNEY B. MARKEY Director October 12, 1949 TO THE CITIZENS OF MILWAUKEE COUNTY: This publication represents a summary of the study made of the voluntary and tax-sup- ported health and welfare services in Milwaukee County. It offers a review point in the work of the Milwaukee County Survey of Social Welfare and Health Services, Inc., since the recommendations contained represent the conclusions of the staff and the com- mittees of the Board with whom there has been consultation. The translation of these recommendations into action, when effected, will result in a community accomplishment of high value. The community owes a debt of gratitude to the Civic Alliance and the Community Welfare Council of Milwaukee County for lending their support in sponsoring our organization and affording substantial financial assistance. We are deeply appreciative of the high value of Joel D. Hunter's direction of our project. His performance, and that of his staff, have exceeded the representations made of them. Their skill, tact, and judgment have afforded open ac- cessibility to information wherever required. Both private and public agencies are strongly commended for their fullest cooperation with our staff. The Executive Committee, under the chairmanship of Robert W. Baird, has contributed an immeasurable service through its great amount of time devoted to steering the affairs of our corporation through our formation period and the investigational efforts. A great deal of our financial support has emanated from private corporations and individuals. We are deeply grateful for their support. Our community will receive great benefits from their investments. The Board of Directors and the membership of the corporation have shown a great interest in the functioning of our organization. They have given much time and thought to the materials made available by our staff. Tremendously valuable discussions have been par- ticipated in, and the recommendations appearing in this summary are presented by the Board of Directors to all organizations concerned for their earnest consideration. A real job lies ahead — that is to implement our recommendations with action. Sincerely yours, ELMER H. GROOTEMAAT President 4 SURVEY STAFF Joel D. Hunter Director Former Supt., United Charities, Chicago Sydney B. Markey Associate Director Former Executive, Council of Social Agencies, Indianapolis, Indiana Nelda Rouleau Office Secretary WELFARE SERVICES Maurice Hahamovitch Economic Security Veterans’ Services Mrs. Bernice Boehm Vol. Family Case Work Former Director, Women’s Service Division, United Charities, Chicago William H. Brueckner Public Group Work and Recreation Director, Chicago Commons, Chicago Bess Craig Child Welfare Consultant, Services to Children, American Public Welfare Association, Chicago Gertrude M. Church, R. N Child Welfare Nursing Consultant, Children’s Bureau, Chicago Mrs. Carolyn Eustice Child AYelf are Case AVorker, Division of Child AVelfare, Illinois Dept, of Public AVelfare, Chicago Edward Press, M.D Child AVelfare Consultant, Social Service Division, Children’s Bureau Mrs. Virginia Lehmann Court Services Attorney, Legal Aid Bureau, Chicago Professor Alton A. Linford Economic Security Professor, School of Social Service Administration, University of Chicago Graduate Student, School of Social Service Administration, University of Chicago Community Welfare Council Group Work and Recreation Services to Aged Youth Aid Bureau Welfare of Negroes Sydney B. Markey .. Maud Morloek Homemaker Services Consultant, Social Service Division, Children’s Bureau Mrs. Ella W. Reed Public Welfare Consultant, Professional Services American Public Welfare Association, Chicago Professor Paul Simon Private Group Work and Recreation Professor, Social Welfare Administration, University of Illinois Earl C. Woife . . .Private Group Work and Recreation Assistant Professor, University of Illinois Glenn Wood Community Chest Campaign Director, Campaign and Finance, Community Chests and Councils of America, Inc. HEALTH SERVICES K. E. Miller, M. D Director, Health Services Medical Director, U. S. Public Health Service Alexander Ropchan Health Service Consultant Executive Secretary, Health Division of Welfare Council of Metropolitan Chicago Bertha L. Allwardt, R. N Public Health Nursing Nurse Officer (R)*, U. S. Public Health Service Frank R. Shaw Environmental Sanitation Sanitary Engineer Director, U. S. Public Health Service Arthur W. Newitt, M. D Tuberculosis Control Senior Surgeon, U. S. Public Health Service Louis Jacobs, M. D Mental Hygiene Senior Surgeon, U. S. Public Health Service E. T. Thompson, M. D. . .Hosp., Clinics and Med. Care Senior Surgeon, U. S. Public Health Service William P. Kroschel, D. D. S Dental Hygiene Senior Dental Surgeon, U. S. Public Health Service A. William Reggio, M. D Rehabilitation Medical Director, U. S. Public Health Service T. II. Butterworth, Ph.D. . . . Public Health Education Assistant Chief, Office of Public Health Education, U. S. Public Health Service Seward Miller, M. D Public Health Laboratories Senior Surgeon, U. S. Public Health Service Leona McGann Medical Social Service Medical Social Work Consultant, U. S. Children’s Bureau, Chicago Allan Filek, M.D Health Administration Director of Local Health Administration, Wisconsin State Board of Health Herschel Engler Refuse Disposal Senior Sanitary Engineer, U. S. Public Health Service T. F. Wisniewski Pollution of Paw Waters Junior Assistant Sanitary Engineer, Wisconsin State Board of Health Harry C. Essick Rodent Control Sanitary Engineer, U. S. Public Health Service L. T. Jodaitis Water Supplies Engineer (R)#, U. S. Public Health Service Jack Pooks . . . .Swimming Pools and Bathing Beaches Senior Assistant Engineer (R)*, U. S. Public Health Service 0. J. Schmidt Pollution of Raw Waters Senior Assistant Sanitary Engineer, U. S. Public Health Service Harold Wainess Milk Sanitation Sanitarian, U. S. Public Health Service C. K. Luchterhand Milk Sanitation Sanitarian, Wisconsin State Board of Health William C. Miller Milk Sanitation Sanitarian (R)#, U. S. Public Health Service Fred Nichols Food Sanitation in Hospitals Restaurant Inspector, U. S. Public Health Service Oliver B. Odom Food Sanitation in Hospitals Sanitary Inspector, Wisconsin State Board of Health Harvey Wirth Trailer Camps Junior Assistant Sanitary Engineer, Wisconsin State Board of Health A. F. Stivarius Trailer Camps Assistant Sanitary Engineer, Wisconsin State Board of Health AVilliam Z. Fluek Industrial Hygiene Engineer, Wisconsin State Board of Health * (R) — Reserve Officer. 5 MEMBERS OF THE CORPORATION #Wyeth Allen Edward P. Allis, HI W. Baird Rabbi Joseph L. Baron # Alice M. Bartlett Metta Bean Walter H. Bender R. W. Blumenthal, M. D. Mrs. Lynde Bradley Dr, Lucia R. Briggs Raymond E. Brooks G. Brurader John H. Budde C. K. Charlton Wm. M. Chester Glenn M. Clarke Wm. L. Coffey Emmett F. Cook, M. D. Joseph A. Cutler James H. Daggett Wm. H. Davidson R. II. Davie J. A. Deglman Carl W. Eberbach, M. D. Dorothy C. Enderis #A. C. Eschweiler, Jr. Ralph S. Evinrude Richard S. Falk Rev. John F. Fedders L. M. Fidler Eliot G. Fitch Harold J. Fitzgerald E. A. Fitzpatrick Theodore Friedlander Max E. Friedmann Wm. C. Frye E. A. Gallun Walter Geist Tdward 0. Gerhardy George G. Goetz Tred D. Goldstone Kenneth P. Goodrich Lowell P. Goodrich f Tonald A. Grant Wm. J. Grede T. F. Gregory Frank W. Greusel Timer H. Grootemaat Kenneth P. Grubb James T. Guy Tester D. Hafemeister Harry B. Hall Joseph F. Heil Richard P. Herzfeld John Huston, M. D. Rt. Rev. B. F. P. Ivins Charles D. James #R. E. Jordan George F. Kasten Rev. Francis E. Kearns * James 0. Kelley J. Martin Klotsche Joseph Kluchesky Wm. D. Knickel John H. Kopmeier *E. R. Krumbiegel, M. D. Fred Kunz Herman W. Ladish Myron Laskin Mrs. F. A. Lukaszewicz #Willard P. Lyons Rev. Thomas B. Lyter Tugene II. Mahler Irwin Maier *'Walter J. Mattison Rt. Rev. M. F. McEvoy Carl B. Melander Mrs. John Messmer Burehell E. Morgan Harry W. Nichols Rev. Edward O’Donnell, S.J. W. I. O’Neill Philip V. Orth August K. Paeschke Capt. Geo. A. Parkinson Wm. R. Pollock, Jr. Taul A. Pratt * Albert S. Puelicher Clifford A. Randall Trank H. Ranney W. F. Rasche * August Reisweber #W. A. Roberts * Philip K. Robinson Will Ross Peter T. Schoemann *Gretchen B. Schoenleber Walter Schroeder L. J. Selzer Rev. William G. Sodt Hon. Herbert J. Steffes Frank M. Surges Francis X. Swietlik Trank L. Taylor George Tiernan *Mrs. T. L. Tolan Mrs. T. L. Trebilcock Albert 0. Trostel *Ralph A. Uihlein * Gould Van Derzee Wm. B. Vogel E. Vogt Robert G. Walsh C. 0. Wanvig, Sr. Thad. F. Wasielewski *Ray H. Weisbrod J. L. Wittet Frederick Winding Russell D. L. Wirth Irwin R. Witthuhn Charles Zadok Lorenz T. Zedler #R. C. Zimmerman Ben R. Zuelke EX OFFICIO Michael S. Kies Lawrence J. Timmerman Frank P. Zeidler of the Board tDeceased ORGANIZATIONS INCLUDED IN SURVEY 145 Participants Boy Scouts Boys’ Club Cancer Detection Center Catholic Home for Aged Catholic Social Welfare Bureau Catholic Youth Organization Central Agency for Chronically 111 Child Care Committee Children’s Court (formerly Juvenile Court) Children’s Service Society Christian Center Civil Court Clerk’s Office Columbia Hospital Community Chest Campaign Community Welfare Council Corporation Counsel’s Office County Association for the Disabled County Children’s Home County Court, Adoption Division County Department of Public Assistance County Department of Public Welfare County Dispensary-Emergency Unit County Hospital County Hospital for Mental Diseases County Park Commission County Superintendent of Schools Cudahy City, Recreation Curative Workshop Deaconess Hospital District Attorney’s Office Divorce Counsel and Court Commissioner’s Office Domestic Conciliation Department Elmore Home Family Service F.S.A.—Bureau of Old Age and Survivors’ Insurance 4-H Clubs of County Agent’s Office Fox Point Village, Recreation Friendship House Girl Scouts Goodwill Industries Granville Village, Recreation Greendale Village, Recreation Greenfield Town, Recreation Health Department — Milwaukee City Health Departments — 17 Suburban Hearing Aid Bureau, State Teachers College Home for Aged Jews Homme Children’s Home Cottage House of Good Shepherd Industrial Commission of Wisconsin International Institute Jewish Community Center Jewish Family and Children’s Service Jewish Welfare Fund Johnston Emergency Hospital Junior League Blood Center Lake Town, Recreation Lakeside Children’s Center Layton Home for Invalids Legal Aid Society Little Sisters of the Poor Lutheran Altenheim Lutheran Children’s Friend Society Lutheran Welfare Society Marquette University Hearing and Speech Clinic Martha Washington Maternity Home Mayor’s Commission on Human Relations Mercy Hospital Milwaukee Children’s Hospital Milwaukee Hearing Rehabilitation Clinic Milwaukee Hearing Society Milwaukee Hospital Milwaukee Psychiatric Services Milwaukee Public Schools Milwaukee Town, Recreation Miserieordia Hospital 7 Mount Sinai Hospital Muirdale Sanatorium Municipal and District Courts Probation Department Municipal Recreation and Adult Education — Milwaukee City National Assoc, for Advancement of Colored People Natatoria Neighborhood House Oak Creek Town, Recreation Our Lady of Pompeii Nursery School Ozanam Home Protestant Home for Aged Public Library Public Museum Red Cross Rescue Mission Roger Memorial Sanitorium Sacred Heart Sanatorium St. Aemilian’s Orphan Asylum St. Ann Rest Home St. Anthony’s Hospital St. Camillus Hospital St. Camillus Monastery St. Charles Boys’ Home St. Elizabeth’s Nursing Home St. Joan Antida Home St. Joan Antida Nurseries St. John’s Home St. Joseph’s Home of St. Raphael St. Joseph’s Home of St. Theresa St. Joseph’s Home of the Sacred Heart St. Joseph’s Hospital St. Joseph’s Orphan Asylum St. Luke’s Hospital St. Margaret’s Guild St. Mary’s Convent St. Mary’s Hill St. Mary’s Hospital St. Michael Hospital St. Rose’s Orphan Asylum St. Vincent’s Infant Asylum Salvation Army Scandinavian-American Old People’s Home School Hygiene Clinic Shorewood Village, Recreation South Milwaukee City, Recreation South View Isolation Hospital Travelers’ Aid U. S. Department of Labor — Wage and Hour and Public Contracts Div. Urban League Veterans Administration, U.S. Veterans Information and Referral Center Areterans’ Service Exchange Visiting Nurse Association Volunteers of America Day Nursery Wauwatosa City, Recreation Wauwatosa Town, Recreation Welfare Counselors of the Pupil Guidance Service Milwaukee City Schools AVest Allis City, Recreation West Milwaukee Village, Recreation AVest Side Hospital AVhitefish Bay Recreation Wisconsin Anti-Tuberculosis Assoc. Wisconsin Heart Association Wisconsin Service Association Y.M.C.A. Y.AV.C.A. Youth Aid Bureau of Milwaukee City Police 8 FOREWORD A. Objectives, Organization, Financ- ing, and Scope of the Survey A citizen of Milwaukee recently said, “I have been in business in Milwaukee a good many years. I have visited nearly every state of the Union and have been abroad. I have kept my eyes and ears open. AYhile I know that Milwaukee is not perfect, its government and people are good. I have advised my sons to live and work here.” Those words might have come from almost any citizen. Those who live in Milwaukee do not apologize for it. They are proud of its history and achievements, but they are well aware that greater things lie ahead. That spirit and those ideas were shown by the organizations which sponsored the survey of health and welfare services in Milwaukee County. They knew things were good, but they wanted to know just how good and in what direction progress might be obtained. The sponsoring groups — the Civic Alliance and the Community AVel- fare Council — arranged for the incorporation of “The Milwaukee County Survey of Social AArelfare and Health Services, Inc.” as a non- profit corporation. One hundred and twenty-five citizens are the corpora- tion members. Their names have been listed previously. These mem- bers elected a Board of Directors who have been responsible for the conduct of the Survey through var- ious committees. They employed Joel D. Hunter as Director and gave him authority to employ the remain- der of the Survey staff. They gave approval to the use of specialists to be loaned by the U. S. Public Health Service and the U. S. Children’s Bureau with the definite understand- ing that they would be under the control of the Director of the Survey. A budget of $75,000 was adopted and spent. In an early publication the ob- jective was stated to be: “A com- plete survey of the health and social complexions of the county and of all the facilities, tax-supported, vol- untarily-supported, nonprofit, and commercial, which are available to meet social and health needs and to prevent occurrence of social ills.” At the beginning of the study a list had to be made of the agencies to be included. The original list was that of the agencies whose expend- itures had been studied by the Community AYelfare Council every other year since 1938, with the ex- ception of 1944. Similar studies were made in twenty-eight other cities and the comparative figures have been published by Community Chests and Councils of America, Inc. As the Survey progressed, some addi- tional private agencies and depart- ments of government were included in order to make the coverage as complete as possible. A list of these agencies precedes this foreword. The selection of staff was very important. All those chosen were experts in their fields, were practical people with administrative experi- ence, and (with two exceptions) were employed. This meant that they could not all be here at the same time. They have worked var- ious periods, the shortest being three weeks, the longest eight months. Their names, regular posi- tions, and Survey assignments are a part of this report. Of the 43 staff members, 14 were regularly employed on the Survey staff; 18 were loaned from the United States Public Health Serv- ice; four from the Children’s Bu- reau; and seven from the AVisconsin State Department of Health. Three students were also used. B. Method and Procedure of the Survey If a survey is to succeed there are at least three essentials; namely: a. The community to be studied must desire the study. b. Methods must be set up through which the findings and recommendations of the survey will receive serious consideration by all agencies involved. c. The findings and recommen- dations must be those of the community itself, as well as of the outside observers. Milwaukee met the first two re- quirements. The Mayor wrote the Surgeon General of the United States, requesting the services of the U. S. Public Health Officers. The citizens requested the survey through the clubs represented in the Civic Alliance, and the social and health agencies through the Com- munity AYelfare Council, So far as the second requirement is concerned, the Bulletin announc- ing the organization of the Survey said: “It is believed that such an ex- tensive and important study as is projected must be concerned not only with the gathering, weighing, and interpretation of facts, and of recommendations based upon facts, but with the problems of carrying the recom- mendations into action. Unless the study is translated into action, the entire project is a waste of effort. To avoid this danger, the active interest and participation of the lay and pro- fessional leaders in the com- munity and the organizations of all types are of paramount im- portance.” Since the completion of the field work of the Survey, it has been de- cided that the organization should continue until December 31, 1950 in order to assist the public and pri- vate agencies involved in their con- sidering and carrying out of the various recommendations made. Mr. Sydney B. Markey, who was the Associate Director of the Survey from the beginning, has been em- ployed as Director, and a budget of $15,840 has been approved for the fiscal year beginning October 1, 1949. In regard to the third requirement, Dr. Butterworth, in his report on Health Education, quoted Ivah Deering as follows: “People do not lightly put aside those plans which they themselves have made.” The Survey staff has tried to work and think with those who reside here. In every one of the following ac- tivities the staff knows that more could have been done. We set out to gather facts, to interpret them, to evaluate them, to relate them to each other, to compare them with 9 other facts from other areas, and to come out with some observations and recommendations. We have had no secrets. Probably every recommen- dation made was known to the agencies involved ahead of time. Some will not sit well. It may be that the judgment of the Survey staff was wrong in making them. There is also a probability that some agencies or people look at change as retrogression rather than progress. No one likes to be told what to do. We have tried to think with the people of Milwaukee. All we can ask is that, whether or not there is agree- ment with the Survey findings and recommendations, they will be given serious consideration. Not one rec- ommendation has been made unless it was felt that the service to some person or persons would be im- proved. The following have been our main activities; 1. Reading published reports. 2. Reading case records. 3. Reading financial statements. 4. Conferring with executives, staff members, board mem- bers, and citizens about the services being studied. 5. Discussing Survey methods, findings, and recommenda- tions with technical commit- tees — usually made up of the executives and board mem- bers of the agencies being studied. 6. Discussing findings and rec- ommendations with special committees of the Board of Directors and Corporation. 7. Making progress reports to the Board, the Corporation, and more frequently to the Executive Committee. 8. Addressing public meetings. 9. Issuing progress reports through newspapers and the News Bulletin of the Commu- nity Welfare Council. Not only the conferences with in- dividuals, but the meetings with technical committees and special committees of the Board have been invaluable. There should have been more of them. There are eighty-eight different special reports on that many dif- ferent subjects. They comprise about 2,000 pages. They will be summar- ized in the 100 pages of this printed report. The special reports have been mimeographed and distributed to the agencies studied and some to interested groups. Their distribu- tion had to be limited. A few extra copies are being kept in the Survey office and at the Community Wel- fare Council. These will be available to interested persons for reference. Special reports were written about the private case work, the private group work, and the public and private child care and nursing agen- cies. These reports went only to the agencies themselves and, if they were members of the Community Welfare Council, to that agency also. C. Some Over-All Facts About Health and Welfare Services Which Are Not Covered in the Summary Report Each separate piece of a picture puzzle could be studied carefully by itself, but at the end of the time the student would probably have no idea whatsoever about the appear- ance of the whole picture when each piece was in its proper place. Therefore, before the courageous reader begins on the special reports, it seems wise to write down a few things about the total picture so that there might be a better under- standing of the individual pieces when they are examined. The first table is very impor- tant. It gives the total expenditure ($25,997,539) in 1946 for health and welfare services in Milwaukee Coun- ty. It shows how these expenditures were divided among “ Fields of Service” and from whence the money came. For these expenditures it also tells each citizen of Milwau- kee County how much it cost him during 1946 and then it shows what the cost was to the average citizen in the twenty-nine urban areas stud- ied at the same time. In addition to the above, the table also shows the expenditures for cer- tain services which are not usually classed as welfare services, but which have to do with the economic security of the community. These are Veterans Administration, Un- employment Compensation, Old Age and Survivors’ Insurance, 'Work- men’s Compensation, and Railroad Insurance. The expenditure for these services was $26,669,986 in 1946, making the total for Milwau- kee County $53,517,249. There are ways in which the posi- tion of the Milwaukee County citi- zen is different. Some of these are: 1. The per capita cost in Milwaukee County was 6.4 percent less than the per capita cost in the 29 urban areas. In Milwaukee County it was $30.41; in 29 areas — $32.48. 2. The main difference was in Public Assistance. In Milwaukee County it was $6.51, as against $9.60 in the 29 areas — 32.2 percent less. 3. Milwaukee County’s per capita expenditures were also low in plan- ning for social and health services, joint financing, and central services. In the 29 areas these services cost 40 cents per capita — in Milwaukee County 20 cents. 4. The Milwaukee County citizen spent more than the average citizen in the 29 areas for health, and for recreation and group work services. There was no great difference in health. In Milwaukee County the per capita was $14.95 and in other areas $14.86. In group work and recreation there was a 45 percent difference. The per capita cost in Milwaukee County was $3.51 and in the 29 areas it was $2.42. For further explanation of the various services the reader is re- fered to the summary of the special reports and/or to the reports them- selves. In the preceding table the year 1946 was used because the study of expenditures for 1948 had not yet been published for the 29 areas. How- ever, the Research Department of the Community Welfare Council has fin- ished the study of Milwaukee County Services, so two tables are given from that study. The first one (Table 2) shows the total expenditures for 1948, divides the total into public and pri- vate, and gives the per capita for 1948. The second (Table 3) compares the per capita cost of 1946 with 1948 and also gives the percentage which the expenditure for each service is of the total expenditures, and the per- centage it is of the expenditures in its field. For example, hospital in- patient service in 1948 was 45.82 per- cent of the total 1948 expenditures and 88.09 percent of the expendi- tures for all health services. These tables show an increase in the per capita expenditure to $42.58 in 1948 from $30.41 in 1946. The greatest increase was in the amount spent for health services. Later tables will show that this expendi- 10 FIELD OF SERVICE Total Ei- pendtturcs 1946 PUBLIC FUNDS PRIVATE FUNDS Per Capita for 29 Areas Total Local State Federal Total Contributions Income From Invest- ments P*yments for Service Net Proceeds From Other Activities All Other Receipts Per Capita Community Chest Sectarian Financial Federation Other Sources TOTAL, ALL FIELDS $25,997,539 $14,526,207 $9,867,01 1 $2,438,259 $2,220,937 $1 1,471,332 $1,378,998 $240,465 $708,348 $197,592 $8,119,403 $160,169 $666,357 $30.41 $32.48 Economic Assistance and Social Adjustment Services—TOTAL 10,046,350 7,459,290 3,700,649 1,629,858 2,128,783 2,587,060 620,065 207,806 519,237 103,818 501,683 28,423 606,028 11.75 14.80 Public assistance services 5,562,782 5,562,782 2,109,191 1,390,704 2,062,887 6.51 9.60 General assistance 1,067,093 1,067,093 1,056,599 10,494 1.25 1.52 Aid to dependent children 887,054 887,054 356,821 291,603 238,630 1.04 1.22 Old age assistance 3,492,656 3,492,656 675,066 1,053,884 1,763,706 4.08 6.63 Aid to the blind 1 15,979 1 15,979 20,705 34,723 60,551 .14 .23 Institutional and custodial care of adults 813,970 313,769 313,721 13 35 500,201 56,503 63,571 51,183 292,891 36,053 .95 .79 Shelters for transients and homeless 83,838 1,776 1,762 14 82,062 9,257 20,669 519 18,132 33,485 .10 ,09 Institutions for aged and dependent adults 730,132 311,993 31 1,959 13 21 418,139 47,246 42,902 50,664 274,759 2,568 .85 .70 Family services primarily social adjustment 773,984 103,518 100,769 2,749 670,466 220,142 46,542 341,798 10,366 30,357 21,261 .90 .88 Family service 610,318 610,318 162,938 46,542 341,722 10,059 27,796 21,261 .71 .66 Social service to travelers 57,917 2,749 2,749 55,168 55,079 66 23 .07 .04 Medical social service 15,921 10,941 10,941 4,980 2,125 10 284 2,561 .02 .09 Domestic relations service 89,828 89,828 89,828 .10 .09 Specialized services for children 2,117,003 1,371,802 1,168,274 203,058 470 745,201 276,129 128,864 95,445 41,895 136,177 1,785 64,906 2.48 2.29 Protective and foster care 1,461,918 912,579 868.684 43,895 549,339 239,867 1 15,633 58,897 26,805 100,987 1,785 5,365 1.71 1.23 Day nurseries 63,557 470 470 63,087 19,713 19,468 23,906 .07 .43 Probation services for children 172,498 172,498 168.098 4,400 .20 .29 Institutions for delinquent children 419,030 286,255 131,492 154,763 132,775 16,549 13,321 1 7,080 15,090 11,284 59,541 .50 .35 Specialized services for the handicapped 609,258 96,088 33,446 62,642 513,170 3,849 4,557 3.668 791 500,305 .71 .61 Maternity home care 52,804 52,804 16,212 7,000 345 374 26,037 1,836 1,000 .06 .06 1*1 105,218 47,230 25,400 13,521 12,553 2,750 3,764 .14 .57 Other 116,549 1 1,331 8,694 2,637 Health Services— TOTAL 12,781,167 5,589,1 19 4,71 1,737 790,978 86,404 7,192,048 289,870 19,596 135,559 81,102 6.638,851 26,033 1,037 14,95 14,86 Hospital in-patient care 11.078.981 4,399,069 3,673,619 725,450 6,679,912 150,562 19,596 42,494 48,567 6,404,028 13,964 701 12.96 12.79 General hospital in-patient service 7,793,715 1,624,957 1,624,957 6,168,758 150,562 19,596 35,222 46,087 5,904,929 1 1,661 701 9.12 10.04 Chronic disease and TB hospital in-patient service 814,129 726,513 567,088 159,425 87,616 1,348 2,480 83,788 .95 .93 Mental hospital in-patient service 2,471,137 2,047,599 1,481,574 566,025 423,538 5,924 415,311 2,303 2.89 1.82 Hospital admitting and certifying bureaus No Organized Service Clinic and out-patient care 634,704 398,526 335,018 542 62,966 236,178 51,370 12,788 21,479 138,766 11,750 25 .74 .78 Clinic service 486,926 257,714 195,477 62,237 229,212 51,370 6,026 21,443 138,623 11,750 .57 .64 Mental hygiene clinics 36,544 36,401 36,401 143 143 .04 .05 School hygiene medical service 111,234 104,41 1 103,140 542 729 6,823 6,762 36 25 .13 .09 Nursing services 474,740 346,664 346,664 128,076 65,390 1,217 3,237 57,913 319 .56 .44 Public health nursing 271,000 142,924 142,924 128,076 65,390 1,217 3,237 57,913 319 .32 .29 School hygiene nursing 203,740 203,740 203,740 .24 .15 Other 592,742 444,860 356,436 64,986 23,438 147,882 22,548 79,060 7,819 38,144 311 .69 .85 Recreation, Informal Education and Groupwork Services—TOTAL 2,996,063 1,477,798 1,454,625 17,423 5,750 1,518,265 308,036 456 53,227 12,672 978,869 105,713 59,292 3.51 2.42 Community-wide building centered programs 368,418 26,020 26,020 342,398 123,466 11,249 363 108,789 97,531 1,000 .43 .72 Neighborhood building centered programs 468,854 371,006 362,718 8,288 97,848 68,299 11,105 942 17,219 283 .55 .35 Neighborhood non-building centered programs 100,223 100,223 74,979 9,400 13,460 2,384 .12 .24 Playgrounds and general recreation programs 1,861,409 1,080,772 1,065,887 9,135 5,750 780,637 3,683 1,929 730,052 524 44,449 2.18 .77 Established summer camps 146,875 146,875 24,773 456 6,272 38 109,349 4,967 1,020 .17 .21 Other 50,284 50,284 16,519 20,918 307 12,540 .06 .13 Planning, Financing and Common Services— TOTAL 173,959 173,959 161,027 12,607 325 .20 .40 Planning 21,691 21,691 21,691 .02 .06 Community welfare council 21,691 21,691 21,691 .02 .06 Financing 119,317 119,317 106,710 12,607 .14 .20 Community chest 106,710 106,710 106,710 .13 .17 Sectarian federations 12,607 12,607 12,607 .01 .03 Common services 32,951 32,951 32,626 325 .04 .14 Social service exchange 12,000 12,000 12,000 .01 .02 Information and referral centers 15,626 15,626 15,626 .02 .06 Other 5,325 5,325 5,000 325 .01 .06 Other Health and Welfare Services— TOTAL 26,669,986 26,669,986 3,755,640 22,914,346 30.90 Veterans' Administration (b) 18,143,380 18,143,380 18,143,380 21.22 Unemployment Compensation (c) 1,926,841 1,926,841 1,926,841 2.25 Old Age and Survivors’ Insurance (d) 3,667,748 3,667,748 3,667,748 4.29 Workmen's Compensation (e) 1,828,799 1,828,799 1,828,799 2.14 Railroad Insurance (f) 1,103,218 1,103,218 1,103,218 1.29 Grand Total—All Expenditures 53,517,249 41,196,193 9,867,011 6,193,899 25,135,283 62.59 (a) Does not include expenditure of 5730.242 for school lunch programs (public and private): submitted after tabulations were completed. (b) Estimate from annual report of Veterans' Administration for year ending June 30, 1947. (c) Unemployment Compensation Statistics, Statistical Department, Industrial Commission of Wisconsin. (d) Regional Office, Bureau of Old Age and Survivors' Insurance, Chicago, III. (e) Workmen's Compensation Statistics, Statistical Department. Industrial Commission of Wisconsin. to Includes retirement, unemployment, survivors' benefits and disability benefits. EXPENDITURES FOR HEALTH AND WELFARE SERVICES. BV FIELD OF SERVICE AND SOURCE OF FUNDS Milwaukee County, Wijeomin—1946 11 TABLE 2 1948 EXPENDITURES FOR HEALTH AND WEL OF SERVICE AND PUBLIC AND FARE SERVICES BY FIELD PRIVATE FUNDS Total All. Exp. Total Public Total Private Per Capita TOTAL — ALL FIELDS $36,489,261 $20,523,518 $12,668,238 $42.58 I. Economic Assistance 13,812,034 10,514,529 3,297,505 16.12 A. Public Assistance 7,877,202 7,877,202 9.19 General 1,352,518 1,352,518 1.58 Dependent Children 1,348,127 1,348,127 1.57 Old Age 5,015,373 5,015,373 5.85 Blind B. Institutional and Custodial 161,184 161,184 .19 Care, Adults 1,178,670 476,881 701,789 1.38 Shelter Transients Institutions for Aged and 132,057 2,378 129,679 .15 Dependent Adults C. Family Services, Social 1,046,613 474,503 572,110 1.23 Adjustment 785,775 144,137 641,638 .92 Family Service 559,588 559,588 .65 Service to Travelers 76,522 76,522 .09 Medical Social Service 24,538 19,010 5,528 .03 Domestic Relations D. Specialized Services for 125,127 125,127 .15 Children Protective and Foster 2,957,036 1,901,063 1,055,973 3.45 Home Care Institutions for Dependent 537,478 152,608 384,870 .63 Children 1,608,873 1,157,441 451,432 1.88 Day Nurseries Probation Service for 80,775 892 79,883 .09 Children 263,120 263,120 .31 Institutions for Delinquents . E. Specialized Service for 466,790 327,002 139,788 .54 Handicapped 781,828 99,125 682,703 .91 F. Maternity Homes 70,744 70,744 .08 G. Other1 160,779 16,121 144,658 .19 II. Health Services 19,355,648 8,384,564 10,971,084 22.58 A. Hospital Inpatient 17,050,599 6,823,277 10,227,322 19.90 General 12,049,437 2,425,766 9,623,671 14.06 Chronic and T.B 1,446,442 1,316,575 129,867 1.69 Mental Hospital 3,554,720 3,080,936 473,784 4.15 B. Clinic and Outpatient Care . . 868,264 507,202 361,062 1.01 Clinic Service 661,359 309,333 352,026 .77 Mental Hygiene Clinics 63,277 63,277 .07 School Hygiene Medical .... 143,628 134,592 9,036 .17 C. Nursing Services 610,941 441,750 169,191 .71 Public Health Nursing 375,982 206,791 169,191 .44 School Hygiene Nursing .... 234,959 234,959 .27 D. Other Health Service 825,844 612,335 213,509 .96 III. Recreation, Group Work, etc. . 3,154,860 1,624,425 1,530,435 3.69 A. Community Wide Building . . 515,417 24,358 491,059 .60 B. Neighborhood Center Building C. Neighborhood Center Non- 544,506 349,339 195,167 .64 Building D. Playgrounds and General 150,200 150,200 .18 Recreation E. Estimated Summer Camps 1,761,219 1,250,728 510,491 2.06 (Established) IV. Planning, Financing, Common 183,518 183,518 .21 Services 166,719 166,719 .19 A. Planning 38,542 38,542 .04 Community Welfare Council . 38,542 38,542 .04 B. Financing 84,992 84,992 .10 Community Chest 70,724 70,724 .08 Sectarian Federations 14,268 14,268 .02 C. Common Services 43,185 43,185 .05 Social Service Exchange .... Information and Referral 15,276 15,276 .02 Centers 14,515 14,515 .02 Other 13,394 13,394 .01 JDoes not include school lunch programs. ture was largely met through an in- crease in payments for service. The next largest increase was in public assistance. Let’s take a look at the amount of money that is received as pay- ments for service and examine the variations between fields of service. These payments do not vary much between Milwaukee and the 29 areas. In Milwaukee County the payments for service were 31.2 percent of total expenditures in 1946. In the 29 areas they were 29.7 percent. In Milwaukee in 1946 the payments for service were 70.8 percent of total private ex- penditures. They increased to a per- centage of 72.6 in 1948. It is doubtful if the ‘‘man on the street” knows that such a high percentage of the cost of private nonprofit organiza- tions is paid for by the users of the service. The actual figures about payments for service are shown in Table 4. This table on “Payments for Serv- ice” covers most of the private non- profit health and welfare agencies in Milwaukee County. Thirty-seven of these agencies are members of the Community Welfare Council and depend on it for that part of their income which comes from contributions. Table 5 gives the total disbursements of these 37 Chest agencies over a number of years (the Chest fiscal year is Octo- ber 1 to September 30) and also shows the allocations from the Chest to those agencies during the same period. The total disbursements and the Chest allocations increased about the same percentage from 1940 to 1948. In two of the main fields of service—Family Welfare and Health — the Chest allocation did not in- crease as much as did the total dis- bursements. In Group Work the in- crease was about the same. In Child Care the allocation from the Chest increased much more rapidly than did total disbursements. That is in- teresting because there was also a large increase in public money spent for child care during that same period. 12 TABLE 3 COMPARISON OF EXPENDITURES PER CAPITA FOR 1946 AND 1948 Per Capita Percent of Total Percent of Field 855,000 857,000 Pop. Pop. 1946 1948 1946 1948 1946 1948 I. Economic Assistance and Social Adjustment $12.60 $16.95 40.31 39.04 100.0 100.0 A. Public Assistance 6.51 9.19 20.83 21.17 51.67 54.22 B. Institutional and Custodial Care of Adults . .95 1.38 3.04 3.18 7.54 8.14 C. Family Services .90 .92 2.88 2.12 7.14 5.43 D. Specialized Services for Children 2.48 3.45 7.93 7.95 19.68 20.35 E. Specialized Services to Handicapped .71 .91 2.27 2.10 5.63 5.37 F. Maternity Home Care . . . .06 .08 .19 .18 .48 .47 G. Other .99* 1.02 3.17 2.34 7.86 6.02 II. Health Services 14.95 22.58 47.83 52.02 100.0 100.0 A. Hospital Inpatient 12.96 19.90 41.46 45.82 86.69 88.09 B. Clinic and Outpatient . . . .74 1.01 2.37 2.35 4.95 4.52 C. Nursing Services .56 .71 1.79 1.64 3.75 3.14 D. Other Health Services . . . .69 .96 2.21 2.21 4.61 4.25 HI. Recreation, Group Work, etc. 3.51 3.69 11.23 8.50 100.0 100.0 A. Community Wide Building .43 .60 1.38 1.38 12.25 16.26 B. Neighborhood Centered Building .55 .64 1.76 1.47 15.67 17.34 C. Neighborhood Center Non- Building .12 .18 .38 .42 3.42 4.88 D. Playground and General Recreation 2.18 2.06 6.98 4.75 62.11 55.83 E. Established Summer Camps .17 .21 .54 .48 4.84 5.69 F. Other .06 .19 1.71 IV. Planning, Financing, Common Services .20 .19 .63 .44 100.0 100.0 A. Planning .02 .04 .06 .09 10.0 21.05 B. Financing .14 .10 .44 .23 70.0 52.63 C. Common Services .04 .05 .13 .12 20.0 26.32 TOTAL EXPENDITURES 31.26 43.41 100.0 100.0 100.0 100.0 I. Economic Assistance and Social Adjustment 12.60 16.95 40.31 39.04 40.31 39.04 II. Health Services 14.95 22.58 47.83 52.02 47.83 52.02 HI. Recreation, Group Work, etc 3.51 3.69 11.23 8.51 11.23 8.50 IV. Planning, Financing, Common Services .20 .19 .63 .43 .63 .44 ‘Includes school lunch programs not included in Expenditures publication, 1946. PER CAPITA EXPENDITURE BY PUBLIC FUNDS IN URBAN AREAS Area Total Local State Federal 29 Urban Areas . . . $17.86 $ 7.12 $6.92 $3.82 Milwaukee County . . 16.99 11.54 2.85 • 2.60 When an examination is made of taxes as a source of revenue for health and welfare services, some differences are noticeable. The difference in the amounts of local and state funds should receive attention. The Director of the Sur- vey has no opinion as to whether the above division of costs is correct or not. If it is examined, the group making the study should include not only experts in public revenue mat- ters, but also some who are familiar with public welfare administration. It is very commendable that the local governments in Milwaukee County have been willing and ready to spend more than the average of local taxes in the support of services under the three main heads, e. g. Economic Security, Health, and Rec- reation. The following three tables are given to show the percentage that local, state, and federal funds are of total public and private expendi- tures for health and welfare services in 15 urban areas compar- able to Milwaukee County. TABLE 4 PAYMENTS BY PERSONS RECEIV ING SERVICES OF MILWAUKEE COUNTY HEALTH, WELFARE, AND RECREATION AGENCIES FOR 1940, 1942, 1946, AND 1948 BY TYPE OF SERVICE, PERCENT CHANGE 1940-1048 AND PAYMENTS AS PERCENT OF TOTAL PRIVATE EXPENDITURE BY SERVICE FIELD Percent Change Payments as Percent of Total Private Expenditure 1940 1942 1946 1948 1940-48 1940 1942 1946 By Field Total $3,468,987 $4,547,000 $8,119,403 $11,897,598 + 243.0 61.2 65.1 70.8 72.6 Family Welfare and Relief 113,239 142,000 365,506 806,859 + 612.5 12.3 11.7 19.8 30.4 WPA, NYA, CCC Other 113,239 142,000 365,506 806,859 + 612.5 12.3 11.7 19.8 30.4 Child Welfare 52,612 76,000 136,177 191,223 + 263.5 10.8 13.9 18.3 18.1 Group Work and Recreation 366,739 373,000 978,869 778,927 + 131.3 55.4 56.0 64.5 50.9 Health Services 2,934,397 3,955,000 6,638,851 10,120,435 + 244.9 84.7 88.9 92.3 92.3 Hospital Inpatient 2,787,994 3,760,000 6,404,028 9,796,205 + 251.4 91.2 93.4 95.9 95.8 Clinic Service 64,561 111,000 138,766 208,428 + 222.8 26.8 56.1 58.8 57.7 Nursing Service 56,396 65,000 57,913 84,780 + 50.3 46.3 50.0 45.2 50.1 Other Health Service . . . 25,446 19,000 38,144 31,202 + 22.6 59.0 20.0 25.8 14.6 Planning and Finance .... 154 + 100.0 0.1 13 1939- 1940 1941- 1942 1945- 1946 1946- 1947 1947- 1948 Per Cent Change 1940 - 1948 Total Disbursements $2,054,420 $2,270,185 $3,308,047 $4,095,816 $4,332,573 + 110.9 Total Community Chest Allowance 1,035,072 1,079,793 1,379,432 2,036,386 2,153,826 + 108.1 Per Cent of Total Disbursements 50.4 47.6 41.7 49.7 49.7 Care of Children Total Disbursements , . . . 499,142 518,600 530,710 868,733 936,343 + 87.6 Total Chest Allowance . ... 249,149 235,793 247,346 510,274 598,226 + 140.1 Per Cent of Total , . . . 49.9 45.5 46.6 58.7 63.9 Family Welfare Total Disbursements 409,576 496,805 943,649 823,568 929,420 + 126.9 Total Chest Allowance . . . . 247,296 291,444 450,112 432,214 500,020 + 102.2 Per Cent of Total 60.4 58.7 47.7 52.5 53.8 Health Total Disbursements . ... 434,135 503,850 685,014 791,431 901,103 + 107.6 Total Chest Allowance 253,904 271,900 286,785 347,112 421,110 + 65.9 Per Cent of Total . . . . 58.5 54.0 41.9 43.9 46.7 Group Work Total Disbursements 590,296 648,746 1,010,446 1,188,336 1,306,324 + 121.3 Total Chest Allowance . . . . 167,416 182,446 262,050 331,372 387,586 + 131.5 Per Cent of Total 28.4 28.1 25.9 27.9 29.7 Central Services Total Disbursements . . . . 114,796 95,310 129,930 226,748 246,258 + 114.5 Total Chest Allowance , 114,407 95,310 129,930 218,414 233,759 + 104.3 Per Cent of Total 99.7 100.0 100.0 96.3 94.9 Unclassified Total Disbursements 6,475 6,874 8,298 19 7,000" 13,125b + 102.7 Total Chest Allowance 2,900 2,900 3,200 197,000 13,125 + 352.6 Per Cent of Total . . . . 44.8 42.2 38.6 100.0 100.0 “Includes $190,000 for U. S. O. includes Survey appropriation. TABLE 5 DISBURSEMENTS OF CHEST AGENCIES BY SERVICE FIELD AND CHEST ALLOCATIONS, 1940, 1942, 1946, 1947, AND 1948 AND PERCENT CHANGE 1940 TO 1948 — MILWAUKEE COUNTY 14 TABLE (5 PERCENTAGE OF TOTAL PRIVATE AND PUBLIC FUNDS RECEIVED FROM LOCAL GOVERNMENTS IN 15 URBAN AREAS 1946 Rank Percent 1. MILWAUKEE 38.0 2. Louisville . . . 3. Los Angeles . 4. San Diego . . . 5. Buffalo 6. St. Louis .... 7. Baltimore . . . 22.4 8. Cleveland . . . 9. Atlanta 22.0 10. Kansas City . 16.9 11. Dallas 12. Portland 13. New Orleans . 9.2 14. Providence . . 7.7 15. Seattle 7.5 change. For those two years the Consumers’ Price Index was 99.1 in December, 1940 and 171.2 in No- vember, 1948 — an increase of 72.1. It is evident that material assistance has gone down, but that it costs more to board children, to care for them in institutions, and to obtain medical care in hospitals. So far as health and welfare services are concerned, the inter- ested citizens should read the re- mainder of this Summary and the special reports themselves on sub- jects of special interest. In this foreword a few observa- tions are made; 1. The local governments in Milwau- kee County are made up of citizens of integrity and sincere purpose. It is a great asset. 2. The “man on the street” is bet- ter informed about health and wel- fare services than his counterpart in many other places. That is in large part due to the factual mate- rial and understanding comment which appears in the daily press. That is also a great asset. 3. When the government has ac- cepted the responsibility for a service it has accepted the full re- sponsibility. This is due to the fact that there are practically no subsi- dies or payments of public funds to private agencies to perform services which have been recognized as pub- lic responsibility. 4. The private agencies’ field of work is fairly well defined from the public largely because of the lack of subsidies. 5. All the public assistance services in the home have been integrated in one department. 6. Not only the “man on the street,” but the business and labor leaders, are confused by the number of fi- nancial campaigns in Milwaukee. Many other cities have the same problem. 7. There is a lag in the development of Central Planning and Joint Fi- nancing. In every urban community private agencies are becoming more and more specialized. They recog- nize the necessity of joining their specialties for the good of their clients, but have not gone as far as they might in doing it. The question is, “How can Central Planning and Joint Financing be organized so that they will be stimulating and in- spirational rather than deterrents?” Milwaukee has strong local govern- ment. It also has the sincere interest of its citizens in the work of the private agencies. It has a fine chance to show just what the correct balance should be between “autono- my for the agencies” and “central control and financing for the great- est good for the greatest number.” The Director wishes to state that many agencies in Milwaukee think more of “specialization” than of “cooperative effort.” This is illus- trated many times over in the special reports. People do not like to be con- trolled, consolidated, or absorbed. Without any of those things hap- pening, agencies and governments can make agreements with each other and can cooperate in their services. It must be done in the health and welfare services. 8. There is very little duplication of services in Milwaukee County. There is some, however, and conferences should be held to justify it or else to eliminate it. 9. There are not many unmet needs. There are more inadequate and in- complete services rather than unmet needs because of lack of proper re- ferral from agency to agency, lack of staff in both number and quality, limited intake policies, and other matters which should be removed through conferences and discussions leading to agreements. 10. Personnel — When one is deal- ing with an unmarried mother, a lonely aged person, a deserted and ill behaved child, an alcoholic, a seriously injured workman, or many other types of people, one needs not only a warm personality, but also understanding and skill. The profes- sion of medicine, nursing, and all branches of social work should have the people of the most wholesome personality and greatest skill. That skill comes from studying what other people have done, and from experience. The Survey made no ef- fort to evaluate the personalities of workers. We know they were care- fully selected by civil service for public positions and in similar ways for private. We could and did get a personnel profile of nearly all the employed staffs. Comment is made in some of the special reports. In general it should be said that there should be more workers with more information and skill acquired through study. This is very import- ant. Suggestions are made about leaves of absence for study, in-serv- ice training, more adequate supervi- TABLE 7 PERCENTAGE OF TOTAL PUBLIC AND PRIVATE FUNDS RECEIV ED FROM STATE GOV ERNMENTS IN 15 URBAN AREAS 1946 Rank Percent 1. Seattle 2. New Orleans 37.8 3. Providence 32.4 4. Portland 5. Buffalo 22.4 6. Kansas City 21.5 7. Los Angeles 21.0 8. Dallas 18.8 9. St. Louis 17.8 10. Cleveland 16.3 11. Baltimore 16.2 12. San Diego 15.6 13. Atlanta 13.3 14. MILWAUKEE . . . 9.4 15. Louisville 8.2 TABLE 8 PERCENTAGE OF TOTAL PRIVATE AND PUBLIC FUNDS RECEIVED FROM FEDERAL GOVERNMENT IN 15 URBAN AREAS 1946 Rank Percent 1. Dallas 20.5 2. Kansas City 16.8 3. Los Angeles 16.6 4. Seattle 14.8 5. Portland 13.2 6. San Diego 12.2 7. St. Louis 11.8 8. Atlanta 11.7 9. Providence 11.1 10. New Orleans 10.6 11. MILWAUKEE 8.5 12. Louisville 8.3 13. Cleveland 6.8 14. Baltimore 6.5 15. Buffalo 5.3 What do all these figures indicate as to the trend of events? The an- swer cannot be given in one table, but Table 9 gives expenditures for 1940 and for 1948 and the percentage 15 sion on the job, higher standards of employment, and new departments in the Wisconsin and Marquette Uni- versities. It is almost true to say that any worthwhile change takes time. Evo- lution is better than revolution. The best clock is the most regular one and not the fastest. Recognizing that all things cannot be done at once, a few suggestions are made about the methods of im- plementation and the principles to follow. 1. In every field, emphasis should be placed on prevention, e. g. establish homemaker service in order to keep families together and arrange for better contacts between schools and health and social agencies. It is in the school the abnormalities in chil- dren are first observed. 2. Examine and keep examining all methods of joint planning and joint financing. To make these things work, vision, statesmanship, and great administrative skill are needed. Milwaukee can meet the test. 3. Examine ways of improving stand- ards of service in each agency. 4. Conferences and discussions are not a waste of time. They are the basis of the democratic way of life. Have them, but point them up to definite agreements about coopera- tive service and joint efforts. The Director is proud that he has made friends in Milwaukee. He is happy about the way in which the Survey staff has worked with the citizens of Milwaukee. We are all grateful for that and innumerable other courteous acts. A great deal of time has been given by hundreds of people. We hope some good may come of it all. This report is our sincere effort to put down what we saw and thought. And now the Summary — the first five sections deal with reports on welfare services. The subjects are: (1) Family Services; (2) Child Wel- fare; (3) Recreation, Informal Education, and Group Work; (4) Special Services, Courts, Aged, Minority Groups; and (5) Planning, Financing, and Central Services. These reports total over 800 pages. To reduce them to about 40 printed pages required very drastic cutting of material. Those interested in spe- cial subjects should read the com- plete text. Copies are on file at the Survey office and the Community Welfare Council. TOTAL PUBLIC AND BY FIELD OF SERVICE FOR TABLE 9 PRIVATE EXPENDITURES IX MILWAUKEE COUNTY 1940 AND 1948 AND PERCENTAGE CHANGE FROM 1940 -1 948 1940 1948 Percent Change ’40-’48 Private Public Total Private Public Total Private Public Total Total $5,670,851 $29,230,686 $34,901,537 $16,378,453 $20,827,443 $37,205,896 + 188.8 - 28.8 + 6.6 Family Welfare and Relief . . 923,261 23,681,473 24,604,734 2,654,242 8,917,391 11,571,633 + 187.5 - 62.4 - 53.0 WPA, NYA, CCC Other 923,261 12,529,449 11,089,024 12,592,449 12,012,285 2,654,242 8,917,391 11,571,633 + 187.5 - 62.4 - 3.7 Child Welfare . . . 488,942 729,184 1,218,126 1,055,973 1,901,063 2,957,036 + 117.0 + 160.7 + 142.8 Group Work and Recreation 661,525 1,078,611 1,740,136 1,530,435 1,624,425 3,154,860 + 131.4 + 50.6 + 81.3 Health Services . . 3,464,048 3,741,418 7,205,466 10,971,084 8,384,564 19,355,648 + 216.7 + 124.1 + 168.6 Hospital Inpatient 3,058,210 2,827,936 5,886,146 10,227,322 6,823,277 17,050,599 + 234.4 + 141.3 + 189.7 Clinic Service . . 240,974 282,504 523,478 361,062 507,202 868,264 + 49.8 + 79.5 + 65.9 Nursing Service . 121,713 288,982 410,695 169,191 441,750 610,941 + 39.0 + 52.9 + 48.8 Other Health Service 43,151 341,996 385,147 213,509 612,335 825,844 + 394.8 + 79.1» + 114.4 Planning and Finance 133,075 133,075 166,719 166,719 + 25.3 + 25.3 Consumers’ Price Index* + 71.2 *1935-1939 — Consumers’ Price Index = 100% 16 I. Family Services A. Economic Security Many of our grandparents pro- duced and made almost everything that they ate and wore. Times have changed so that the modern urban dwellers produce almost nothing for self-use. They buy the necessary things to eat and wear. Therefore, they are dependent on the amount of money they have to exchange for food, clothing, and shelter. The wages a man earns are, therefore, his main economic security. In this study we made no original study of wages in Milwaukee County. Our concern is with those who have lost the economic security of wages through death of the wage earner, unemployment, accident, old age, disability, or for some other reason. An effort has been made to study the resources that have been set up to provide assistance or benefits to those unable to support themselves. The first set of benefits which were examined were those from in- surances set up by governmental ac- tion — some of them by the Social Security Act. The programs studied were those of: 1. Unemployment Compensation 2. Old Age and Survivors’ Insurance 3. Workmen’s Compensation 4. Railroad Retirement 5. Veterans’ Benefits 6. The Public Assistances Amount and Source of Benefits The Federal government provided over 80 percent ($26,646,788) of the nearly $331/4 millions ($33,221,157) of the total Economic Security ex- penditures in Milwaukee County in 1947, with the State government providing 12.29 percent, and Mil- waukee County the remaining percent. Milwaukee County’s percent was entirely for Public Assistance, of which the largest item was general relief ($1,194,180), fol- lowed closely by Old Age Assistance, and then by Aid to Dependent Chil- dren. The Veterans Administration ex- penditures amounted to about 60 percent of the $33,221,157. Of the remaining 40 percent, about half (21 percent) was attributable to all of the public assistance services to- gether (General Relief, Old Age As- sistance, Aid to the Blind, and Aid to Dependent Children), and the rest (about 20 percent) constituted ben- efits paid by the State and Federal insurances; namely, Old Age and Survivors’ Insurance, Railroad Re- tirement, Workmen’s Compensation, and Unemployment Compensation. The reader will be impressed with the number and variety of economic security programs operating in Mil- waukee County. The number of per- sons receiving benefits, and the amount of money expended for them, are equally impressive. In- surances, as a method of replacing wages lost because of old age, death, illness, disability, and unemploy- ment, are to be preferred to public assistance. To the extent that in- surances fail to provide needed ben- efits to persons or groups of persons, and to the extent that certain haz- ards are not included either in the public or private insurances, the burden of dependency caused by these hazards, fall squarely upon the County’s public assistance programs. This latter point is of special sig- nificance in the Survey, because the costs of the “residual” public as- sistance program; namely, general assistance, are borne entirely out of local taxes. Milwaukee County has most of the elements of a sound economic secur- ity program already in operation: a. A series of social insurance measures, including Un- employment compensation, Workmen’s Compensation, Old Age and Survivors’ In- surance, and Railroad Insur- ance, which insure against the hazards of unemployment, industrial injury, old age, death, and (in the case of Railroad Insurance) disabili- ty. 1). A public assistance program including Old Age Assistance, Aid to Dependent Children, Aid to the Blind, Aid to Total- ly and Permanently Disabled, and General Relief. c. A comprehensive program for veterans, providing to this group security against dis- ability, death, unemployment, old age, and the costs of medical care. Probably the greatest defect in this economic security system is that insurances have not been made to carry enough of the burden. Insur- ances, paid in part by the benefi- ciary, should be Milwaukee County’s chief weapon against individual and family insecurity resulting from un- employment, old age, death, injury, disability, and the costs of medical eare\ Far too much of the burden is left to the public assistance serv- ices, which supply assistance to a considerable number of people who should obtain benefits from insur- ance programs. These programs are preferable as a method of assuring minimum eco- nomic security because they offer benefits on the basis of the rights earned by the individual, and offer the potential beneficiaries opportu- nities to pay for their own economic security (in part at least) while they are working and able to do so. Coverage and Adequacy of Programs The two questions that this Survey wants to state for consideration are: 1. Do the insurances cover as many people who suffer economic loss be- cause of death, disability, sickness, old age, unemployment, industrial and other injuries, as they should? 2. Are the benefits which are re- ceived adequate to meet minimum needs? Wisconsin has made a thorough study of sick-benefit plans in effect in October 1948. As sickness is a hazard which is not covered in any public insurance program, Wiscon- sin deserves credit for the rapid growth of sick-benefit plans under private auspices. Before any dis- cussions of the insurances set up by governmental action, some comment is made about the group insurances now active in Milwaukee County. The following paragraphs are quota- tions from the news release of April 8, 1949, by the Wisconsin Industrial Commission: “Sick-Benefit Plans Protect 4 7 Percent of Wisconsin Workers. — About 338,000 Wisconsin workers — nearly 47 percent of the 725,000 pri- vate employees covered by Wiscon- boosts of medical care means assistance granted to individuals to pay for care. It does not mean cost of hospitals, clinics, etc. 17 sin’s unemployment compensation law — were protected by formal group sick-leave or sick-benefit plans in October 1948, according to a comprehensive survey made by the state industrial commission. “Those 338,000 workers were thus protected — against complete loss of wages due to non-job injury or ill- ness — by about 2,600 private em- ployers and about 2,800 established group plans for sickness compensa- tion, financed by employers or by workers or usually by both. “That left nearly 387,000 workers — or 53 percent of those who are covered by Wisconsin’s unemploy- ment compensation law — without any assured group protection to com- pensate them for wage losses due to non-job injury or illness.” The above figures refer to the workers in Wisconsin covered by Unemployment Compensation. As 45 percent of these workers live in Milwaukee County, it is safe to as- sume that a higher percentage than 45 of the 338,000 protected by formal sick-benefit plans live in Milwaukee County1. These insurances in many cases are the only group protection the workers have against non-job illness. The benefits in Wisconsin from the three different types of sick- benefit plans are shown in the fol- lowing quotations from the bulletin of the Industrial Commission. “Sick Leave and E.M.B.A. Plans in Wisconsin. — Of the 338,000 Wis- consin employees covered by sickness compensation in October 1948, under some 2,800 private group plans, well over 40 percent were protected either by formal sick-leave plans financed by their employers, or else by E.M.B.A. sick-benefit plans, ac- cording to the state’s survey. “Sick ‘Leave3 Plans. — All-told, there were 710 formal sick ‘leave’ plans, which protected some 92,000 workers in October 1948. 510 of those plans, covering some 52,000 of those workers, provide the only group protection those workers have against non-job disabilities. As to the other 40,000 workers, protected by the other 200 sick ‘leave’ plans, they work for employers who have more than one type of plan; so some of them are also covered by sick ‘benefit’ plans. About three-quarters of all sick- leave plans limit the duration of their payments to six weeks or less per year; and such limits apply to about 62 percent of all the workers who are covered by formal sick-leave plans. In some cases, however, un- used annual sick leave may be ac- cumulated, within limits, thereby providing more adequate protection. The more generous plans permit much longer durations, ranging up to six, nine, or even twelve months, usually based on some years of serv- ice. “Sick Benefits under E.M.B.A. Plans. — Most of the 92 sick-benefit plans which are handled by ‘em- ployee mutual benefit associations’ were established some years ago, with only a dozen or so started within the past three years. All-told, the 92 E.M.B.A. plans provide sick- benefit protection for 91,000 work- ers. Fifty of those plans, covering some 32,000 of those workers, provide the only group protection those workers have against non-job illness or injury. As to the other 59,000 workers, covered by other 42 E.M.B.A. plans, they work for em- ployers who have more than one type of plan; so some of them have other forms of group sickness protection beside their E.M.B.A. benefits. As to the possible duration of E.M.B.A. sick benefits, the plans vary rather widely. A substantial group of E.M.B.A. members can draw benefits for 13 weeks per ill- ness ; but some have less protection; and still other large groups may draw benefits for 26 weeks, or even for 52 weeks, if necessary. “Sick Benefits under Group In- surance Plans. — In October 1948 there were 2,006 group ‘accident and health’ insurance plans, covering about 202,500 Wisconsin workers, according to the state’s survey. 1,824 of those group insurance plans, covering some 161,000 of those work- ers, provide the only group protec- tion those workers have against non- job disability. As to the other 41,500 workers, covered by the other 182 insured sick-benefit plans, they work for employers who have more than one type of plan; so some of them also have another type of group sick- ness protection. “Benefit Provision. — As to the weekly rate of sick benefits, only about a third of the insured plans, covering about 28 percent of the in- sured employees, pay the same ‘flat’ rate of benefits to every dis- abled worker, regardless of his wages. Under those plans the most common ‘flat’ rates are $10 or $15 or $20 per week. The other insured plans base their varying benefits on wages, or wage groups, or sex groups, or other differences. Their maximum weekly payment ranges from $15 to $20 or $25, on up. Sev- eral hundred plans, covering about 60,000 workers, pay a top benefit rate of $36 or more per week to some workers. ‘ ‘ As to the possible duration of sick benefit payments under group in- surance plans, over 80 percent of the plans, covering over 77 percent of the insured employees, provide for thirteen benefit weeks per ill- ness, usually without any limit per year. Nearly 18 percent of all in- sured workers are protected under plans which permit 26 benefit weeks per illness. At the two extremes, a few thousand workers cannot draw as many as thirteen weeks per ill- ness ; but a few thousand others could draw up to fifty-two weeks of sick benefits, if necessary. “Most insured plans — like other group plans — end their sick-benefit protection for any insured worker fairly soon after his employment ends, and do not permit him to con- tinue such insurance in force while he is unemployed.” Not much information is available about other types of insurances un- der private auspices to provide secur- ity against hazards other than non-job illness. That many such plans exist is well known. The Wis- consin Industrial Commission gives the following tabulation about Other Group Benefit Plans. Percent of Hazard Number 297,3402 Retirement 88,363 29.7 Death (Group Life) 169,237 56.9 Hospital Expense 194,510 65.4 Surgical Expense 165,623 55.7 Essentials of a Public Economic Security Program The wage earner and his family are constantly threatened by the haz- ards of unemployment, disabling illness, industrial and other injuries, old age, and death, all of which have the effect of shutting off the wage for short or long periods. The work- er and his family by themselves often are unable to save enough to either prevent these hazards, or to meet their effects. For this reason society has organized various measures to prevent and relieve distress caused by these several economic hazards. !The Wisconsin Industrial Commission gave the percentage as 53.6 or 159,231 workers in Milwaukee County. 2Number of workers privately employed in Milwaukee County and covered by Un- employment Compensation law. 18 It is an exceedingly complex prob- lem and it requires a variety of pro- grams to accomplish the purpose of preventing economic distress. The best assurance of economic security that any family could have is opportunity for its employable members to work at employment which they like and in which they take pride at a compensation that enables the family to purchase the goods and services it requires. Next to a job, an insurance bene- fit is the best method of providing a family with needed income because it can be so organized that it can be paid for in advance — at least in part, by the workers while they are working, spreading the costs over the whole group, and because the worker is entitled to the benefit without the necessity of a “means test” or examination of personal or family resources. Public assistance should be a re- sidual program, a place of last resort among the economic security mea- sures, designed to meet the require- ments of needy persons who are ineligible for any social insurance benefit, who have exhausted their rights to such benefits, whose veri- fied needs are greater than their insurance benefits, or their wage or other resources. Public Economic Security Measures Unemployment Compensation. — One of the greatest and most persist- ent threats to the economic security of families is that of unemployment. Wisconsin has played a leading role in the development of Unem- ployment Compensation in this coun- try. This state had the only Unem- ployment Compensation prior to the enactment of the Federal Statute in 1935, and a number of Wisconsin men became the architects of the national system. A rough measurement of the amount of unemployment and the way in which it has varied from year to year may be seen from the num- ber of unemployment compensation checks. The number of unemploy- ment checks issued to claimants re- siding in Milwaukee County was: 1941— 90,538 1942 —102,304 1943 — 10,234 1944— 6,312 1945— 75,834 1946 — 109,588 1947— 34,392 1948— 31.690 Each of these checks was unemploy- ment compensation for one week. At almost every session of the Wisconsin legislature in the last ten years liberalizing amendments have been adopted. This is especially true of the sessions in 1947 and 1949. These modifications would seem to indicate that the state is willing to adopt such changes as are neces- sary to make unemployment com- pensation a more effective bulwark against the hardships resulting from unemployment. Insurance programs such as unemployment insurance should be under constant examina- tion. The provision of the law relat- ing to coverage, benefits, waiting periods, availability for employment taxation, should be continuously studied. It is generally accepted that unemployment compensation is an equitable and fair way to meet the hazard of unemployment. Wisconsin was the first state to have an advisory council to recom- mend changes in the unemployment compensation act. It is composed of employer, employee, and general public representatives. Constant re- view by such a representative per- manent council is sound practice. Workmen’s Compensation. — The hazard of the wage earner suffering an injury while at work and of con- tracting a disease growing out of employment conditions also affects the economic security of families. Workmen’s Compensation, the oldest of this country’s economic insurance programs, has been operat- ing continuously in AYisconsin since 1911. The Wisconsin statute is in most respects one of the best in the coun- try. It provides for compulsory coverage, extends to most of the employing units in the state, pro- vides relatively adequate benefits, and it is well administered. Old Age and Survivors’ Insur- ance.— Old Age and Survivors’ In- surance is a federal program that is designed to pay cash benefits to persons and families when (1) the worker retires at age 65 or after; (2) the worker dies leaving a wife, dependent children under 18, or de- pendent parents over the age of 65; and (3) the retired worker dies, leaving a dependent wife over 65. Although this program began paying benefits in 1940, the number of ben- efits paid will grow gradually only as the members of the labor force of 1937 (when the payroll tax took effect) die or reach retirement age. In the long run, this is the program upon which the country will place chief reliance to provide a modicum of economic security to the aged retired workers and their families and to surviving dependents of the deceased workers. In June of 1948 Old Age and Sur- vivors’ benefits were being paid at the annual rate of $4,634,552 (in- cluding death benefits) in Milwau- kee County. The average monthly payments per beneficiary are insuf- ficient by themselves to provide a livelihood for a retired worker with or without dependents, or for the survivors of deceased workers. This is partly due to the fact that the pro- gram has been in operation only twelve years. The statute also sets a maximum benefit which in some instances is less than the actual needs. Railroad Insurance. — The most comprehensive system of social in- surance in the United States is administered by the Railroad Re- tirement Board for the employees of railroads. Social Security Benefits for Vet- erans. — For many years the Feder- al Government has concerned itself with the welfare of the veterans of national wars and their dependents. It is estimated that approximately $19.6 millions were spent during the fiscal year of 1948 on behalf of vet- erans in Milwaukee County, It seems abundantly clear that Social Security Benefits paid to veterans free the state and local governments from an enormous burden of security payments. Public Assistance. — Milwaukee County is to be congratulated on its liberal public assistance program: a. It has substantially supple- mented (from local funds) the maximum grants estab- lished by the federal and state governments permissi- ble to recipients of Old Age Assistance, and Aid to the Blind. b. It has removed the limita- tions on the amount of assist- ance to be granted in the Aid to Dependent Children pro- gram. c. It participates in a new form of public assistance—the Aid to the Totally Disabled. d. It provides home nursing and convalescent care, when nec- essary, to the recipients of 19 Old Age Assistance, Aid to the Blind, Aid to Dependent Children, and General Relief. Furthermore, a uniform family budget is used to determine eligibil- ity for care and to determine the amount of aid to be granted (with slight variations) to aforementioned non-institutional public assistance programs. The budgets are based on price and use studies made by the Budget Research Committee of the Milwau- kee County Community Welfare Council. The budgets are considered sufficiently adequate to maintain a minimum standard of health and de- cency. The total annual expenditures for public assistance have declined con- siderably since 1940, when they amounted to $10,138,554. These ex- penditures reached a low point of $4,176,777 in 1945, but then rose to $6,785,935 in 1947. Over 50 percent of the public assistance expenditures for the eight-year period 1940 to 1947 went for Old Age Assistance. The creation in 1946 of a new category of public assistance for the disabled represents an interesting and forward looking development. Accessibility of Economic Security Benefits Points already stated should be re-emphasized: 1. Insurance is to be preferred to public assistance. 2. The extent to which the Social Security and industrial group insur- ances fail to provide needed benefits causes the burden of dependency to fall squarely upon the public assist- ance programs. 3. All things considered, it seems quite clear that unemployment com- pensation is unavailable to con- siderable numbers of potentially unemployed workers in Wisconsin. This is mainly because the law cov- ers only employees of six or more. 4. In respect to accessibility of Workmen’s Compensation benefits to those injured workers who need them, this Survey finds that the Wisconsin statute rates high because employees of three or more are cov- ered. 5. The coverage of Old Age and Sur- vivors’ Insurance is not extensive. Only three of every five of the work- ing population are covered. The ex- tension of coverage to include many groups of workers now excluded is being considered by the present Congress. 6. The Wisconsin Public Assistance program, instead of being one gen- eralized residual program, is itself broken into categories and special groups, each with its special eligibil- ity requirements differentiating one category from another. Adequacy of Economic Security Payments The requirements of families vary widely because some have many de- pendent members and others have a few or none; some have greater need for medical care and other services than others. In contrast with the social insur- ance benefits, the amounts of which are fixed by statute, public assist- ance payments vary from month to month, according to the needs of the individual or family. The amount of each family’s need is measured by use of the family budget device, which involves an analysis of the family’s minimum needs, from which any resources are then deducted. Except in Old Age Assistance, Aid to the Blind, and Aid to the Dis- abled, which have ceilings estab- lished by law on the amount of each monthly payment to an individual, the assistance payment conforms to the aforementioned budget figure. In December of 1948, the Milwaukee County Board of Supervisors author- ized supplementary payments for persons in receipt of Old Age As- sistance and Aid to the Blind, in addition to the Federal-State ceil- ings, which supplementary payments are being paid entirely from local funds. Ail things considered, the public assistance payments, while not gen- erous, are quite satisfactory. The Old Age and Survivors’ Insurance and all other insurance benefits are usually smaller, or do not last during the period of dependency, and people receiving them sometimes must ask for additional assistance. Administration One of the serious governmental problems in the United States is the determination of the proper division of responsibility between the dif- ferent levels of government — local, state, and federal. In the Economic Security program in Wisconsin, a certain pattern has been worked out which places most of the administrative authority with local governments, even though most of the money comes from federal and state sources. These higher levels of government set certain standards which must be followed. It is a working and practical rela- tionship which is producing results. It is a pattern of governmental rela- tionship which should be studied. It has many merits. In the main, the services performed under it are efficient and the governmental relationship is satisfactory to all concerned. B. The Public Assistance Programs Since the Survey was completed the Wisconsin Legislature passed a law which made the Department of Public Assistance a part of the De- partment of Public Welfare of Mil- waukee County. The findings and recommendations are as of May, 1949. Practically all of them are applicable to the Department of Public Assistance in its new position as a Division of the Department of Public Welfare. Philosophy and Principles of Public Welfare During the recent decades our knowledge of how persons can best be helped toward leading useful, self-sufficient lives has changed greatly. A committee appointed by the Board of the American Public Wel- fare Association early in 1947 had frequent discussions on what were the principles and the standards of public assistance. This committee had as its members departments of public welfare, home economists, and heads of divisions of standards of assistance. This committee’s final report in December, 1948 includes the following statement: “In the United States certain rights of the individual have been established by federal and state legislation as a recognition that it is in the public interest to provide income to those in the population who are tempo- rarily or permanently unable to be self-supporting. The will to be financially independent, to be a producing member of the community, and to improve one’s standard of living is a predominant characteristic of American society. This will can be weakened by inability to find work, or inability to contribute otherwise to community enter- prise.” This will can also be weakened by granting assistance in such a way that the recipient’s self-respect and personal dignity and hopes are in- 20 jured, discouraged, or destroyed. In the present-day economy, the loss of the usual financial resources can, and frequently does, immediately af- fect the individual’s capacity to deal effectively with the everyday affairs of his life. “Workers in public welfare agen- cies need a general understanding of how economic dependence may af- fect the recipient’s capacity to carry on his usual responsibilities.”1 Great responsibility is placed on public welfare workers for determin- ing eligibility in accordance with legal requirements and for provid- ing financial assistance to meet the needs of recipients. The workers also have the obligation to provide the assistance in such a way that re- cipients do not lose their desire for independence, have the greatest pos- sible freedom in using the resources of the community in developing their own strengths, and thus facili- tating their maximum degree of rehabilitation and their return to self-support. In families with children this has special importance, so that children may have the opportunity for normal growth and education, leading to later self-supporting and useful citi- zenship. Administrative and Organizational Background The Milwaukee County Depart- ment of Public Welfare2 was created by County ordinance (Section 46.01) on October 28, 1947, which reads in part: ‘ * There is hereby created a Department of Public Welfare to be administered under the direction of the judges in the county courts and to consist of a director of public wel- fare and such other officers and employees as may hereafter be authorized.” Section 46.02 reads in part: “The Department of Public Welfare is em- powered and directed to exercise all powers, duties, and functions vested in the following departments or divisions as they existed immediately prior to the creation of this depart- ment; namely: 1. Department of Old Age Assist- ance3 2. Department of Aid for Dependent Children and Aid to Blind4 3. Foster Home Division of the Home For Dependent Children 4. Adoption Division of the Office of the Register of Probate.” In Milwaukee County there is no supervisory board or committee for the Department of Public Welfare. The County Board of Supervisors delegates the responsibility for the Department of Public Welfare to the two County Judges. In reality these are the administrators of D.P.W. In exercising this responsi- bility, the policy has been, in general, to delegate the actual administra- tion to the County Director. Weekly conferences between the Director and the County Judges now general- ly take place. General policy is discussed and plans for the depart- ment are considered. Wisconsin has chosen to have the Public Assistance part of the Social Security program administered by local units of government under state supervision. It could have chosen to have state administration. The State Department of Public Welfare conducts administrative re- views to check compliance with federal and state regulations and provides consultation and assistance Public Assistance Report No. 8. Fore- word Page 3, Social Security Board, 1945 “Hereafter referred to as D.P.W “Hereafter referred to as O.A.A. referred to as A.D.C. and A.B. TABLE 10 1949 BUDGET OF MILWAUKEE COUNTY’S SOCIAL SECURITY AIDS Source: Milwaukee County Board Proceedings, October 21, 1948, pages 1235 and 12:?« Federal Aid State Aid Local Funds Grand Total Social Security Aids Amount Method of Computing Amount Method of Computing Amount Old Age Assistance Grants Medical Aid Supplementary Aid = 50% plus $5 per month per case* $1,384,500 227,500 = 30 % of total assistance* = 35% of $650,000 $ 377.000 422,500 150.000 $4,615,000 650.000 150.000 Total Old Age Assistance . . $2,853,500 $1,612,000 $ 949,500 $5,415,000 Aid to Dependent Children Grants Medical Aid Total Aid to Dependent Children ..$ 474,500 - = $16.50 per 1st child, plus $12.00 for added children $ 443,000 24,500 = Vs of total assistance = 35 % of total medical care $ 412,500 45,500 $1,330,000 70,000 . . $ 474,500 $467,500 $ 458,000 $1,400,000 Aid to Blind Grants Medical Care Supplementary Aid ..$ 100,650 = = 50% of total assistance** 49,500 5,250 = 30% of total assistance** = 35 % of total medical care $ 15,150 9,750 2,000 $ 165,300 15,000 2,000 Total Aid to Blind ..$ 100,650 $ 54,750 $ 26,900 $ 182,300 GRAND TOTAL SOCIAL SECURITY AIDS . . $3,428,650 $2,134,250 $1,434,400 $6,997,300 *Not in excess of $50 per **Not in excess of $50 per month Federal month Federal and State ceiling, and $65 per month State ceiling. 21 in various other ways to local gov- ernments. Budget for 1949 The budget in Table 10, is put in the Summary for two purposes: 1. To show the amounts paid from the Federal, State, and Local govern- ments, and 2. To call special attention to the amount of Milwaukee County funds. Because the county has appro- priated funds for Public Assistance it has been possible to make adequate grants to families in need. That this has not lead to excessive expenditure was shown in a table in the foreword, indicating that a smaller amount per capita is spent in Milwaukee County than in 29 urban areas. An- other comparison is made with Buf- falo as that community is more like Milwaukee than any other1. Table 11 shows the trend in the five different public assistances. The number of recipients shows very little change from 1940 to 1947 except in General Assistance. That is as it should be for those who receive Old Age and Blind Assist- ance and Aid to Dependent Chil- dren are dependent for long periods of time. Those receiving General As- sistance are those not covered in the other programs nor by Unemploy- ment Compensation or like measures. The number receiving General As- sistance goes up and down very rapidly as the economic pattern of the community changes. Personnel The tabulation of the qualifica- tions of the welfare staff in the Department of Public Welfare points Up the absence of technical training of the large majority of the social work staff in the division of O.A.A., A.D.C., and A.B., as well as lack of experience elsewhere than in Mil- waukee. There is a general shortage of qualified workers in the United States, and all public agencies have had difficulty recruiting social work personnel. Most urban public wel- 1947 Agency No. of Units Under Care No. Recipients Under Care Average Grant Milwaukee County A.D.C. 1,051 $92.37 Erie County .... A.D.C. 1,719 95.29 Milwaukee County A.B. 284 38.69 Erie County A.B. 129 49.36 Milwaukee County O.A.A. 8,704 38.70 Erie County . . . O.A.A. 4,637 45.71 Milwaukee County . . . Gen. Relief 1,576 52.59 Erie County 2,240 57.30 'Community Health and Welfare Services Bulletin 142, Chests and Councils of America, Inc., 155 East 44th Street, published by the New York City. Community TABLE 11 NUMBER OF RECIPIENTS,a AVERAGE MONTHLY PAYMENTS,b AND ANNUAL EXPENDITURE FOR ASSISTANCE, MILWAUKEE COUNTY, 1940-1947 PUBLIC OLD AGE ASSISTANCE AID TO THE BLIND Year Total Expenditures For Public Assistance Average Number Recipients Per Month Total Annual Expenditures Average Monthly Payment Per Recipient Average Number Recipients Per Month Total Annual Expenditures Average ' Monthly Payment Per Recipient 1947 . . .$6,785,935 8,688 $4,461,674 38.60 259 $131,840 36.18 1946 . . . 5,527,053 8,284 3,579,214 34.87 288 113,439 32.17 1945 . . . 4,176,777 7,694 3,012,590 32.49 293 105,605 30.08 1944 . . . 4,213,941 8,130 2,972,707 30.89 310 107,555 28.92 1943 . . . 4,752,378 8,587 3,004,040 29.03 351 114,083 27.09 1942 . .. 6,499,147 9,166 3,085,124 28.05 370 119,204 26.85 1941 . .. 8,063,225 9,191 3,054,382 27.69 371 117,712 26.44 1940 . . .10,138,554 8,576 2,820,639 27.41 361 112,881 26.06 “Data obtained from the Division of Public Assistance of the State Department of Public Welfare. '•Averages calculated on basis of assistance given directly to needy individuals and families. Payments for medical care, hos- pitalization, and burial March, 1943. included in total annual payments, but excluded from average monthly payments to families, after M M M h-4 h-4 M 4-1 4-1 CO CO CO CO CO CO CO CO Year 4^ 4t 4t 4t 45t 4t 4^ 4^ o crq P 3 i 2 o 4-1 to CO 4^ cn 05 -a p ui p: > 3 Ul rt- M 4H a o4 3* P 'U fD trq p to to 4-1 h-4 M Average p o o 05 o 00 05 CO o Families o 3 W M 05 Cn CO -a o CO to cn Per CO 4t CO 00 h-4 05 05 H-4 Month o *5 a> 4*0 C-l H 4) p §5 4* 4t- to h-4 h-4 to to Average H o’ 3* P te- Cn GO cn 00 05 Cn CO 00 o * 05 4^ Number Children d — o M CO CO cn o 05 Per Month H 5’ - P -69 2 H o L_1 0 H-4 4-1 H-4 4-1 O a c 0 kee 946. to 00 to 00 h-4 o 00 05 to 05 o 00 05 4-1 05 Total < Ul M o cn to I-4 4^ M 4^ Average Number tt d P o 4t- h-4 to o cn cn Cases H & 4^. CO CO cn CO to o 4^ cn -1 - J CO CO 4^ Per Month K 0 K o -€/9 w to Q P Q -s CO 05 to 00 cn 4t CO CO Total H a 0 g 4^ 05 to 00 4-4 o o o o to 05 CO to cn CO 4- Annual Grants r4 cn 4-1 05 ro CO CO cn cn H 3 05 to to o CO 00 cn Pi c M 00 o 4^ CO o 05 cn > <6 o d o p M 3" to to CO CO CO CO h-4 CO CO CO cn 4^ 00 cn to Average Monthly Payment Per Case m Ul co to CO cn CJ1 4^ -a o CO cn 00 o 00 05 05 cn Ul rt H 3 4^ Cn cn cn cn -69 Average > o CO CO 00 CO —] -a h-4 cn Monthly o rt CO 00 Payment H (l> -41 to 05 4^ 05 05 Per Family O rt> Average 4-L M H—4 h-4 to to to CO Monthly P CO 4t. 00 00 H-4 CO oo 4^ Payment cn CO CO CO cn 00 to cn Per Single Ul 4^ H-4 h-4 CO oo o Person P g Ul 50 Average > rt 00 Number O Families d i-3 Per Month & -69 rt 4^ CO Total 5 d o CO to Annual *< K- 4^ Bxpendi- rt p pr o h-4 4^ tures 2 3 COp. o o w2 3 4^ cn Average dS 3 00 CO Monthly H a 4-1 05 Payment d v -1 05 Per Family o. 22 fare agencies have placed emphasis on recruiting technically qualified and experienced persons for the su- pervisory positions, and then have counted on a staff development pro- gram as the way of helping welfare staff acquire skill in working with families and individuals under care. Strengthening the supervision by appointment of fully qualified and experienced persons will make the recruitment of welfare workers easier. The thoughtful, promising younger college graduates wish to be well supervised in their early ex- perience so that their experience will have meaning and value. An educational leave plan for the younger members of the staff is needed. Staff should be encouraged to take educational leave. Milwaukee County has realistical- ly met the problem of the higher cost of living. The adoption of the for- mula which added $83.02 per month to the basic salary in 1948 and $100.58 for 1949 were sound moves. Background of the Administration of General Relief in Wisconsin Since the beginning of Wisconsin’s history as a state, the responsibility of the relief of the poor has been vested with each city, village, town, or county. Chapter 28 of the first statutes in 1849 dealt with poor relief. Under this law the Town Supervisors were the responsible relief authorities. One year’s residence was required for legal settlement. This law also provided that a town giving relief to a person with settlement in another town could charge the town of legal settlement for such care upon filing- charges. General Relief, more recently called Public Assistance, has been on a county-wide basis in Milwaukee since 1851. Many of the character- istics noted in the administration of public assistance in Wisconsin are also found in the Milwaukee County Department of Public Assistance. The department derives its authority from state statutes and county ordinances. Section 49.02 of the state statutes entitled “Relief Administration,” says in part: 49.02 (1)—Every municipality shall furnish relief to all depend- ent persons therein and shall establish or designate an official or an agency to administer the same. 49.02 (2) — Every county may furnish relief to all dependent persons within the county but not having a legal settlement therein, and if it elects to do so, it shall establish or designate an official or an agency to administer the same. 49.02 (3)—When the settlement of a dependent person is unknown or in doubt, relief may be adminis- tered by the municipality in which such person is found in need but the matter shall be promptly in- vestigated and reported or referred as the case may be to the county in which the municipality is situated. 49.02 (6) —Officials and agencies administering relief shall assist dependent persons to regain a con- dition of self-support through every proper means at their dis- posal and shall give such service and counsel to those likely to be- come dependent as may prevent such dependency. Under power given in Section 49.03, the Milwaukee County Board of Supervisors adopted an ordinance accepting all powers conferred and duties imposed in Chapter 49. The Survey believes it important to call special attention to (6) in light of the absence of some of the social services to recipients in the Milwaukee Department of Public Assistance. Detailed discussion of the differ- ent divisions of the Department of Public Welfare, including the De- partment of Public Assistance, can- not be included in this Summary. For these the reader is referred to the main reports. Main Findings — Department of Public Welfare 1. Case loads have been too high to make possible anything more than a routinized redetermination of eligi- bility, without careful planning with relatives of the aged recipients or careful referral to medical care and community activities. 2. The supervisors have had too many workers to direct to make pos- sible helping workers develop more understanding and skill in working with aged people. 3. The reception of applicants and recipients at the intake desk is pa- tient, courteous, and prompt. The interviews are not always intelligent- ly focused, however. During the weeks the Survey staff was working in the department, it was observed to be the exception rather than the rule for the worker to start an in- terview with drawing out the appli- cant’s point of view, his experiences, and his thinking. Applicants were given little op- portunity to participate in the plan- ning for their own situations. Re- cipients of assistance, like all other human beings, learn to take respon- sibility by being given responsibility. 4. In many of the records studied the rehabilitative services over and above the giving of the grant, were missing. Thoughtful and skillful re- ferral of the family with a social problem which the agency could not meet, to appropriate social services in the community, was missing. 5. The records studied and the dis- cussions with supervisors and work- ers gave indication of a day-by-day working relationship with the De- partment of Public Assistance, with Unit IT of the County Hospital, and with the several courts. The records, however, revealed little of a cooperative working relationship with the voluntary social welfare agencies or with the other public re- habilitative services of the commu- nity. 6. The D.P.W. figures a careful fam- ily budget based on current living costs for each recipient. Milwaukee County has done a most creditable job in making awards sufficient to cover the budget deficit. 7. There is need to help the staff have a fuller understanding of the meaning of medical diagnosis, and a greater awareness of the medical needs of the families under care. More than half of the records gave evidence of the recipients’ need of some medical care — either acute, preventive, or remedial. 8. The discussions with the staff and records studied revealed that 22 of the 214 cases studied, were situ- ations where homemaker services would have been appropriate. A number of infirm aged individuals, and some of the aids to dependent blind family units have need from time to time for homemaker services. 23 The D.P.W. has made relatively little use of homemakers. The home- maker service maintained by the Family Service has so many de- mands that there is not much oppor- tunity for getting this service for the families under care of the de- partment. 9. Supervision in both the O.A.A. division and the A.D.C. and A.B. division is inadequate. It has con- sisted chiefly of checking of the eli- gibility factors, the accuracy of the budgeting process, and the determi- nation of size of the grant. Super- vision of public welfare activities should include helping staff achieve greater skill in working effectively with recipients with the aim of the recipients taking greater responsibil- ity toward achieving their economic independence and social happiness. 10. There have been staff meetings but these have not been carefully focused towards the development of greater skill of workers. 11. The workers and the supervisors of D.P.W. are conscientious, earnest, and interested in doing an accept- able social work job. The need for skillful supervision was evident wherever workers dealt with dis- traught, troubled, and disturbed per- sons. The salary ranges for the classifi- cations of welfare workers, and for the classifications of supervisors are comparable to salaries paid in other urban communities. 12. Administratively the organiza- tional setup under which the Mil- waukee County Department of Pub- lic Welfare presently operates is cumbersome and unnecessarily com- plicated. The Director of the Depart- ment, instead of being directly responsible to the County Board of Supervisors, is responsible to the County Judges who represent the judicial branch of the county gov- ernment. It is a sound principle that the executive, judicial, and legisla- tive branches of government should not overlap. At present there is no citizenship participation in any man- ner. 13. Many policies and procedures which are in memorandum form have not as yet been put into a written manual. Work had been started on a manual of local policy and procedure before the Depart- ment of Public Welfare was created in 1948 and there is included in the “projected” next steps of the diree- tor such an item. This is com- mended. Main Recommendations It is recommended that: 1. A staff development and/or in- service training program be care- fully planned and carried out. It should be focused on helping staff attain greater case work skill in working with families and individ- uals. 2. The responsibilities of supervi- sory personnel in relation to specific duties be clarified. Focus on an en- larged concept of supervision, is needed. 3. A plan of educational leave be developed and staff encouraged to use such leave. 4. Supervision be strengthened. This can be done by appointment of technically qualified and experienced persons to all future supervisory va- cancies. 5. Consideration be given to a re- view of the content of material that should be included in case records, specifically in relation to the rede- termination of eligibility and contin- uing contacts with recipients after the initial eligibility is established. 6. More attention be given to the health problems of clients with special emphasis on the preventive aspects of medical care. 7. More use be made of the available health and other social resources in the community by thoughtful refer- ral of the applicant and recipient to these resources. The staffs need help in developing skill in referrals. 8. The present division of responsi- bility between the County Judges and the County Board of Supervi- sors be eliminated. Citizenship par- ticipation should be made a part of the program. If legislative change is necessary to accomplish these ends, it should be sought after at the next session of the Wisconsin Legislature. The Director of the Department of Public Welfare should be responsible to the County Board of Supervisors, who should appoint an unpaid Board of not less than five of Milwaukee County’s leading citizens to act as an advisory board to the Director. The County Board of Supervisors should not delegate administrative authority but should use citizens in an advisory and consultative capac- ity. Many administrative boards have been dispensed with in govern- ment services. The advisory board supplies a channel through which citizens can keep in close touch with public services and express their opinion on matters of policy. Main Findings — Department of Public Assistance 1. The reception of applicants and recipients is courteous and planned for by orderly procedures. 2. Emergency financial needs of families and individuals are prompt- ly cared for. 3. Eligibility for assistance is thor- oughly established by careful check- ing of sources of income and other resources of the applicant. 4. Home visits are usually on a monthly basis. Some families are visited more frequently. 5. Family budgets are carefully figured and checked. The records studied indicate that the basic eco- nomic needs of the families and individuals under care are adequate- ly met. 6. The services to recipients consist almost entirely of granting assist- ance on the budgetary basis. 7. The case material read and the conferences with the staff give little evidence of careful referral of clients to community resources such as recreational, educational, health, counseling, and other social facili- ties. 8. Veterans are interviewed in an Intake Unit especially set up for veterans. The home visit to vet- erans’ families follows the same pattern as that for home visits to others. 9. The legal settlement and resi- dence of applicants is carefully determined. 10. The policies set down by the Board of Public Welfare are some- times rigidly applied when carried out. There is no evidence that the staff intend or plan to be inflexible in carrying out policies, but rather that the lack of adequate supervi- sion of staff results in their carrying out the rules without considering the total family situation. Personnel 1. The staff needs leadership and supervision. 2. There is no one presently em- ployed in the Department of Public Assistance who is qualified or clas- sified as supervisor. 24 3. The Acting Superintendent is carrying an impossible and unreal- istic assignment. The position of Superintendent has not been filled by a duly certified and appointed person since 1943. 4. The current salary ranges estab- lished for the welfare worker classi- fications, and for the classifications of supervisors, are comparable to salaries paid in other urban commu- nities. 5. The staff needs knowledge, in- formation, and help in the under- standing of behavior, and how to work effectively with other than economic problems. Clerical and Business Procedures And Controls 1. The number of forms currently used in the department is many. There is reason to study these with a view to reducing them to a mini- mum. 2. The office procedures, statistical and financial, are carefully carried out by the staff, but inter-divisional procedures are elaborate and need simplification. Relationship to the Community 1. There is no up-to-date manual or handbook of policies and procedures, no written agreements with other departments and agencies, public or private, nor of community resources. The latest compilation was in 1939. 2. The case material read and the conferences with staff give little evidence of careful referral of clients to community resources, such as recreational, educational, health, counseling, and other social facili- ties. Main Recommendations In order to improve the effective- ness and the quality of service to families and individuals under care of the department, the following steps are recommended: Organizational Setup 1. The lines of authority within the department should be clarified. Responsibility should be centered in the Superintendent. 2. Similar functions and activities should be placed in one division. 3. More discussion of social policy and discussion of methods of car- rying out such policies, and study of the policies and procedures with a view of determining the effect of these on client situations by the Board of Public Welfare. 4. District offices will be needed when the functions of the Depart- ment of Public Welfare and the Department of Public Assistance are integrated. Personnel 1. The following positions should be filled at the earliest possible date: Superintendent of the depart- ment. Supervisor of Social Services. (This person should meet the re- quirements of the Civil Service Classification Supervisor II.) Supervisors for the Family Divi- sion. (The supervisor in charge of this division should meet quali- fications for classification Super- visor IP.) Supervisors for the Special Serv- ice Division, Supervisor for the Intake Divi- sion. (These two supervisors should meet the requirements of the Civil Service Classification of Super- visor I.) Administrative Assistant. (The Civil Service Classification of Administrative Assistant II.) Note: Some of the above positions will need to be established or re- established in the classified serv- ice for the department. 2. An in-service training and/or a staff development program should be set up for all department person- nel. Services to Families and Individuals Under Care 1. More careful referrals of recip- ients to the community facilities and social resources in the com- munity. 2. Fuller information of these com- munity resources should be made available to the staff. 3. More information and knowl- edge as to ways of working effec- tively with people in trouble is needed by the welfare workers. (This is one of the reasons an in- service training program, under competent technical leadership is urgently needed.) 4. Workers should be helped through supervision in bringing the preventive health facilities, and other facilities (recreational, edu- cational, etc.) to the families under care. 5. Some of the social policies now prevailing in the department need modification and re-evaluation in their application to family situa- tions. To illustrate: the policy that children under specified circum- stances contribute 50 percent of the income to the family budget; the three-day care policy for transients; the surrender of auto licenses; the certifications to work projects; and the rules governing the giving of assistance to homeless, unattached persons, etc.) C. Voluntary Family Case Work Agencies Included in This Study 1. American Red Cross — Milwau- kee County Chapter 2. Family Service of Milwaukee 3. International Institute 4. Jewish Family and Children’s Service 5. Men’s Social Service Center of the Salvation Army. 6. Psychiatric Services of Milwau- kee 7. Rescue Mission of Milwaukee 8. Salvation Army — Family Serv- ice Division 9. Travelers Aid Society of Milwau- kee 10. Wisconsin Service Association 11. At its request, another agency, St. Vincent De Paul Society, has been included only in statistical analyses. Community Significance of Voluntary Family Case Work Agencies The private family case work agencies have been a significant factor in the development of com- munity-wide social welfare pro- grams. The basic function of these agencies has always been the pres- ervation of the fundamental values of family life. The efforts of these agencies to strengthen family life have taken many paths, and have developed and changed with chang- ing community patterns and with increased knowledge about human behavior. In the early period of their de- velopment the efforts of the private family case work agencies to pre- serve family life were devoted largely to the provision of financial !The difference between Supervisor II for Social Services and Supervisor II of the Family Division would be one or more years of satisfactory experience as a su- pervisor. 25 assistance, since this was the out- standing community need of the period. Later, the voluntary family agencies did significant pioneer work in promoting the establishment of a program for financial assist- ance to needy persons and families through public tax-supported agen- cies. The activities of the private family agencies also expanded into the promotion of legislation and other community measures to safe- guard health, employment, financial security, housing, and other basic needs of family life. Through their close work with families, these agencies were able to point out to the community the fundamental requisites for adequate family liv- ing; and we find that the voluntary family agencies have been, and con- tinue to be, a vital force in the stimulation of widespread commu- nity social welfare programs. At the present time the basic provisions for financial security are provided through public agencies, and the private family welfare agen- cies have been able to turn their at- tention to the many other social and emotional problems that constitute a hazard to present day family life. An excellent illustration of the type of family problems for which service is now given by the private family agencies is found in the interpreta- tive booklet, “What is Family Serv- ice of Milwaukee?” The agency offers help with many problems, in- cluding such problems as husband- wife relationship, parent-child mis- understanding, difficulty on the job or at school, personal and family problems related to physical, mental, or emotional ill health, and various problems of home management. Present day psychiatric findings point out the basic significance of family life in the emotional develop- ment of the child, and in shaping the future behavior of the adult; and consequently, the need for pre- ventive work with problems of family living takes on even greater importance. The present case work program of the private family wel- fare agencies serves as a needed supplement to the basic program of service and financial assistance pro- vided by the public tax-supported agencies by providing individuali- zation and experimentation which is more difficult to achieve in the large scale public program. Be- cause of the complexities of provid- ing service to families in the area of individual social and emotional problems, the programs of the pri- vate family agencies should meet the requisite of flexibility, thoughtful planning, skilled and well-trained personnel, and case loads small enough to permit adequate individ- ualization of persons and families receiving service. These requisites should be the minimal requisites for a private family agency program in Milwau- kee County. The community already has a well developed public program for providing financial assistance to individuals and families, and the private family agencies should be able to devote their attention to a program of individualized service and counseling. A program of this type calls for a high degree of com- petence in professional activity and community participation, but it is only in this way that the private family agencies can effectively sup- plement the program of the public agencies. In addition, it is impor- tant that the program of the private family agencies should not be crys- tallized into a permanent status quo, but that these agencies should con- tinue to explore new areas of serv- ice, and at the same time maintain their function of pointing out addi- tional areas of service which the public agencies can gradually as- sume. Methods of Study Several general questions have been borne in mind in reviewing the program of each agency. Among these questions were the following: 1. Does the service of this agency meet a genuine community need? 2. Does the agency provide suffi- cient service to meet the community need? 3. Is the quality of service adequate to meet the community need? 4. Is the program of the agency sufficiently flexible to enable it to adjust to changing community pat- terns? 5. Has the agency program been in- tegrated into the general program planning for community welfare needs ? The following specific methods were employed in reviewing the pro- gram of each individual agency: 1. A perusal of general material, such as a. The charter and bylaws b. Minutes of board meetings c. Agency manual d. Specific written policies such as, intake procedures, proce- dures for making and accept- ing referrals, inter-agency agreements, etc. 2. A statistical study of financial and service reports. 3. Interviews with a. Agency executive b. Members of supervisory and case work staff c. Occasional board members and other lay persons d. Staff members of cooperating agencies e. Staff members of the Commu- nity Welfare Council 4. A study of personnel through a. Reading personnel policy and classification material b. A review of schedules for each professional staff member show- ing present status, educational qualifications, and previous ex- perience. 5. The reading of agency case rec- ords. a. The number of records read in each agency ranged between 25 and 45 b. The records contained a sample of each type of work done by the agency, as well as a sample done by each professional staff member in the agency. A detailed individual report has been written for each agency in- cluded in this section of the Survey, containing specific recommendations regarding the program of each agen- cy. These reports have been sent to each agency for its own use. Only general data and the principal rec- ommendations are here-in included. Agency Services. — The private family welfare and adult case work agencies provide case work service and some financial assistance to a large number of families and indi- viduals in Milwaukee County. In 1948 the number of families and in- dividuals served by these agencies, exclusive of the shelter program, totaled 20,493. Table 12 shows the total number of cases served in 1948 by each agency, as well as the month- ly average case load, number of cases receiving financial assistance, amount of financial assistance, and average size of professional staff. The services of the Rescue Mission and Men’s Social Service Center are shown in a separate table, because 26 of the differences in methods of re- claims bring many people to the at- porting shelter statistics. tention of the Red Cross who might It is apparent that the major not otherwise be reached by agency emphasis in the program of these services. agencies is upon service rather than During the past three years there upon financial assistance, since in has been a small decrease both in all agencies, except the Salvation volume of service and relief expend- Army, the relief cases form only a itures for this group of agencies, small proportion of total case loads, The decrease for both case load and Social Service Center of the Salva- tion Army. It is evident from the figures that the need for shelter care has in- creased during the past year, and that the present facilities are operat- ing to capacity. Another important factor revealed in this table is the high proportion of local residents residing in the shelters. A careful examination of the case load of the shelters is indicated in order to determine whether or not outside living plans can be made for many of the men. In addition to the value for the men themselves, this would pro- vide the community with additional facilities for the care of transients. Agency Expenditures. — The total expenditures of the voluntary family case work and adult case work agen- cies represent a considerable com- munity investment. In keeping with the purposes for which the agencies were set up, the greatest proportion of this expenditure represents an expenditure for service, since the basic financial assistance needs of the community are being met, and should be met, by the public tax- supported agencies. Table 14 indi- cates the total expenditures for each agency in 1948, the sources of in- come, and the amount expended for direct relief purposes. Findings Agency Structure 1. Basic family case work services are provided through three family case work agencies, one non-sectar- ian, one Catholic, and one Jewish. 2. The clearance and cooperation carried on between these agencies avoid duplication without endanger- TABLE 13 TOTAL CASES AND AVERAGE MONTHLY FIGURES FOR EIGHT VOLUNTARY FAMILY AND ADULT CASE WORK AGENCIES IN MILWAUKEE COUNTY, 1948 Undupli- cated Monthly Monthly Average Total Average Average Average Size Cases Cases Relief Relief Profes- Under Under Cases Expendi- sional Care Care Monthly tures Staff TOTAL .20,493 4,168 460 $9,124 78 Family Service . 3,132 604 77 3,975 22 Jewish Family and Children’s Service . . . 399 99 10 623 4 St. Vincent De Paul . . . 1,309 351 36 1,537 8 Salvation Army Family 430 Service . 2,635 318 195 3 American Red Cross — 2,441 24 Home Service . 8,065 1,221 122 Wisconsin Service Assn. 469 220 No Report 78 3 Travelers Aid Society . . 1,742 145 20 40 8 International Institute . 3,204 1.210 6 and average somewhere between 10 and 13 percent of their total cases. As might be anticipated, the largest relief expenditure per case is found in the three major case work agen- cies, since these agencies carry a con- tinued responsibility for their cases, and since their cases consist largely of families, rather than single indi- viduals. The Family Service Depart- ment of the Salvation Army on the other hand, has the largest average number of relief cases, but also has the smallest amount of relief ex- penditure per case, averaging slight- ly more than two dollars. This is a result of its special case load, which consists primarily of transient men, as well as the fact that assistance is limited largely to meal tickets and incidental clothing. The major responsibility for gen- eral family case work service rests with the Family Service of Milwau- kee, which carries the largest total and the largest monthly average number of cases among the general family case work agencies. However, the largest total number of families and individuals receiving service from any one agency is found in the Home Service Department of the American Red Cross. This points up the need for a good program of case work service and referral within the Red Cross, particularly since its specialized service for governmental relief expenditures has been relative- ly constant for all of the agencies in this group, except for the relief expenditures of the Salvation Army, which increased from $3,182.56 in 1947 to $5,161.75 in 1948. This de- crease has been in keeping with the nation-wide trend as shown in the report on “Community Health and Welfare Services” published by the Community Chest and Councils in 1947. In contrast with the decline in vol- ume of service shown by the agencies included in Table 12, the statistical TABLE 13 NUMBER OF MEN SERVED BY TWO SHELTERS IN MILWAUKEE COUNTY AND NUMBER OF MEALS AND LODGINGS PROVIDED Men’s Social Service Center — Salvation Rescue Mission Army 1948 1947 1948 1947 Meals Provided Total 86.021 76,697 78,979 74,511 Average 7,168 6,391 6,582 6,209 Lodgings Provided Total 103,808 93,695 26,581 24,747 Average 8,651 7,808 2,215 2,062 Total Number Individuals Served 14,374 10.310 828 788 Non-residents 3,813 3.350 143 144 Residents 10,561 6.960 685 644 ing the right of the client to select the agency from which he wishes to seek service. 3. The specialized services of the other seven agencies include service reports for shelter care for unat- tached men reveal an increase. Table 13 presents a comparison of service statistics for 1948 and 1947 for the Rescue Mission and the Men’s 27 and financial aid for veterans and families, moving persons, non-resi- dents, prisoners and families, local and transient unattached men, and persons having difficulty with prob- lems of immigration and natural!- zation, 4. The agencies providing special- ized services have avoided duplica- greatest proportion of this expend- iture represents an expenditure for service, since the basic financial as- sistance needs of the community are being met, and should be met, by the public tax-supported agencies. 3 Seven of these eleven agencies are members of the Community Chest and derive their chief financial sup- staff in the voluntary family and adult case work agencies have corn- pleted graduate training in a school of social work. The case work sal- aries in the private agencies are lower than those paid in the public agencies. 4. The large number of untrained or partially trained persons em- TOTAL EXPENDITURES, SOURCE AND ADULT OF INCOME, CASE WORK TABLE 14 AND RELIEF AGENCIES IN EXPENDITURES FOR MILWAUKEE COUNTY, NINE VOLUNTARY FAMILY 1948 SOURCE OF INCOME Total Expendi- tures Community Chest Contributions Sectarian Federation Other Payment for Service Other Income Relief Expendi- tures TOTAL $698,773 $287,953 $48,000 $287,309 $53,149 $22,362 $109,479.54 Family Service 201,538 176,095 2,798 8,707 13,938 47,698.88 American Red Cross — Home Service 235,671 228,957 6,714 29,297.38 Jewish Family and Chil- dren’s Service — Family Division 28,209 27,868 86 255 7,481.51 St. Vincent De Paul 69,999 48,000 16,670 5,329 18,438.30 Salvation Army— Family Service 33,476 12,673 18,410 2,393 5,161.75 Travelers Aid Society . . . . 37,549 30,911 193 5,555 890 470.78 International Institute . . 30,359 26,757 96 2,299 1,207 Wisconsin Service Assn. . 13,902 13,649 6 247 930.94 Rescue Mission 48,069 20,093 24,043 3,934 No Report tion and overlapping with each other and with the public agency, except for services to transients and prisoners. 5. The public agencies make almost no referrals to the private case work agencies and do not utilize suffi- ciently the case work facilities of the private agencies for their clients. Agency Services 1. In 1948, the number of families and individuals given case work service and some financial assistance by the private family welfare and adult case work agencies, other than the shelters, totaled 20,493. 2. The major emphasis in the pro- gram of these agencies is upon serv- ice rather than upon financial as- sistance, and in all but one agency, the relief cases averaged less than 15 percent of the total case load. 3. The two shelter programs for men furnished a total of 130,389 lodgings and 165,000 meals in 1948. The need for shelter care has increased during the past year, and the present facili- ties are operating to capacity. Agency Expenditures 1. In 1948 the total expenditures of the eleven agencies included in this study were $711,293.00. 2. In keeping with the purpose for which the agencies were set up, the port from this source; two of the. agencies have individual community- wide campaigns; one agency derives its support from a sectarian fund campaign, and one agency derives its funds from the collection and sales of salvage items. 4. The Milwaukee community is sub- jected to a variety of fund cam- paigns which present confusion to the individual giver, and may result in a diversion of funds to the most popular and publicized programs, rather than to the areas of greatest need. Agency Personnel 1. An important step in the develop- ment of adequate social work stand- ards took place in 1946, when the Community Welfare Council devel- oped a classification system for pro- fessional social work positions. The plan is adaptable to any case work agency. 2. Many agencies still employ per- sonnel who do not meet the basic minimum requirements set up in the classification system. 3. Salary scales and educational qualifications for supervisory and case work personnel vary widely from agency to agency. Approxi- mately one-half of the supervisory staff and one-fourth of the case work ployed in these agencies presents serious hazards to the case work pro- gram of the agencies, and points out the need for an extensive scholarship program and well developed plans of in-service training. General Recommendations Services to Families 1. Further expansion is needed in the case work programs of the gen- eral family case work agencies. 2. Closer cooperation should be de- veloped between the general family agencies and the American Red Cross, in order to make certain that veterans and their families are re- ceiving needed case work services. This service should be given through referral to general family case work agencies and through increased case work services within the Home Serv- ice Department of the American Red Cross. 3. Priority should be given to ex- pansion in the area of work with families concerned with children’s behavior problems since there is a marked lack of child guidance facil- ities in the community. Services for Education in Family Living 1. The family case work agencies should experiment with group coun- 28 seling in order to develop preventive case work. 2. The program should focus at this time, primarily, on the study of child development. Services to Transients 1. Major responsibility for this group should remain with the De- partment of Public Assistance. 2. Private agency services should be confined to those requiring the special case work services of a pri- vate agency, or to those ineligible for public agency care. 3. Private agency services to tran- sients should be centralized in one community agency which will serve as a center for referral and direct service. The Travelers Aid Society appears to be the agency best suited to this purpose. 4. Case work service should be pro- vided at the Rescue Mission to co- ordinate the shelter and service programs to transients. This service should be provided through a joint arrangement with the Travelers Aid Society. Services to the Aged 1. This field of service needs ex- pansion, both in the area of direct service to the aged, and in the area of coordinating of the services of the sectarian and non-sectarian insti- tutions for the aged. 2. Institutions for the aged should be encouraged to refer situations to the family agencies for case work services, and should also use the family agencies for direct or consul- tative case work services for their residents. Services to Unmarried Mothers 1. Additional services to unmarried mothers are necessary, particularly in the Protestant and non-sectarian group. 2. Case work services should be given to the unmarried mother in the area of her own emotional prob- lems, rather than considering the problem primarily one of planning for the child. Such problems are within the scope and competence of the private family agency, and its services should be extended to un- married mothers, as it is to other adults. 3. Policies should be developed to differentiate cases which will be accepted by the child welfare agen- cy, the public welfare agency, and the private family agency. Services to Young People 1. Older adolescents and young- people should be given a greater volume of service by the family agencies, since these young people frequently face difficult problems of adjustment. 2. Cases of this kind should be reached through community-wide publicity and through cooperative relationships with children’s and group work agencies. Services to Immigrants 1. The services given for immigra- tion and naturalization problems should be expanded because of new immigration legislation and in- creased concern in the community regarding immigration. 2. Provision should be made for bet- ter coordination among national groups sponsoring immigration. 3. Follow-up interviews should be held with newly arrived immigrants, and situations should be referred to community case work agencies if further case work services are nec- essary. Services to Prisoners 1. Private agency services should avoid duplication with services of- fered by the Department of Cor- rections. They should focus upon the group not receiving service from the public agency, or upon the group of men and families needing help of such a skilled nature that it is not readily available in the large scale public program. 2. Well-trained and highly skilled staff should be utilized who can use and contribute to advanced think- ing in criminology. Coordination of Services 1. Inter-agency agreements for re- ferral and cooperative procedures need to be formulated and imple- mented. 2. A central referral and informa- tional service would be valuable in coordinating referral and intake pro- cedures of the various agencies. 3. Careful provision should be made for inter-agency conferences on specific eases, and more integrated planning should be done when sev- eral agencies are working on the same case. D. Homemaker Services Homemaker service means the su- pervised placement by an agency of a woman chosen for her skills and her ability to get along with people in a home where her services are needed to maintain and preserve the home as a unit. Homemaker service started in the 1920’s when two Jewish agencies in Philadelphia and Chicago decided it was better to care for children in their own homes wherever possible through the use of a homemaker. At present approximately 70 agencies employ homemakers. For the most part, these are family agen- cies supported by private funds. However, public welfare agencies are showing an increasing interest in this form of care. Two of the larger such agencies have 95 and 35 homemakers as staff members. The present homemaker program in Milwaukee is provided by the St. Vincent De Paul Society and the Family Service. The St. Vincent De Paul Society started its service in 1934 to give long-time resident care to families with children. The Family Service started in 1933 to provide long-time care to motherless families. In 1945 the Community Welfare Council appointed a committee which has been considering all prob- lems relating to this service. Both the above agencies feel that they cannot expand their services sufficiently to meet the existing need. This need exists particularly in cases needing short-time care — many of which are already known to the public agencies. The logical place for the expansion of this serv- ice is in the Public Welfare Depart- ment as a part of its total program. The recommendations which fol- low are abbreviated. Those inter- ested should read the entire report which is available at the offices of the Survey and the Community AVel- fare Council. As this is a service of proven value, it should be given im- mediate consideration. Recommendations It is recommended that: 1. Homemaker service be regarded as the responsibility of both public and private agencies and as a part of their total case work program. 2. As a first step, the Department of Public Welfare of Milwaukee Coun- ty provide homemaker service to its own clients. Soon this service should be available to all families 29 eligible for any health or welfare service of Milwaukee County. 3. Additional voluntary funds be made available to strengthen and extend the existing homemaker serv- ice of Family Service and St. Vin- cent De Paul Society. 4. Some special provision be made for homemaker service for Jewish families and for individuals whose income is such that they would not be eligible for such care from the public agency. 5. Careful selection continue to be made of the families in Milwaukee who can profitably use homemaker service. 6. The person who has administra- tive responsibility for the home- maker program be a well qualified person with professional training and experience in social work, pref- erably in the supervision of case workers, or who has had other ad- ministrative responsibility. 7. Homemakers be carefully selected and chosen primarily for their abili- ty to get along well with both adults and children. 8. Personnel practices be adopted to attract and hold competent home- makers and give them status in the agency. 9. The Committee on Community Planning for Homemaker Service continue its meetings. Either the committee as a whole or a subcom- mittee might consider some of the health aspects of homemaker service such as differentiation of the types of care to be given by the trained nurse, practical nurse, and home- maker. 10. An agency needs the services of a physician skilled in psychosomatic medical care to advise them in cer- tain situations. 11. In all probability public health nurses could be helpful with a great- er number of families. 12. Additional research and the prep- aration of articles on certain aspects of the agency’s homemaker service would be helpful to the agen- cy in evaluating the program, to the community in its planning, and to agencies in other cities. 13. Consideration be given to the need for public interpretation of homemaker service. 14. Funds be available so that Mil- waukee can have a representative at the two-day meetings held anually by the National Committee on Home- maker Service. Perhaps we can summarize all this by saying that: a. Homemaker service in Milwau- kee County should be extended and strengthened through the use of both public and private funds. b. The service should be developed in the Milwaukee County De- partment of Public AVelfare on as broad and a sound a basis as possible. c. Case work service is essential to a good homemaker program. Many of the situations requir- ing the placement of a home- maker are accompanied by emotional and social problems. d. Families using homemaker serv- ice must have their basic re- quirements met, such as food, clothing, equipment, bed linen, etc. The city has been a better place in which to live for many families because homemakers have been avail- able in a time of crisis. The com- munity has demonstrated that through this service many children can be kept in their own homes to the satisfaction of both children and parents. In its use of homemakers, Milwaukee has given more than lip service to the values of family life and the belief that homes offer the best opportunity for the normal de- velopment of children. Milwaukee also has shown the value of home- maker service in the care of the aged. The progress made in the past clear- ly marks the happenings of the future. It gives every assurance that Milwaukee will continue to plan wisely and boldly its homemaker program. 30 II. Child Welfare Services Agencies Covered 1. Catholic Social Welfare Bureau 2. Children’s Service Society 3. Friendship House 4. Homme Children’s Home Cot- tage 5. House of Good Shepherd 6. Jewish Family and Children’s Service 7. Lakeside Children’s Center 8. Lutheran Children’s Friend So- ciety 9. Lutheran Welfare Society 10. Martha Washington Maternity Home 11. Milwaukee County Children’s Home 12. Milwaukee County Department of Public Welfare 13. St. Aemilian’s Orphan Asylum 14. St. Charles Boys’ Home 15. St. Joseph’s Orphan Asylum 16. St. Joseph’s Home of St. Teresa 17. St. Margaret’s Guild 18. St. R-ose’s Orphan Asylum 19. St. Vincent’s Infant Asylum 20. Child Care Centers Tenth Street Cass Street 21. Our Lady of Pompeii Nursery School 22. St. Joan Antida Nursery Cass Street Beloit Road 23. Volunteers of America Day Nurs- ery 24. Welfare Counselors of the Pupil Guidance Service Milwaukee City Schools This report contains information about the care provided children in Milwaukee County. It was written from the point of view of the total facilities and services available and the extent to which these resources meet the requirements of all chil- dren in need of such care. Copies of the report have been sent to all the agencies (26 in number) in- cluded in the study, and to the Com- munity AVelfare Council. The broad recommendations and general data contained in the main report were supplemented by more specific suggestions and comments sent in letters to each child caring agency and institution. It is unfortunately true that there are thousands of children in Milwau- kee County and every other large urban area who are deprived of home and parental care. For these, other care must be provided. It seems well, before giving any sum- mary of the report, to make a gen- eral statement of the underlying philosophy about child care. Children are our nation’s most precious resource. The future alone will show the extent to which we have planned wisely and well for the nurture and rearing of those boys and girls whose parents are, for any reason, unable to meet their daily needs. Milwaukee, not unlike other prosperous urban communities, has developed a labyrinth of social service agencies and other services which are designed to further the care and protection of families and children and to sustain family life wherever possible. This is as it should be. “Home life is the highest and finest product of civilization. It is the great molding force of mind and character. Children should not be deprived of it except for urgent and compelling reasons.”1 The complete report on Services to Children is 99 pages in length. The summary must be brief, but will include: 1. The principles which are general- ly agreed upon and which have in- creasingly been accepted as sound in developing local programs of care and social services. 2. Several tables showing the num- ber of children cared for in Milwau- kee County, the types of service rendered, and the source of revenue. 3. The main findings and recom- mendations. Information about in- dividual agencies will not be in the Summary and not all the findings and recommendations can be in- cluded. Those who have a special interest should read the entire re- port. Principles Generally Agreed Upon And Increasingly Accepted 1. Children should only be removed from their own families when it is evident that the care they need can- not be supplied by the natural parents. 2. A well-rounded program of social services should include provision for extending help and remedial services to families and children so as to eliminate, whenever possible, the necessity of placement of a child outside of its own home. 3. For some children, however, foster care placement is inevitable; therefore, every urban community needs a properly balanced and well- rounded foster care program. Such a program must include provision for both institutional and foster home care, thereby making it pos- sible for those agencies responsible for planning with parents for the care of their children to select facil- ities which will, as nearly as pos- sible, meet the individual needs of each child accepted for care. In some instances, the circum- stances of the placement, the age of the child, or other factors may indi- cate that it is advisable for the child to be placed for either a temporary or longer period of time in an insti- tution or small group care facilities; for others, a boarding home place- ment may be immediately necessary. In any event, it is important that sufficient resources and facilities be available so that there may be a choice. 4. Providing care for “other people ’.s’ ’ children is very serious business. The foster parents or institutional personnel who carry this responsibility are of inestimable influence in the lives of the children they serve. Therefore, the personal qualities and capabilities of these persons are of vital importance. 5. Case work services are a neces- sary ingredient of any child care program. Such service should be available to parents and children prior to and after placement. A child needs to be helped to fit into his new environment and to under- stand what he may expect in day- to-day living. Whenever possible, parents should be encouraged and helped to re-establish or so improve the family home situation, and there- by make it unnecessary for children to remain away from home for in- definite periods. 6. Facilities must also be available to meet the needs of children who are extremely disturbed and for whom psychiatric or other special- ized forms of treatment and care are necessary. 1 Proceedings of the Conference on the Care of Dependent Children, Washington, D. C„ 1909. 31 Tables Showing- Number of Children Under Care, Types of Service, and Source of Funds. Many hundreds of Milwaukee children receive care every day in either substitute parental homes or of 2,439 neglected and dependent children under care each month by both voluntary and public agencies. Of this group, 1,169 were in institu- tions. These averages do not reflect the total number of different chil- children who received care were in institutions, 39.2 percent were in foster homes, and 14.2 percent were in the homes of their parents or other relatives. The trend in child care, as taken from the nine years (1940-1948) shows a noteworthy increase in public responsibility, with more than a doubling in the foster home pro- gram. The number in public institu- tions continues to be relatively large. In the private agency field, the num- bers served have increased only slightly, with the trend toward in- creased foster home placements and less institutional treatment except for specialized needs. Table 16 gives statistics for the period 1940 through 1948. Table 17 carries data showing the whereabouts of children under care in six urban areas of somewhat com- parable size to Milwaukee. Milwaukee has the greatest per- centage of children receiving care in institutions of any of the cities in- cluded in this selected group. Five1 cities are included in the total group of 34 which have a higher percent- age of children receiving care in in- stitutions. St. Paul, Minnesota has the smallest percentage of children receiving institutional care in the entire group. In that city 6.5 per- cent of the children were in insti- tutions, 42.8 percent in foster homes. The balance, or 50.7 percent, were living with parents or other respon- sible relatives. The percentage of children in foster homes is slightly lower in Milwaukee than the aver- mublished by Community Chests and Councils of America, Inc. TABLE 15 NUMBER OF DEPENDENT AND NEGLECTED CHILDREN UNDER DIRECT CARE OF CHILD CARING AGENCIES AND INSTITUTIONS IN 19481 In Home In Home In of of Foster In Total Parents Relatives Homes Institutions Monthly Average . . . . 2,439 166 122 982 1,169 Voluntary Agencies . . 1,256 157 69 571 459 Public Agencies 1,183 9 53 411 710 includes Milwaukee County children only. institutions. Data carried in Table 15 for the calendar year 1948 per- tains to the dependent and neglected children served by 13 voluntary child caring and child placing agen- cies and institutions, one facility providing temporary shelter, and the two services maintained under public auspices; namely, the Mil- waukee County Children’s Home and the boarding care program very re- cently transferred from the Chil- dren’s Home to the County Depart- ment of Public AVelfare. These data do not include those children served exclusively by the Children’s Court or the children adjudged delinquent and cared for by St. Charles Boys’ Home or the House of the Good Shepherd, which provides care for delinquent girls. This information, taken from re- ports published by the Community Welfare Council, reveals that during the year 3948 there was an average dren who received care ; however, the figures are none the less significant. Similar data compiled in 1947 lends itself to comparison with data avail- able from other urban communities. For example, in the report “Com- munity Health and Welfare Serv- ices”1 there is comparative infor- mation for the year 1947 about the foster care provided in 34 urban communities, including Milwaukee. The different ways in which com- munities are providing foster care for children is of great interest. The wide extent to which institutional care has been used in Milwaukee, is immediately obvious. Of the chil- dren under care in 1947 in these 34 urban communities, 41.2 percent were in foster homes, and 29.7 per- cent were living in institutions. The other children, or 29.1 percent, were in the homes of relatives or their own parents. In Milwaukee 46.6 percent of the TABLE 10 AVERAGE NUMBER OF CHILDREN UNDER CARE ON THE LAST DAY OF THE MONTH CHILD CARE AGENCIES IN MILWAUKEE COUNTY 1940-1948 BY PUBLIC AND PRIVATE 1940 1941 1942 1943 1944 1945 1946 1947 1948 Total Under Care . . . 3,373 3,314 3,348 3,251 3,315 3,957 4,092 3,991 3,767 Public ... 874 874 876 918 944 1,009 1,112 1,208 1,245 Private . . . 2,499 2,440 2,472 2,333 2,371 2,948 2,980 2,783 2,522 Total — Public In Homes of Parents or . .. 874 874 87 6a 918 944 1,009 1,112 1,208 1,245 Relatives . . . 157 132 91 87 78 67 63 63 61 In Foster Homes ... 207 233 223 230 247 263 310 372 411 In Institutions . . . 466 450 503 542 550 604 663 705 713 All Other Types of Care . . 44 59 59 59 69 75 76 68 60 Total — Private In Homes of Parents or . . . 2,499 2,440 2,472 2,333 2,371 2,948 2,980 2,783 2,522 Relatives ... 647 552 498 412 452 565 510 438 397 In Foster Homes . . . 778 849 869 830 872 1,254 1,359 1,315 1,142 In Institutions . . . 861 820 859 856 782 803 781 809 761 All Other Types of Care . . ... 213 219 246 235 265 326 330 221 222 (Based on monthly reports received by the Research Department, Community Welfare Council, from two teen private children’s agencies.) "D.P.A. Children’s Division discontinued May, 1942. public and four- 32 WHEREABOUTS OF TABLE 17 CHILDREN UNDER CARE IN SIX URBAN AREAS Area Total In Home of Parents In Home of Relatives In Foster Homes In Institutions Average of 34 Urban Communities 100.0 24.5 4.6 41.2 29.7 Atlanta, Ga 100.0 13.4 5.1 53.7 27.8 Baltimore, Md 100.0 13.2 5.0 48.2 33.6 Buffalo, N. Y 100.0 37.9 4.9 30.8 26.4 MILWAUKEE, WIS. . . 100.0 9.1 5.1 39.2 46.6 Providence, R. I 100.0 29.7 5.5 35.5 29.3 San Diego, Calif 100 0 19.3 3.0 44.4 33.3 age in 34 urban communities and considerably lower than the percent- age reported for Atlanta, Georgia; Buffalo, New York; San Diego, Cali- fornia. The foregoing by no means pro- vides a picture of the total func- tions or services provided. Each of the agencies and institutions has developed certain policies and procedures which determine the con- 1Erie, Pennsylvania; Grand Rapids, Mich- igan; Port Worth, Texas; Oklahoma City, Oklahoma: and Sioux City, Iowa. TABLE 18 FOSTER CAKE FACILITIES PROVIDING 24 HOUR CARE IN MILWAUKEE COUNTY1 DECEMBER, 1948 Name of Agency Auspices Type of Foster Care Provided2 Source of Funds3 Age and Sex of Children Served Catholic Social Welfare Bureau Voluntary Sectarian Foster Home Care Community Welfare Council; Archdiocesan Catholic Charities Council; Voluntary Contributions Boys and Girls Infancy to 18 Years Children’s Service Society Voluntary Foster Home Care Community Welfare Council; Voluntary Contributions Boys and Girls Infancy to 18 Years Friendship House Voluntary Temporary Shelter Endowment Boys Under 8 Years Girls Under 16 Years Accompanied by Adults Homme Children’s Home Cottage Voluntary Sectarian Institutional Care Evangelical Lutheran Church; Voluntary Contributions Boys and Girls 6 to 16 Years House of Good Shepherd Voluntary Sectarian Institutional Care Archdiocesan Catholic Charities Council; Voluntary Contributions Delinquent Girls 14 to 18 Years Jewish Family and Children’s Service Voluntary Sectarian Foster Home Care; Institutional Care Community Welfare Council; Voluntary Contributions Boys and Girls Infancy to 21 Years Institutional Care 5 to 16 Years Lakeside Children’s Center Voluntary Foster Home Care; Institutional Care Community Welfare Council; Endowment Boys 4 to 12 Years Girls 4 to 14 Years Lutheran Children’s Friend Society Voluntary Sectarian Foster Home Care; Institutional Care Lutheran Churches of the Mis- souri, Wisconsin Norwegian and Slovak Synods; Voluntary Contri- butions Boys and Girls Infancy to 16 Years Lutheran Welfare Society Voluntary Sectarian Foster Home Care Community Welfare Council; National Lutheran Welfare Coun- cil; Voluntary Contributions Boys and Girls Infancy to 18 Years Milwaukee County Children’s Home Public Institutional Care County Funds Boys and Girls. Infancy Through Eighth Grade Milwaukee County Dept, of Public Welfare Public Foster Home Care County and State Funds Boys and Girls. Infancy to 18 Years St. Aemilian’s Orphan Asylum Voluntary Sectarian Institutional Care Archdiocesan Catholic Charities Council; Voluntary Contributions Boys 6 to 14 Years St. Charles Boys’ Home Voluntary Sectarian Institutional Care Community Welfare Council; Archdiocesan Catholic Charities Council; Voluntary Contributions; School Lunch Program; Sale of Farm Products Delinquent Boys 12 to 18 Years St. Joseph’s Orphan Asylum Voluntary Sectarian Institutional Care Community Welfare Council; Archdiocesan Catholic Charities Council; Voluntary Contributions Polish Boys and Girls 3 to 18 Years St. Joseph’s Home of St. Teresa Voluntary Sectarian Institutional Care Archdiocesan Catholic Charities Council; Voluntary Contributions Boys 3 to 14 Years St. Margaret’s Guild Voluntary Sectarian Institutional Care Archdiocesan Catholic Charities Council; Women’s Auxiliary Girls 14 to 18 Years St. Rose’s Orphan Asylum Voluntary Sectarian Institutional Care Community Welfare Council; Archdiocesan Catholic Charities Council; Voluntary Contributions Girls 6 Years Through the Eighth Grade St. Vincent’s Infant Asylum Voluntary Sectarian Institutional Care Community Welfare Council; Endowments: Voluntary Contri- butions Girls and Boys Infancy to 6 Years Exclusive of care provided by Children’s Court. 2Foster Home Care includes care in boarding-, free, work, or wage homes, as well as adoptive homes. Institutional Care in- cludes group care provided on a 24 hour basis. 3In addition to payments by parents. 33 TABLE 19 DAY CARE FACILITIES FOR LESS THAN 24-HOUR PERIODS MILWAUKEE COUNTY — DECEMBER, 1948 Name of Agency Auspices Type of Care Source of Funds1 Age and Sex of Children Served Child Care Centers Tenth Street Cass Street Voluntary Day Care Community Welfare Council Boys and Girls 2 to 5 Years Our Lady of Pompeii Nursery School Voluntary Sectarian Day Care Voluntary Contributions Boys and Girls 2 to 6 Years St. Joan Antida Nursery Cass Street Beloit Road Voluntary Sectarian Day Care Voluntary Contributions Boys and Girls 2 to 6 Years Volunteers of America Day Nursery Voluntary Day Care Community Welfare Council Boys and Girls 2 to 9 Years Jin addition to payments by parents. cies has either the necessary staff or funds to take responsibility for pro- viding such services to families and children. 5. There is inadequate provision in the community for children who are extremely disturbed and in need of continuous study and observation in a controlled environment. 6. Group care which is adapted especially to the needs of teen-age boys and girls is not available for other than a very small number of children. 7. There is need for more coordi- nated planning between child caring agencies and institutions, under both public and voluntary auspices, so that the total foster care program in Milwaukee County will more effec- tively meet the needs of children. Child Placing Agencies 1. Agencies have made provision to employ staff with necessary case work skill and competence to per- form the child placing function. All agencies during the period of the Survey had staff vacancies and, as a temporary measure, some are uti- lizing to a serious extent, persons who have not had either the train- ing or experience required. 2. Even though effort has been made to receive them, all child placing agencies are handicapped because they do not have the boarding homes needed to care adequately for chil- dren for whom they are responsible. 3. The absence of a sufficient num- ber of boarding homes has resulted in: a. The placement of some children in institutions, even though the age of the child or the problems of the child are such that in- stitutional placement is not wise. b. More than 75 percent of the children in institutions are liv- ing in overcrowded conditions. 4. All child placing agencies have waiting lists of parents who are seek- ing to adopt children. Many months, and, in most instances a year or more, elapse after persons made ap- plication to adopt a child, before the adoptive study is made and a child offered to the adoptive parents for consideration. 5. Child placing agencies periodical- ly are unable to accept applications from couples wishing to adopt chil- dren. Such practice is followed be- cause of staff shortages and the limited number of children available for adoption. Some of the reasons for this are: a. A large number of children re- ceiving foster care either in boarding homes or institutions are not available for adoption usually because one or both parents are still living, and have not terminated parental rights. b. The value of utilizing a child placing agency in making an adoptive placement of a child is not recognized or understood by many parents and, in some instances, by other responsible persons. e. Most persons desiring to adopt a child wish to have a very young child, and many of the children in foster care are school age or otherwise do not meet requirements of adoptive parents. 6. Services available to unmarried parents and their children are inade- quate in the following ways: a. Agencies have tended to focus their efforts almost exclusively on making plans for the place- ment of children born out of wedlock, and have not consist- ently given proper attention to the problems of unmarried parents. b. Because of this practice of focusing services on the child almost exclusively, sufficient consideration has not been given to the personal and emotional problems of unmarried moth- ers. c. Unmarried mothers who are not residents of Milwaukee do not get the services they need, nor do Negro unmarried mothers. d. For the past two years services available to Protestant unmar- ditions under which children are accepted for care. The large number of agencies and institutions serving children in Milwaukee makes for complications and difficulties in de- veloping a child care program which is both flexible and comprehensive in coverage but which, at the same time, is so clearly defined that it is always possible for all persons, in- cluding parents who wish to utilize the child care services, to know where they should turn for help and guidance. Main Findings and Recommendations General 1. Staff in every agency and institu- tion visited appeared to have great concern about the children under care. 2. There were evidences of marked improvement in the past two years in the quality of social services pro- vided children by child placing agen- cies. 3. Agencies operating under volun- tary or sectarian auspices, with exception of the Jewish Family and Children’s Service, are unable to consistently carry out stated intake policies for one or more of the fol- lowing reasons: a. Insufficient staff to perform necessary services. b. Lack of boarding homes or other facilities needed for prop- er care of a particular child. c. Fund limitations in some in- stances, mitigate against the acceptance of responsibility for some children in need of long- time care. 4. Case work services which might prevent the need for placement of some children are not readily avail- able to parents. None of the agen- 34 ried mothers have been espec- ially limited due to a change in intake policies by the only voluntary non-sectarian child placing agency in Milwaukee. Children in Institutions 1. Children are often placed in insti- tutions in Milwaukee County be- cause there is no other way in which to care for them. 2. Children living in institutions are given good physical care and are almost without exception well fed and clothed. 3. There is evidence that some chil- dren are harmed by protracted periods of care in an institution or several different institutions. 4. More than 400 children of pre- school age are under care in in- stitutions in Milwaukee County. Institutions should not be expected to care for very young children. Ex- perience has repeatedly shown that they need and can be better cared for in boarding homes. 5. The Milwaukee County Children’s Home has been required to provide care for far more children than they can reasonably be expected to serve. 6. Most of the institutions in Mil- waukee were built 50 or more years ago. Almost without exception they are so constructed that it is difficult to provide care for children on other than a rather impersonal, routinized and congregate basis. 7. Many children living in Catholic institutions and all children living at the Milwaukee County Home for Dependent Children attend school in the institution. Consideration which is being given by some addi- tional Catholic institutions for send- ing' an increasing number of chil- dren to parochial schools is wise. 8. Supervisory staff employed to direct the daily care of children in the majority of institutions needs help in understanding children’s problems, and in developing in- creased skills in working with them. 9. Institutions need to be encouraged to increasingly provide care for fewer children and for shorter periods of time. Daytime Care 1. The care available to children in the two child care centers and the day nursery operated by Volunteers of America meets a very real need. 2. The extent to which these facili- ties are able to supply the total need for daily care and nursery education for children whose parents, either because they must work or for other reasons cannot care for them during the day, is not known. 3. It is not feasible to consider fur- ther at this time a merger of these three centers operating under volun- tary auspices. 4. Recognition has very properly been given by these non-sectarian day care agencies to the need for utilizing case work skills in the handling of applications for day care and in counseling with parents dur- ing the time children are in the centers. 5. Increased efforts should be made for more joint planning and a closer coordination of services provided by each day care center. 6. Adequate information could not be secured about the three nurseries operated for the care of Catholic children. It is known that at least one of these facilities is planning to markedly expand; that the pro- grams do not include nursery educa- tion ; and that case work services are not available to children in care. Recommendations It is recommended that: 1. A well-rounded foster care pro- gram be developed which will make it possible to place children in ac- cordance with the needs of each in- dividual child. 2. There be increased coordination of existing child care programs and facilities so that comparable and adequate services are available for all children irrespective of race, creed, or religious affiliation. 3. Services provided by existing agencies and institutions be strength- ened and improved through a con- tinuous and vigorous recruitment program supplemented by more formalized efforts to develop in-serv- ice training programs for the help and guidance of all employees. As a means of furthering these objectives, it is recommended that: a. Coordinated planning between child caring agencies and insti- tutions be developed. b. Agencies formulate written policy statements to control day-to-day problems of referral and placement. c. The County Department of Public Welfare develop its child care programs. d. Agencies renew efforts to find more foster homes. e. Agencies encourage parents to participate in cost of care pro- vided their children. f. Agencies cooperate and make every effort to place children of pre-school age in foster homes. g. Increased attention be given to the handling of adoptive appli- cations. h. That both child care and family agencies develop a service for the care of children in their own homes. i. That Welfare Counselors in- creasingly use the service of ex- isting case work agencies. j. That plans be made for services to unmarried mothers as well as for their children. (There are gaps in this service now. See main report.) In order to provide the best pos- sible care for children placed in institutions some recommendations are made. In brief they are: a. That privately supported insti- tutions continue efforts to ac- cept children on a selective basis. b. That age limit of all children accepted for care by institutions be given attention and the num- ber of pre-school children be consistently reduced. c. That the number placed in Milwaukee County Children’s Home be reduced. d. That more adequate case work service be made available to children in institutions for a long period of time. e. That children in institutions be provided opportunity for activ- ities and schooling in the com- munity. So far as daytime care of children is concerned, some of the recommen- dations are: a. That there be developed an op- portunity for the governing boards and staffs of day care centers to discuss their com- mon interests and problems. b. That the plan used by one of the non-sectarian day care centers serve as a pattern for others. c. That there be discussions with persons responsible for govern- ing the day care centers oper- ating under sectarian auspices, with a view to strengthen the 35 services and to arrange for case work service for the children. d. That day care centers be li- censed by the state. e. That a further study be made to determine how adequately the present day care centers meet the need. The report shows that considera- tion needs to be given to the estab- lishment of two new services. 1. A Study Home which would pro- vide a sound basis for determining the needs and necessary plans for children who are seriously disturbed mentally. 2. Group homes for adolescents. It is suggested that one for girls and one for boys be established at an early date. III. Recreation, Informal Education, and Group Work Modern urban community life is such that many activities which used to be centered in the home are now provided by community organiza- tions such as the schools, churches, playgrounds, clubs, and parks. Op- portunities for play, recreation, and group experience must be provided for all children, youth, and adults. The way in which these activities are carried on, and the people who direct them, are of great importance to the parents and citizens of Milwaukee County. In this county many organ- izations, publicly and privately sup- ported, offer such services. Each of these has the responsibility for con- ducting its program with the aim of developing qualities of good citizen- ship, the promotion of neighborliness and civic responsibility, and for pro- viding each participant the fullest measure of self-development as an individual. It is recognized that the primary re- sponsibility of the publicly support- ed agency is to provide a background of facilities, qualified leadership, and services on a community-wide basis. The Department of Municipal Rec- reation, Park Commission, Libraries, and Museum, are examples of broad, community-wide service groups. It is also recognized that the pri- mary responsibility of the private agency is to develop, against the background of the publicly support- ed agencies, the specialized programs of voluntary group associations found in activities of the Y’s, Scouts, Boys’ Club, neighborhood, and sec- tarian centers. Both the public and private pro- grams are supported by the commun- ity dollar. Finances, regardless of source, must be effectively distrib- uted to cover all areas of the county in accordance with known needs. To accomplish this, all agencies must coordinate their work, using a cen- tral channel for cooperative plan- ning. Coordination of recreation, in- formal education, and group work programs in Milwaukee County, is perhaps their greatest need today. Six types of programs exist. They are found in the Department of Municipal Recreation and Adult Ed- ucation in Milwaukee City, the pub- lic recreation programs of municipal- ities outside the city, the private agencies, the County Park Commis- sion, the camps, and in other organ- izations like the Natatoria, Police Youth Aid Bureau, Libraries, Mu- seum, and 4-H Clubs. A. Department of Municipal Recreation and Adult Education, City of Milwaukee, School Board This program is the larget organ- ized recreational activity in the county. Milwaukee’s public recrea- tion program has national and in- ternational renown as both a pioneer and leader in the field. In 1947 an attendance of 4,827,296 was record- ed. Its expenses that year totaled $826,524. Established under Wisconsin laws of 1911, the activities of public rec- reation are under the jurisdiction of the Board of School Directors. Funds are provided by designated city rev- enue separate from the educational budget of the School Board. The work of the Department is in three major areas. First are the social centers. Thirty-eight were op- erated during the past year and provided grade school, teen-age, and adult activities. Some centers were specifically devoted to neighborhood or community basketball and some to conducting of open game room sessions only. The tendency is to develop centers to serve practically all age groups in the neighborhood. This is sound. The second area of activity is play- ground work. Eighty-five neighbor- hood playgrounds were operated with spring and fall programs. Twen- ty-two of the grounds are used as ice rinks during the winter. During the summer, playgrounds begin ac- tivities in the morning and, in many cases, run until 9 :30 p.m. The spring and fall playgrounds open after school hours and some run until 9 :00 p.m. The third phase of work is in ac- tivities in the field of athletic pro- grams involving tournaments and leagues and some entertainment fea- tures such as dramatics or musical productions. The activities in these three areas are very extensive. Their operations over a long period of years have been developed through a central plan and administration. This has tended to create a degree of inflexibility in the consideration of specific and spe- cial neighborhood needs. The centers occasionally are regarded by patrons as imposed programs; participation by the patrons, especially adults, was not and is not, highly developed. This danger is recognized by the present staff and it is working on changes in assignments and using staff training to develop greater con- sciousness of responsibilities for pa- tron participation. Two major prob- lems in the present administrative setup need to be solved: a. Social center directors need to become more aware of their neigh- borhoods. They need to conceive their assignment as one of general agent in the community, sensitive to unmet needs for recreation and education, and to broaden defini- tion of these two terms. They then need to make much greater use of other available neighborhood serv- ices — both public and private. b. Supervisory processes need to be revised and improved to achieve the goal of professional develop- ment of personnel. According to current job descriptions, the super- visors are too heavily oriented to specific recreational skills and ac- tivities. Fortunately, the caliber of staff permits a sounder approach. It has been recommended that the Department add a person to the supervisory staff with training 36 and experience in the field of so- cial group work and community organization. A third point requiring attention is relationship between social center directors and school principals. The present plan is not clear enough. It is obvious that understanding and cooperation from principals is es- sential. Responsibilities between di- rectors and principals should be very clearly defined and district super- intendents used in interpreting the function of the social center. Several other phases of the De- partment’s work require review or strengthening. Restoration of the club program of the centers on an experimental basis with pre-adoles- cent and young adolescent children, is recommended. Redefinition of the function of athletic activities is need- ed in order to learn whether youth is involved in too much competitive league and tournament play. The ex- cessive involvement of the Depart- ment Director in planning of new services and other details, is adminis- tratively unsound. Working relation- ships with the Welfare Department of the schools need to be reviewed, aimed at establishing procedure to be used by both departments in serv- ing students with whom both deal. Finally, it is recommended that the planning activities of the Depart- ment be related to efforts of other agencies through an established pat- tern in the Community Welfare Council for over-all planning of ex- tension to leisure-time services. A review of the programs in these communities showed some to be more highly developed than others. In summary, it can be said that there is great opportunity for community organization and improvement of service, especially where there are very inadequate recreational activ- ities. This is specifically true in Cudahy, and the Towns of Oak Creek, Lake, Greenfield, Granville, and Milwaukee. It is recommended that local gov- ernments, the boards of education, and superintendents of schools be invited to review the need for rec- reation and informal education, to examine the present programs and future possibilities, and to appraise the financial ability of their com- munities with regard to recreational programs. To carry out this recommendation, the Community Welfare Council should be used to help in study and analysis of the problems. The County Park Commission likewise has a re- sponsibility to assist in the establish- ing of local recreation. C. Private Group Work Agencies Milwaukee County is served by eleven group work agencies — Boy Scouts, Boys’ Club, Catholic Youth Organization, Neighborhood House (Episcopal City Mission), Girl Scouts, Jewish Community Center, Milwaukee Christian Center, Salva- tion Army, Urban League, Y.M.C.A. and Y.W.C.A. In addition to the services provided by these agencies, the International Institute, Goodwill Industries, the Junior Red Cross, and the Milwaukee Hearing Society offer specialized group services under vol- untary auspice, and the American Youth Hostels operates a branch in Milwaukee. Private group work agencies offer services of a recreational, informal educational nature which, in many forms, are similar to the leisure-time program operated under tax-sup- ported auspice. The similarity of services offered frequently gives rise to the question of the relative re- sponsibility of the private and public leisure-time agency. It has become common to accept the point of view that widespread need for social serv- ices should properly become the re- sponsibility of government; indeed, there has been very noticeable na- tional growth during the past several decades in the size and extent of publicly financed recreational serv- ices, not only as reflected in facili- ties, but also in supervisory person- nel. In the light of this general growth of public service, it is essential to clarify some of the alignments and relative responsibilities between the private group work agencies and the tax-supported program. Actually there are no hard and fast rules, but only some principles which may be useful at the moment. In years to come it is inevitable that some of the present considerations may be modi- fied, but it is a safe prediction that in a democratic society there will al- ways be some private agencies. The Survey shows that the public program is held in high esteem among the private agency staff and board members, as well as among the general citizenry of Milwaukee Coun- ty. Yet the role of the private agency remains distinctive and highly im- portant. It should be pointed out, in the very beginning, that the relative roles of private and public agencies in this field are very much enhanced to the extent that coordinated plan- ning continues to take place. This point cannot be emphasized too strongly in the light of the current practices. Repeated comments have been offered to the effect that, “We do not have sufficiently strong cen- tral planning in Milwaukee.” Strong central planning involves the prob- lem of unity or integration. No valid attack upon the social conditions of a metropolis can be successful if based upon a compartmentalized ap- proach. At the moment in Milwau- kee, central planning amounts to little more than the cooperation of agencies to see that they do not “occupy” each other’s territory. The agencies do not sufficiently oper- ate as integral parts of a total or- ganization, nor as connected and related segments of the whole. In the face of earlier Milwaukee practices to restrict the operations of the private agencies, there is no doubt that their future depends upon their capacity for joint action — not for the preservation of the private agencies as such, but for the preser- vation of sound methods of attack on the many issues which need the combined efforts of public and pri- vate agencies alike. For the private group work agencies, this means utilizing the existing channels for coordination; namely, the Group Work Division of the Community B. Public Recreation ProgTams — Municipalities Outside of Milwaukee Activities of leisure-time programs under auspices of boards of educa- tion and other municipal authorities exist in the following governmental units; 1. City of Cudahy 2. City of South Milwaukee 3. Village of Greendale 4. Town of Oak Creek 5. Town of Lake 6. Village of West Milwaukee 7. City of Wauwatosa 8. Town of Greenfield 9. City of West Allis 10. Village of Fox Point 11. Village of Whitefish Bay 12. Village of Shorewood 13. Town of Granville 14. Town of Milwaukee 37 Welfare Council, for purposes of looking at the totality of Milwau- kee’s need. The success of joint planning is based upon the accept- ance by the agencies of the fact that they constitute the Council. The private agency’s role and re- sponsibility for the provision of group work and recreational services is indicated in a number of ways: 1. The voluntary agency offers op- portunity to socially conscious citi- zens to discharge their human obliga- tions by means of financial support and voluntary service in those direc- tions which they see as being nec- essary for the solution of some of the specific social issues. 2. Even the strongest of public agen- cies need the supplementation of pri- vate agencies in areas or kinds of special need. The most effective public service still does not please everybody. The private agency pro- vides necessary opportunity for tem- pering influences and control. 3. Traditionally, private agencies have assumed responsibility for ex- perimentation and demonstration in the development of service ultimate- ly leading to public acceptance and public support. While experiment and demonstration should naturally be a concern of the public agency, it is frequently limited by statute or otherwise in the extent to which this may be done. A strong supportive role is indicated here for the private agency. Not only should the private agency initiate research, experiment, and demonstration, but it should also serve as a resource to the public agency and the community at large in carrying on the above roles. 4. The private agency is the only instrumentality for bringing serv- ices to special interest groups. For a variety of reasons, there are always particular religious, geographic, eco- nomic, age, sex, racial, ideological or nationality groupings in need of intensive and specifically directed services. As an agency interested in total societal welfare, the private agency will be exceedingly conscious of the dangers of sectionalism or fac- tionalism and will, therefore, inten- tionally direct efforts, not only at amelioration of problems in the par- ticular groupings, but also at the en- hancement of integrative efforts of a total society. 5. The private agency makes avail- able services on a basis that allows freedom of choice, not only in mat- ters of program emphasis, but also in matters of auspice. The inherent values of small group participation for individual guidance and for dem- ocratic experience are well known. While such groups are frequently conducted under public recreation programs, the private agency finds this an important area of supplemen- tation. 6. The private agency carries a par- ticular responsibility in helping in- dividuals and groups of people who are having difficulty in establishing satisfying social relationships. Fre- quently, persons who are pre-delin- quent and who show other symptoms of emotional disturbance find con- siderable help in the intensive serv- ices of the private agency. Some of these persons occasionally require referral to psychiatric and case work services and sometimes respond very favorably to “protected” group ex- perience which can be legitimately provided by the private agency. Usually the public recreation pro- gram is filled to capacity by those who want its services. Yet there are many persons who for one reason or another do not seek group activities and opportunities for this kind of socialization. The public agency in- frequently is in a position to concern itself with the so-called “unclub- bable.” If so, the private agency should make specific attempts to con- duct research and investigation of this particular problem. 7. The private agency has a partic- ular obligation with reference to problems of neighborhood organiza- tion as such. Certain types of agen- cies are more suited than others for this particular responsibility since it requires concentration of service in defined geographic areas. 8. There may be some tendency for the public, having accepted public recreation to the extent of paying the bill, to shrug off further respon- sibility. Frequently, this means that the private agency has responsibility for stimulating social consciousness through development of voluntary leadership and committee service. The above considerations apply to some of the concerns entering into the planning process for the private agencies. To reinforce the develop- ment of their services, several addi- tional provisions may be taken into account. 1. Care should be taken to avoid duplication of services which may be rendered more effectively by the public agencies. This refers specifi- cally to large scale athletic or recrea- tional programs and the provision of facilities for conducting them. In some cases it may be necessary for the private agency to provide both facilities and staff for such services, but they should be transferred to the public auspice as early as pos- sible, 2. The private agency should not at- tempt to justify duplicate services on the basis of superior quality of leadership. It should rather devote its energies to the methods of bring- ing about an improvement in the public services if there is actual jus- tification for such. 3. While not needing to consider its existence as temporary, the private agency may frequently view at least a part of its service as temporary, avoiding the development of “ vested interests.” Historically, the private agency has been a forerunner in dem- onstrating the need for gymnasia, natatoria, health clinics, kindergar- tens, and other needed services which have subsequently been provided un- der public auspice. Private agencies have in the past, and must continue in the future, to always view the po- tentials in their own services as related to possible future growth in the public services. Recommendations It is recommended that: 1. The private agencies intensify their efforts at coordinated central planning in cooperation with the public agencies and with each other. The agencies, public and private, actually do constitute the Commun- ity Welfare Council. Agencies should be represented by board members and executives, as well as by staff. 2. The total Community Chest ap- propriation for the private group work agencies be increased. For de- tail, refer to general report and the reports for specific agencies. 3. A comprehensive plan for the re- newal of facilities be undertaken. With one exception the facilities used by the private group work agencies are old and inadequate for a modern program of service. It is recognized that some plans are already under way for the renewal of facilities. It is also recognized that not all facil- ities can be renewed at once; hence the suggestion that an over-all plan be considered. 4. Several studies be undertaken with the cooperation of the Group Work Division, and the Research De- partment of the Community Welfare Council. These studies should be 38 planned now to be completed when the 1950 census figures are available : a. A constituency survey, to show the unduplicated number of per- sons served by each agency and by all, as related to age, sex, and place of residence. b. An index of social need, show- ing areas in need of service, and establishing priorities for the pro- vision of appropriate programs. 5. Expansion of services by any agency be reviewed and revised or approved after a study has been made by an appropriate subcommit- tee of the central planning body. Agencies’ requests for additional Chest appropriation should be con- tingent upon such action. Requests for such studies should be made by the agencies well in advance of the budget hearings. The study com- mittees should have representation from the Research Department, the Group AYork Division, and the Social Planning Committee of the Commun- ity Welfare Council, as well as from the general public. 6. Immediate steps be taken to pro- vide greater services for the three broad geographic areas immediately surrounding the downtown business district, to the north, west, and south. It is recognized that the needs of these areas have been under con- sideration for some time. Sevices have been found to be inadequate and there has been some question as to the division of responsibility among the agencies for providing greater service. The responsibility for the provi- sion of such services falls primarily upon those agencies operating, by intent and designation, neighborhood building centered programs. In gen- eral these agencies are more ade- quately equipped to serve the less favored communities. Neighborhood non - building centered services in these communities should operate in conjunction with the building cen- tered agencies who should provide facilities and sponsorship. 7. More emphasis be given to serv- ices to the family as a unit. At present, services on the basis of age and sex groupings are out of pro- portion to the services rendered to neighborhood and family groups. 8. The total amount of work done with small friendship groups and the services for women and girls, es- pecially in the lower income sections of the population, be increased. 9. Programs of community organiza- tion as relating to the needs for service in the various communities of the county be developed. The initiative in the formation of district and area councils should be taken by the private group work agencies, although continuing leadership will have to be provided through the central planning body. Organization efforts of the neighborhood building centered agencies should be increased and should be specifically related to broader community organization pro- grams. 10. The private agencies give in- creasing recognition to the fact that Milwaukee is developing a metro- politan atmosphere. A growing city, with a growing number of suburbs and a shift of population away from the central business district, calls for a decentralization of program and the development of branch opera- tions. Decentralized operations need not be restricted to any one type of private group work agency. 11. The private agencies assume some initiative for the establishment of social group work services for emotionally disturbed children. While such services should not be established under the auspice of any of the agencies included in this re- port, the agencies do find among their membership certain individuals who are in need of more intensive treatment. In some of these cases referral to case work services may be the first step; in others there is a need for treatment in a psychiatric setting which should include provi- sions for the use of social group work in helping the individual establish more satisfying social relationships. 12. The attention and services de- voted to the promotion of better in- terracial relationships be increased and strengthened. Immediate prior- ity should be given to a considera- tion of expansion of services avail- able to Negroes on a nonsegregated basis. 13. Personnel policies of the group work agencies become an item for discussion in the Group Work Divi- sion of the Community Welfare Council with a view to establishing consistency and unity. This is es- pecially necessary for the establish- ment of sound standards of budget- ing. 14. The present efforts to maintain high standards of education and ex- perience, as well as other qualifica- tions in the selection of personnel, be maintained. A concerted effort should be made to secure personnel with full professional equipment which will meet the standards of the University of Wisconsin for the su- pervision of graduate students in training for group work. 15. The present plans for the devel- opment of services for the aged he carefully studied and plans projected for the increase of service necessi- tated by the growing number of people in the “golden age” bracket. D. County Park Commission The Survey is concerned with the operations of the Milwaukee County Park Commission because of the leisure-time program opportunities therein. The Commission deals with several other areas of work outside the scope of Survey responsibilities, and no study has been made of these except in reference to their relation- ship to recreation. Study of the recreation program in the park system can only be made when two other factors are consid- ered. First is the resolution of the County Board of Supervisors, dated July 1,1948, officially requesting the Park Commission to meet with the Milwaukee School Board, and with private charitable and civic groups, in order to develop “a well inte- grated and coordinated program for the use of public facilities ... in the promotion and supervision of recrea- tional activities.” Second is the question of division of responsibilities among organiza- tions serving the leisure-time needs of the people of Milwaukee County. This incorporates the point of the Board of Supervisors’ resolution and brings into focus the three areas which have been surveyed separate- ly; namely, (1) recreation under boards of education and/or munic- ipal authorities; (2) the voluntarily supported services like scouting, Y’s, neighborhood houses; and (3) the county park programs. The Survey staff who studied the three separate areas, believes it es- sential to have a statement of Gener- al Principles on Division of Responsi- bilities. They follow: 1. The leisure-time needs of boys, girls, men, and women of Milwaukee County require the programs of the public and voluntarily supported agencies in this field. 2. The extensive needs to be served call for division of responsibilities to form a basis of unduplicated and directed effort. 3. It is practical to divide responsi- bilities between all organizations in this field. Specifically, branches of government engaged in the work 39 should coordinate their programs through division of responsibilities. 4. The plan of coordination should bring about central county planning of leisure-time services through agreements defining the responsibili- ties for the county and those of the various local units of governmental operations (municipal and school). 5. Agreements should recognize the following divisions: a. Leisure-time service require- ments of the population of the county are vast and need programs on many fronts. b. The county, as the broadest gov- ernmental unit, has three distinct areas of competency: (1) Development of parks, park- ways, and play areas for all sec- tions of the county area. (2) Assisting local units of gov- ernment to demonstrate pro- grams of recreation suitable for their constituency. Such pro- grams should emphasize stand- ards of modern recreation. (3) Fullest utilization of exist- ing parks by making facilities available for informal recrea- tion, and equipping the Recrea- tion Division to coordinate all programs. c. Local units of government with- in the county are best suited to conduct leisure-time activities for people in a local area. This will require them to have : (1) Direction by an administra- tion which meets standards and is able to devote time to the work. (2) Alertness to leisure-time needs of all ages in the popula- tion. (3) Educationally sound pro- grams using personnel trained in modern practices. (4) A plan of citizen participa- tion in formulation and evalua- tion of the local program. 6. The division of responsibility be- tween governmental agencies can be established today. It means: a. The county should continue its program of land acquisition to pro- vide the areas required by the to- tal population. b. The county needs to relate its available facilities to a practical plan of program planning and op- erations. This requires centraliza- tion of all organized leisure-time services in its Division of Recrea- tion by giving it direct authority for use of facilities and personnel. c. The county should continue and expand its planning of land acqui- sitions in cooperation with similar efforts of local governmental units. This will make possible the use of grounds and buildings for many purposes, as well as provide un- duplicated community leisure-time resources. d. Through the recreation division of the county, efforts should be directed to assisting local govern- mental units establish and carry on their own programs. Demon- stration can be undertaken by the county under condition that the local unit is participating with the ultimate goal of assuming full responsibility. Since school dis- tricts are the major group con- cerned in any demonstration, the office of the County Superintend- ent of Schools should be involved for the liaison it can establish. e. Neighborhood playgrounds and community centers to which per- sons come because of walking proximity, are a responsibility of local government. The county should not operate any programs which exclusively concern a local unit except as demonstrations. f. Programs which are county- wide, should be carried out by the Recreation Division of the county. Local units should not operate mass activities such as league and tournament play, festivals, and musical affairs county-wide in in- terest and value. 7. The County and City of Milwau- kee have established a sound plan of coordination in their respective ef- forts at land acquisition for park and playground usage. The County Park Commission and the School Board of the City of Milwaukee need to immediately develop stated poli- cies to cover the programs and op- erations of these areas, and any ac- quired in the future. These policies should be guided by the principles stated above. Stated agreements made at the policy level, are required to guide the recreation departments operated by both. The experience of defining working relationships with- in Milwaukee will serve to guide the county in developing similar policies with other governmental units. 8. The role of the private agency in offering leisure-time services remains distinctive. Its effectiveness is en- hanced through full coordination and correlation between public and private agencies. a. Private agencies can effectively supplement work of public groups in areas of great need. b. Experimentation and demon- stration, in keeping with a planned effort for the total community, is a particular role which the private agency can discharge. Public agencies should experiment within their limitations on setting up new services, but should call upon private agencies for the flexi- bility they possess in experi- mentation beyond that which public agencies can efficiently do. c. Private agencies should serve special interest groups existing because of religious or racial cohesiveness. The efforts should be directed toward bringing such groups into relationship with the total community. d. The desire of persons for free choice in leisure activities, par- ticularly in small groups where intimate experiences are valu- able to the individual’s growth, gives the private agency a dis- tinguishing role. Such services are required in metropolitan Milwaukee County. The stated General Principles give the basic recommendations regard- ing the role of recreation in the county’s park system. Findings sub- stantiating these conclusions follow; The Park Commission responsibil- ities are extensive: 1. Reservation and acquisition of lands for public use. 2. Survey, map, and make plans for a comprehensive county park system, including a county system of streets, roads, and boulevards. 3. Plan for the protection from pol- lution of streams, lakes, pools, and the banks thereof. 4. Develop reforestation of tracts of land for public use, conservation of flooded areas, and preservation of places of natural beauty, and his- torical and scientific interest. 5. Act as zoning authority for areas outside the limits of incorporated villages and cities. 6. Plot lands in accordance with zoning regulations. 7. House veterans of World War II in temporary shelters. Park and parkway areas in the county system totaled 5,846.38 acres on December 31, 1948. These grounds, 40 the facilities, and the activities they offer, make up the recreational pro- gram of the Park Commission. Eighty-two units are among them. These vary in size from one-fourth of an acre in a neighborhood park to 634 acres in Whitnall Park and 864 acres in the Root River Parkway. Facilities vary greatly. They go from small, undeveloped, grass cov- ered plots, to “swimming only” at Big Bay and on to a complete pro- gram such as is found at Brown Deer, where baseball, bicycling, bridle path, boating, card room, coasting, dancing, cooking, football, golf, hiking, horseshoe, ice skating, indoor recreation, nature study, picnicking, skiing, table tennis, and tobogganing, are offered. In consideration of the variety of responsibilities in the Park Commis- sion, and the range in recreational resources, study was made of the Commission’s policies, administra- tive procedures, and departmental organization. The period 1935 to 1949 was reviewed, using minutes, reports, and financial statements of the Commission. Finding’s 1. Policies on recreation have been slow to evolve and appear to be fragmentary and opportunistic. 2. A clearly stated assignment for the Recreation Division is lacking. This is Required. It must be done in relation to the best practices for both the organized and the informal rec- reational opportunities in the park system. It requires recognition of other responsibilities of the Park Commission as well as for an admin- istrative arrangement most practi- cal for the total program. It must be related to other leisure-time services in the county. 3. Administrative procedures re- quire all recreational programming to go to the Commission through the Superintendent of Parks, and the Executive Secretary. A standing Commission Committee is used by the Recreation Director as a means of direct reporting. 4. The Recreation Division does not direct all phases of recreation oper- ated in the parks. Tennis, swimming, boating, and golf are examples of activities supervised by individual park supervisors as part of their over-all work. Supervisors are re- sponsible to the Parks’ Superintend- ent and their cooperation with the Recreation Director comes through sanction of the Superintendent’s of- fice. These specific recreational ac- tivities are separately budgeted and have no relationship to the Recrea- tion Division’s budget or control. 5. Matters of maintenance and de- sign of new areas for recreational work are not the responsibility of the Recreation Division. They are operated by separate divisions. An established pattern of cooperation in which the Recreation Division’s in- terests are recognized, is lacking. 6. The many programs and the re- quirement of Commission approval on administrative detail, make for unwieldy practices in which recrea- tion is practically lost from sight. The details for construction and maintenance of parks and parkways, their building, landscaping, and pav- ing requirements all flow through the Commission and are many and time-consuming. The same is true regarding work of the zoological gardens, horticulture, forestry, nurs- eries, arboretum, conservatory, and refectory programs. When added to the Commission’s work on zoning, stream and lake pollution, plus land acquisition, the volume becomes tre- mendous. 7. The finding is inescapable that the Recreation Division does not occupy a sound position in the park system. The dividing of responsibilities be- tween the Recreation Division and individual Park Supervisors does not allow for efficient planning and ef- fective coordination. Absence of a defined and stated relationship to the Planning Department, is un- sound. Unavailability of mainte- nance personnel directly controlled by the Recreation Division, is a hin- drance to its work. 8. Administrative practices indicate that the Commission is following a general policy of accepting respon- sibility for informal recreation to whatever extent it can be developed by individual supervisors in manage- ment of all park details. 9. The civil service requirements for the supervisor’s position, the in- service training program conducted, and the wide variety of responsibili- ties faced in daily work, lead to the conclusion that supervisors have neither the time nor the training to conduct modern indoor and outdoor recreational programs. 10. The analysis of policies, proce- dures, and organization of the Park Commission’s recreational work shows that the principal emphasis is on acquisition of parks and park- ways needed to complete the forward pointing master plan for encircling the county with a green belt usable largely for informal recreation. It must be interpreted to mean that other organizations, school boards, municipal authorities, private agen- cies, etc., have the primary responsi- bility for organized recreation, as well as for whatever informal rec- reation they are now carrying for their local areas or defined clientele. Therefore, any effort of the County Park Commission in the field of or- ganized recreation must be meshed with the specific services of existing organizations. 11. The existing resources of the park system can be used to greater ad- vantage through the Commission’s recognition of two specific tasks its Recreation Division can perform. One is to provide specialized programs. Day camping and nature lore are two programs for which the park system is eminently suited. Instruction in tennis, water activities, and ice skat- ing, can make these activities more fully enjoyable and satisfying pur- suits of leisure time. The second is for the Commission to set its Recreation Division to work assisting governmental units in un- developed sections of the county to establish recreational activities for persons within their areas. A park area or local school grounds can be used. The role of the Recreation Division must be that of carrying out a demonstration, having an agreed-upon date for the local au- thority to assume full responsibility. 12. The final interpretation is that the Commission needs to do its pres- ent job of recreational planning and operations with a more efficient in- ternal arrangement. A rearrange- ment of assignments, enabling the Recreation Division to deal directly with activities, maintenance, and planning for all phases of recreation- al work, is essential. These findings are developed in the role assigned to the Park Com- mission by the statement of General Principles on division of responsibili- ties between county, city, and private agencies in leisure-time services. One further observation is offered. All leisure-time service agencies need to establish more effective channels for regular cooperative planning. The Community Welfare Council must take leadership in making its Group Work Division that channel. It is recommended that the role of the Park Commission in recreation should be to: 1. Emphasize informal recreation after establishing the Recreation Di- 41 vision on a sounder administrative basis. 2. Use park resources for specialized activities like nature instruction un- der direction of the Recreation Di- vision. 3. Assist undeveloped areas in estab- lishing recreational programs through local governments, these to be demonstrations with established terminal points for county partici- pation. 4. Develop policies and agreements with local authorities through which available local park recreational fa- cilities are used by them and county- wide activities are taken over by the Commission. E. Camping The camping facilities available to residents of Milwaukee County in- clude primarily the organized resi- dent camps operated by Milwaukee social agencies. There are several day camping programs and some short-term camping facilities in ad- dition to which private camps are used by some Milwaukee people. The camping services provided by the Milwaukee agencies through res- ident camps Avill accommodate ap- proximately 1,200 campers at one given time. Very few of the camps visited have been able to observe a fixed rated capacity. The camps are primarily for boys and girls between the ages of nine and seventeen and the fees approximate an average of $2.50 per day per camper. The camps are operated on a self-sustaining basis as much as possible. Camper subsidy is sometimes available through the agency itself or its Chest appropriation, and through the Camp Selection and Placement Com- mittee. This Committee operates within the Community Welfare Coun- cil and receives some funds directly from the Community Chest. The camps are, on the Avhole, Avell equipped and Avell staffed, although a few operate on very small tracts of ground in relation to their capacity. In general the camps are equipped and staffed to serve the so-called average camper. Individuals needing special help in adjustment are ac- cepted at seAmral camps in very small numbers. In most instances the camps meet sanitary and health standards of the American Camping Association. Physical examinations, health ser\T- ice, sewage, garbage, rubbish dispos- al, refrigeration, water supply, safe- ty precautions and other factors in health, sanitation, and safety are in general above minimum require- ments. Program planning and execution vary considerably from camp to camp. The general objectives of character and citizen development are sought for in many ways through supervised educational and recrea- tional activities. Water front activi- ties occupy a prominent place in the type of activity offered, with athlet- ics and handicrafts also being heav- ily used. Archery, rifle, dramatics, woodcraft, and hiking are frequently used. Greater variations exist in philos- ophy underlying program develop- ment. These range from fairly fixed program outlines to almost complete flexibility in camper planning and participation. From the staff point of Anew, experience and maturity are represented in the directors and section, or unit, heads. The majority of counselors come from college stu- dent ranks and have limited exper- ience. Some camps are setting ob- jectives in the direction of securing a greater proportion of older, more experienced staff, even in the coun- selor ranks. A limited number of winterized facilities are available at present and there is movement toward in- creases. Agencies see this as an es- pecially desirable adjunct to their year-round programs with groups. This Summary has only briefly described the resident camping serv- ices. The detailed camping report will include data for the 1949 season. The recommendations should be con- sidered on the basis of present data. It is recommended that: 1. An increase in resident camping facilities be projected under public auspice but available for operation by private agencies and especially aimed at low-cost camping. The pos- sibilities of subsequent public opera- tion should be explored for the fu- ture. 2. A broad approach to low-cost camping be considered, including in some cases greater Community Chest support of camps, and in others, in- dividual camper subsidy. 3. Camping opportunities for girls be more nearly equal to the oppor- tunities for boys. 4. More opportunities for family camping be developed. 5. More opportunities for emotional- ly disturbed children be developed. 6. Increased facilities for Negro children be made available. 7. The Camp Selection and Place- ment Committee of the Council transfer its function to a regular camping agency. F. Other Organizations Natatoria of the City of Milwau- kee. — The interest of the Survey in the natatoria is based on the po- tential recreational resource their swimming pools offer. Swimming pools are important assets to a com- munity plan of recreation and educa- tion. The future value of the natatoria lies in the possibility of their be- coming part of the public recreation program of the city. Their affilia- tion with the Department of Munici- pal Recreation will add a needed new program feature for the Depart- ment, as well as provide a tie-up with a clientele which will use the swim- ming facilities. The operation of the Department under the school system means that the natatoria can be opened to public schools for water activities during hours when the general public does not use the facil- ity. The working relationship which the Department of Municipal Rec- reation has with voluntary agencies like Red Cross, Boy Scouts, Girl Scouts, and neighborhood centers, will bring an additional group of persons to the natatoria. Natatoria are currently operated by the Bureau of Bridges and Public Buildings of Milwaukee. In the face of declining attendance, the in- creased cost per bather which reached an all-time high of 31.5 cents in 1948, the report of the City Bud- get Supervisor under date of May 8, 1949, calling attention to the ex- perience of declining use of the nata- toria, and the common sense factor of their belonging under jurisdiction of the recognized recreation plan- ning and operating resource, early transfer of the natatoria to the De- partment of Municipal Recreation, is recommended. Milwaukee Police Department Youth Aid Bureau. — The Youth Aid Bureau of the Department of Police, City of Milwaukee, was established on February 4, 1946. Its purpose is stated to “ ... eliminate . . . con- ditions conducive to the development of juvenile delinquency and crime and to encourage activities designed to provide wholesome environment and activities ...” In describing how it will work, Chief of Police Polcyn indicated that 42 the Bureau should “ . . . assist fully and cooperate wholeheartedly . . . with the existing and established agencies dealing in youth welfare.” Further, it “ ... stands ready to aid and work harmoniously with these organizations, not to usurp, overlap, or substitute their function.” From the viewpoint of social wel- fare, the work of the Bureau touches three phases of services involved in the Survey. They are the Juvenile Court, the voluntary case work agen- cies like Family Service and Travel- ers Aid, and the leisure-time services exemplified by the Department of Municipal Recreation and voluntary group work agencies, such as neigh- borhood houses, Y’s, and Scouts. The work of the Bureau with the Juvenile Court is on sound footing. The procedures used leave cases with the Court which it is equipped to handle and make the Bureau a source used by policemen throughout the city for juvenile offenders. For cases not involving the Juven- ile Court, and which should be the concern of the case work agencies in the community (Family Service, Catholic Welfare, Children’s Service, Lutheran Welfare, etc.), no definite procedures have been developed. The Bureau becomes involved in treat- ment for which it is not equipped and which consumes too much of its effort. In operating the Police Athletic League (PAL), the Bureau engages in two forms of recreation. One, for which the police gymnasium is used, is designed to meet the needs of in- dividual boys. The other, while aimed at individuals known to the Bureau, has become an open, city- wide baseball league. Ninety teams have been enrolled for the 1949 sea- son. The Survey questions whether the latter type of athletic planning is a responsibility of the Bureau. It belongs in the Department of Muni- cipal Recreation. The leisure-time programming of Boy Scout troops in district station houses under volunteer policemen, and in accordance with Scouting standards, is a commendable activity. More efforts of this type should be planned, involving resources of neighborhood houses, Y’s, etc. Recommendations It is recommended that: 1. Case work agencies and the Bu- reau develop better referral tech- niques. This can be done through discussions in the Case Work Divi- sion of the Community Welfare Council. It is further recommended that one of the case working agen- cies consider loaning the Bureau a professional worker to experiment in developing a screening procedure by using the Social Service Ex- change, and in cooperating with other case work agencies. 2. The Bureau undertake discussions with the Department of Municipal Recreation regarding the responsi- bility involved in the Bureau’s op- eration of a city-wide, open baseball league under PAL sponsorship. The principle should be maintained of the responsibility for city-wide rec- reational programming belonging to the Department of Municipal Rec- reation. It is also recommended that dis- cussions be held among the Bureau, the Department of Municipal Rec- reation, and the voluntary group work agencies regarding the respon- sibility of the leisure-time service groups for more activity with social clubs indentified by the Bureau. Both phases of this recommenda- tion should be channeled through the Group Work Division of the Community Welfare Council. Milwaukee Public Library — The library of the City of Milwaukee is operated as a branch of government. It is governed by a board consisting of nine persons — three aldermen and four citizens appointed by the Mayor, and two members of the school board. The library operates seventeen branches, many of which are in in- adequate rented quarters. Circula- tion of books in 1948, was approxi- mately five per capita of population. This is reported to be better than the national average. Expenditures are rated as adequate by national standards. The library works closely with school systems, both within the City of Milwaukee and in areas of the county where no libraries exist. It would like to enlarge services of book clubs, hobby forums, film and record circulation, and a program for shut-ins. The greatest need of the library is for accessibility to the public through properly housed branches as well as a central building. Milwaukee Public Museum — The museum is another branch of the City of Milwaukee government, and is governed by a board chosen in the same manner as the library board. Sharing a large building with the library, the museum offers many programs contributing to the educa- tion and recreation of all ages in the population. An active program is carried on with the parochial and public schools. The museum acts as the visual aid service for the schools, using a col- lection of slides, film strips, speci- mens, and motion pictures. Special activities for school children are car- ried on, with emphasis on Saturday programs. The museum estimates that 40 percent of its services go to school age children. Adult activities consist largely of visitation to the many attractive displays, use of films, and attendance at free public lectures, many of which have turn-away crowds. The museum, while financed by the City of Milwaukee, is used by residents of the entire county. Re- newal of discussion aimed toward making the museum a responsibility of the county government, is recom- mended. 4-H Clubs — In the year 1948 there were 24 4-H Clubs in Milwaukee waukee County with 570 enrolled members, 310 girls and 260 boys, ranging in age from twelve to twenty. The Club program is directed by the Assistant County Agricultural Agent. The expenses of the program come from State and Federal re- sources, with the county furnishing quarters and supplies. The 4-H Clubs are found in the northwestern, west central, and southern sections of the county. One is located in West Allis. Practically all groups meet in rural schools. The program is in keeping with the national 4-H plan of projects around interest of rural life. Cattle, crops, livestock, weed control, dairy work, gardens, orchards, wild flow- ers, handicrafts, soil conservation, clothing, and food preservation are some of the projects around which youth interests are captured. The 4-H program is a valuable as- set to total youth services. Its pro- gram skills, as well as problems of heavy drop - outs among members, need to be related to the experiences of other organizations serving youth. Active participation in the Group Work Division of the Community Welfare Council is recommended. 43 IV. Special Services A. Veterans’ Services When the findings and recom- mendations on Veterans’ Services were discussed with the Technical Committee, on which were represent- atives of practically all of the agen- cies providing special services for veterans, there was disagreement with the report. At the time this Summary is written, no letters have been received from the agencies studied. Even so, their opposition to the recommendations was clearly stated in discussions and in state- ments published in the daily papers. The recommendations of the Sur- vey are not mandatory, but are the sincere opinion of the staff. In the future discussions to reach an agree- ment, there should be an effort to distinguish between the services which should be available to veter- ans as veterans, and those which are needed by them and also by other citizens of the community. The other main question to be settled is, ‘ ‘ What agency or agencies in the community are best equipped to perform the special services for veterans in the most economical and efficient man- ner?” The entire report should be read by those interested. It is avail- able at the Survey office and also at the office of the Community Wel- fare Council. The following paragraphs give a digest of the report and the recom- mendation. The veterans are an important seg- ment of any community. During time of war their service in the armed forces interrupted their ef- forts to establish economic security for themselves and their families. Therefore, they are entitled to spe- cial consideration on their return to civilian life, in the form of programs designed to enable them to “catch up” on lost time. This country has been very generous in this regard. The program of the Veterans Ad- ministration, in its various facets, contains almost every conceivable method of helping the veteran re- establish himself into his community. The program is impressive, and its success has been attested to by the majority of those who have studied it, including veterans’ organizations. An evaluation of the Veterans Ad- ministration program has not been included in this Survey. Over and above that program, there is still the need for private groups to operate, to assist the veteran. There are gaps, even in a program as seemingly all- inclusive as that described above. Private veterans’ groups are re- quired to press for the filling of these gaps. There are three major private or- ganizations giving service to veter- ans. Two, the Veterans’ Service Ex- change and the Veterans Information and Referral Center, are Community Chest supported. The third is the Red Cross. From the point of view of simplic- ity and efficiency, it would seem that the whole operation of the Veterans’ Service Exchange is a duplication of the work of the Red Cross. However, as representatives of the veterans’ groups have been quick to point out, this is to consider the problem theo- retically only, and not realistically. The fact is that there are many vet- erans who consider the Red Cross in much the same way as they do the Veterans Administration, as at least a semi-official body, and they would prefer to have their claims processed by an organization dealing with vet- erans only, because it might be more interested in the veteran’s side of the story. Moreover, these spokes- men assert, organizations such as the American Legion, the V.F.W., and the D.A.V., and others, are re- luctant to give up the service of representing the veterans at the Vet- erans Administration. Therefore, even if Chest funds were withdrawn from the Exchange, these organiza- tions would continue to operate, probably less efficiently, and large numbers of veterans would go to them rather than to the Red Cross. This, of course, is merely to accept a situation by refusing to do any- thing about it; in fact, it is con- tributing to its perpetuation. Vet- erans’ organization representatives, however, counter that it is not a bad situation; that while it may be du- plication of services, it is necessary and desirable; that there should be a choice offered veterans as to who should represent them. In review, it would seem that the Exchange is duplicating work al- ready handled by the Red Cross which, while not a Community Chest member, is a community sponsored organization, operating with contrib- uted funds. It would appear, too, that it is actually better equipped to handle all problems of veterans, whereas the Exchange is limited largely to gathering of data prelim- inary to presentation of claims. How- ever, the fact that all the other major veterans’ groups are cooperating in the use of the Exchange is indication that there is a demand for its serv- ices. The situation in Milwaukee as far as duplication of services is con- cerned, appears to be better than in some other cities where there is not even cooperation between the major organizations to the extent that ex- ists in the operation of the Veterans’ Service Exchange. Therefore, there would seem to be justification for temporarily continuing the operation of the Exchange, principally for the purpose of the preliminary work in the handling of claims. Its informa- tional and referral services, of course, cannot be closed down completely, as any organization operates an in- formation and referral service to a certain extent, but this is an area where specially trained personnel is required, and it should be left to specialized organizations. The Veterans Information and Re- ferral Center is essentially what its name implies. At one point it was handling a great number of questions on matters such as state bonus, term- inal leave pay, G.I. Insurance, and the like. Recently, however, the de- mands on its services have been more in the nature of civilian problems: unemployment, relief, housing, legal aid. This lends weight to those who argue for a civilian community in- formation and referral center, not restricted to veterans, along the lines established in other cities. This in- volves more than a mechanical set-up conveying information alone. It en- tails some personnel with training in social work. Whether there is a need for such a center in Milwaukee, considering the expenses involved, is a matter for special study. Here we can record only the belief that if an information and referral center is to be maintained by community funds at all, it should be an all-inclusive one, and not directed to veterans alone. In fairness to the present management of the Center, it may be said that they are in complete accord 44 with the view that there is a need for a community-wide center, but take the stand that if one is not set up, then at least there should be one for veterans. At present specialized re- ferral service is given veterans by the Information and Referral Center, the Veterans’ Service Exchange, the County Service Office, and the American Red Cross. In summary, it may be said that the veterans of Milwaukee are re- ceiving fine service from the official agencies, and that the veterans’ or- ganizations which operate in the com- munity are also rendering conscien- tious and sincere service to their members. Praise is due those who operate the two privately supported central agencies. They are sincerely interested in helping the veterans who come to them for assistance with their problems. The recommenda- tions embodied in this report are not to be construed as a criticism of their work. The question involved concerns their relationship to each other and also to other services. We believe that our recommendations will not deprive the veterans of any services now being rendered but will provide them in a more efficient and economical manner. Recommendations It is recommended that: 1. The Community Chest for another year continue to support the Veter- ans’ Service Exchange. Theoretical- ly, only one such agency is justified, and the Red Cross is in a position to do a more inclusive and better inte- grated job. Even so, the Exchange is serving a useful function in coor- dinating the work of the veterans’ organizations to the extent that it does, and should therefore be con- tinued until all arrangements have been made to take over the services. The Exchange should limit itself to its claims service to veterans. Vet- erans with simple claims should be sent directly to the Veterans Admin- istration. It is suggested that at least three members be added to the Board of Directors to represent the general interests of the community. The plan should be to have the work of the Service Exchange taken over by the Red Cross. 2. With regard to the Veterans In- formation and Referral Center, in view of the fact that the trend in re- quests for information is toward mat- ters less identifiable as veterans’ problems as distinguished from com- munity-wide problems, that commun- ity funds be withdrawn unless the agency be reorganized to become a community-wide agency, with a rep- resentative board, and trained staff to act as an information and referral center on all matters which concern social and health agencies. If this expansion is not carried out, the In- formation and Referral Center should be closed and the Community Welfare Council should expand its referral service to include all matters relating to the civilian problems of veterans, and the Red Cross should be the information and referral cen- ter for the war connected problems of veterans, B. Court Services The purpose of this section of the Survey is to determine the type and quality of services in connection with legal proceedings to persons in Mil- waukee County who are involved in problems of domestic difficulty and child care; to determine, especially whether these services are adequate, and to what extent they are geared together so that all services needed by any one family can be given smoothly without overlapping or gaps. This type of study has not been included in similar surveys made in other cities. It was included here because Milwaukee County has a suf- ficiently adequate program of court services to make such a survey pos- sible and the subject is an important one in total community planning. It is the firm belief of this staff that the use of legal procedures in solving problems of domestic difficulty and child care require both free legal services to indigent clients and so- cial services to supplement court action. The use of social services in con- nection with legal procedures is rel- atively new and the interrelation- ships between the two types of serv- ices are still in a formative state. In general, ease work services in this connection are utilized in three dif- ferent ways: 1. To help the client decide how to handle his problem, including the de- cision as to whether or not to resort to court action. 2. To gather information which will assist the court in making a decision especially with respect to questions such as the custody of children, which the law leaves to the discretion of the trial courts. 3. To help the client adjust to the changes in his way of life which follow as a consequence of court action or to the responsibilities which the law requires him to meet. The second function described above is the one most generally thought of in connection with social services in the courts. It is not, how- ever, the only one, nor necessarily the most important. Nine agencies were covered: 1. The Juvenile Court (now the chil- dren’s Court) 2. The Office of the Corporation Counsel 3. The Office of the Clerk of the Civil Court — in connection with illegitimacy proceedings 4. The District Attorney’s Office and 5. The Adult Probation Department — insofar as they deal with fam- ily or child care problems 6. The Adoption Division of the County Court 7. The Office of Divorce Counsel and Court Commissioner 8. The Department of Domestic Con- ciliation 9. The Legal Aid Society The first eight agencies are all part of the public offices dealing with the administration of the law, and will be handled together in this Summary. The Legal Aid Society is a pri- vate agency. It was included in this section of the Survey since its serv- ices are primarily legal and impinge, to a certain extent, on the work of the public law administration agen- cies. Each of the courts in Milwaukee County, six in number, has jurisdic- tion over some phases of domestic and child care problems. The Circuit Court has general original jurisdiction and, therefore, has juris- diction over all cases (with the pos- sible exception of adoptions), the jurisdiction of the other courts being concurrent. However, the practice is to use the other courts for all cases which come, respectively, with- in their jurisdiction. The complete report at this point describes the present practice of each court and of the Legal Aid Society. The conclusion is reached that the work of the various court services interlocks and that any one family might be involved with sev- eral of the courts and court services either successively or simultaneously. 45 The Legal Aid Society has excellent relationship with the various courts and court services. Even so, its amount of work is well below the national average for case loads in a legal aid society. It hesitates to make itself better known until it has a larger budget and more adequate quarters. A description of the work of the different services is in the main report, which is available at the Survey office and also at the Community Welfare Council. In this Summary it seems best to give the gaps and discrepancies in community planning, and make certain recommendations relating thereto. Gaps and Discrepancies Central Intake. — First and fore- most is the lack of some sort of over-all coordination of the work of the various courts and public agen- cies dealing with problems of do- mestic difficulty and child care. Ideally, one would hope that all these family and child care prob- lems could be brought under the jurisdiction of one court. Failing that, it would seem that there should be some sort of central intake office to which clients would apply before initiating any legal procedure in these sorts of cases. A central intake office would imply that such office must, neces- sarily, be detached from at least some of the courts and agencies through which proceedings might eventually be initiated, since at present, family and child care prob- lems are distributed through six courts and eight court service agen- cies. On the other hand, there are real values in the present system of separate social service units attached to the courts they serve. There is an apparent conflict between having a central intake and specialized social service units attached to the various courts. This apparent conflict is resolved if we go back to the analy- sis of the functions of social services in connection with legal proceedings, namely: 1. To help the client decide how to handle his problem, including the decision as to whether or not to re- sort to court action. 2. To gather information which will assist the court in making a decision, especially with respect to questions such as the custody of children, which the law leaves to the discre- tion of the trial court. 3. To help the client adjust to the changes in his way of life, which follow as a consequence of court ac- tion, or to the responsibilities which the law requires him to meet. The first of these three functions could be placed in a central intake service, while the second and third functions could be carried by the specialized units attached to the courts they serve. There would be difficulties, of course, in working out such a system, since it would involve the voluntary cooperation of many different agencies. It is a prob- lem in community planning. Lack of Rapport Between the Private Social Agencies and the Court Services. — Most of the court service staffs seemed to be unaware of the kind of help their clients might get from private agencies. They think of social work, apparent- ly, in terms of financial assistance, material services, or supervision, rather than in terms of helping clients toward a healthier and hap- pier way of life. The staffs of other court services are well aware of the potentialities of case work services as given in private agencies, but seem to feel that the private agencies are not responsive to referrals by them. Most of the workers in the court services in both groups in- dicated a desire for closer relation- ships with the private agencies along the lines of participating in commu- nity planning, in group discussions of mutual problems, in mutual inter- pretation of each other’s functions and limitations, etc. Main Conclusions and Recommendations Specific recommendations regard- ing the court services studied are not given in this Summary. They have been sent to the services and to the Community Welfare Council. Problems in Community Planning 1. Court Services — Private Agency Relationships. —- The Community Welfare Council should assume re- sponsibility for bringing the court service agencies and the private agencies closer together through joint participation in community planning, case conferences, and dis- cussions of mutual problems. (Comment: Although special serv- ices are mentioned in the two follow- ing recommendations, they relate to general policy and planning for the various services.) 2. Evaluation of Applications to the District Attorney’s Office in Cases of Domestic Difficulty or Child Care. — Consideration should be given by the District Attorney and other agencies concerned with family wel- fare to the problem of intake proce- dures in the District Attorney’s Office, with a view of minimizing the use of criminal prosecutions in family and child care problems. The possibility of using the Department of Domestic Conciliation in this re- spect should be taken into considera- tion. Thought should be given to the advisability of having the intake interview take place in some loca- tion other than the District Attor- ney’s Office. 3. Analysis of the Functions of the Department of Domestic Concilia- tion. — The functions of the Depart- ment of Domestic Conciliation should be re-evaluated in the very near fu- ture. If all the functions as defined by statute are considered valid, then efforts should be made to increase the staff of that department to such a size that all the functions can be fulfilled. At the same time efforts should be made to build up the use of the department by the other court services so that the Depart- ment of Domestic Conciliation as now defined can function effectively. If, on re-evaluation, some of the functions as defined by statute should be considered as inappropri- ate, then the statute should be amended. Ultimate Goals Bearing in mind the people of Milwaukee County who look to legal procedures as a possible solution of their difficulties in the area of fam- ily and child care problems, the ultimate goal would seem to be a central intake service for all appli- cations. This could function in con- junction with separate social serv- ice units servicing the various courts. If, at some time in the future, one court should assume jurisdiction over all legal procedures in family and child care cases, the intake service and the separate court service units could be combined into one general court service agency. In conclusion, it should be said that the integrity and sincerity ex- hibited by all the public servants in Milwaukee County is impressive. These suggestions and recommenda- tions are not made in any spirit of criticism but are offered with the hope of strengthening and perfecting 46 work which is already done well. All the agencies studied were most helpful, not only in submitting factual material, but in helping the reviewer to see through to the basic problems involved, and in analyzing possible ways of improving service. C. Services to the Aged Planning for the needs of the aging population is becoming one of the major concerns of health and welfare services. Two reasons for the problem can be advanced. First, more persons are living longer, and second, the public has accepted re- sponsibility for meeting the needs of individuals described as aged. In 1940 Milwaukee County had 46,251 persons, or 6 percent of its population 65 years of age and over. The forecast for 1950 is more than 62.000, or 7.8 percent. For 1960 it is 87,000, or 10.8 percent. By 1980 it is estimated that persons 65 years of age and over will total more than 119.000, or 14.3 percent of the total population. The aged live in urban centers. 37,448 of the 46,251 in the county resided in the City of Milwaukee in 1940. There are more aged women than men. Only 19 percent of the aged were reported to be in the labor force in 1940. Even at the peak of war employment nationally, 68 per- cent of the aged remained outside the labor market. The economic security needs of the aged present a challenge to industry to provide work opportunities designed to uti- lize the skills which aged possess, while safeguarding health. AYhile greater employment will help to a degree, existing opportunities for saving and longevity after retirement lead to the conclusion that the com- munity must organize programs to provide income for a large percent of the aged retired workers and their families. The leading causes of death today are diseases characteristic of matur- ity. The health of the aged has be- come of major concern since 54.4 percent were reported to be chroni- cally ill or invalid in 1940. This means that over 25,000 aged were requiring bedside care. Hospitals are not the answer due to reasons of high cost, the importance of re- taining hospital beds for emergen- cy purposes, and the need to realize that the chronically ill and invalid can best be served in their own homes or in a similar environment. The major programs for the aged in Milwaukee County and estimates of numbers served show the follow- ing: programs, ranging from homes which are busy centers with resi- dents demonstrating purposeful liv- ing, to homes which seem to offer clean surroundings where residents apathetically await their passing. There is the question of obsolete plants, built on the traditional dor- mitory style and requiring consider- able expenditures to maintain and modernize. The wisdom of more tra- ditional institution-type buildings is questioned in light of the numbers of aged, their needs, and demonstra- tions elsewhere of more meaningful services in the individual’s own home or through a communal living plan. This is a problem requiring atten- tion from leaders of private philan- thropy. The relationship between volun- tary supported homes and the pri- vate services regarding use of case work skills in selection of residents, the apparent inability of homes to refer persons they turn away to other social services, and the responsibility which privately sup- ported philanthropy has to experi- ment with new ways to meet the needs of the much larger numbers of aged than now served, is a fourth conclusion drawn from study of findings behind the tabulation. A fifth set of facts stems from findings showing that the commer- cial nursing homes play an impor- tant role in serving the aged. The need for uniform county-wide stand- ards of health and safety, the re- sponsibility for bringing operators together to achieve better services (with fees ranging from $60.00 to upward of $250.00 per month) are only two phases of commercial home services needing coordination. They offer a challenge to which those responsible for over-all social planning must give attention. Recreation for the aged in the gen- eral community is offered to 457 men and women sixty years and over, through thirteen cIuIds. The program is of immeasurable value and de- serves fullest support. It should be enlarged so as to include several times the numbers currently enrolled. Happy people, particularly when aged and idle, are not sick people. Opportunities for neighborliness, friendly associations, and congenial companionship, wherein fun is had by all in an environment away from home, which is “theirs” for a few hours, means so much to aged per- sons. Recreation costs for the aged are small in comparison to other services. Program PUBLIC SERVICES Financial Help & Social Service Monthly Count of Numbers Served Old Age Assistance Blind Assistance Old Age and Survivors’ Insurance 8,908 123 10,831 Institutions County Infirmary 1,143 PRIVATE Non-Institutional Social Services St. Vincent De Paul Jewish Family and Children’s Service Family Service 50 22 70 Institutional — Non-Profit 19 Social Service Homes 1,138 Institutional — Profit 37 Commercial Nursing Homes 577 PUBLIC AND PRIVATE Recreation 13 Golden Age Clubs 457 Several significant trends come from study of the facts behind this tabulation. One is that tax-sup- ported agencies are giving the bulk of services. A second is that most services are incomplete in them- selves, except for some of the in- stitutional programs. The pattern appears to be a smattering of a lot of efforts, with few sufficient in themselves. The average monthly grant for Old Age Assistance was $43.33 per case. With some workers carrying case loads of 400, it is understand- able why clients of the assistance program are appealing to private case work services for attention to their individual problems. This is a service which should be supplied by a professionally competent staff ad- ministering the assistance program. Old Age and Survivors’ Insurance provides funds from a federal pen- sion plan financed through con- tributions by workers and their employers. No means test is in- volved; payment is earned through a plan of insurance. The average monthly payment of $23.54 neces- sitates supplementation from other agencies and resources. A third conclusion is that the role of institutional services requires re- evaluation. There are marked varia- tions found among institutional 47 Its positive values makes this sixth form of community effort a most valuable investment. Recommendations It is recommended that: 1. The Central Agency for the Chron- ically 111, through channels of the Community Welfare Council, give immediate attention to services re- quired by aged whose needs for medical care can best be met at home. 2. The Central Agency for the Chron- ically 111 act as the coordinating resource for improving services in nursing homes. 3. The citizenry of Milwaukee Coun- ty support efforts to liberalize the Old Age and Survivors’ Insurance program in order to bring about more nearly adequate retirement benefits. 4. The two county departments serv- ing the aged, together with the private agencies experienced in pro- viding homemaker service, proceed immediately to offer such a service in accordance with recommendations appearing in the Homemaker Service division report of the Survey. 5. The Community Welfare Council establish a plan to bring together representatives of the private, non- profit homes for aged, in order to evaluate their programs and to stim- ulate more activities for the individ- ual residents of homes. 6. Both public and private agencies undertake programs calling for joint efforts between case work, medical, and institutional resources. The ob- ject is to provide needed services to aged remaining in their own homes or being housed in something other than the traditional institution for the aged. A Milwaukee version of the Montifiore plan of New York should be developed. 7. More clubs offering varied recrea- tional programs for aged be estab- lished by public and private agencies throughout the entire county. D. The Welfare of Negroes and The Urban League In discussing this division of the Survey under the title given, a par- ticular purpose is intended. Negroes are citizens of the total community. Their need of health and welfare services is common to those of others. “The, American Way” stands for the practice of equality for all races, religions, and creeds. It is not intended to discuss the broad question of civil rights for citizenry of color. However, it is necessary to view welfare services within the framework of existing community patterns. A survey of welfare programs must be cognizant of distinguishing barriers which af- fect whole segments of the popula- tion. Several welfare agencies which serve the Negro population almost exclusively are located in what is generally described as the Sixth Ward. Others give considerable serv- ice to that area as part of their county or city-wide effort. Some organizations, dealing with promot- ing understanding in the total com- munity, are especially concerned with securing equality of opportun- ity for Negroes. A partial list would include the Mayor’s Commission on Human Rights, the National Associa- tion for the Advancement of Colored People (N.A.A.C.P.), City of Mil- waukee, Department of Municipal Recreation, the County Park Com- mission, the Young Men’s Christian Association, (Y.M.C.A.), the Hous- ing Authority, the Young Women’s Christian Association, (Y.W. C.A.), Ministerial Association, and a num- ber of agencies offering relief and social services (The Department of Public Welfare, Family Service, etc.) The organizations in the first group; namely, those giving almost their entire services to Negroes, are of two types. First are those estab- lished for operation of direct client services with headquarters, staff, budgets, and boards of directors. The Urban League and Y.W.C.A. are examples. The distinguishing factor of the second type is their emphasis on promoting equal welfare services for Negroes. The Mayor’s Commis- sion on Human Relations and the N.A.A.C.P. illustrate this group. Both kinds of approaches are essential. They are not mutually exclusive. Their difference lies in method of work; an operating agency like the Urban League uses one set of tools, and a promotional association, like the Mayor’s Commission, uses an- other. Population Trends The concentration of Negro popu- lation is within the City of Milwau- kee. Table 20 shows the increases over the years; TABLE 20 CITY OF MILWAUKEE’S NEGRO POPULATION Source: City of Milwaukee Health De- partment— Division of Vital Statistics Year Negro Total City Percent Negro of Total 1900 . . 862 285,315 .30 1910 .. 980 373,857 .26 1920 . . 2,229 457,147 .49 1930 .. 7,501 578,249 1.30 1935 . . 8,161 583,000 1.40 1940 . . 8,821 587,472 1.50 1942 .. 9,000 600,000 1.50 1944 . . 10,000 602,000 1.66 1946 . . 10,540 620,000 1.70 1948 .. 14,500 627,000 2.31 The concentration of Negro popu- lation is another significant fact. In 1946 it was reported that three- fourths of Milwaukee’s Negroes lived in the area of a little less than one- half square mile, which is bounded by West Brown, West Juneau, North Third, and North Twelfth Streets.1 The concentration of Negroes within an area of less than one-half square mile has brought with it the inevit- able crowding, resulting in many and diverse welfare problems. These problems are accentuated when so many of the inmigrants come un- familiar with responsibilities of ur- ban living because of their limited rural experiences. Without attempting to evaluate the factors involved, recognition must be given to the importance of prompt and specific attention to the welfare needs of the Negro residents of Milwaukee. In the main report comments are made about the services being ren- dered by various agencies and there is also discussion about the educa- cational and promotional activities of other agencies. Special attention is called to the Urban League because it is both an operational agency and an educational and promotional one. The League has high ideals and a broad scope of work. There are some ways in which consideration should be given to strengthening its work. Because of its importance to the wel- fare of Negroes in the community, the recommendations relating to it are given first. Recommendations It is recommended that: ]. The Urban League strengthen both its board and staff aiming to make the agency a more dynamic force. Milwaukee’s Negro Community, Citi- zens’ Governmental Research Bureau, March, 1946. P. 1. 48 Required are; a. Practice of rotation in board membership, clearer bylaws and staff-board relationships in accord- ance with today’s concepts of lay policy making and staff adminis- trative responsibilities. b. Centralization of board records at the League office. These were not available at time of study. T -i • u t i c. Inclusion among board members, community leaders able to con- n e 0 sPeci u aieas 0 agency d. Redirection ot the League pro- gram, giving major emphasis to promoting and conducting activi- ties essential to fullest employment tor Negroes. e. Re-emphasis on the program aimed at adjustment of new ar- rivals in the community. Educa- tion in all aspects of urban living responsibilities and privileges is needed. Required is staff able to ‘innlv technirmes of n 3 •H I § & 13 c a 5 8 *l 0 la §° 1 Bureau of Public Health Nursing Public Health Education g •H I ® c £3 fc 3 c o t C t Bureau of Child Welfare 5 "3 s *3 gd 48 85 € | i| MATDR AND COUNCIL DEPUTI COMMISSIONER 8 H *H 8 a || CO B COMMISSIONER Hospitalisation of Comunlcable Diseases Rapid Treatment Center Bureau of Epidemiology Tuberculosis Control Center Cooperating Agencies County Institutions Visiting Nurse Association Wisconsin Anti-Tuberculosis Association Milwaukee Safety Council Health Centers Nuisances Social Hygiene Clinic Housing Isolation And Placarding Administration Statistics Bureau of Errviromental Sanitation Sanitary Engineering Promise Inspection General Sanitation Acute Comaunicabls Diseases Morbidity Reports Rodent Control Chemical Industrial Hygiene Bureau of Laboratories Food Processing And Handling Bacteriological Animal Diseases Milk Foods Meat 60 all reporting directly to the Com- missioner. The bureaus differ from the divisions only in size since there is no echelon arrangement. The proposed breakdown of or- ganization is designed for more flex- ibility, better facilities for expansion, and more delegation of responsibili- ty and authority. From various sources the impression has been gained that the Commissioner tends to carry too much personal respon- sibility, rather than distributing it judicially among his subordinates. Funds for operating the Health Department reflect a high apprecia- tion of the Department by the public. One handicap, however, is in the lack of adequate salaries for key personnel. Grant-in-aid funds from the Fed- eral government, which are admin- istered by the State Health Department, are allocated to Mil- waukee for only venereal disease control and tuberculosis control. Other grants in which the city might share are those for mental hygiene and cancer control. Also, it would be preferable to have these funds furnished in cash rather than in kind. Recommendations It is recommended that: *1. In order to provide a method of citizenship participation in govern- ment and also to assist the Commis- sioner of Health in matters of policy and public relations, an Advisory Council with wide civic representa- tion be established. 2. The qualification specifications for the Commissioner and Deputy Commissioner be more clearly de- fined in accordance with recognized standards. 3. Much greater emphasis be placed upon technical public health train- ing for all professional personnel, with financial assistance if possible, from the State Health Department, but in the absence of such help in sufficient amount, funds be set up annually in the city appropriation specifically designated for training purposes, including travel, tuition, and a living stipend, for a specified number of trainees. *4. Salaries for technically trained personnel, and particularly those in charge of bureaus and divisions, be placed at levels sufficiently high as to enable the Commissioner to at- tract persons of outstanding ability. For this purpose the adherence to the standards promulgated by the American Public Health Association and by the National Organization of Public Health Nursing is urged. *5. The structural organization of the Department be rearranged in accordance with the proposed or- ganization chart. 6. New bureaus be added to the De- partment, including Mental Hygiene, Cancer Control, and Geriatrics, for which corresponding positions of bureau chiefs will have to be set up. 7. A competent epidemiologist be employed to head up the work of communicable disease control, and to serve as consultant to other activi- ties when epidemiological service is required. 8. Plans be perfected for the public health aspects of civil defense by drawing upon the resources of the several branches of the Department as may be necessary, but the direc- tor of this program should by all means, be a properly trained full- time official. 9. All inspections now conducted by the State Department of Health be delegated to the City Health De- partment. (See Section on Environ- mental Sanitation.) 10. There be established in the City Health Department a liaison officer to serve as the link between the of- ficial and voluntary health agencies. This official should be selected by joint agreement between the official and voluntary health agencies, and might properly be jointly financed, but should be under the administra- tive direction of the Commissioner. His duties should be to coordinate the work of the voluntary agencies as they relate to public health. *11. The City Health Department receive a generous allotment from each of the grant-in-aid funds de- rived from the Federal government for specialized health activities, and that such funds be turned over to and administered by the City Health Department in accordance with plans and budgets submitted to the State Health Department. The State Health Department should, of course, reserve the right to withdraw such funds in the event of inappropriate or unproductive use of allotted funds. C. Suburban Health Departments At this point only the organiza- tional aspects are discussed. Opera- tional programs in the fields of public health nursing and environ- mental sanitation are covered in the sections devoted to these sub- jects. There is no organization on a county-wide basis. Instead, there are 17 separate health jurisdictions, each having a health officer and subordinate personnel. All except one of the health officers are on a part-time basis. Subordinate per- sonnel range from the half-time serv- ice of a nurse in the Towns of Franklin and Oak Creek to a group consisting of ten nurses, two in- spectors, one part-time physician, and two clerks in West Allis, which is also served by a full-time health officer. Population figures range from 661 in River Hills to 40,826 in West Allis. Next in order is Wauwa- tosa with 32,779. Eight are between 12.000 and 20,000, and the remainder are below 6,000. Population is a guiding factor in the determination of the size and character of a health department. The American Public Health Asso- ciation has decided upon 50,000 as being the minimum population group capable of supporting the basic min- imum full-time health service. Where a comprehensive or optimal service is desired a much larger population group is necessary. Due to the fact that laboratory and certain other facilities are obtainable from county and city sources, the population min- imum for affording a full time health service may be scaled down somewhat so as to bring AVest Allis within this range and perhaps eventually AVauwatosa. For the other suburban units, however, the only solution is by combinations of two or more adjacent areas into health districts, or better still, a county wide organization to include all suburban areas. Best of all would be a county-city health department under one central management, with districts comprising populations of 150.000 to 200,000. Authority al- ready exists in the state law for such procedure. For detailed information there is a report on Suburban Health De- partments and 17 other reports on the administration and nursing serv- ices of the health departments out- side of Milwaukee City. Recommendations It is recommended that: 1. In order to secure a reasonable coverage of the basic minimum health services, a population group- ing of at least 50,000 should be the basis of calculation. 61 2. Two of the local municipalities, West Allis and the City of Wauwato- sa, are in the population range which might be capable of meeting the de- mands. 3. In order to secure optimum local health services of comprehensive scope and superior quality a much larger population grouping is de- sirable. The lower limits of such a population grouping should be in the range of 100,000 to 150,000. 4. The most successful grouping would be the entire county popu- lation under a single county-wide unit, broken down into four or five health districts, each comprising a population of 150,000 to 200,000. D. Recording and Processing of Vital Statistics The Vital Statistics Division of the City Health Department carries a dual responsibility. It not only receives, processes, and preserves the records of births, deaths, and marriages in Milwaukee, but plays a major role in public health educa- tion. In the latter function, the policy is to make Vital Statistics vital rather than dead records. It is thus a potent factor in the interpre- tation of records to the public and in the guidance of the entire pro- gram of the Department. The rec- ords for birth have met the accepted standards for completeness and ac- curacy since 1869, and for deaths since 1893. Annually the Division receives, verifies, corrects, and indexes nearly 39,000 birth, death, and marriage certificates. The total of such rec- ords has increased from 28,537 in 1941 to 38,576 in 1947. Since 1941 all records have been adjusted as to residence. In the interest of con- serving space and making the rec- ords more readily accessible, all of the old card index records are being transferred to books where one line takes the place of a card. Micro- filming has been tried, but has not proven too satisfactory, due to the difficulties involved in the many instances where corrections are nec- essary. A veritable maze of weekly, monthly, and annual reports is routinely prepared and issued by the Division. These, however, are too numerous and complex to out- line in the Summary. As a routine also, the Division issues certified copies of birth, death, and marriage records, totaling 16,254 in 1948, as compared with 7,923 in 1940. Like- wise in 1948 there were 18,437 file searches, as compared with 14,532 in 1940. The mechanical equipment of the Division consists of the usual type- writers, adding and calculating machines, and a key punch machine. Sorting, tabulating, and other types of record processing devices are not maintained in the City Health De- partment, but the Department has access to them in other offices at the City Hall, and these machines are used extensively. They are not, however, utilized as fully as they could and should be, due to the lack of adequate key punch service. Nu- merous operations now performed by hand could be handled more ef- ficiently and with the saving of valuable time by use of business machines. Other operations which are not done at all, but would mate- rially augment the services of the Division, are subject to the same type of treatment. The Division keeps abreast of all accepted practices in the handling of Vital Statistics, and an atmos- phere of systematic and intelligent planning is inescapable. Space, especially for the storage of records, is overtaxed at the pre- sent time and is becoming progres- sively more critical. The space occupied by clerical workers is none too generous, and any plans for en- larging the Health Department quarters should contemplate sharing the increase with the Vital Statistics Division. Recommendations It is recommended that: *1. A wider use be made of machine methods for tabulations and other operations to which they are adapted. *2. In order to accomplish the fore- going, adequate key punch service be made available. 3. More space, especially for the storage of records, be included in any future plans for expansion of office space for the Health Depart- ment. 4. The health education work now done by the Vital Statistics Division be transferred to a new division operating directly under the office of the Commissioner and designated as the Division of Public Health Education. E. Public Health Laboratory Facilities The tax-supported laboratories in the Milwaukee area are of two types: (1) those rendering routine service to sanitation activities—water, milk, foods, and sewage; and (2) those aiding in the diagnosis of human ailments. The work of each is pri- marily bacteriological. Both cate- gories also include chemical studies, but only the latter involves serolog- ical work. Sanitation laboratories are main- tained by the water purification plant (Milwaukee), the Sewage Com- mission, the City Health Department (Milwaukee), the County Institu- tions and certain private labora- tories. Diagnostic services are afforded by the Milwaukee Health Department, the West Allis Health Department, and the laboratories of the County Institutions. No virus or rickettsial diagnostic service is available at this time. Personnel are generally well qualified for their respective duties, and adherence to Standard Methods is fairly uniform, but in some in- stances outmoded editions of Stand- ard Methods are used as the guide. A vacancy exists in the directorship of the Milwaukee Health Depart- ment Laboratory due to insufficient salary to attract the desired talent. Lack of adequate supervision of sub- ordinate laboratory personnel at the County Institutions is noted. For this purpose a trained assistant to the Director is required. A program of monthly staff meetings and other phases of in-service training for workers in the County Institutions, together with a long range plan for advanced technical training for routine workers and refresher cours- es for key personnel, is advocated. The quarters at the City Health Department for the bacteriological laboratory are overcrowded, and facilities for laboratory animals are quite inadequate, but the equipment and supplies are ample. While there is no special comment with respect to equipment and supplies at the other laboratories, the inference is that these items are satisfactory. The volume of work, broken down into the various laboratory proce- dures is set forth in the report, but the details are not considered ap- propriate for inclusion in this Sum- mary. Suffice it to say that needs of the community for sanitation and diagnostic laboratory service at public expense, with the exception of virus studies, appear to be rea- sonably well met. Recommendations It is recommended that: 1. The suburban areas be stimulated to make more general use of labora- 62 tory facilities, and that the labora- tories serving these areas make plans accordingly. 2. That the laboratories be equipped with the latest editions of Standard Methods, and that laboratory per- sonnel be currently informed by their respective chiefs, of any changes. *3, Plans be made for more general use of short refresher courses in the Standard Methods of water, milk, and other examinations. Such cour- ses are offered free at the Environ- mental Health Center of the U. S. Public Health Service in Cincinnati, Ohio. *4. Since the space in the City Hall can never be adequate, especially for the bacteriology laboratory, the entire laboratory plant be moved to South View Hospital and combined with the laboratory already there. 5. In addition to the foregoing, there be established at the South View Hospital, a virus laboratory, with provisions not only for serological tests, but also for isolation techniques involving the use of animals and fertile eggs. 6. If, and when the laboratory is moved from the City Hall to South View Hospital, plans be made for added sanitation services, and clini- cal pathology services for diabetes, cancer, and geriatric diseases. 7. The position of Director of the City Health Department laboratories be filled as soon as the conditions of salary and suitable applicant will permit. *8. Additional space, which is badly needed, at the central laboratory of the County Hospital be provided, by means of a new wing to the Hospital, rather than a separate building. 9. The central laboratory in the County Hospital prepare culture media, stain solutions, antigens, and reagents for all of its component branches. *10. The Director of the central lab- oratory in the County Hospital be furnished with a properly qualified assistant at the earliest opportunity in order to afford close supervision over all laboratory technicians. 11. In the interest of morale and technical improvement, regular monthly staff meetings be instituted. 12. A long-range program for ad- vanced training of technical person- nel at the county laboratories be instituted. Much of this might be carried on in the central county laboratory, but for key individuals, refresher courses elsewhere may be necessary. F. Child Welfare Bureau The services of the Bureau are extended to infants and pre-school children. Only well children are ac- cepted at the clinics. The Bureau also has direct supervision over day nurseries and conducts the Habit Clinics in conjunction with the Mil- waukee County Guidance Clinic. The Clinic procedures include weighing, measuring, physical exam- inations, immunizations, and discus- sion of feeding and behavioristic problems. The popularity of the Wel- fare Clinics is attested by the fact that in the 34 clinic stations there was an attendance of 57,446 in 1947 as compared with 45,779 in 1946. The new babies registered in 1947 were 8,409, which is a figure 57 percent as great as the total live births for that year. In the pre- school clinics at 191 locations in 1947, 9,648 children were examined, result- ing in a classification of 9,246 “good”1 physical condition, 359 “fair,” and 31 “poor.” In the Child Welfare Clinics in 1947 a total of 7,768 children were immunized against diphtheria, of whom 2,210 also received whooping cough vaccine at the same time, and 5,936 were vaccinated against small- pox. In the pre-school clinics 956 were immunized against diphtheria and 1,009 against smallpox. The mo- bile trailer clinic contributed 1,617 more immunizations against diph- theria, and 2,091 smallpox vaccina- tions. The infant death rate of 27.3 per 1,000 live births in 1947 was next to the lowest on record in this area. The maternal death rate of 1.2 per 1,000 live births in the same period is also cause for favorable comment. Recommendations It is recommended that: *1. The Bureau of Child Welfare be expanded to include all services to children, notably the School Health Services, exclusive of sanitation and public health nursing. *2. Closer supervision be exercised over the standards and methods of examination in the pre-school clinics. 3. In view of the rapidly increasing clinics attendance, and for the sake of maintaining adequate standards, more clinicians be employed. 4. Consideration be given to the em- ployment of full-time career physi- cians in lieu of part-time clinicians, to do all phases of child welfare work on a district basis. (See School Hygiene report.) G. School Hygiene In both the county and the city, school hygiene occupies a position of prominence. In fact, in the sub- urban areas generally, school hy- giene overshadows all other activi- ties. Since this work in the suburban areas consists largely of public health nursing, it will be discussed in that section. Immunization and physical examinations done for school child- ren in the suburban areas are cov- ered in the reports on individual communities. The Division of School Hygiene, with City Health Department admin- istration of this work, is placed in a bureau which also has charge of communicable disease control. There is a provision for a full-time Director of the Division, but the position has been vacant for some time, due to in- adequate salary to attract a director of the proper caliber. The staff for school examinations consists of a part-time director and 29 part-time physicians, two of whom are special- ists in eye, ear, nose, and throat work; one half-time dental director, one part-time dental operator, three full-time operators, and five dental hygienists three-fourths time; and one instructor in nutrition. The type of examinations done by physicians includes morning inspec- tions, partial examinations, and com- plete examinations. All children in the 5th, 8th, and 10th grades are given complete examinations; like- wise, children from other grades who are considered to need immediate attention. In 1947 the record was as follows: 1The term “good” means that the child does not have any defect that is not under treatment. It includes children who are in good condition, those whose defects have been corrected, and those who are under treatment. The terminology is not clear to any outsider, and consideration should be given to the use of a different term. Defects Morning Partial Complete Rec’d for Insp. Exams Exams Found Correction Children Examined . . . 15,070 *9,121 **1,678 6,612 45,013* 37,313** were high school children were high school children 5,419 63 Dental examinations are reported in the section on Dental Hygiene. Special emphasis is placed upon defective vision and hearing. Diag- nosis and follow-up in these fields is considered outstanding. Mental and emotional states are not included in the routine examina- tion conducted by the Health Depart- ment. The volume of work done by school physicians is impressive, considering the fact that the time scheduled in the schools is from 9:30 A.M. to 11:00 A.M. Since their scheduled quota is twelve elementary school children or fifteen high school chil- dren, however, the maximum time which could be devoted to each child would be seven and one-half minutes for elementary and six minutes for high school students. Even though assembly line methods are used, ex- aminations within those time allot- ments must inevitably be exceeding- ly superficial and unworthy of being rated as “complete,” even for the abridged type of examination com- monly practiced on school children. Either fewer examinations should be made, or more examiners should be employed, if complete examinations are attempted. AYhere time is a crit- ical factor, quality of service is most likely to suffer by lack of adequate supervision exercised by properly qualified full-time career workers. Even under favorable time condi- tions, where so large a number of part-time employees is involved, close supervision is essential. Correction of physical defects is a major objective. The record for 1947 lists the results of follow-up work done by nurses, indicating that in 10,214 cases with, defects, 8,578 cor- rections were secured, 1,070 “refus- als,” and 566 “cleared in other ways.” The term “correction,” how- ever, is not clearly defined. Upon inquiry, it was found that the term may signify that cognizance of the defect has been taken, and that re- medial steps have been taken, or that “something is being done about it,” though actual correction may never be accomplished. Immunization is a joint effort be- tween the Child Welfare Division and the Bureau of School Hygiene. Types of immunization include small- pox, diphtheria, and to a small ex- tent, scarlet fever. Schick and Dick testing are done for immunity against diphtheria and scarlet fever respec- tively. The 10,465 whooping cough vaccinations were all reported from the Division of Child Welfare. The school program extends to kindergar- ten and school children. During 1947, toxoid against diphtheria was given in the schools to 4,536; smallpox vac- cination to 14,658; and Schick tests to 10,904, showing negative reac- tions or immunes in 73 percent of the tests. These figures do not represent either all of the immunizations and tests done by the Health Depart- ment or those done by private physi- cians which are believed to be far in excess of the work done by the Health Department. The emphasis on diphtheria and whooping cough immunization is properly placed up- on the infant and pre-school groups. Though the exact figures on inci- dence of immunity to the foregoing diseases are not available, all the evidence indicates that the percent- ages run very high, so that for prac- tical purposes the school population is well protected against them. The nutritional program is tied up with public health education and, in the pre-school group, with mental hygiene. The program includes: (1) instruction in the schools; (2) in- structions to public health nurses and affiliates; (3) demonstrations in the homes and to selected groups; and (4) adult education through group conferences. Either directly or indirectly these all impinge upon nutritional education in the schools, although there are no graded lessons to suit each age group. Recommendations It is recommended that: *1. The school hygiene program be transferred to the Bureau of Child Welfare and become a division of the same. 2. A full-time medical officer be em- ployed as director of the division. *3. The director of the division main- tain much closer supervision over the work of part-time physicians en- gaged in school examinations and immunization work than has been possible under the present regime. For this purpose additional super- visory assistance would probably be required. 4. A pilot project be undertaken to determine the practicability of sub- stituting full-time career physicians instead of part-time physicians, and that such physicians encompass all phases of child welfare on a district basis. 5. A study of the intensity and qual- ity of complete physical examina- tions is indicated. *6. The City Health Department in- clude mental and emotional disturb- ances in its routine appraisal of the child’s health, 7. The City Health Department main- tain close liaison with the nutritional work in the schools. 8. For the sake of schoolroom hy- giene, modern developments in the techniques of lighting and seating be investigated. 9. All schools be equipped with ade- quate facilities for physical examina- tions and consultations. 10. Ways and means of providing corrective treatment for the medical- ly indigent be more clearly defined so that everyone in this category may know where and how to apply for assistance. To this end, a central referral agency, such as the Secre- tary of the Medical Care Committee of the Community Welfare Council, is suggested. H. Communicable Disease Control The communicable diseases were the source from which the first pub- lic health concepts sprang, and dur- ing the early stages of the modern public era their control was the sole objective of public health. Right and proper as this was in former times, the emphasis on communicable disease control has become gradu- ally less because many of the most devastating diseases in this category have, for all practical purposes, been eliminated. In other instances the dangers have been minimized to the extent that they may be considered to be under adequate control. Deaths from communicable diseases are now only small fractions of what they were in former generations. This does not, however, mean that they can be ignored or that vigilance can be relaxed. For illustration, there are numerous instances in modern times where severe outbreaks of smallpox have occurred in communi- ties where vaccination has not been maintained as a routine procedure. Methods of communicable disease control also have changed with the increasing knowledge of the causes of disease. Whereas quarantine was originally almost the sole defense mechanism, immunization dominates the field, thus placing the emphasis upon positive protection. A recent revision of the Rules and Regulations of the State Health Department has eliminated placarding in a number of instances. In dealing with actual 64 cases and contacts, isolation has largely supplanted quarantine. The City Health Department util- izes all known methods for commun- icable disease control. In addition to isolation and immunization, edu- cation and demonstration conducted largely by public health nurses, the Department must be credited with a large measure of the success in keeping communicable diseases un- der subjection. The statistics of the Health De- partment for 1947 show a total in- cidence of 12,275 reported cases, of which 795 were measles, 444 scarlet fever, 1,554 whooping cough, 6,477 chickenpox, and 2,370 mumps. For a city the size of Milwaukee, these figures are gratifyingly small. While comparatively little immun- ization work is done by physicians in the Division of Communicable Disease Control, the Child Welfare Clinic and the school clinics in 1947 reported the following: Toxoid (persons inoculated) . .12,660 Schick tests • 14,522 Smallpox vaccinations 24,752 Whooping Cough vaccinations 10,465 In addition to these figures, a very large but undetermined number of immunizations were given by private physicians. As a result of immuniza- tion work by all agencies, studies of immunity among school children in- dicate a high degree of protection. For organization purposes the com- plete report proposes that commun- icable disease control be set up in the Health Department as a separate bureau in charge of a competent epidemiologist. Considerable interest attaches to the status of the South View Hospital for contagious diseases. The present capacity of this institution is 200 beds. The average occupancy during 1948 was 32, with the per capita cost $18.93. Since it is known that com- municable disease can be safely cared for in a general hospital, the question is raised as to the advisabil- ity of taking care of needed hospital- ization at the County Hospital and converting the South View Hospital to some other purpose, such as a substation of the City Health De- partment to house the Tuberculosis Control Center (which is already there), the Social Hygiene Clinic, the Medical Clinic, the laboratory, or other activities of the Health Department as may be desired. It might even be converted to a con- valescent center in conjunction with all of the general hospitals in Mil- waukee, thus increasing the capacity for acute cases. Recommendations It is recommended that: 1. Communicable disease control be divorced from School Hygiene in the organizational setup and placed in a new bureau to be designated as the Bureau of Epidemiology. 2. A competent epidemiologist be employed as the director of the fore- going bureau. 3. The simplification which has re- cently been adopted for the home isolation of communicable diseases is in the right direction, and that further simplification should be con- sidered as promptly as public opinion will permit. 4. The hospitalization of commun- icable diseases be objectively studied with the possibility in view of caring for them in general hospitals. *5. Regardless of whether or not communicable diseases are hospital- ized at South View Hospital, the space in excess of the needs for hos- pital purposes be converted to other requirements of the Health Depart- ment, the most urgent of which is the removal of the laboratories in the City Hall to South View Hospital. Other needs which might also be served are the furnishing of quarters for the Social Hygiene Clinic in lieu of rented quarters, and possibly quarters for the Medical Clinic now maintained in the City Hall. I. Venereal Disease Control Although the venereal disease con- trol program is administered by the City Health Department, its services are on a county-wide basis. The total amount of funds specifically ear- marked for venereal disease control was $52,300.00 in 1948, of which all but $4,800.00 for rental on the build- ing occupied by the Social Hygiene Clinic, is underwritten by the State Health Department using funds de- rived from the U. S. Public Health Service, in the category of grants-in- aid to the States. The three principal facets of the venereal disease control program are: 1. The Social Hygiene Clinic, which conducts diagnostic work and epi- demiological investigations, and af- fords treatment for about half of the cases of syphilis discovered, and practically all the cases of gonorrhea. 2. The laboratory in the City Hall, which does serological and other types of laboratory diagnosis. 3. The Rapid Treatment Center at South View Hospital, where all cases designated for hospitalization are cared for. The treatment here fea- tures the use of penicillin to effect a cure in a matter of a few days, as compared with many months by the use of arsenicals and bismuth prepa- rations. Case findings is a prerequisite to an effective control program. An in- soluble obstacle, under the present laws, results from the fact that ven- ereal diseases in Wisconsin are re- quired to be reported only by num- ber, with no identification as to name or place of residence. Moreover, the reports must be made to the State Health Department, after which they are eventually referred to the local health officers having jurisdiction. If and when they finally reach the local health officer, the reports are so old that contact investigation is almost worthless, even though ade- quate identifying data were provid- ed. Moreover, in the case of venereal diseases in the infectious stages, the interval between the initial diagnosis and the final notification of the local health department is such as to allow for numerous contacts. In those instances where the in- fectious cases were known as, for instance, the clients of the Social Hygiene Clinic, contact investigation was exceedingly good. At the pres- ent time this work is done by the nurses attached to the Clinic. A well-trained lay investigator might profitably be employed to release one of the nurses for work more specifically in the nursing field. The evidence from every angle points to a very low incidence of in- fectious syphilis in Milwaukee Coun- ty. Continued pressure, therefore, holds out a hope for ultimate con- quest of the disease in a reasonable length of time. Rapid treatment methods now in use have simplified the attack on this disease, as well as gonorrhea, beyond all previous con- ception, so that the final death blow to these diseases becomes more than a possibility. Recommendations It is recommended that: *1. The law pertaining to the report- ing of venereal diseases be revised at the earliest possible moment so as to require reporting by name and 65 areas have had dental care in terms of one or more filled permanent teeth. The higher economic children were found to have about 64 percent of their numbers with evidence of dental care, while in the lower eco- nomic area about 50 percent of chil- dren had dental care. In the Mil- waukee Negro children only 20 per- cent of the group with one or more D.M.F. teeth showed evidence of fillings. Dental care in the deciduous teeth for the Milwaukee white children aged five to twelve years, showed that 39 percent have had one or more fillings. The high economic area children again led with 49 per- cent of their group having fillings, as compared to 39 percent for the children in the low economic area. The Negro children show evidence of having extremely little care, only 5 percent of the children were found with one or more fillings. The study findings indicate that among the white children in the three economic areas, the two higher economic areas have significantly lower tooth mortality rates. At age sixteen the children in the high eco- nomic area have a tooth loss rate of .9 of a tooth per child, as com- pared to 1.6 teeth per child in the low economic areas. The Negro school children were found to have a significantly lower percentage of D.M.F. teeth by specific-age groups and they were shown to have re- ceived less dental care in the perma- nent dentition than white children. The tooth loss rates by specific-age groups were a little higher than the tooth mortality rates for the white children in the lower economic areas. The following is a brief summary of the study of the dental health activities in Milwaukee County: The children in the Milwaukee County area are definitely in need of more dental care, either in the form of remedial services or more appropriately by means of the known preventive measures. This section of the study primarily enumerates the public or voluntary agency resources which are available to meet this de- mand for dental services and the effect this effort has on the entire health picture in the child popula- tion. At the time this data was collected there were 791 practicing dentists, or one to every 1,073 people in Mil- waukee County. There were 18 clinics where remedial dental service place of residence directly to the local health officer having jurisdic- tion. 2. While the continuous mass blood survey should be encouraged as a fixed routine, special emphasis be placed upon finding infectious cases of syphilis. 3. In the event of a proven low in- cidence of infectious cases, some re- duction in force and the removal of the Social Hygiene Clinic to South View Hospital should be considered. #4. The money now being spent by the State Department of Health for venereal disease control in Milwau- kee be turned over to the City Health Department to be expended in ac- cordance with a budget submitted to and approved by the State Depart- ment. J. Dental Care This report set out to gather per- tinent facts on dental health condi- tions and facilities. It has two parts. It deals first with the dental needs among the school children of Mil- waukee and then with the dental health activities in Milwaukee County. A brief summary of the facts about the dental needs of Milwaukee school children follows. The dental survey of 9.481 white and 1,283 Negro school children in Milwaukee shows that there is no substantial difference in age-specific rates of dental caries prevalence for white children in three different eco- nomic areas. By the time the white children had reached their sixteenth birthday, 97 percent from all three economic areas had experienced den- tal decay. The Negro children, how- ever, have a substantially lower den- tal caries prevalence rate than the white children. At age sixteen, about 85 percent of them had experienced dental caries in their permanent teeth. The annual increment of dental decay in the white children of Mil- waukee is found to be .86 D.M.F.1 teeth per child per year, while for the Negro children the annual den- tal caries rate is only about one- third as high — .29 of a tooth. The dental caries attack rates for the Milwaukee, Wisconsin children, white and Negro, as compared with Chicago, Illinois children are found to be substantially the same. It is found that more than half of the white children in the three economic TABLE No. 31 DENTAL SERVICE FACILITIES IN MILWAUKEE CITY AND COUNTY AVAILABLE IN 1949“ CLASSIFIED ACCORDING TO ADMINISTRATIVE CONTROL Number Number of Dentists Location and Control Number Number Half-days Full- Part- Clinics Chairs Per Week Total time time MILWAUKEE COUNTY TOTAL . . 18 203 94 110 8 102 Departments of Health . 3 7 10 5 3 2 Governmental Hospitals 7 10 26 8 0 8 Voluntary Hospitals . . . 8 27 53 1 52 Children’s Homes 3 3 15 5 0 5 Dental Colleges 1 164 11 38 4 34 Industrial Clinics 1 1 5 1 0 1 MILWAUKEE TOTAL . . 10 193 55 85 8 77 Department of Health . 3 7 10 5 3 2 Governmental Hospitals 1 2 5 4 0 4 Voluntary Hospitals . . . 3 8 27 53 1 52 Children’s Homes 2 2 2b 2 0 2 Dental Colleges 1 164 11 38 4 34 (304 Students No. Si . Class) MILWAUKEE COUNTY EXCLUDING MILWAUKEE TOTAL 8 10 25 8 0 8 Departments of Health . 0 0 0 0 0 0 Governmental Hospitals 6° 8 21 4 0 4 Voluntary Hospitals . . . 0 0 0 0 0 0 Children’s Homes 1 1 3 3 0 3 Industrial Clinics . . . . . 1 1 5 1 0 0 “Dental service other than school examinations. bOne clinic only open ten half days per year. Small population served. 'Includes all of Milwaukee County Institutions except Milwaukee County Dispensary- Emergency Unit. 1Decayed, missing', or filled. 66 programs were in operation. These clinics were staffed with 110 dentists who were providing ninety-four half- days of care each week. The number of dental clinics in- cludes : ten in hospitals for the care of the mentally ill, tuberculosis, crippled children, aged and other- groups ; three in health centers oper- ated by the Milwaukee Board of Health for the low income groups; three in Children’s Homes for the benefit of the institutionalized chil- dren; one industrial plant; and one dental college for the benefit of the general population in the community and State of Wisconsin. The dental facilities are main- tained and controlled by the local department of health, voluntary and tax-supported hospitals, sectarian in- stitutions, a dental school, and one industrial organization. Clinic funds are provided by taxes, fees, endow- ments, allocations from community funds, budgets of hospitals and den- tal schools, contributions by private organizations, special welfare funds, official welfare agency and indus- trial organizations. Diagnostic and remedial services are rendered to a reasonably ade- quate extent by 17 of the clinics. One clinic limits its services to diagnostic and referral service to a special adult group. Eight of the dispensaries limit their services to dentistry for children and only to those whose parents are unable to pay for such services or to institu- tionalized groups; six tax-supported clinics are chiefly for adult patients; two voluntary hospitals limit their services to dentistry for children. Two clinics are for both the adult and child patient. A general summary of the dental facilities in Milwaukee County is presented in Table 21. A reasonably well-rounded dental health program is being carried on by the Milwaukee Health Depart- ment. The program is under the direction of a part-time dental director and consists of: 1. Dental remedial services for chil- dren from low income groups which is provided for in three district clinics staffed with three full-time and one part-time dentist. 2. A dental examination and educa- tional program carried on chiefly by six dental hygienists for the benefit of all school children in Milwaukee. In the 17 health jurisdictions in Milwaukee County (excluding Mil- waukee City) there are five local health departments which have a dental health educational program included in their over-all health pro- gram. The remaining 12 areas have little or no dental health activity. No dental care programs are in opera- tion under the direction of these 17 health departments. All children in these local areas whose parents are unable to pay for dental services are sent to the Milwaukee County Dis- pensary, Children’s Hospital, or Marquette University Dental School for treatment. Recommendations (Those who are interested in dental care should read the full report. Copies can be studied at the Survey office or the Community Welfare Council. The factual material obtained led to the following recommendations. These recommendations were dis- cussed — as was the whole report — with the officers and designated committees of the Milwaukee Dental Society. Certain changes were made at their suggestion.) It is recommended that: 1. The Milwaukee Health Depart- ment, in addition to the dental ex- amination program, take immediate steps to redesign the Dental Health Education program so that greater emphasis be placed on direct dental educational activities with the chil- dren and school teachers. 2. An in-service training program for professional personnel be estab- lished by the Milwaukee Health Department, as well as other organ- izations and agencies which are ren- dering dental services to children. 3. The need for dental interns in hospitals be vigorously stressed and professional supervision and instruc- tion be provided for them. 4. A uniform dental recording sys- tem which would permit evaluation of dental programs be established and placed in operation by all agen- cies in Milwaukee County which are extending dental care to children. *5. Marquette University Dental School make every effort to estab- lish at the earliest possible date a special clinic with dental equipment suitable for dental care of children. The necessary personnel for super- vision and teaching purposes should be added to the staff as soon as funds are made available. 6. A course consisting of lectures and field trips in public health be made a required subject in the cur- riculum for all senior students at Marquette University Dental School. *7. The Milwaukee Health Depart- ment Dental Division, in cooperation with the Milwaukee Board of Edu- cation and the Parochial School authorities, be made responsible to institute workshops in dental health for school teachers and the Milwau- kee Normal students. 8. The training course for dental assistant be transferred from the University of Wisconsin Extension School in Milwaukee to the Mar- quette University Dental School. #9. Topical fluoride therapy for the prevention of dental caries in chil- dren be instituted in Milwaukee County school and community health programs. 10. The Milwaukee County Dental Society cooperate to locate recent graduates in areas where the dentist- population ratio is not favorable. 11. Immediate steps be taken to establish a well-organized dental health program, supervised and ad- ministered by a dentist, in those areas in the county which do not now include this activity in their over-all health program. 12. The Milwaukee County Institu- tions appoint a full-time dental di- rector to administer the remedial dental care program. Full-time in- ternships and residencies should be established in order that a better ser- vice be realized by the beneficiaries. 13. Industries be encouraged to pro- vide the following services to its em- ployees : preplacement and periodic oral examination and diagnostic services for all employees; emer- gency dental treatment, including the treatment of occupational injuries and diseases; treatment of oral sep- sis; education in dental health, and encouragement of periodic and regu- lar dental care. K. Mental Health The report defines mental health as a state of well-being, of efficiency at work, and of harmony in human relationships. Stress is placed upon the need for emotional and mental guidance from the cradle to . the grave. Community activities in which mental hygiene is incidental or complementary to other more spe- 67 cific functions are the pre-natal and well-baby clinics, day care nurseries, nursery schools, the courts, and the public and parochial schools. In all of these some attention is given to mental hygiene, although the extent and quality of such service varies widely between the several agencies, and specific recommendations are of- fered accordingly. The existing community facilities for dealing with emotional and men- tal problems are classified as to con- sultation, diagnosis, and treatment. In the consultation field, which in- cludes educational, promotional, and referral service, are the Milwaukee County Mental Health Committee and the Milwaukee Psychiatric Serv- ice. Diagnosis is furnished primarily by the psychological service in the schools, and by the psychiatric pro- gram of the City Health Department. The Milwaukee Guidance Clinic, which includes the Habit Clinic, provides both diagnosis and treat- ment, but the main reliance for treat- ment rests with the practicing psy- chiatrists, (about twelve in number) the “acute” and “chronic” county hospitals, the Veterans Hospital, and four private hospitals for mental diseases. Outpatient service is pro- vided by the County Guidance Clinic, the Veterans Hospital, and the Con- vulsive States Clinic at the County Dispensary. The latter is specially equipped to take care of chronic alcoholics. The inpatient service of the County Hospital carries an average census of 1,000 at the Hospi- tal for Mental Diseases (acute), and 2,200 at the County Asylum (chronic). The quality of personnel engaged in psychiatric work is commended, but the quantity leaves much to be desired. Considerable shortages also are noted in the field of medical so- cial service. All of the public facilities are over- crowded ; an acute shortage of space is noted at the County Guidance Clinic and at the County Hospitals. Plans are being developed, however, for relief of this condition in the County Hospital setup. The program for training in men- tal diseases is far below the wealth of material that is available. The Medical School at Marquette Uni- versity, and the University of AVis- eonsin Medical School have not suf- ficiently capitalized upon these op- portunities. There is a recognized need for more persons trained in psychiatry, and it is suggested that the best way to meet this need is to train them locally. More residencies for graduate students would be a practical approach to this problem. AVhile the number of agencies which are interested in and attempt- ing to do something about the prob- lem of mental hygiene is commend- able, their activities appear to be lacking in over-all planning and co- ordination. The correction of this situation is essentially a job for the City Health Department. For illus- tration, the County Guidance Clinic is designed to serve the needs of all referral agencies in the county. Dur- ing 1948 the twenty-one welfare counselors and four psychiatrists in the public school system gave over 5,000 psychological tests in the schools and 1,500 children were seen in consultation. Of the 1,238 considered in need of further atten- tion, twenty-three or about 2 percent, were referred to the Guidance Clinic. The record for this year showed only two so referred at the time of the study in April. Among professional non-medical groups whose routine work is inti- mately associated with mental hy- giene problems, the legal profession and the clergy are given special rec- ognition. The need for a more thor- ough acquaintance with their poten- tialities for assisting individuals as well as the over-all program is cited. Recommendations — General Activities It is recommended that: 1. In the event of amalgamation of the Visiting Nurse Association with the Health Department nurses,1 the pre-natal, well-baby, and pre-school (habit) clinics be made available for many more of the mothers in the county. These clinics seem to be a function of the public health nursing- services. The Visiting Nurse Associa- tion has conducted the pre-natal classes for years, but it would seem that this makes for some duplication of the Health Department’s public health nursing efforts. 2. It be determined whether the day care centers are adequate in number and whether the staffs are adequate in number and preparation. The day care centers are filling a real need in the county. More intensive orien- tation toward mental health implica- tions of the program at each of the centers is desirable. This implies a definite in-service training program for the staffs in this field. They are to be commended for their acting in some cases as sources of referral to specialized clinical facilities includ- ing the available psychiatric facili- ties. 3. A beginning be made in the mental health orientation of the staffs of the existing nursery schools, as well as an extention of this effort so that they will be available to all. Recommendations — Schools It is recommended that: 1. A supervising psychologist be ap- pointed in the school system to direct the activities of the “psychological counselors ’ ’ (psychometrists). *2. Psychiatric consultation be made available. This doctor will consult on all of that estimated 10 percent of the pupils who need psychiatric study. 3. An in-service training of the wel- fare counselors and the psychome- trists be continued under the direc- tion of the above mentioned profes- sional mental health persons. 4. A modern bureau of child study be established to coordinate diagnostic counseling and guidance services. 5. The role of the Health Depart- ment continue to be in the field of school hygiene and the tie-up in men- tal health activities between the two agencies definitely continue to their mutual benefit. The Health Depart- ment is obliged to educate its nurses and doctors in school health prob- lems including their emotional as- pects and thus there need be no overlapping. Recommendations — Welfare Activities It is recommended that: 1. Wider participation in the psychi- atric consultation activities available be arranged for the staffs of the var- ious agencies. 2. To this end, of course, an increase of psychiatric consultation facilities will be needed. An expansion of the available resources, especially that of the Milwaukee Psychiatric Serv- ices, would be of much help. Recommendations — Courts It is recommended that: I. The number of Children’s Court Probation Officers be increased. This will allow thorough work to be done in all cases. *2, The question of facilities be con- sidered. It is the opinion of many that a Study Home for 30 or 40 children, separate from the present aSee report on Nursing', page 71. 68 Detention Home, should be insti- tuted. This Study Home, under competent professional mental health direction, will provide the opportun- ity for intensive study and treatment for those in need of it. Recommendations — Health Department It is recommended that: *1. The Health Department organize a mental health section or unit or expand its present Bureau of Child Welfare into such a unit so as to coordinate all mental health activi- ties and mental health education. 2. This unit be headed by a profes- sional mental health person, prefer- ably a psychiatrist. 3. Its functions be to institute in- service training for the public health nurses and pediatricians assigned to its well-baby clinics, habit clinics, and school hygiene programs. Its further function should be mental health education of the community by means of lectures, pamphlets, and other audio-visual aids. Recommendations — Treatment Facilities It is recommended that; *1. Efforts be made to enlarge the quarters and perhaps move the lo- cation of the County Guidance Clinic. Serious recruitment attempts by the Guidance Clinic staff should be made to expand its personnel. Its com- munity educational activities should not be abandoned, although these work a heavy burden on the staff, unless more cooperation from local psychiatrists can be obtained for this work. The local Psychiatric So- ciety should be encouraged to assist. 2. The Milwaukee Psychiatric Serv- ices make efforts to obtain full-time psychiatric services at the earliest possible moment. 3. An over-all psychiatric director for the various clinics at the Dispensary- Emergency Unit be obtained in order to insure the continuity and effec- tiveness of these clinics. 4. The Mental Hygiene Committee of the local Medical Society be con- stantly consulted about the expan- sion and improvement of these out- patient facilities. *5. Efforts be made to convince the administration of the Marquette Uni- versity School of Medicine of the need for taking advantage of the many opportunities for psychiatric training which exist in Milwaukee. The outpatient clinics, County Hos- pitals, and the Medical School itself can furnish a real opportunity for the training of students, and par- ticularly of graduates and residents in this field. Milwaukee needs men in its inpatient and outpatient treat- ment facilities and like every place else, can do better if it trains them. Recommendations — Inpatient Service It is recommended that: *1. Steps be taken to accomplish the building of the acute hospital pro- posed by the Director of the Mil- waukee County Institutions to serve for research and early treatment and perhaps for the site of the outpatient department. Until that time it might be advisable to establish an outpa- tient clinic at the County Dispensary- Emergency Hospital for the conva- lescent, as well as pre-hospitalization patients. This would complement the other clinic services beginning with the County Guidance Clinic and pro- vide a complete outpatient and in- patient treatment facility run en- tirely by Milwaukee County. 2. Efforts to increase training op- portunities for psychiatric residents in Milwaukee be intensified with the Marquette University School of Med- icine. 3. A full-time psychiatric service be provided on the “eighth floor” until the proposed new unit is built, 4. Commendation be given for the efforts of the staffs of the two coun- ty hospitals to carry on in spite of considerable handicaps as well as for the foresight of the Director of Coun- ty Institutions in pushing the build- ing program. L. Chronic Alcoholism A conception that chronic alcohol- ism is a disease which is capable of both prevention and cure to a large extent, is fundamental to an under- standing of the problems involved. It is conservatively estimated that one out of every 300 users of alcohol ultimately become victims of the dis- ease. In the Milwaukee area there are estimated to be 25,000 problem drinkers and 5,000 chronic alcohol- ics. About one in nine of the patients entering mental hospitals will go there as a result of alcoholic psy- chosis. While the ravages of chronic alco- holism are staggering, it does not occur in dramatic epidemics, but is rather a continuous pandemic. Its course is insidious and long drawn out, and no drinker has the slightest idea that he may be in the incipient stages of the disease. Public sentiment has already been aroused to the dangers of the dis- ease, and aggressive measures to meet the situation have been adopted. The Wisconsin Association for the Prevention of Alcoholism, a non- profit, non-partisan, and non-sectar- ian organization, engaged in educa- tional and promotional work, has secured action to establish the State Bureau of Alcoholic Studies and the course in Alcoholic Studies at the University of Wisconsin. Locally there has been established the Alco- hol Information and Referral Center as a voluntary agency, and tax-sup- ported facilities for medical care at the County Emergency Hospital. St. Michael Hospital and the Ivanhoe Treatment Center also provide clin- ical service. Clinical care, however, is futile without proper follow up by those who understand the psychic aspects of chronic alcoholics. The most ef- fective instrument in this field is Alcoholics Anonymous whose mem- bers have personally experienced all of the difficulties that have to be faced by those who are attempting to gain their freedom from alcoholism. It is most encouraging to note that as a result of all of the forces that can be brought to bear upon the dis- ease, about 40 percent of its victims can be reclaimed. It is emphasized that the fight is not against the use of alcoholic bev- erages, but rather against their mis- use. M. The Medical Clinic With a technical staff of one phy- sician, one x-ray technician, and one laboratory technician, the Health De- partment conducts a diagnostic serv- ice primarily for city employees and civil service applicants. Bartenders also comprise a large contingent of the clientele. Other eligibles include school teachers, food handlers in school cafeterias and at carnivals, persons referred from various wel- fare agencies, candidates for training at certain hospitals, candidates for the Badger Home for the Blind, can- didates for marriage (eugenics ex- amination), Gray Ladies, and baby sitters. The last named group are not examined as employees in pri- vate industry, but as citizens of Mil- waukee who are entitled to this serv- ice upon request. First aid is furnished for all em- ployees at the City Hall, but no other 69 treatment is dispensed by the Med- ical Clinic. During 1947 there were 14,234 visits to the Clinic, of whom 11,472 were new cases. The total physical examinations were 6,636. The total of laboratory tests performed was 26,965. N. Public Health Nursing (Director’s Note — In addition to the general report on Public Health Nursing, which is herewith summar- ized, detailed studies were made of the nursing services of the Milwau- kee City Health Department, the 17 other Health Departments in the county, the Visiting Nurse Associa- tion, and the Social Hygiene Clinic. These reports have all been sub- mitted to the agencies studied. Any- one interested in the total Public Health Nursing Program should study all of them. Copies are at the Survey office and the Community Welfare Council.) In February, 1949 there were 195 nurses employed for public health work by 19 agencies in Milwaukee County; 109 by the City Health De- partment ; 44 by 15 suburban health departments (all but Creendale and River Hills) ; 37 by the Visiting Nurse Association; four by the State Board of Health for service in the Social Hygiene Clinic; and one by the Creendale School District. Since the Visiting Nurse Association serves the entire county, residents living in any part of it except River Hills, may be under the care of two public health nursing agencies, the Visiting Nurse Association and Health De- partment or School Nurses. The over-all ratio of nurse to population in the city and county was 1:3995. There was considerable difference in the ratios in the city and suburbs, ranging from 1:1654 in Fox Point to 1:10,311 in the Town of Wauwa- tosa. In the City of Milwaukee it was 1:4480; in the county 1:3262. The recommended ratio for com- plete coverage, including bedside care, is 1:2000. For Milwaukee and Milwaukee County this would mean an additional 208 nurses —174 in the city and 34 in the suburbs. The number of visits increased from 7,477 in 1907-1908 to 274,246 in 1948. In this same year nurses from nine industries and one hospital made 15,199 home visits in the in- terest of home nursing care. This makes a total of 289,445 visits in 1948. On February 7, 1949 nurses reported 115,692 cases under care. In 1948 the total expenses for the 195 nurses was $679,048 ($509,386 tax funds, $169,662 private funds), or 90.5 cents per capita. It is esti- mated that the nursing budget for a community will cost no less than one dollar per capita. All the basic services usually in- cluded in public health nursing pro- grams are offered in Milwaukee County. The Visiting Nurse Associa- tion has contracts with various in- surance companies and gives special service to polio and cancer patients through cooperative arrangements with the American Cancer Society and the National Foundation for Infantile Paralysis. It offers bedside nursing care on a visit basis; physi- cal therapy treatments; maternity care, including maternity classes; and home delivery service. All health departments provide school nursing services in all public and parochial schools in the commu- nities they serve as well as communi- cable disease nursing, follow-up of tuberculosis patients, and health supervision. Their nurses staff the various clinics— immunization, well child, tuberculosis, and the like. A few home nursing classes are taught and some lectures in child care are given at the Shorewood Vocational School. While all the basic services are offered, some are better developed than others. For example, the school, infant, and tuberculosis serv- ices are fairly well developed, but maternity; bedside care; health su- pervision of crippled children, pre- school, and adult patients ; and group teaching need to be greatly ex- panded. Part-time nursing in the smaller industries should be offered and developed. There are two aspects of the total program that are worthy of special mention. All health department nurses are also the school nurses. Bedside nursing care is offered to the entire county by one agency (the Visiting Nurse Association) which has contracts with all the dif- ferent groups who usually offer nursing services to their benefici- aries. Everything possible should be done to see that this situation con- tinues, but with a close linkage of the two services under the direction of the City Health Department. The history of the Visiting Nurse Association show-s that it took the lead in developing a number of serv- ices which it later transferred to other agencies, i. e., the tuberculosis service to the Health Department and occupational therapy to the Curative Workshop. The time has now come for it to relinquish two more services; namely, maternity (except for those patients who will have home deliveries) to the health departments, and physical therapy to the Curative Workshop. This will leave bedside care. In 1948 only one-fourth the number of patients expected were given this care. Since the number of persons who need home care for acute illnesses has decreased in the last several years, it is expected that most of the in- crease will be among patients having long-term illnesses, whose care often is time-consuming. The Nursing Division of the City Health Department has succeeded in generalizing its services to such an extent that every nurse who visits patients also has school and well child clinic responsibilities. This is one way in which field and clinic activities are coordinated. Another is through the activities of the lia- ison nurse assigned to the tubercu- losis clinic. The Social Hygiene Clinic is usually considered a health depart- ment responsibility. In Milwaukee, the nurses assigned to this clinic are paid by the State Board of Health and have not been included in any local supervisory or in-service edu- cation plans. This is undesirable and should be changed so that they be completely integrated into the program of the local health depart- ment. Of the suburbs, only West Allis has a staff which is sufficiently large to warrant the employment of a full- time supervisor. This should be done. In eight other communities there are nurses designated as super- visors but they also have staff re- sponsibilities which interfere with their giving adequate supervision and initiating in-service education programs independent of those ar- ranged by the State Board of Health. Therefore, suburban health depart- ments need to develop plans for- giving their nurses adequate super- vision and in-service education pro- grams. This can be effectively accomplished only by merging the local departments with larger popu- lation groups, preferably in a coun- ty-wide health unit. The completion of a year’s ac- credited course in public health 70 nursing is necessary for nurses who do not have adequate supervision. In Milwaukee County 21 percent of the nurses have this preparation. In the country as a whole, 31 percent have it. Nurses should be urged and encouraged to complete these cour- ses. Public health nurses need the help of representative citizen groups to plan, develop, and interpret the pro- grams in the communities they serve. Without this help, the service they give will have only limited success. In Milwaukee County there is only one such group — the Visiting Nurse Association — which has forty-seven corporate members coming from a small section of the county. It is not sufficiently large or representa- tive to function effectively for the entire county. Therefore, it is sug- gested that a citizen committee for public health nursing be formed in each suburb. In considering the future of public health nursing in Milwaukee County it is important to develop an organi- zation which will assure an adequate and sound service and which will make it possible for one public health nurse to give health guidance and bedside care to the entire fam- ily. Controlled experiments prove that a service of this kind is the most effective. This could be ac- complished by establishing a combi- nation service jointly administered and jointly financed by the official and voluntary agencies with all field service rendered by a single group of public health nurses. Recommendations In order to improve and expand existing public health nursing serv- ices and adequately meet the needs of Milwaukee and Milwaukee Coun- ty, it is recommended that: *1. The services given by the various public health nursing agencies be more closely coordinated with each other and with other health and wel- fare services of the area, and that good cooperative procedures and a sound referral system be developed. *The use of the Social Service Ex- change be increased as a basis for making plans for meeting the health needs of the family and for wisely using community resources. 2. Vital statistics and known social and health problems be studied in order to determine and plan for the needs of the different sections of the county. 3. The quality of service be im- proved by — Providing competent supervision and in-service education for all pub- lic health nurses in the area. This is especially important for those nurses who are working in the Social Hy- giene Clinic and in the suburban health departments. nurses of as many non- nursing functions as possible through the use of volunteers, clerks, or subsidiary workers. more emphasis on a fam- ily health service. The nurse will then see her patient as an integral part of his family and will feel re- sponsible for helping with all health problems she finds in the home. Including more teaching and dem- onstration of care as well as improv- ing and expanding the individual teaching done in well child clinics. Critically studying the school pro- gram, especially in the suburbs, in order to find ways and means for using nursing time to best advantage and for improving the services to school children. Expecting and assisting nurses to complete their public health nursing preparation and studying and re- vising merit system qualifications as needed so nurses will not be given responsibilities for which they are not prepared. In an effort to at- tract to Milwaukee County well- prepared, energetic, and ambitious young nurses, broad and varied ex- periences, including internships in supervision, should be offered to qualified staff members. some nurses adequately prepared in the nursing specialties — maternity, tuberculosis, venereal disease, mental hygiene, and pediat- rics — so they may provide in-serv- ice education in these specialties for all staff nurses.1 4. Existing programs be expanded by — Securing the active cooperation of physicians, hospitals, out-patient de- partments, social agencies, nurses, and citizen groups, so that they will refer for care all individuals who need it. At least trebling the bedside nurs- ing program of the Visiting Nurse Association and expecting it to in- elude care to chronic and geriatric patients. Assisting small industries to secure necessary industrial nursing service. Expecting health departments, in addition to their present programs, to assume responsibility for the ma- ternity program; group teaching in maternity and child care, nutrition, and care of the sick; and health supervision services to infants, pre- school, and adult patients. Increasing the number of nurses, especially in those areas which have a low ratio of nurse to population. more citizen participa- tion in the public health nursing program. a. Organize citizen committees for public health nursing in the sub- urbs and various sections of the city. b. Develop school health commit- tees. #Work toward the combination of nursing services — City Health De- partment and the Social Hygiene Clinic; Visiting Nurse Association, suburban health departments, and the City Health Department. 0. Medical Social Service Although there was a pioneer de- velopment of a social service depart- ment in a hospital in Milwaukee in 1914, progress has lagged. Only five hospitals and outpatient departments out of 20 hospitals, plus the Wiscon- sin Anti - Tuberculosis Association, are listed as having social service departments. This is in spite of the recommendation by the American College of Surgeons that the Medical Social Service department exist in every hospital. Of the 20 staff mem- bers, eight who have had specialized training are in the public institu- tions. Another six who have special- ized training are in the W.A.T.A. Four workers, none with specialized training, but one eligible and a mem- ber of the American Association of Medical Social Workers, staff the private departments. In the one hos- pital, the supervisor of the out- patient department, a nurse along with her other duties, handles all the problems of a social-emotional nature which come to her attention. When the medical social worker is available, the hospital becomes a less strange and frightening place to the patient for he can have under- standing of his fears and supersti- tions about his disease, help with his 1In addition, each nurse, after she has completed one year’s experience, should receive in-service education in physical therapy so she will be alert to recognize deviations from normal and be able to give some physical therapy follow-up. For example: know when appliances are in good condition and correctly used. 71 financial difficulties, and a knowl- edge that someone will keep him in touch with his family when they are unable to visit him. The social worker may also plan with this patient for special training, or assist him in securing a different position if the doctor tells him that he must not return to his former employ- ment. Hundreds of patients, partic- ularly those with heart diseases and tuberculosis, receive these recom- mendations by their doctors every day. Evidence of poor health and pro- gressive crippling conditions, need for medication examinations — both for prevention and diagnosis — were noted among the many patients under the Department of Public Welfare and Public Assistance. In 1948, 204 patients left Muirdale Sanatorium against the advice of the physicians. About 50 percent of this number were those who over stayed leaves and had to be read- mitted. The possibility of these pa- tients recovering from tuberculosis is usually remote if they remain untreated. Their leaving against ad- vice is, among the other factors, a sign that the social, emotional, and economic needs of the patients were not being met. Perhaps we need to reflect on a field worker’s report to the Super- intendent of the County Hospital in 1915: ‘‘that before the creation of this department, many a patient who, when discharged was on a fair road to physical health, lost all of the benefit of the surgeon’s skill and physician’s knowledge expended upon him, because he failed to heed the doctor’s recommendations.” Recommendations It is recommended that: 1. The social service department of Milwaukee County Hospital and Dis- pensary — Emergency Unit, Milwau- kee Children’s Hospital, and the W.A.T.A., review their activities and outline and redefine their function. a. The hospital pursue its plans to reorganize and set up social service and admissions as separate units. b. A position of supervisor of ad- missions be created for both the hospital and dispensary in order to release more time of the present Director (hospital) and Case Work Supervisor (Dispensary- Emergency Unit) to develop a more comprehensive case work service. c. There be immediate efforts to expand the number of qualified personnel, including a case work supervisor at the hospital. 2. Muirdale continue to exert its efforts to fill the already budgeted vacancies and that a position of director of social service be created; that upon securing a director of the department, the activities of the de- partment be reviewed and redefined. 3. The staff of Milwaukee Children’s Hospital be immediately increased by a case work supervisor and one medical social worker. 4. The department of St. Michael be reorganized in order to offer case work services to the patients and fulfill the functions outlined for Social Service departments; that a qualified Director and Senior Case Worker who meet A.A.M.S.W. Standard Statement requirements be employed as soon as possible. 5. Mt. Sinai consider setting up a department under a qualified direc- tor to offer case work services and fulfill the functions outlined for Social Service departments and that the admissions and social services be separated. 6. In all the departments, the director endeavor to determine the number of additional staff needed to carry out the functions of the Social Service department. 7. Job specifications, duties, and professional qualifications be out- lined. 8. A salary scale and increment plan be formulated which will at- tract qualified personnel. 9. Additional clerical personnel be employed in order that the workers may more adequately record, and workers be relieved of some of the clerical duties they are performing — making appointments, arranging for transportation, securing of pros- thesis, etc. 10. The departments review their personnel practices, particularly in reference to vacations, sick leave, and provisions for educational ac- tivities. would offer generalized consultation service. 12. The Curative Workshop pursue their plans to employ a medical so- cial worker, and that she develop appropriate activities. 13. The hospitals without social service departments explore the pos- sibility of establishing them. 14. The Health Division of the Com- munity Welfare Council be utilized as a clearing agency, and that it be informed of developments in medical social work. 15. The Community Welfare Coun- cil promote the practice of social work in hospitals and outpatient departments, and exert every effort to raise the standards of medical social work practices. In order to carry out this recom- mendation, it is suggested that a committee be appointed by and func- tion under the auspices of the Coun- cil, and that there be representatives from the physicians, hospital ad- ministrators, and psychiatric and medical social worker groups, and that they immediately attempt to set up uniform job classifications, qualifications, and salary schedule, for the field of medical social work. P. Voluntary Agencies The heart and soul of a community are best exemplified by the things its people do for others without com- pulsion but merely for the spon- taneous desire to be helpful. Such is the motivating principle behind the work of voluntary agencies. Of those working in the field of health and related interests there are two classifications: (1) Those whose function are es- sentially in the field of health and whose activities are, therefore, sup- plemental to the work of the official health agency; and (2) Those whose work is an incident- al rather than an essential factor in the health program. The list of voluntary agencies fur- nished by the Community Welfare Council includes ten agencies which belong to the first classification above, as follows: 1. The American Red Cross 2. Milwaukee Hearing Society 3. Clinics at Marquette University Medical School a. Hearing Rehabilitation Clinic b. Speech Clinic 11. The Milwaukee Health Depart- ment and the W.A.T.A. review, as planned, the demonstration now in progress, and that the health depart- ment consider the establishment of a medical social work unit which 72 4. Central Agency for the Chroni- cally 111 5. Milwaukee Cancer Detection Center 6. Curative Workshop of Milwau- kee 7. Milwaukee Goodwill Industries 8. Milwaukee Psychiatric Services 9. Visiting Nurse Association 10. Wisconsin Anti-Tuberculosis As- sociation All of these except Nos. 2 and 3 are discussed in other related sec- tions of the Survey. In the second classification are: (1) the welfare organizations whose program incidentally impinge upon health problems; and (2) the voluntary general hospitals and institutions for the care of chronic diseases. All of the institutions in this clas- sification are dealt with elsewhere in appropriate sections of the re- port. Milwaukee is fortunate with re- spect to the popular and professional interest centered upon hearing and speech defects. The voluntary agen- cies working in this field are the Milwaukee Hearing Society, the Speech Clinic and the Hearing Re- habilitation Clinic at Marquette University, and the Hearing Aid Bureau at the State Teachers Col- lege. The multiplicity of agencies having the same or similar interests might presage duplication and cross purposes. On the contrary, there appears to be good cooperative re- lationship not only between the several agencies in this group, but also with the official health agencies. The close linkage between voluntary and official agencies is illustrated by the agreement whereby the Mar- quette University Hearing and Speech Clinics do preliminary hear- ing tests in the parochial schools for the Milwaukee City Health Depart- ment, and for eight parochial schools out in the county. The Milwaukee Hearing Society is an outgrowth of a social club, and the club spirit is still the power of attracting persons having a common problem. The purpose, however goes beyond hearing and speech improve- ment and is aimed at improvement of morale and emotional stability. The Hearing Aid Bureau is con- cerned with selection of hearing aids to fit the individual, and in training in the use of them. A very interesting and valuable voluntary service not reported else- where is the Junior League Blood Center. Since its organization in 1947 it has become self-supporting, but much more important than that is the fact that it has underwritten the job of supplying blood of all types and in all desired quantity to all of the hospitals in Milwaukee County and to the Waukesha Gen- eral Hospital. From March, 1948 to March, 1949 there were 15,379 donors, and 14,833 units of blood were sold to the hospitals. Eight percent of blood drawn was con- verted to plasma, and 22,720 cc. were processed for serum. Q. Industrial Health Scope and Plan of Survey A questionnaire type of survey was decided upon as the only meth- od which could give a reasonable sample, in the limited time available, of basic information on number, type, and size of plants, operations having potential health hazards, and plant health and welfare services. A mailing list of approximately 3,000 business firms was supplied by the Milwaukee Association of Com- merce. The questionnaire was mailed to each of these firms with a form letter explaining the purpose of the Survey. A total of 683 completed questionnaires, or 23 percent, was returned in time for statistical tabu- lation. Elimination of those replies which were not applicable to the Survey reduced the number finally used in the tabulation to 549, or 18 percent. Acknowledgments Grateful acknowledgment is given to the Milwaukee Association of Commerce for sending the question- naire to its entire membership; to the Division of Statistical Services, Wisconsin State Board of Health, for its splendid cooperation in the tabulation and statistical analysis of questionnaire data; to Mr. Orrin Fried, Chief Statistician, Statistical Department, Industrial Commission of Wisconsin, for providing census figures and occupational disease re- ports ; and to all others who assisted in the preparation of this report. Introduction The health and efficiency of the industrial segment of the popula- tion is of outstanding importance. Industrial workers comprise one of the largest and most important groups of the population both from the economic and sociologic view- point. It has long been recognized that some occupational groups are ex- posed to health hazards characteris- tic to their work and which may result in occupational diseases. In addition, there are a great many factors, both within and without the workroom which impair the work- ers’ well being, comfort, and effi- ciency without actually causing illness. The present day concept of industrial hygiene is not only the control of occupational diseases but also the maintenance of the general health and efficiency of the indus- trial worker. Approximately one-fourth (24.4 percent) of the state’s entire popu- lation resides in Milwaukee County. Those gainfully employed in Mil- waukee County number 317,474 or 40.1 percent of the state’s total. Of the employed group, 181,859 or 57.3 percent were working in manufac- turing industries where the need for protecting workers against occupa- tional health hazards is particularly important. The control of environmental con- ditions hazardous to health in in- dustrial establishments is essential for the maintenance of the workers’ health and efficiency. It is also es- sential that the facts be determined regarding the physical and mental capacities of new workers, that they be suitably placed at work they can do safely and efficiently, and that their health be supervised and main- tained while on the job. Proper medical and engineering control are required to accomplish those needs. Size and Distribution of Plants The number of plants and male and female employees reported in the 549 questionnaires were tabu- lated, classified by industry. Of the total of 151,680 employees covered in this Survey, 112,048 (73.9 per- cent) were male and 39,632 (26.1 percent) were female. The total of 151,680 employees represents 47.9 percent of the gainfully employed persons in Milwaukee County in 1947. The iron and steel industries accounted for the largest number of employees (61,147) and the second largest number of plants (79). Other large categories were trade1 (15,744 employees, 120 plants) ; food (11,332 employees, 35 plants) ; transporta- VTrade includes automotive, garage, re- tail food including dairies, eating and drinking establishments, lumber, building material and fuel dealers, general mer- chandise and apparel and other retail and wholesale trades. 73 tion (8,145 employees, 46 plants) ; paper and printing (6,127 employ- ees, 40 plants) ; and chemical (3,843 employees, 27 plants). The main report has 14 tables and charts and is of value to students of Industrial Hygiene. A copy of the original and full report is at the Milwaukee Association of Commerce. Here is given a brief summary, the conclusions, and recommendations. Summary and Conclusions Some occupational groups, be- cause of the nature of their work, are exposed to toxic materials or abnormal physical conditions which may result in occupational diseases. In addition there are numerous causes, both within and without the plant, which frequently impair the worker’s well being, comfort, and efficiency without causing actual illness. Effective industrial health pro- grams should be developed to pre- vent illness and to promote the worker’s health and efficiency. Adequate medical supervision is necessary to place workers at jobs for which they are best suited phy- sically, to prevent excessive illness by proper health supervision, to de- tect illness in the early stages, and to treat industrial injuries and ill- nesses to minimize their effects. Industrial hygienists (engineers and chemists) are required to evaluate exposures to health hazards in the workroom and to advise upon proper methods for their control. The serv- ices of nurses, dentists, and first aid workers are all needed for effective performance of the over-all indus- trial health service. This report shows room for im- provement in the provision of health services to Milwaukee County in- dustrial employees. There were very few full-time physicians, and none in small plants. A small percentage had nursing services. Industrial hy- gienists were reported by only one large plant on a full-time basis. Many plants, without full-time serv- ices of physicians, nurses, and hy- gienists, utilize the services of the Industrial Hygiene Division of State Board of Health and local health de- partments, as well as the medical and nursing services of insurance carriers. There was a considerable varia- tion in the degree to which health and medical services were provided. Although 86.2 percent of all plants studied provided treatment for plant injuries, only 55.4 percent treated minor on-the-job illness. Accident records were maintained on 61.5 per- cent of workers in all plants, where- as illness records were kept on only 36.8 percent of the workers. Pre- employment physical examinations were conducted in 25.0 percent of the plants and periodic follow-up examinations were done in 15.3 per- cent. In every category, much more adequate service was provided in the larger plants than in the smaller ones (100 workers or less). Welfare provisions, which include group life and health insurance, and group hospital and medical care plans were provided to almost as great an extent in the small plants as in the larger plants. Much of the industrial hygiene service to industry has been sup- plied by governmental agencies, mainly the Industrial Hygiene Divi- sion of the State Board of Health and the City of Milwaukee Health Department. With present small staffs, these agencies were unable to provide anywhere near an adequate service to Milwaukee County indus- trial establishments. Recommendations It is recommended that: 1. More adequate industrial hygiene services be supplied to Milwaukee County industry. The way this is to be done should be discussed with the Industrial Hygiene Division of the Wisconsin State Board of Health. 2. Every industrial establishment which has not had an industrial hy- giene survey for the evaluation and control of environmental health haz- ards, arrange for such a survey to be made by technically qualified personnel. 3. The much greater use of regularly scheduled services of physicians and nurses in all sizes and kinds of in- dustrial establishments, be promoted by joint efforts of management, labor, and professional groups. 74 X. Medical Care A. General and Special Hospitals In Milwaukee County It is axiomatic to state that pro- tection and conservation of health are to the interest of individual and national welfare of every citizen. Lack or impairment of health in- flicts an economic loss upon the in- dividual and has a deleterious effect upon all social, business, and com- munity activities. Basic to the pro- tection and conservation of health are the facilities for caring for the sick and injured. This study of the hospital facilities has as its objectives the following: 1. To complete a survey of all exist- ing general hospital care, beds, and the associated service. 2. To evaluate such beds and serv- ice. 3. To determine the general hospital care bed needs. 4. To ascertain the anticipated fu- ture planning for new and addi- tional general hospital care beds. 5. To evaluate such plans. 6. To propose a program of future development of existing and/or new general hospital care beds. Inventory of existing facilities must be a periodic review as the facilities are changing constantly. However, it is expected that the factual data presented may serve as the foundation upon which the fu- ture development, integration, and coordination of the hospitals and related facilities of the community may be based. If the Survey can point the way toward providing effectual and ade- quate facilities to meet the ever- increasing need of this growing community, it will have served its purpose and been worth the value in effort expended. From the patients’ viewpoint, the paramount problem facing the gen- eral hospitals of the Milwaukee area today is, as it has been for several years, the shortage of hospital beds. Based upon population estimates and characteristics, mortality, mor- bidity, and birth rates, etc., the Survey reveals a shortage of ap- proximately 1,550 beds. The type of beds needed are as follows: 320 beds for the Milwaukee County Gen- eral Hospital, 100 beds for maternity eases, 40 beds for pediatrics, and the remainder for general medical and surgical cases. A surplus of beds for communicable diseases exists, and the recommendation is made that 100 beds for these con- ditions be established at the Milwau- kee County General Hospital, and that the care of such cases be trans- ferred by the City Health De- partment to that hospital, with conversion of the South View Isola- tion Hospital to other public health uses. Location of the existing hospitals does not adequately serve all the people of the county; two areas, one, the south lake shore area, and the other, the southwest region of the county, are poorly served. It is rec- ommended that when additional beds are built in this community, 100 beds be provided for the Cudahy- South Milwaukee region; and that approximately 200 beds be provided in the southwest section of the metropolitan area proper to serve the people living in the Towns of Franklin, Greenfield, Greendale, etc. Transportation in this region is direct to the southwest portion of the metropolitan area of Milwaukee, and a hospital located in that area would serve both the metropolitan and rural regions of southwest Mil- waukee County. The majority of the hospitals in the area show evidence of crowding. The local occupancy rate is 1.9 per- cent higher than the national aver- age. The majority of the hospitals have waiting lists for admission averaging 33 patients per list. The average length of stay in local hospitals is 6.9 as compared with the national average of 10.5. The utilization factor is high, and only 198 days of service are rendered by local hospitals per death, as com- pared with the established rate of 250 days per hospital death. Regarding quality of facilities and service, it may be said that the phy- sical condition of the buildings in general is good, but show evidence of age. The average age of hospital buildings in the community is 29.9 years, with approximately 333 beds housed in units which require im- mediate replacement. Fire inspec- tion and control of the local hospitals is excellent. Food service received only a 55.1 rating according to the U. S. Public Health Service stand- ards, and emphasizes the necessity of constant vigilance to the funda- mental principles of good sanitation and hygiene. Recognition, accredi- tation, and approval of hospitals associated with education of interns and residents emphasizes the im- portance of including residency training in physical medicine and the degenerative diseases. Associated with this program is the need for a School of Physical Therapists in the community. The autopsy ratings in the hos- pitals are high and the records are of a superior quality. Future building programs of local hospitals are sound and when com- pleted will meet approximately 65 percent of the present bed deficiency. Blue Cross prepayment plan cover- age of the population in this area is high, covering approximately 46.6 percent of the population. Local hospitals have not taken full advantage of their opportunity to further public health. Routine radiographic chest examinations on admission, and extension of routine laboratory tests for syphilis, etc., could be amplified with advantage to general public health. Extension of public health educa- tion through use of hospital facili- ties should be encouraged. Public emergency ambulance serv- ice in this area is excellent and justi- fies Milwaukee’s enviable position of being one of the large metropoli- tan and industrial areas with an emergency ambulance service of outstanding quality. No approved, or even unapproved, cancer clinic is available to the citi- zens of this area, and the recom- mendation is made that a diagnostic and therapeutic cancer clinic meet- ing the standards of the American College of Surgeons be established. Outpatient departments estab- lished do not reflect proper credit upon the associated institutions. Many patients wait for hours on hard benches in surroundings not conducive to alleviation of appre- hension. 75 But in general the hospitals of the community are doing superb work in face of the many difficulties be- setting them in modern times. Recommendations It is recommended that: 1. Approximately 1,550 additional general hospital beds be provided for the Milwaukee metropolitan area. 2. 320 of these beds be added to the Milwaukee County General Hospi- tal. 3. 100 of the 1,550 beds be for ma- ternity cases. 4. Forty of the 1,550 beds be for pediatric cases. 5. A minimum of 200 of the 1,550 beds l)e located in the southwest portion of the urban area. 6. A minimum of 100 of the 1,550 beds be located in the South Milwau- kee-Cudahy shore area. *7, Serious consideration be given to the inclusion of a communicable disease section in the Milwaukee County General Hospital. *8. The activities of the South View Isolation Hospital be transferred to the Milwaukee County General Hos- pital. Either the South View Hos- pital should be closed and the patients cared for in general hospi- tals, or that space in excess of the needs for hospital purposes con- verted to other cases. (See section on Communicable Disease Control.) *9. The present South View Isola- tion Hospital be utilized for other public health services. 10. All hospitals cooperate more ex- tensively with official public health agencies in the extension of their program of preventive medicine in- cluding public health education. 11. All hospitals institute routine serological tests and radiological chest examinations of all patients admitted to hospitals or clinics. *12. The existing hospitals not ap- proved by the national accrediting associations make every effort to increase their standards to warrant such approval or registration. 13. Hospital authorities responsible for those institutions which have non - acceptable non - fire resistant units housing patients, make every effort to eliminate the housing of patients or personnel in such units. 14. The Marquette Medical School establish a department of physical medicine. 15. The Milwaukee County General Hospital expand its department of physical therapy. 16. The Milwaukee County General Hospital in cooperation with the Marquette Medical School establish a school for physical therapists. 17. The Milwaukee County General Hospital and other large metropoli- tan hospitals consider seriously the establishment of approved residen- cies in cardiovascular disease, gastro- enterology, and physical medicine. 18. No hospital of less than 100 bed capacity be approved in the metro- politan area. *19. An organic relationship be de- veloped between the small hospital (less than 100 beds) and the larger more completely organized medical centers. *20. The large general hospitals re- view their policies with intent to provide a more comprehensive serv- ice in the future, particularly in regard to admission and care of the acute psychiatric, etc. *21. The large general hospitals consider seriously the provision in separate and associated buildings for the care of long-term illness cases. B. Services for the Chronically 111 There is no question that chron- ic illness is the major health and welfare problem confronting the citizens, the health and welfare agencies, and the professions in the Milwaukee area today. The problem, however, is not local to this com- munity but is present throughout each and every community in the country. It is only in recent years that an awareness of the problem has developed; hence much differ- ence of opinion as to the best solu- tions of the problems exists. But it seems well established in inter- ested groups that the ultimate solu- tion will be hastened by a twofold attack: (1) increased adequate facili- ties for care, treatment, and rehabili- tation; and (2) increased and inten- sive research into the causes of chronic illness. The latter has the possibility of supplying the solu- tions through preventive measure to decrease or eliminate the cases of chronic illness. Until very recent years the impe- tus and interest of the medical pro- fession was directed toward acute illnesses with the exception of two groups of conditions in the field of chronic illness; namely, mental dis- ease and tuberculosis. However, with the conquest of the majority of acute communicable diseases, attention is being1 concentrated on chronic ill- nesses which now are responsible for the majority of all deaths. Lack of a clear definition of chron- ic illness has resulted in much con- fused thinking. An administrative definition of the chronic illness which merits much consideration is that proposed by E. C. Rogers, “American Journal of Public Health,” April 1946. He defines chronic illness as a “disease that may be expected to require an ex- tended period of medical supervision and/or hospital, institutional, nurs- ing, or supervisory care.” For all practical purposes, the use of the expression “long-term illness” for chronic illness is advocated. Summary of Regular Chronic Illness Long-term illness and chronic in- validism is the number one health problem in the Milwaukee commu- nity. It is estimated that there are 120,000 long-term illness patients in this area, of whom 8,000 are chronic invalids, and that these patients are increasing at such a rate that by 1970 the number over sixty-five years of age with long-term illness will have increased from the pres- ent number of 17,000 to 38,000, and chronic invalids from 2,100 to 4,500. At present, of the 8,000 chronic invalids, another 2,000 can be cared for in their own homes with outside assistance, and 2,400 need institu- tional care. The above figures are exclusive of patients suffering from mental illness or tuberculosis. Beds available for these chronic invalids number 1,330, of which 570 are in commercial nursing homes, 210 in charitable nursing homes, and 550 in two chronic disease hospitals. On the basis of 3.3 beds per 1,000 population—the accepted rates—a total of 2,800 beds are needed to ac- commodate the chronic invalids. A deficiency of 1,500 beds there- fore exists. Only 400 additional beds are being planned in the community at the present time. Home nursing care, home house- keeping service, and home physical therapy facilities and service avail- able, do not meet present demands, and all need extension and expan- sion. 76 Rehabilitation is limited by the facilities of the Curative Workshop which is in the process of expan- sion. The major recommendations stress the establishment of nursing homes in connection with hospitals; the as- sumption of responsibility by the Central Agency for the Chronically 111 of continuous public education in the problems, needs, facilities, pro- grams, and solutions for the chronic- ally ill; as well as emphasis by the Marquette Medical School, the Med- ical Society of Milwaukee County, and the Health Department on re- search, study, etc., in geriatrics, de- generative diseases, and physical medicine. Recommendations It is recommended that: 1. 1,500 additional beds be provided for long-term illness patients and chronic invalids. 600 of these beds should be built as additions to gen- eral hospitals. (480 beds are already planned for the Milwaukee County Hospital.) *2. Private nursing homes be en- couraged to expand both facilities and services. *3. Hospitals seriously consider the establishment of nursing homes in conjunction with the hospital. *4. Hospitals add facilities and serv- ices for active treatment of long- term illness patients requiring hospital care because such care is inseparable from care of acute ill- ness. 5. All institutions—commercial, non- profit, and governmental—provide all essential services required for the high quality care of the long- term illness patient. *6. The Central Agency for the Chronically 111 maintain an up-to- date registry of all facilities and services in the county for the chronically ill. *7. The Central Agency for the Chronically 111 establish a program of seminars and institutes for oper- ators of nursing homes, and assume the responsibility for the continuous education of the community in the problems, needs, programs, and solutions of the chronically ill. *8. The Central Agency for the Chronically 111 cooperate and coor- dinate with the Milwaukee Health Department in elevation of standards for operation of nursing homes. *9. Visiting Nurse Association ex- pand its service of home nurse visi- tation to chronic invalids. 10. All interested agencies refer their requests for home nurse visitation to the Visiting Nurse Association with both moral and financial support. *11. Home housekeeping service sup- plied by the present agencies be ex- panded to meet the present demand for such services. 12. Physical therapy and rehabilita- tion services be provided by the Cur- ative Workshop for chronic invalids at home, and that this service be actively and financially supported by other interested and concerned agencies. 13. The Marquette Medical School place more emphasis in its under- graduate teaching curriculum on physical medicine and geriatrics. 14. The Milwaukee County Hospital establish residencies pointed toward the degenerative diseases and dis- eases of the aged, such as cardio- vascular, gastroenterology, and phy- sical medicine. 15. Milwaukee County Medical So- ciety use its influence to stimulate interest in the medical aspects of the problems of long-term illness. 16. Milwaukee Health Department set up in its organizational structure a Bureau of Degenerative Diseases with a grouping in this Bureau of nursing homes, heart, cancer, dia- betes, etc., activities. 17. Various agencies such as the Mil- waukee Division of the American Cancer Society and the Wisconsin Heart Association, publicize more widely the services they have to offer to the chronic invalid. 18. Milwaukee Division of the Ameri- can Cancer Society and the Wiscon- sin Heart Association underwrite all expenses of home visitation by the Visiting Nurse Association to all cancer and heart patients, and that this coverage be extended to all of Milwaukee County. 19. Planning of facilities for the chronically ill always be reviewed from the community as a whole and not only from the viewpoint of the indigent. 20. Periodic medical examinations be encouraged to facilitate early recog- nition and treatment of long-term illnesses. 21. All agencies actively support all accident prevention programs to re- duce the number of physically han- dicapped due to accidents. *22. Old folks’ homes change admis- sion policy to accept chronic invalids and not necessarily on a life-time contract. C. Tuberculosis Milwaukee County as a large met- ropolitan center has a lower death rate from tuberculosis than any oth- er of equal or larger size in the United States. From the investiga- tions made and information gath- ered as basic data, it is plain that this favorable condition is the result of long-term, farsighted appreciation of the tuberculosis control problem on the part of officialdom of both city and county. It is the result of the acceptance and prompt applica- tion of every useful control proce- dure by the directors of the pro- gram as soon as they were proved to be of value. The rapid increase in Negro popu- lation in the last several years por- tends that a serious problem for control of tuberculosis will develop among them. The fact that Negroes are crowded into substandard hous- ing in blighted areas increases the problem by adding the probability of rapid spread of infection to that of high racial mortality. The mass chest X-ray survey that was carried out in the spring of 1947 was an excellent demonstration of the existence of a great many hitherto unknown cases of tubercu- losis among presumably well people of Milwaukee County. There is con- siderable concern that lack of suffi- cient personnel in the Tuberculosis Control Division of the Milwaukee Health Department has prevented completion of statistical analyses of this survey. The location of the Tuberculosis Control Center and offices of the Tuberculosis Control Division on the south side is convenient for people living in that section of the city, but difficult of access to people living in the central and northern sections. The County Dispensary at 2430 West Wisconsin Avenue, limited as it is to the care of medically indigent per- sons, is not at present in a position to function adequately as a second control center. The personnel of the Tuberculosis Control Division is not sufficient to carry out the full requirements of the program in the City of Milwau- kee. The Division of Public Health Nursing has functioned admirably in carrying out the field services, 77 but the Tuberculosis Control Divi- sion is lacking clerical help necessary to keep the case register and other records current. Outside of the city, the multiplicity of health jurisdic- tions and the lack of coordination between them prevent uniformity of action. A Tuberculosis Control Officer, having authority over and responsibility for the whole city- county program would provide the necessary administrative head. The Milwaukee County Dispen- sary-Emergency Hospital at N. 24th Street and AVest Wisconsin Avenue is completely equipped and well lo- cated. Because of the regulation restricting most patients to those receiving public assistance, its po- tential activities in tuberculosis con- trol are not fully developed. This restriction is inconsistent with the law providing free sanatorium care to all bona fide residents regardless of their ability to pay the costs. Muirdale Sanatorium deservedly enjoys a national reputation among first class sanatoriuras in the United States. Its physical plant, business administration, and professional care of patients are excellent. AVith the contemplated tuberculosis division in the new County Hospital, Mil- waukee County will be able to amply provide hospitalization for its tuber- culous people without delay. Recommendations It is recommended that: *1. Inasmuch as the rapidly increas- ing population of Negroes in Mil- waukee portends an increasingly im- portant reservoir of tuberculous infection, special emphasis be given to the prevention of overcrowding, unhygienic living conditions, and nutritional deficiencies, as well as the close supervision of known and potential cases of tuberculosis. Case- finding among the Negro population should include careful epidemiology as well as periodic mass chest X-ray survey. 2. An epidemiological study be made to determine, if possible, the reasons for the high fatality rate of men in the middle and older age groups. 3. Special efforts be made to increase the number of cases reported by physicians in private practice. Rou- tine tuberculin testing of children, and routine chest X-ray of private patients with respiratory ailments would be important case-finding pro- cedures if they were to be universal- ly adopted as routine by practicing physicians. 4. Tabulation of basic data regard- ing over 50,000 persons whose 70mm films were found to be negative during the 1947 mass X-ray survey be completed as soon as possible in order to evaluate the total results of that survey. 5. Two full-time X-ray technicians and one full-time clerk be assigned to each of the 70mm chest X-ray units in order that they may be oper- ated continously and simultaneous- ly. A fully qualified and experienced health educator should be added to the staff to make preliminary ar- rangements for survey of groups of the population and to direct all ac- tivities in the mass X-ray program. *6. A fully qualified physician with training and experience in tubercu- losis and public health be appointed as Tuberculosis Control Officer. The need for close coordination of the city and county activities in tuber- culosis control has been recognized by the officials of both city and county. The control officer should be given authority for the promo- tion, promulgation, and direction of all activities of official agencies of both city and county insofar as they relate to the tuberculosis control program as a whole. It is doubt- ful that a well qualified control officer would be attracted by the salary ranges now offered. Security of tenure of office should be estab- lished so that a complete long-range program can be developed and car- ried out. 7. Medical supervision given to chil- dren at the Gaenslen School for children with orthopedic and cardiac defects, and to children in “better health rooms” in other schools, now being carried out by clinicians of the Tuberculosis Control Center be assumed by the general school med- ical service or by specialists in the particular medical fields in which the children are classified. These services should not be construed as making any material contributions to the tuberculosis control program. 8. The staff of the Tuberculosis Con- trol Division of the Milwaukee Health Department and the Tuber- culosis Control Center be augmented by the addition of a trained, exper- ienced record analyst to assume charge of the tuberculosis case reg- ister and other records. This record analyst should gather necessary de- tailed statistical data for current knowledge and evaluation of the program. !). There is need for a receptionist to expedite the handling of patients and visitors at the Tuberculosis Con- trol Center. Considerable time of clerks and stenographers could be saved by the use of mechanical dic- tation equipment by the physicians of the staff. *10. There is need for an adequate medical social service department at Muirdale Sanatorium. The staff of such a department should consist of one director, one case supervisor, and five case workers. *11. At least from the standpoint of the tuberculosis control, and un- doubtedly in other fields of public health, one health department with jurisdiction over the entire county, including the City of Milwaukee, would have a great many advan- tages. Such a department would provide the needed coordination of all public health activities with those of tuberculosis control. D. Rehabilitation The size of the task in the Mil- waukee area is such as to stagger one’s imagination. The National Health Assembly in 1948 estimated that one out of every six or seven persons in the United States has some form of physical or mental defect. In a population of 850,000 this means from 131,000 to 141,000 potential candidates for restorative service. It would be unsafe to haz- ard a guess as to how many of these might eventually become actual cas- es requiring this service. However, a compilation of Milwaukee Work- men’s Compensation statistics in 1947 by the Industrial Commission of Wisconsin reported 12,232 injur- ies alone, approximately 9,500 of which were such as to require restor- ative service of a physical and/or occupational therapy nature. According to information secured by questionnaire, restorative service in 1948 was rendered to about 9,000 patients by thirteen hospitals and other agencies in Milwaukee, thus approximately equaling the case load from injuries alone without touch- ing the reservoir of cases in the 131,000 to 141,000 potential candi- dates for this service. The job, though large, is not hopeless and much salvaging is readily possible. Facilities for restorative service are centered in thirteen hospitals, the Curative Workshop, and Goodwill Industries, The extent, nature, and 78 quality of service vary in each in- stitution from poor to reasonably ad- equate. The most striking deficiency is lack of medical social service. Ten of the thirteen hospitals included in this part of the Survey report none. The Curative Workshop is the hub of the outpatient type of restorative services in this community. Two im- portant deficiencies in the regular staff, however, exist; namely, a con- sulting and supervising physician and a medical social worker. It is further suggested that the program of the Curative Workshop be ex- panded to take over the home visits now being made by the physical therapist of the Visiting Nurse As- sociation. There is no sheltered workshop for handicapped persons in the true sense of the term. The Goodwill In- dustries is the nearest approach to this important need. It is pointed out, however, that the one prime consideration is the patient rather than the products of merchandise. Handicapped persons cannot be ex- pected to compete with able bodied workers; hence the sheltered work- shop should not expect to be self- supporting. Though the Goodwill Industries does not now fulfill these concepts, its physical plant might well be adopted to the development of a sheltered workshop. That the agencies engaged in re- storative service already recognize many of the shortcomings is illus- trated by suggestions received from twelve of them specifying principal def iciencies: 1. A sheltered workshop in its full- est concept. 2. Education of employers regard- ing employment possibilities of han- dicapped persons. 3. Psychiatric treatment to a greater extent than available at this time. 4. Augmented observation and out- patient services for mental patients. 5. A better referral system to insure referral to the agency which can best provide the services needed. 6. More vocational training facilities for the deaf and hard-of-hearing. 7. Fundamental academic training for illiterates or those with low school grade attainment. 8. Funds for the State-Federal vo- cational rehabilitation program. 9. More adequate diagnostic, test- ing, and training facilities to cope with the problems of the blind and/ or visually disabled. 10. More adequate means of provid- ing transportation to places of em- ployment for the handicapped. 11. An improved method of earlier referral of handicapped cases. 12. Extension of the highest quality of educational, vocational, and psy- chological counseling personnel. 13. More flexible and varied train- ing programs especially designed to meet the needs of the handicapped person. 14. More effective cooperation be- tween all agencies dealing with han- dicapped persons. The report strongly urges more emphasis in the medical schools upon training in physical medicine and internships and residencies in this field after graduation. Among the most valuable items is the suggestion that there be es- tablished a convalescent center sup- ported cooperatively by all the hos- pitals and the community, or possibly by a foundation. Recommendations It is recommended that; *1. A central body be established where the activities of all the agen- cies can be coordinated and where all information regarding their avail- able services can be furnished to any inquirer. This could profitably be located either in the Community Welfare Council or the Medical So- ciety. A liaison officer from the City Health Department would be advisable. This would further a closer interagency liaison and refer- ral system for the benefit of both client and physician to assure refer- ral to the proper agency to meet the specific needs of the patient. *2. A sheltered workshop be devel- oped in the fullest sense. #3. A medical director be included on the staff of the Curative Work- shop. *4. A medical social worker be in- cluded on the staff of the Curative Workshop. *5. The Curative Workshop take oyer from the Visiting Nurse Asso- ciation the home visits made by the physical therapists. 6. Serious consideration be given to providing a medical soical worker to every agency requiring one. 7. Industry become acquainted with the possibilities in employing some handicapped workers in jobs suit- able to their capabilities. 8. No agency commence expanding beyond its ability to handle an in- creased case load until a numerically adequate, fully trained professional staff can be employed. 9. Physical therapy and occupational therapy be developed at certain hospitals. (See Hospital Chart as a guide.) 10. Serious consideration be given to the advisability of having a medical man acquainted with restorative methods in charge at every hospital where such services are available. 11. The possibility of training phys- icians in physical medicine be taken up with the Marquette Medical School and certain hospitals; then residencies be established in physical medicine and the possibilities of es- tablishing a school of physical thera- py be explored. *12. Serious consideration be given the question of establishing a con- valescent center. *13. A long-range plan be made on lines recommended having in mind the provision of adequate funds, per- sonnel, and space and the avoiding of overexpansion lest forced retrac- tion nullify any advantages gained. The following charts show the re- habilitation staffs and services of hospitals and agencies. 79 hospitals General Medical and Surgical BEOS PHYSICAL THERAPY OCCUPATIONAL THERAPY IN CHARGE MED. SOC. WKRS. PSYCH. SOC. WKRS. PSY- CHIA- TRIST EXPANSION PUNS REFER PATIENTS TO 7 THERAPISTS TRAINING DAILY LOAD EQUIPMENT THERAPISTS TRAIN INC DAILY LOAD FUNCTIONAL OR DIVERSIONAL EQUIPMENT OF DR. OR PHYSIATRIST 1 COLUMBIA ISO 3 Approved School 30-10 3 infra; I U.V. 2 S.W. Diathermy 1 Muscle Stimulator Fajr Gymnasium Hubbard Tank Whirlpool - Paraffin Bath 0 0 0 0 0 Doctor 0 0 0 Yes Bui Iding P.T. 1 O.T. Doct or's Responsi- b i 1 i ty 2. MOUNT SINAI 175 1 Masseuse Hot a P.T. Exper ience and Proper Tra in ing 13 2 Infra - 3 Radiant - 5 U.V. 2 S.W. Oaithermy 1 Rhythmic Constrictor 4 L.V. Stimulator Good Gymnasium Hubbard Tank - Whirlpools I A. A L. Paraffin Bath - Contrast Baths 1 Approv. School 15 Both Bike - Thera. 1 Treadle i Floor i Table Loom Cycle 1 Braid Weave Loom Wood Working Tools Minor Craft Equipment Posture Mirror No 1 0 2 Part time No Oep't. is Big Enough to do * 9 Load -Will Add Thera- pists S.O.S Yes As and Where |n- d icated 3. ST. LUKE'S 135 2 Approved School IB Rad iant Heat Lamps S.W. Diathermy i MicroWave Diathermy Electric Stimulation Machine Whirlpool Bath Paraffin Bath Gym - Weights. II Bars Ladder; Bicycle - Sh. Wheel - Pulley Weights 1 Approv. School 3 Both 7 Yes Phys iatrist 0 0 0 Yes Ex pans ion Plans Call For Complet Rehabi1ita- tion Ser- vice Yes As and Where Needed 1. ST. MARY'S 210 1 R.N. With Special Train- ing in p.T. , 3 (1 Yr. 662) 5 Infra Red Lamps 1 U.V. 1 S.W. Diathermy 1 Pavex Boot 0 - - - 0 No 0 0 0 Not At Present Doctor's Job 5. WEST SIDE 35 0 Treatment Given by Floor Nurse 3 1 Diathermy Whirlpool Bath 0 - - - 0 No 0 0 0 Plan Larger O.P.D. Curative Workshop 6. ST. JOSEPH'S 350 2 Aides ? 20 6 Zoalite; 10 Baker Lites (?) 3 U.V. 1 S.W. Diathermy 1 Pavsx Boot 1 Whirlpool I Paraffin Bath 0 - - - 0 No 0 0 0 No No 7. ST. MICHAEL'S 135 1 0 6 5 Infra Red 1 U.V. 1 S.W. Diathermy Whirlpool, Arm and Leg Meager Gymnasium 0 - - - 0 No 2 0 0 If I When Planned Will Have Larger O. t P. Oept's Doctor's Job 8. MILWAUKEE COUNTY 950 5 1- RN h- OK Approved School 60 S.W. i MicroWave Diathermy Muse. 1 Nerve, Test I Stimulate Fever Cabinet Grad Gymras ium Whirlpools. Kenny Hot Pack pa raff in 1 Approv. School 20- 30 Both ? Yes Physiatrist 3 We 1 fa re Workers 6 1 0 Visi- ting Only Complete P.T. i O.T. S Rehabil. planned In Ex pans ion Yes As Needed 9. ST. ANTHONY'S ill 0 - - 2 S.W. Diathermy 1 U.V. 1 Infra Red 0 - - 0 No 0 0 2 Consul- tants Med.a Surg. Units Pediatric Unit Ch. Ill Colored Chi Idren 7 O.T. No Plans On P.T. Ye. By M.D. As Needed 10. MILWAUKEE HOSPITAL 298 3 Reg istered 12 3 S.W. Diathermy 1 Whirlpool Gymnasium '’Var iousFxerr » 0 - - - 0 M. D. Gene ra1 Supervis. 0 0 0 Yes General Yes As Needed II. DEACONESS 135 0 - - 0 0 - - - 0 No 0 0 0 in 2 Yrs. Add P.T. No 12. MERCY 50 0 - * 0 0 - - - 0 No 0 0 0 0 No 13. HISERICORDIA 111 0 - - 0 0 - - - 0 No 0 0 0 - No BEOS 2818 hospitals CHART C 80 AGENCIES CASES ACCEPTED 1998 o CX o oc O 3- DAILY LOAD 1998 CAPACITY OF DAILY LOAD PROFESSIONAL STAFF SERVICES PROVIDED REQUIREMENTS FOR ACCEPTANCE OF CASE SOURCES OF REFERRAL COUNSELOR PSYCHOLOGIST O. P. SOCIAL SERVICE NURSE PHYSICIAN OTHER COUNSEL, r TESTING m SPEECH w P.T. AND O.T. EQUIPMENT PROSTHESIS TRAINING OTHER TRAINING SPECIALTRAINING JOB PLACEMENT m.o. consult'nt; SPECIAL EQUIPMENT ae 0 1 REFER TO ANY OR ALL OTHER AGENCIES TYPES OF CASES TAKEN 1. CURATIVE WORK SHOP 2097 150 AFTER JULY 225 0 REFER OTHER AGENCY 6 1 2 9 REFER 9 P.T.'S ARE 2] PRACT'L NO MED SOC.A L.M.O. 1 SPEECH THE R'ST Y 1 yes COMPLET HEARING CER. PALSY PARAPLEGICS REFER NO POOL i HUBBARD TANK YES YES HOT L.M.O. REFER WHO CAN BE HELPED L.M.O. OTHER AGENCY HOSPITAL 2. 01V. FOR BLIND. STATE DEPARTMENT PUBLIC WELFARE IB 18 1 PART TIME EYE PART TIME INDIVIDUAL FOR BLIND YES EYE-PART TIME YES YES BLIND 16 AGE RESI- DENCE DITTO 3. GOODWILL INDUSTRIES 60 131 150 1 1 0 ■ YES PART TIME SPECIAL TEACH'S SPEECH 1-2-3 YES SLIGHT YES YES YES YES YES YES ALL MlLW.CO. A SOME OTHERS DITTO 9. JEWISH VOCATIONAL SERVICE 862 1000 25 25 SAME 5 PART 2 1 1 PSYCH. PART TIME YES r ONLY YES IF OTHER AGENCY ASKS YES ALL ANYBODY NEEDING IT DITTO 5. MILWAUKEE CO. GUIDANCE CLINIC 1268 1300 3 5 PSYCH. S.S.W. PSYCH. 2 A IPART 2 YES PSYCH AN IATRIC TES GUIDANCE TING ONLY YES MENTALLY ILL Ml LW. CO. UNABLE TO PAY DITTO COURTS ETC. 6. MILWAUKEE HEARING SOCIETY 965 300 2 2 ■ 3 TEACHERS 1-2-3 YES RECREA- TION " CLUB" LIP READING USE OF HEARING AIDS HELP O.V. YES R. YES HARD OF HEARING ONLY ANYBODY NEEDING IT DITTO 7. MILWAUKEE HEARING REHABILITATION CLINIC ; to i 780,-' 7 f • 15 A WE EK 2 CONSUL- TANTS EAR OR EXAMIN AT ION AND ADVICE ON .Y 2 AUDIO- METER TECHNI. YES DEAF ANYBODY HEEDING IT DITTO 8. MILWAUKEE PSYCHIATRIC SERVICES 186 166 1 1 PSY. S.S.W. PSYCH. 2 t 3 YES MENTALLY ILL FROM ANY AGENCY DITTO 9. STATE WISCONSIN VOCATIONAL AND ADULT EDUCATION (O.V.R.) 665 1000 6 1 PART TIIC 1 PART TIME 1 A 2 YES A .L SERVICE ARE BOl GHT ALL ANYBODY NEED ING 16 + DITTO (in Wise) 10. SPEECH CLINIC A HEARING LAB. MARQUETTE UNIVERSITY 1259 2000 7 o § SEMESTER 1 CONSUL TANT 3 SPEECH THERAPISTS EAR OR. UNDER GRADS. 39 SPEECH THERAPY LIP R. YES SPEECH ft CER.PALSY ANYBODY NEEDING IT DITTO II. WISCONSIN STATE EMPLOYMENT SERVICE 1500 650 20 30 3 2 PART 1 t 2 YES YES YES ALL ANYBODY NEEDING IT DITTO 12. MILWAUKEE VOCATIONAL AND ADULT SCHOOLS 5 + 2 Y 1 ES 1 SOME 250 TEACHERS 1 A 2 YES AS NEEDED YES ALL KINDS MANUAL ARTS,ETC. TO STATE REHAB. OR WHERE NEEDED SCHOO LING 16 A OVER "SEE LIST NEXT PAGE CHART D AGKHCIES 81 XI. Environmental Sanitation A. Introduction to Environmental Sanitation In this part of the study there were 14 different specialists who took part. The reports written were reviewed with great care by a com- mittee of technical advisors under the chairmanship of Mr. L. F. Warrick, State Sanitary Engineer. In summarizing these reports, a brief statement of the factual mate- rial gathered will be given under suitable headings, followed by the recommendations. With few exceptions, transmissible diseases are a man-to-man affair — sometimes by person-to-person con- tact, and sometimes through an in- tervening medium, either animate or inanimate. It is with the intervening media that environmental sanitation is concerned. For example, water, milk, and other foods are the vehi- cles by which cholera, typhoid, and paratyphoid fevers, dysenteries, diphtheria, and other so-called “food poisonings” gain access to the human body. Likewise, numerous animal and insect hosts are involved in the transmission of human dis- ease. Mosquitoes transmit yellow fever, encephalitis dangers, malaria, and filariasis. Certain fleas which live on rats and other rodents trans- mit bubonic plague and typhus fe- ver ; certain ticks transmit Rocky Mountain spotted fever, tularemia, and relapsing fever; and numerous other combinations of animal host and insect or protozoan victors could be cited as agents involved in the spread of disease from man to man. Even chemical and physical factors in human environment contribute to disease. Lack of iodine in the food, water, or intake causes endemic goi- tre; lack of fluorine predisposes to dental decay, and too much causes mottled enamel; lead poisoning, sili- cosis, irradiation poisoning, and vari- ous gaseous intoxications result from industrial exposures. In the physical field, improper illumination, heat- ing, ventilation, low or high air pressures, shock, excessive noise, and vibrations are all factors of environ- ment which are detrimental to health. The cure for environmental ills is exceedingly simple in principle — do away with the cause or break the chain of transmission. For example, malaria may be eliminated by either destroying the breeding of anophe- line mosquitoes, by destroying the adult mosquitoes, or by exclusion of infected mosquitoes from the non- infected person. Breaking the chain at any one of the foregoing links will accomplish this purpose. And so it is with all other diseases of envi- ronmental origin. Little as the general public may know or suspect, the most monumen- tal public health achievements of all time have resulted from environmen- tal sanitation. To this we owe the conquest of cholera, yellow fever, plague, typhus fever, malaria, and other major scourges of the public’s health. Most of these have been so long gone from modern civilization that their very names have faded in- to antiquity, but to our forefathers in this very same locality they were stark realities to be contemplated only with terror. The popular conception of envi- ronmental sanitation regards it es- sentially as an esthetic factor rather than a vital force for the prevention of disease. Unsightly collections of refuse and offensive odors are the uppermost concepts of sanitation in the public mind. Actually, sights and smells do not cause sickness, so that effort spent upon them is, from a public health standpoint, largely non-productive. But where in all the field of public health do we find such opportunities for wholesale health protection as in the sanitary controls which govern the safety of a water supply for a large city such as Milwaukee? Sanitation is, indeed, a vital force in any com- munity for the protection of health, as well as in improving esthetic ap- pearances, but the public interest should be focused more on the rela- tive values of its various aspects. Generally speaking, environmental sanitation deals with community problems rather than individual cases. It is, therefore, specially adapted to governmental adminis- tration. In this area the agencies in- volved are: State 1. The Wisconsin State Board of Health 2. The Wisconsin State Depart- ment of Agriculture County 3. Milwaukee County Park Com- mission 4. Milwaukee County Regional Planning Department 5. Milwaukee County Smoke Con- trol Department Metropolitan 6. Sewerage Commission of Mil- waukee County. 7. Sewerage Commission of the City of Milwaukee City of Milwaukee 8. Department of Health 9. Public Works Department 10. Building Inspection and Safe- ty Engineering 11. Housing Authority 12. Public School System Similar governmental agencies are involved in other municipalities. The scope of environmental inves- tigations included in the Survey is indicated by the following items: 1. Water Resources a. Lake Michigan b. Ground Water 2. Public Water Supplies, exclusive of the City of Milwaukee. 3. Stream Pollution and Sewage Disposal 4. Swimming Pools and Bathing Beaches 5. Refuse Collection and Disposal 6. Rat Infestation and Control 7. Milk Sanitation 8. Industrial Hygiene 9. General Sanitation 10. Atmospheric Pollution 11. Housing 12. Functional Governmental Rela- tionship Due to the unavailability of per- sonnel at the time of the Survey, the very important problem of the sani- tary preparation, storage, and dis- pensing of foods was not carried in the report, except as regards the hospitals. 82 B. Public Water Supplies With the advancement of civiliza- tion a vicious chain of circumstances has been created. The aborigines could drink freely from springs and streams in comparative safety be- cause the waters were either not contaminated from human sources, or the contamination was in such dilution as to be negligible. In this country the coming of the white man has changed the picture. First, there has been the increasing con- centration of population which has placed excessive contamination loads upon surface waters from surface run-off, and second, water-carried sewerage, another product of civili- zation, has literally deluged the sur- face water supplies with human filth in raw and concentrated form. The evil influence of civilization upon water purity has even extended to ground water supplies. Open wells and springs are the most vul- nerable because contamination can give access to them directly with ease, but even drilled and cased wells may be affected by seepage along the casing or by contamination reaching the water bearing strata through fissured rock. Perhaps no single item of public health procedure has been as pro- ductive of health dividends as has the purification of water supplies. In Milwaukee County the public water supplies are the following: Using Lake Michigan water; 1. Milwaukee 2. Cudahy 3. South Milwaukee 4. Carrollville Using ground water: 1. City of Wauwatosa 2. Town of Lake 3. Sanitary Districts of Bro- son Manor and Bluemound 4. Miscellaneous Cooperatives Lake Supplies Of all the foregoing, the water sup- ply of Milwaukee is by far the larg- est and most interesting. For reasons of public policy, however, the Survey was not permitted to make a defin- itive study of the plant and its operations. There was fear that in- formation about the Milwaukee Water System might be misused to the financial disadvantage of the city. Although a report based upon public records was made, it has been withheld from circulation, as there was no original investigation by the Survey staff. Cudahy. — The original 14-inch in- take and the pumping plant were built by the Cudahy Packing Plant and placed in operation in 1895. The present intake is through a 24-inch line from a submerged crib 2,800 feet from the shore. Chlorination was instituted near the beginning of the present century and has con- tinued to be the only treatment. Even the method employed in ap- plying chlorine is questionable, as are also the data relative to chlorine residuals in samples tested twice daily at the packing plant. The monthly reports show figures rang- ing between .2 and .25 p.p.m1, which, to say the least, is an amazing uni- formity, in the face of great and sudden variations in the character of raw water. Seven of the 23 samples of treated water in 1946 were shown to be unsafe by state laboratory examination. No samples were sent out in 1947. From the evidences of equipment and methods of operation, too intricate to review in detail, the water supply does not measure up to potable standards, and is considered hazardous. South Milwaukee. — The intake is through a cast iron pipe 24 inches in diameter, extending 3,000 feet into the lake. The rated capacity of the plant is 25 million gallons per day, which corresponds with the filter capacity of 2 gallons per square foot per minute. While the average re- mains within capacity limits, the filters become overtaxed during the summer, as shown by the average daily rate of 28 million gallons per day during August, 1948. The plant was built in 1912, util- izing coagulation, settling, filtration, and chlorination. The services of a trained operator are lacking. Chlo- rine residual tests are said to be done three time per day, but no chlorine demand or any other tests on raw water are made. Whereas the rec- ords showed the astounding uni- formity of .2 p.p.m. of residual chlo- rine, actual examination showed only .05 p.p.m. There was apparently no conception of the significance of chlorine demand determinations. The detention time of water for contact with chemicals and for co- agulation and settling were both far below the desirable levels, and chlo- rine dosage was approximately half the amount needed to maintain the proper residual. While the bacterio- logical samples of treated water were within acceptable limits, the physical ip.p.m. means parts per million. and operational hazards in the plant are such that the examinations are no guarantee of safety. The South Milwaukee water treat- ment plant is potentially hazardous. Being antiquated, it is considered to have outlived its usefulness. Carrollville. — The water works is owned and operated by the U. S. Glue Division of the Peter Cooper Corporation. It is essentially an in- dustrial supply, hut it also serves the homes of plant workers, the total population being about 300. Water is brought in through 3,000-foot pipe, 30 inches in diameter. Treatment is by pressure filtration and chlorina- tion. The combined capacity of the 14 filter units is 3,500,000 gal- lons per day. The dilapidated chlor- inator, rated at 40 pounds capacity per day, was connected to a 100- pound cylinder, but there was no scale to determine the rate of ex- haustion. Chlorine dosage was kept at or below .1 p.p.m. instead of the standard .2 p.p.m., in order to avoid taste; the stress, therefore, being placed upon taste rather than the killing of bacteria. Two of the sam- ples submitted to the state labora- tory in 1947 and two of the twelve in 3948 were unsatisfactory. Due to the lack of proper equip- ment and methods, and the lack of technically adequate operational con- trol, the plant is not suitable for the production of water for domestic use. Future planning for the entire southern portion of the county should recognize that eventually the water supply must come from Lake Michigan. The three plants in that area now taking water from the lake are either imminently danger- ous, or by reason of equipment op- eration or other causes, are unsuited for the purposes intended. The logi- cal development, therefore, is the construction of one modern water plant to serve the three areas of Cudahy, South Milwaukee, and Car- rollville and the territories adjacent to them. Such a plant should also be designed for expansion to serve the entire southern portion of the county. This demand should not be far off as the population is expand- ing rapidly in that direction. There is, of course, no reason why such a plant should not become a unit of the Milwaukee system. Ground Supplies City of Wauwatosa. — The first well was drilled in 1898. There are now eight wells, the latest of which was 83 equipped in February 1949. The depths of wells range from 1660 feet to 1804 feet. All are cased to the deep limestone structure, but only No. 8 is grouted with cement to exclude seepage along the casing. Well No. 2 is scheduled for abandon- ment. During 1948 the combined pumpage ranged from 43 gallons per capita per day in January to 220 in August. The total hardness of the water runs from 360 p.p.m. to 460 p.p.m. as compared with the desirable limit of 150 p.p.m. The iron content also runs much above the accepted limit, and in two wells the total solids are above normal. Only occasional samples have shown evidence of contamination, but the samples taken are too few to warrant any conclusions as to the bacteriological quality of the water. Chlorination is not employed. In view of the dangers associated with ground water supplies in this region, the unchlorinated supply used in Wauwatosa must be regard- ed with suspicion, if not regarded as definitely hazardous. Town of Lake, — The system is sup- plied by two deep wells, one of which is not in use, and serves 80 percent of the population. The remainder of the population continues to use pri- vate wells. The monthly average pumpage in 1948 was 59 gallons per capita, and the maximum was 95. There is no treatment except in a zeolite softening plant. Bacteriolog- ical examination of samples in both 1947 and 1948 showed contamination above allowable limits, with increas- es in all categories. For the immediate future, chlor- ination should be adopted. In long- range planning, the Town of Lake should be included in any project that would develop a modern water treatment plant in that area, using water from Lake Michigan as the source of supply. Greendale. — The water plant in- stallations consist of two deep wells, two pumping stations, and a zeolite water softening plant, all designed to serve a population of 5,000 as compared with an existing popula- tion of about 2,800. The wells are constructed, cased, and grouted in accordance with state requirements. The monthly average pumpage in 1948 was 57 gallons per day at the minimum and 125 maximum. The bacterial content of the water from April, 1947 to February, 1949 was within the accepted limits. No treat- ment other than softening is applied. The location of the wells with re- spect to the contaminating influence of industrial wells and the cone of depression in the deep water bearing strata, render them relatively safe for the present. Chlorination, how- ever, should be considered as an ad- ditional factor of safety. Other public or quasi-public water supplies are those of the Sanitary Districts of Broson Manor and Blue- mound, and miscellaneous coopera- tives. Sufficient information as to well construction to .judge the ability of these supplies to produce a suit- able quality of water was not ob- tainable. It is known, however, that in no instance is the production and distribution of water under adequate supervision. C. Ground Water Supplies For domestic purposes the two essential factors in ground water supplies are (1) permanence and (2) safety. In the Milwaukee area both of these are in danger. In pioneer days ground water was apparently inexhaustible; it was also relatively free from hazards to health, but that was before the com- ing of large population concentra- tions and before the machine age. All conceptions of the safety of water from a health standpoint start from the premise that all natural waters in this region of the world are free from danger until contaminated from human sources; hence the in- creasing hazards with greater popu- lation concentrations. But the ques- tion that at once arises is, “How can water coming from great depths in the earth receive human contam- ination?” There are two answers to this question: (1) that this area is underlaid by fissured limestone stra- ta, so that any surface contamination gaining access to the limestone stra- ta may travel along the strata until a fissure is reached through which it may eventually gain access to the deeper water bearing structures; (2) that contamination may travel down along the outside of deep well cas- ings which are not especially pro- tected against this hazard. In either of these instances the danger is ma- terially enhanced by heavy pumpage which lowers the ground water levels and creates a downward draft to any surface contamination. Strange as it may seem, the per- manence of ground water supplies in this area is being threatened. Seasonal variations are well recog- nized, and the rapid rise after spring thaws clearly indicates that surface waters reach the ground water res- ervoirs promptly and in appreciable amounts. According to the deep well survey made in 1945-46 by the Milwaukee County Regional Planning Depart- ment, the static ground water levels have receded from about 96 feet above the lake level prior to 1880, to about 63 feet below the lake level in 1945. The center of the cone of depression in the deeper aquifers in 1948 was observed to be 210 feet below the lake level. This rapid depletion is due much more to in- dustrial uses of water than to domestic use, but the latter suffers all the hazards resulting therefrom. Eventually the entire county will have to resort to Lake Michigan for its water supply. The survey located 112 deep wells which ranged from 961 to 2,100 feet. Eighty-four of these are now in use, and 28 have been abandoned, due perhaps in most instances to ex- haustion. Public water supplies are derived from ground waters in the following locations; 1. City of Wauwatosa 2. Town of Lake 3. Sanitary District of Broson Manor 4. Sanitary District of Blue Mound 5. Village of Greendale 6. Miscellaneous Cooperatives In order to keep up with the water demands, it has been necessary in some instances to add more wells or to increase the pumpage, or both. In 1948 the Town of Lake pumpage was increased 25 percent over the previous year. Any hole which pierces the deep structures is likely to be an avenue through which surface pollution may contaminate the water bearing stra- ta. For this reason, since 1935, the State Department of Health has re- quired that the area between well casing and the surrounding earth shall be filled with grout to exclude surface water. In no instance is the sampling of water for bacteriological examina- tion in accordance with standard practice. Samples which are collected and examined, however, have shown contamination in sufficient frequen- cy to indicate the need for routine 84 chlorination of all ground waters used in public water supplies. This is further supported by the physical circumstances associated with well construction and the potentialities of contamination due to faulty well protection. D. Deep Wells — Non-Public Investigation was made of 18 deep wells in and about the City of Milwaukee. Except for the well at the Zoo, all were at industrial es- tablishments. While it is true that water from them is used only in a few instances for drinking purposes, all deep wells in this area are of sanitary significance since they ex- tend into the deep water bearing- structures. Any contamination, there- fore, which may affect a deep well, regardless of whether or not it is in use, endangers the entire water- table from which water for domestic use may be drawn. The report shows conclusively that such hazards exist in many instan- ces, and that in general there has been very little attention directed to specific measures for protecting the deep water resources from pos- sible contamination. Wells were found in close proximity to sewer lines; others offered the possibility of surface flooding; cross connec- tions from potentially hazardous well supplies to the city water sys- tem were found; in many instances there was an absence of grouting around the casings to exclude sur- face seepage; and a number of aban- doned wells were observed which had not been filled with cement or other suitable material. In no in- stance where water was used for drinking purposes was any form of treatment applied. It is rather odd that the con- struction of deep wells is exempted from the control of the state well drilling regulations. This is obvious- ly a serious omission. E. Swimming Pools and Bathing- Beaches As in the case of domestic water, the health hazards associated with waters used for recreational bathing are due almost wholly from con- tamination of human origin. Con- sequently the number of bathers, the dilution factors, and the provi- sions for bactericidal treatment are among the most important elements in the proper management of swim- ming pools and bathing beaches. These items have been critically studied by sanitation authorities and the bounds of safety, for practical purposes, have been laid out. The specifications include both design, equipment, and operating methods. (See “Recommended Practice for Design, Equipment and Operation of Swimming Pools and Bathing Beach- es,” American Public Health Asso- ciation.) Since 1931 the State Department of Health has required registration of all pools and the submission of plans for new installations or chang- es in existing installations. At the present time there are 12 controlled bathing beaches in Milwaukee Coun- ty and 51 public or quasi-public swimming pools. Other beaches at Fox Point, Shorewood, Whitefish Bay, and Cudahy are not controlled. Ownership of swimming pools is divided as follows: 1. County Park Commission .... 8 2. Department of Bridges, City of Milwaukee 7 3. Board of Education 10 4. Institutions 9 5. Clubs 10 6. Other Municipalities 7 Bathing Beaches (ownership) 1. County Park Commission .... 7 2. Local Governmental Units (Fox Point, Shorewood, Whitefish Bay, and Cudahy) 5 Random selection of 27 swimming- pools was made, and these were examined in accordance with the routine rating schedules approved by the American Public Health Association. The following tabula- tion represents the percentage of in- spected pools which show the viola- tions specified: Violation Percent 1. Lack of foot baths 81.5 2. Insufficient wash water . .. .51.5 3. Excessive bathing load 51.5 4. Improper gauges on filter . .48.1 5. Insufficent disinfection .... 40.7 6. Insufficent bacteriological examination 37.0 7. Improper application of chlorine 33.3 8. Improper suitable disinfection 29.6 9. Improper inspection of bathers 25.9 10. Improper handling of suits. .25.9 11. Improper suits 18.5 From the standpoint of design the more serious violations were: Violation Percent 1. Insufficient filter area 73.5 2. Closed system unsatis- factory 58.8 3. Back siphonage possible . . . 52.9 4. Improper method of make- up water 50.0 5. No sewage tank 47.1 6. Unsatisfactory drinking water dispenser 38.2 7. Improper disposal of wash water 35.3 8. Insufficient shower units . . .24.7 9. Unsatisfactory apparatus for disinfection 11.7 Bathing Beaches From Whitefish Bay on south to Carrollville all of the beaches are more or less subjected to sewage contamination, sometimes much more severely than at others, depending upon wet weather by-passing of the sewage treatment plant and numer- ous other factors, A bacteriological study of six of these beaches from Fox Point to Grant Park, made by the Tri-State Survey of Bathing Beaches in 1948, showed all but one with bacteria content in excess of 1,000 per 100 cc. (the upper limit of safety for bathing beaches) in 2.8 percent to 37.8 percent of the 36 samples from each beach. A considerable amount of improve- ment in the operation of swimming pools could undoubtedly be effected by better trained pool operators. To this end systematic in-service train- ing would be very helpful. Reduc- tion of bathing loads would also be of material assistance. At the lake shore bathing beaches much benefit should be derived from improvements now in progress at the Jones Island Sewage Treatment Plant. F. Sewage Collection and Disposal, and Water Pollution The people of Milwaukee County have been unsually alert to the prob- lems associated with sewage dispos- al. Sixty-nine percent of the land area is within the Metropolitan Sewerage District, 971/2 percent of the total assessed valuation, and 941/2 percent of the population. Re- search in sewage treatment has been unequaled or at least unsurpassed, and has yielded immense dividends both in financial savings and in ef- ficiency. In spite of phenomenal 85 achievements, however, more re- mains to be done. Aside from avoidance of noisome nuisances, the only reason for sew- age treatment is to prevent exces- sive pollution of the water courses from which domestic water supplies are derived. While water treatment plants are capable of handling con- siderable quantities of pollution in raw water, as pollution loads be- come heavier, the equipment, skill, and cost of operation required are inordinately increased, as well as the hazards incident to possible tem- porary mechanical failure. The report traces the pollution concentration in the several streams in the Milwaukee area, all of which eventually discharge into Lake Mich- igan, thereby affecting both the raw water for domestic use and the bath- ing beaches. It is shown that pollu- tion of the streams converging to- ward the harbor is within reasonable limits until near the mouth of the combined rivers. Due to sluggish flow and heavy contamination, it becomes necessary at times to flush the outlets with fresh water through special tunnels from the lake to pre- vent excessive putrefaction. These measures, together with an efficient sewage treatment plant, are material aids in minimizing the pollution load. When it is realized, however, that the Milwaukee Sewage Treatment Plant is designed for 154 million gallons per day and receives a nor- mal flow of 138 million, with wet weather flows running so high that some sewage has to be by-passed, it should be clear that the plant is even now at times overtaxed and will inevitably become more so as the population served increases. The combined raw wastes from 756,550 persons have an oxygen demand com- parable to that of raw sewage from 2,300,000 persons, from which it is seen that Milwaukee sewage is high- ly concentrated. Even though the degree of treatment is 95 percent complete, the actual amount of resid- ual pollution together with that received from the rivers is a very important problem to be reckoned with, since the ultimate discharge is into the lake, close enough to the water supply intakes as to affect the bacterial content of the raw water reaching the water plant under cer- tain circumstances. In substance, the harbor is a sewage lagoon dis- charging into the lake. The rate of discharge or the sewage dosage varies widely with such factors as prevailing winds, water currents, and storm water carrying with it by-passed raw sewage. Much more critical study should be made of these factors in the interest of safe- guarding water supply intakes and bathing beaches, both in Milwaukee and in the suburban areas above and below Milwaukee. Under normal circumstances the present plant at Jones Island is able to discharge the responsibility placed upon it, but factors of safety are being seriously taxed, both as re- gards treatment capacity and stand- by equipment. Additional sewage driers, for instance, would obviate the necessity of having to release raw sludge at times when drier units are out of commission for repair or cleaning. Chlorination of the efflu- ent is suggested as an additional fac- tor of safety. Municipal and sanitary district sewage disposal works outside the Metropolitan Sewerage District, ap- parently function satisfactorily un- der normal operating conditions. The need for uniformity of local regula- tions in outlying municipalities, how- ever, to correspond with those in effect in the Metropolitan District is stressed, particularly in view of the fact that the District may ulti- mately be extended to include the entire county. Since the authority to investigate and correct stream pollution in the metropolitan district is granted to the County Park Commission, as well as to the Metropolitan Sewerage Commission, there is the possibility of overlapping and jurisdictional conflict unless effective liaison facil- ities are established and permitted to maintain close coordination be- tween these two agencies. G. Refuse Disposal The problem of refuse disposal is older than recorded history. In fact, the accumulations of bones and discarded utensils and instruments at sites of former human habitations, have contributed much to the knowl- edge of prehistoric culture. In mod- ern civilization it is recognized as a communal problem to be handled by local governmental agencies. The term “refuse” is all inclusive, signi- fying all forms of cast-off material, including garbage. It is the latter particularly that makes refuse col- lection and disposal a health problem. The 18 local jurisdictions in Mil- waukee County utilize a variety of methods for refuse disposal. Six dispose of garbage by incineration, nine by combined dumping of gar- bage and rubbish, two by home de- vices, and one has no service. Rub- bish is dumped separately in nine communities. From the collection standpoint, the odd custom of remov- ing ashes from basements is in vogue in nine communities, including the City of Milwaukee and all of the larger municipalities. Approximate- ly 90 percent of the population throughout the county is eligible to receive this service. Undoubtedly this is a convenience which those served would not like to part with, but if they knew how much extra it is costing to maintain this service, it is questionable whether the ma- jority would choose to pay for it. Moreover, those who have no ashes to remove are paying their propor- tionate share of this extra and un- necessary service. Some of the incinerators now in use are in need of overhauling or replacement. Dumping also poses problems in some instances. Where no dump sites are locally available, they must be obtained in the terri- tory of adjacent governmental units, which, sometimes gives rise to fric- tion. Where combined dumping of garbage and rubbish is done, special care must be taken to cover the dump facings regularly and effectively to prevent rat harborage and breeding. This is best accomplished by the sanitary land fill method which is soon to be placed in operation to serve the City of Cudahy. Considering the multiplicity of small units of government in Mil- waukee County and the problems with which each one is faced sepa- rately in the collection and disposal of refuse, any plan which would sim- plify this problem, and produce bet- ter service at less cost, should appeal to all communities concerned. In the judgment of the investigators who prepared the report, these objectives could be accomplished by formation of sanitary districts, including two or more adjacent communities, for the purpose of setting up refuse col- lection and disposal facilities to serve all of the governmental units in each such district. The length of haul to disposal sites would automatically limit the number of units in a dis- trict. In the City of Milwaukee refuse disposal requires the services of ap- proximately 800 employees, with an annual payroll of approximately $2,000,000. Over 250,000 tons of gar- 86 bage, rubbish, and ashes are collected and disposed of annually from 125,- 000 premises in 8,000,000 visits. The cost of collection per ton of garbage has been steadily rising as follows: Cost per ton in 1940 $5.83 1943 8.06 1946 9.39 1947 10.88 1948 12.49 The major portion of the increased cost in recent years has been due to the increase in wages granted to city employees through the cost of living adjustment. Four of the incinerators were built in 1910 and three in 1930, the total capacity being 525 tons per day. The average daily load is about 300 tons. Operation is efficient and free from objectionable odors. Of more imminent concern is the matter of dumping area for the incinerator res- idue and other non-combustible ref- use. Some of the dump sites are almost filled, so that additional space may be required within a year or more. The purchasing of strategic- ally located sites well in advance of actual need would be a wise pro- cedure. Certain needed improvements in methods and equipment are outlined by the report. On the whole, the City of Milwau- kee and the suburban areas generally have achieved a reputation for a cleanly and orderly appearance. Es- thetically this is fine, but the report emphasizes refuse disposal as a health measure through the elimina- tion of rat feeding and the breeding of rats and flies. H. General Sanitation In accordance with laws applica- ble to the whole state, the Wiscon- sin State Board of Health conducts inspections of hotels, barber and beauty shops, plumbing, and well drilling in the local area. It is recog- nized that the State Board of Health must maintain supervision over all sanitary functions, but where the local community is equipped to do such inspections as above indicated, the responsibility for this duty is best delegated to the local health department, with periodic cheek re- views from the state level. Milwaukee. — The work is organized under what is known as the Bureau of Inspection, which comprises a variety of inspection functions as follows: milk, meat, foods, day nurs- eries, housing, rodent infestation, routine inspection of business estab- lishments, and inspections in re- sponse to nuisance complaints. The Bureau employs 38 men in addition to the Engineer Supervisor and two assistants. This list is further broken down as follows: 5 Quarantine officers 6 Housing inspectors 5 “Exterminators” on rodent control 21 General inspectors 1 Rooming house inspector For inspection purposes the city is divided into 18 districts, with one inspector regularly assigned to each. The others are assigned as circum- stances dictate. In 1947 general in- spections and reinspections totaled 114,2101; written orders issued, 8,024; verbal orders, 8,266; com- plaints verified, 5,389; complaints not verified, 1,586. Of the total inspections, 13,557 were in connec- tion with rat control; 16,844 related to the general cleanliness of streets, alleys, lots, and yards (in the general category of esthetic prob- lems) ; and 12,883 were calls in connection with communicable dis- eases (principally quarantine). Inspectors are deputized as police officers with powers of arrest, and certain ones wear police uniforms and badges similar to those of the police. They do not, however, carry any weapons for either offense or defense. In case of trouble, there- fore, it would be necessary to call upon regular policemen. On general principles, the wearing of a uniform by a health department employee is not wise because it places the emphasis upon law enforcement rather than the educational ap- proach. A review of the organization and activities of the Bureau of Inspec- tion raises a question as to whether the emphasis in all instances is prop- erly placed. Suburban Health Departments. — West Allis is the only city in this group which has full-time inspection service. One sanitarian devotes his whole time to milk sanitation, which involves six pasteurization plants and 700 dairy farms. The other sani- tarian is engaged entirely in gen- eral sanitation. The statistical report indicates a wide range of activities, which seem to have been very effective insofar as orders are concerned. Of the 66 written orders issued, compliance was obtained in 62 instances; and 333 compliances resulted from 492 verbal orders. Of the other suburban communi- ties, only Cudahy and South Milwau- kee employ one part-time inspector each. While the inspector in the former instance is a full-time em- ployee of the city, only part of his time is devoted to the work of the health department. His work con- sists largely of nuisance control and general premise cleanliness. In South Milwaukee the sanitation service is essentially the same as that of Cudahy. In substance, there are only two full-time sanitarians and two part- time in the entire suburban area representing approximately 170,000 population. The lack of technical training is an essential weakness. Even in the City Health Department of Milwaukee, more technical train- ing is sorely needed. And, nowhere in the county are standard methods for milk inspection, restaurant in- spection, or swimming pool inspec- tion being utilized. I. Atmospheric Pollution In view of the great number of industries and the fact that soft coal is used extensively for these and for residential heating, it be- comes obvious that Milwaukee has an atmospheric pollution problem of the first order. The relation of this problem to health is well illustrated by the well-known “smog” episode which occurred last year in Denora, Pennsylvania. In March, 1948 the County Board of Supervisors took cognizance of the smoke problem and created a Department of Smoke Regulation, with authority extending to all sec- tions of the county, thus relieving the Milwaukee City Department of Building Inspection of the respon- sibility for smoke abatement, and the issuance of installation permits. In June, 1948 a mechanical engineer, and later a chemical engineer as deputy, were employed to have charge of the program. Five inspec- tors with suitable background of experience have been employed and they work in assigned districts. It is estimated that at least 15 are needed. It is anticipated that the VThese figures do not include milk, meat, or food inspections, which are discussed in other sections of this report. 87 full number will be employed as soon as they can be recruited and trained. The work of the inspectors is largely educational, though they are clothed with enforcement authority. Another important duty of the De- partment is the review and guidance of plans for smoke control and the issuance of Certificates of Opera- tion. The coverage of this function is said to be highly inadequate. Although the Department has authority over all types of air pollu- tion, actiAdties are thus far limited to Smoke Control. As this Depart- ment is in its infancy, judgment cannot be passed upon the efficiency of its performance. J. Rat Infestation and Rodent Control The most serious rat-borne dis- eases — endemic typhus fever, in- fectious jaundice, rat-bite fever, and bubonic plague — are not encoun- tered in the Milwaukee area. There is always, however, the possibility of their occurrence. Physical or traumatic damage resulting from rat bites in infants is not an uncommon experience. But the most common hazard to health in this area is the contamination of food with rat ex- creta giving rise to acute intestinal disorders, sometimes called “food poisoning.” Another urgent need for rodent control in this region, however, is for protection against economic loss from human food con- tamination and food consumption, including cereal grains. In Milwaukee sporadic poisoning campaigns were pursued up to 1942, when it became apparent that in spite of them, the rat population was steadily increasing. At that time an ordinance was adopted “relating to the extermination of rats, the elimi- nation of rat harborages, and the rat proofing of such places.” The enforcement of this ordinance be- came a function of the City Health Department. All of the 21 inspectors on general sanitation include rat infestation in their routine inspec- tions. In addition, there are five men who devote their full time to this service and are known as “Extermi- nators. ’ ’ While poisoning procedures con- tinue as an important cog in the machinery for control, the emphasis is being switched more and more to “starving out” methods of which rat exclusion from buildings is the most important. In 1947 the fol- lowing kinds and amounts of poisons were distributed: Poisons Antu 259 lbs. Calcium Cyanide . . 134 lbs. Red Squill 386 lbs. Poisoned Bait Materials Candy 150 lbs. Corn Meal 200 lbs. Flour 100 lbs. Meat 3,300 lbs. Scratch feed .... 200 lbs.' Of the 27 court cases filed, it is notable that only one was dis- missed. Seven resulted in fines, seven in suspended sentence with costs, and 12 in suspended sentence without costs. On the whole, rat infestation is not heavy in Milwaukee. In order to carry out systematic survey and to apply control measures in local- ized areas, however, it is estimated that an additional inspector is needed in the northern district, tAvo in the central district, and one for a period of one year in the southern district. In West Allis no evidence of rat infestation was discovered at the time of investigation. Garbage stor- age, collection, and incineration were •such as to provide very little food for rats. The City of Cudahy has evidently been troubled with rats for some time, since there was passed in 1944 an ordinance “To Exterminate the Rat Menace, ’ ’ which is modeled after the Milwaukee ordinance. There has been little effort, however, toward enforcement. Garbage and rubbish are separated for collection, but are dumped together in an open-faced dump which is highly infested with rats. Plans have been made for cor- recting this condition by use of a sanitary landfill project. The situation in South Milwaukee is similar to that of Cudahy, except that an incinerator is used for gar- bage disposal instead of an open dump. An undue accumulation of garbage was noted in the alleys, which, if continued, will rapidly stimulate rat propagation. K. Housing An appreciation of the relation- ship between housing and health is nothing new. In fact, before the advent of scientific knowledge of disease, stress upon this factor was often overdone, as at times when buildings that had housed contagious disease were destroyed by fire on the theory that a house may become so seeded with disease as to be beyond reclamation. Milwaukee has been acutely conscious of housing as re- lated to health, but in a more ration- al manner. It is one of the few cities in this country that has attempted a systematic study of this problem. The City Health Department main- tains a force of five inspectors and one supervisor who devote their full time to this work. The housing sur- vey is, therefore, a continuous ac- tivity which is guided by standard procedure recommended by the American Public Health Association. By utilizing certain well-known elements of blight, the degree of blight may be assessed for the areas studied, and this in turn forms a reliable guide to community plan- ning. From 1945 to 1949, six different estimates of housing shortage in Mil- waukee have been made by as many different agencies. They range from 16,526 to 24,000, with 17,500 being a conservative mean. A splendid summary statement relative to housing needs was issued by the Milwaukee Journal on Feb- ruary 5, 1949. The findings were based upon shortages indicated by (a) double-up families; (b) tempo- rary housing units; (c) Red Cross applications; and (d) vacancy rates. The total estimated needed units for the county were placed at 17,500. Some of the amplifying comments are quoted as follows: “1. So long as Milwaukee County continues to grow at the rate of 5,000 families per year, as it has in the past nine years, several thou- sand housing units will be needed each year, in addition to those needed to overcome the shortage of 17,500 homes which have been built up through the depression years and the Avar years. The increase in fam- ilies during the past three years has exceeded the increase in housing units in the county, with the result that the shortage has remained at practically the same level. “2, A number of persons working in Milwaukee County are now living in distant areas because of the short- age of homes in the county. Since these persons are not included in the county family estimate, their num- bers would add further to the short- age indicated, in proportion to the 88 number who might prefer to live closer to their work. “3. In addition to the homes needed to overcome the present shortage and to supply the needs of the nor- mal increase in families, there is also need for additional homes to replace demolitions which have been prac- tically halted during the past few years. More than 50,000 dwelling units in Milwaukee County are more than fifty years old, according to the 1940 Census. Some 20,000 units are sixty to ninety years old.” Since adequate studies have al- ready been made or are in progress relative to specific housing units, it was not deemed necessary for the this Health and AYelfare Survey to engage in this phase of investiga- tion, except to say that the studies of the Health Department are well conceived and executed. L. Trailer Camps In a metropolitan industrial area such as Milwaukee County it is in- evitable that there be a considerable number of persons who by choice or necessity must live in temporary housing units. Especially is this true in the presence of an acute shortage of permanent housing units. AYhile temporary units cannot be expected to afford all of the domes- tic conveniences that are obtainable in fixed homes, those which are es- sential to the protection of health should be made mandatory. Temporary housing in this area is somewhat of a no-manVland, insofar as standard requirements are con- cerned. The State Board of Health has no basic specifications having the force and effect of law as to location, equipment, water supply, waste disposal, or operational pro- cedures, except wartime emergency regulations applicable only to areas declared by the Board to be engaged in defense activities. Such regula- tions as are applied are by local ordinances which are not necessarily complete or uniform. The county ordinance is deficient in many re- spects, there being no requirements as to the proportion of sanitary facilities to the units to be served. The Survey records 21 trailer camps in Milwaukee County. Five of these, with a total capacity of 884 units are owned and operated by the County; nine of the privately owned camps have a capacity of 559 ; the capacity of the seven remaining private camps is not stated. On the whole, the sanitary facili- ties of the County owned camps are good. All use water from approved public sources, and all discharge sewage into the metropolitan sys- tem. The proportion of toilets, bath- ing facilities, laundry facilities, etc., though of a communal nature, are reasonably adequate. On the privately owned camps, however, the score is not so good. The general conclusion with respect to these camps is summed up in one word — unsatisfactory. Complaints addressed to the State Board of Health have employed such terms as “overcrowded,’’ “filthy,” “rat infested,” “lack of privacy,” “pig- pen, ” “poor drainage,” “one toilet for both sexes,” “no water,” and “unhealthful.” Investigations of complaints and routine surveys have generally confirmed the validity of the above complaints. In some in- stances there are no urinals; toilets average one to twenty-five trailers, which is about one-third of the de- sirable minimum; lavatory facilities are as meager as one to seventy trailers, with an average of approxi- mately one to twenty; well water supplies of pit construction are in existence in some camps; and sewage and garbage disposal leave much to be desired. It is not intended to convey the impression that the deficiencies above cited are common to all. It is, however, a fact that they are all too general. There is a crying need for local sanitary supervision which is practically non-existent in the sub- urban areas, but lack of supervision is only to be expected in the whole suburban area which affords only one full-time general sanitary in- spector and two part-time inspectors. The inspections made by AYest Allis and Milwaukee are of the occasional general nuisance type. Persons who live in temporary housing units deserve more sanitary safeguards than are now assured them by state and local health agen- cies. M. Lake and Stream Building Sites Along the rather numerous water courses in Milwaukee County there are areas subject to overflow, which are obviously not suitable for resi- dential sites. Unsuspecting home seekers at times of dry weather are often led to purchase building sites which eventually prove to be subject to overflow. The three agencies concerned with plotting are: 1. The State Board of Health through its Blotting and Sanitation Code exercises control over lake and stream shore plots. 2. The State Regional Planning Of- fice exercises control over areas out- side incorporated cities, but exempts the county from obtaining approval of the Director of the Regional Planning Office. 3. The Milwaukee Planning Board appears to be independent of either the State Code or the Regional Plan- ning Board, but in practice freely consults with both. Through the County Zoning Ordi- nance and enabling State legislation, with the concurrence of Town boards in which low lands are situated, the County can reasonably zone such lands to discourage building there- on. It would appear, however, that a less complicated machinery might be found for providing a more direct and positive means of prohi- biting home construction in lowlands along streams which are subject to periodic overflow. N. Milk Sanitation One specific milk supply may be classified as good or bad, depending upon the standards by which it is judged. A nationally recognized standard takes the guesswork and personal judgment out of the prob- lem of rating milk supplies from the standpoint of sanitary safeguards to health. These are the standards which have been utilized in the ap- praisal of milk sanitation in the Milwaukee area. Although there has been general agreement for more than twenty years among health officers on the one hand, and representatives of the dairy industry on the other, as to the specifications for safe produc- tion and distribution of fluid milk, not one of the local governmental units has as yet adopted them. Wis- consin is, in fact, one of the few states which maintains control of milk in the Department of Agricul- ture rather than the Department of Health, which serves to illustrate that the economic side of the milk industry takes precedence over the sanitary quality and nutritional value. 89 It is, therefore, not surprising that when milk sanitation in this area is weighed in the balance, it is found wanting. What will surprise many, however, is the extent of the defi- ciencies in the scale of numerical ratings. All pasteurizing plants wue surveye , ml t e stu y u farms was necessarily reduced to a random sampling. Only the Cities of Milwaukee and West Allis main- tain any semblance of milk super- vision. The following table tells an eloquent story: nine production and butter fat. Even the grading terminology is wholly deceptive in comparison with the generally recognized standards, Grade A in Milwaukee means some- fhiriP- miite different from Grade A undfr the s0.ealled standard Ordi- nance. Locally it signifies only a , t ,, » , , , N* butter fat content, whereas in standard terminology it connotes a high degree of compliance with all of the specifications for superior sanitary quality milk, as well as its 2. Until such time as the collection of fees for inspection services is eliminated, all fees from businesses in Milwaukee be collected by the City Health Department even though part of certain fees must be trans- ferred to the state. 3. Arrangements be made, with the „ xl assistance of the officials of the several governmental units of the county, whereby the personnel of the State Board of Health can be increased so as to render more ad- Retail Raw Milk Raw Milk Sold to Plants Pasteurization Plants Total % Farms Rating Total Farms No. Surveyed % Rating Total Plants No. Sur- veyed % Rating Percent Rating of Percent Enforce- Rating of ment Past. Milk Methods Milwaukee . 2,510 49 51.71 14 14 77.26 68.74 51.90 West Allis . 834 25 50.58 8 8 64.01 59.47 35.00 County Area 12 47.60 244 25 48.34 10 10 35.24 39.09 * *The County Area includes those dairy farms and pasteurizing plants not under supervision of either Milwaukee > or West Allis Health Departments. Since there is no enforcing program, the enforcement efficiency could not : be rated. The highest percentages in all categories are scored by the City of Milwaukee, though the record is not in any instance impressive. From the above table showing the percent- age rating of raw milk sold to plants, it appears that there is little dif- ference between the milk coming from unregulated areas and that from areas under the control of West Allis and Milwaukee. The pasteurizing plants in these areas rated 35.24 percent for the County area, 64.01 for West Allis, and 77.26 percent for Milwaukee City. The sampling also showed enforcement measures rating 35 percent for West Allis and 51.9 percent for Milwau- kee City. The foregoing figures indicate that there is much room for improve- ment in providing additional safe- guards to the sanitary quality of milk, and in perfecting existing ef- forts in this direction. The report sets forth in detail the deficiencies in equipment and methods observed at the farms, in the pasteurizing plants, and in the enforcing agencies. It will be noted that some of the milk produced and sold in the Coun- ty Area is not even pasteurized. It is a sad commentary that Wis- consin health agencies, except by local ordinance, have no control over the sanitary aspects of milk production and distribution. Gen- erally speaking, the emphasis upon essential sanitation is therefore overshadowed by the interest in vol- content of butter fat and other milk solids. Local milk ordinances are anti- quated and should be brought in step with the prevailing thought and practice in the field of milk sani- tation. Likewise, the same principle should be adopted at the state level so as to effect uniformity along mod- ern lines throughout the state. This, incidentally, would greatly facili- tate the sale of milk in other states which have adopted the recom- mended ordinance as their standard. Because of inadequate standards, Wisconsin milk is excluded from some of the largest and best markets. From the local standpoint at least, one cannot escape the conclusion that the most practical and desira- ble solution to the problem of sani- tary control of milk production and distribution is to be found in uni- form regulations administered by a single county-wide agency. 0. Recommendations a. State and Local Relationships It is recommended that: 1. Arrangements be made to allocate to the Health Department of the City of Milwaukee all inspectional activi- ties within the city, provided suffi- cient qualified personnel is employed locally. The State Board of Health should limit its activity to periodic check reviews and rating surveys. visory service, conduct in-service training courses, and make check reviews and rating surveys in Mil- waukee and the county as well. 4. Representatives of the State Board of Health make more frequent in- spections of water works and per- sonally collect samples of water for bacteriological examination in the State Laboratory. Formal orders should be issued wherever improve- ment cannot be secured by other procedure. 5. The officials of all government units of the county endeavor to get the state legislature to transfer the sanitary aspects of the control of milk to the State Board of Health. 6. If the district organization is to continue to include Milwaukee Coun- ty, additional sanitation personnel be located in the district office to insure more adequate supervision over local sanitation activities. *7. From the sanitation standpoint a city-county health department be established as soon as practicable. If not possible for a considerable period of time, then there should be formed a county health department to serve that part of the county which is out- side of the City of Milwaukee. The minimum alternative would be a combination of local population groups into units of not less than 50,000. *8. Arrangements be made to cen- tralize all routine inspection in the 90 city-county health department or the city and the county health depart- ments. (If licenses must be issued by the state and fees collected by state men, this should be based upon coun- ty or city approval after inspec- tion.) 9. With centralization of all inspec- tion, the State Bureau of Sanitary Engineering devote all of its ener- gies in the county and city to check review of activities, periodic rating surveys, in-service training, and quarterly collection of water samples by its own men for bacteriological examination by the State Labora- tory. b. City of Milwaukee Health Department It is recommended that: 1. Section 70-25.1 of the Milwaukee Code be revised to limit veterinarian requirements to Chief Meat Inspec- tor and one assistant. *2. The qualification requirements for the Chief of the Bureau of Food and Sanitation be broadened. 3. The sanitary inspectors not wear uniforms. They should carry in their pockets health department badges for identification, but they should not be deputized. #4. Nuisance and certain routine in- spections be shifted to the Police Department so the sanitary inspec- tors can devote their time to matters of public health significance. 5. As funds can be made available and men can be spared, the sanitary inspectors (and the milk and food inspectors) be sent to one of the recognized in-service training schools and with the aid of the State Board of Health, inaugurate a comprehen- sive in-service training program for all of the inspectors. 6. The City Health Officer examine the practices of the department with the purpose in view of delegating authority insofar as possible. *7. The present Bureau of Inspection be designated as the Bureau of En- vironmental Sanitation under the direction of a sanitary engineer with broad public health training. c. Suburban Health Departments West Allis It is recommended that: 1. If the Health Department contin- ues as a separate unit, the sanitation force be supplemented by at least one, and preferably two, trained in- spectors. Where inspectors are employed or contemplated in other localities — Wauwatosa, Cudahy, South Milwau- kee — they should be on a full-time basis, and meet the recognized stand- ards for technical training in general sanitation. d. Public Water Supplies — Suburban Areas Recommendations on the Milwau- kee Water System were made from information in the public reports and records. No original survey was made. It was felt that information published by the Survey might be misused to the financial disadvan- tage of the City of Milwaukee. Rec- ommendations will be sent to the Mayor. In general, reports show that Milwaukee has a good water system but that water pollution is increas- ing and the peak load of the filtra- tion plant is being approached. Long- time plans should be made to meet these problems. Whether or not they are, the Survey was not informed. It is recommended that: *1. In those communities which have public water supplies — the Town of Lake, the Villages of Carrollville and Greendale, the Cities of Wau- watosa, Cudahy, and South Milwau- kee, and the Sanitary Districts of Broson Manor and Blue Mound — the numerous recommendations for immediate improvement set forth on the individual reports be carefully studied and executed. 2. From an over-all standpoint, steps be taken to form a water district to include Carrollville, South Milwau- kee, Cudahy, the Town of Lake, and adjacent areas for the purpose of constructing a joint water treatment plant and distribution system using Lake Michigan as the source of sup- ply- 3. Such a water plant be of strictly modern design and be planned with the view to expansion, either in con- junction with the water system of Milwaukee or separately to meet the needs of the entire southern portion of the county. #4. Insofar as practicable, capital ex- penditures on existing systems in suburban areas be avoided, until such time as the possibilities of a joint system in those areas are thoroughly explored. e. Ground Water Supplies, Public, Quasi-Public, and Private It is recommended that: 1. Adequately treated Lake Michi- gan water be used instead of ground water for all domestic purposes throughout the county as soon as such is practicable. #2. All existing public ground water supplies be chlorinated. *3. All abandoned wells be filled with cement grout throughout their depth. 4. Active wells and those needed as reserves be reconstructed in ac- cordance with sanitary practices in- so far as possible. *5. All cross-connections (or inter- connections) between private, in- dustrial, institutional, park wells, and public water systems be elimin- ated. Instead, a disconnected means of having the facility of the public service should be installed. 6. All regulations relative to the drilling and construction of wells be rigidly enforced. *7. There be established by the State and City Health Departments an or- ganized plan of a continuing series of bacteriological examinations of samples of water taken frequently from carefully selected wells of dif- ferent depths located at such places as would reflect contamination trends in the various aquifers in dif- ferent parts of the county. *8. All public, quasi-public (coopera- tive) and private ground water sup- plies, including sanitary districts, be examined bacteriologically with the frequency recommended by the na- tionally accepted drinking water standards. Sampling should include water direct from the wells. 9. The advices rendered by the State Board of Health to such water sup- plies be extended and made more uniform for all systems. 10. The State and City Health De- partment be sure that all operators and industrialists understand the necessity of safe bacteriological sam- ples. They should be informed that such results indicate only the qual- ity of the water sampled and do not evaluate potential hazards which may become actualities between times of sampling. However, when taken with sufficient frequency they are indicative and very valuable. 11. If further consideration is given to replacement of ground water by the return to the aquifers of used process water, due thought be given to the possibility that this relatively warm water may increase the danger to ground water by creating fissures in the limestone. 91 12. Any water which is returned to the ground be potable and any serv- ice from a city system be rendered through an air gap and be direct connection. *13. The “Sanitary District” and the “Cooperative” water supplies be routinely inspected and examined bacteriologieally by the State De- partment of Health as all of these are public water systems and relate to the health of many citizens of the county. 14. The officials of the county and the incorporated cities and villages jointly request the state legislature to provide an adequate appropria- tion for the Wisconsin State Board of Health to enforce existing state laws relative to wells, ground water, and public water supplies. f. Sewage Collection and Disposal, and Water Pollution in Milwaukee It is recommended that: *1. Construction of facilities pro- jected, planned, and presently build- ing at the Jones Island disposal plant be prosecuted to the limit in order to eliminate the need for by- passing raw sewage to the lake in dry weather periods. *2. Serious consideration be given to the immediate installation of chlorination facilities in order to minimize the influence of the efflu- ent from the plant as a factor in the pollution of the inner harbor. Such additional treatment is needed to re- duce the bacteriological load on the water treatment works and to reduce the bacteriological contamination of the bathing beach waters during the bathing season. *3. In order to secure more flexibil- ity in plant operations and avoid the necessity for by-passing, more sludge driers and more aeration be installed, and the installation of more pumping facilities be considered. 4. There be construction of addi- tional special relief sewers to relieve combined sewers of cooling and process water, as well as storm run- off water, in those portions of the city where surcharging of combined sewers is occurring. Feasibility of construction of storm water relief sewers in other areas of the city to reduce the frequency of storm water overflow, should be carefully con- sidered. *5. In order to relieve the normal and seasonal loads on the sewage disposal plant, and to anticipate the needs for servicing the entire south end of the county, a relief sewage treatment plant be installed in the vicinity of Carrollville. *6. The County Park Commission and the Metropolitan Sewerage Commission work closely together and give due regard to each other’s special interests. All conditions in streams and the lake front within the Metropolitan Sewerage District found by the Park Commission, which require special chemical or bacteriological investigation, should be referred to the Metropolitan Com- mission because that Commission has the technicians and equipment re- quired for such investigations. Like conditions in other parts of the county should be referred to the State Board of Health for the same reason. All matters relating to health and sanitation which become contro- versial should be referred to the State Board of Health. 7. Studies be continued of Lake Michigan waters to determine the degree of pollution resulting from the discharge of raw sewage into the lake through combined sewer relief outlets at Whitefish Bay, Mil- waukee, Shorewood, and Cudahy. 8. Investigation of the pollutional effect on Lake Michigan of by-pass- ing raw sewage at the sewage dis- posal plant and other appurtenances in the sewerage system at South Milwaukee, be conducted. In the event that serious pollution is found as a result of such by-passing, cor- rective measures to eliminate or re- duce by-passing, should be carried out. 9. A study be made of the sanitary conditions in Lake Michigan at South Milwaukee and the New Deal Sanitary District (Carrollville) in the vicinity of the sewer outlets from the various industries which discharge raw or partially treated sewage into the lake. Where serious pollution is discovered, the industries involved should be required to pro- vide acceptable treatment of their wastes or should be required to dis- charge such wastes into a near-by sewer system, if available. 10. Densely populated unincorpo- rated communities where the need is indicated, provide sewage collec- tion systems and disposal works. *11. Policies regarding problems of sewage disposal in the rural part of Milwaukee County outside of the Metropolitan District, be made the same as those inside the Metro- politan District by adoption of uni- form rules and regulations by the following agencies: a. Metropolitan Sewerage Commis- sion b. The towns outside the Metro- politan Sewerage District (In the event a county health department is organized, it could carry on this program in place of the towns.) 12. The people of the community be educated to the necessity for good housekeeping in the community and their cooperation in preventing use of streams for disposal of rubbish and other wastes be encouraged. g. Sewage Disposal, Town of Greenfield It is recommended that: 1. Steps be taken immediately to require all schools, residences, and places of business to connect to sewers where they are now available. 2. Public sewers be extended throughout the area within the Met- ropolitan Sewerage District. 3. Such steps as necessary be taken to effect a public sewerage system for the area outside of the present Metropolitan Sewerage District. 4. Pending the accomplishment of recommendation Number 3, all es- sential improvements be made under the guidance of the Sanitary Engi- neering Division of the Wisconsin State Board of Health. (The above recommendations concur completely with those already made by the State Department of Health.) h. Rodent Infestation and Control Milwaukee It is recommended that: 1. The title of inspector on rodent control be changed from “Extermi- nator” to “Sanitarian” or other ap- propriate designation. *2. An index of rat infestation be established for the areas under con- trol, and that the distribution of poisoned baits by the inspectors be limited to those areas where infes- tation is sufficient to warrant this procedure. 3. In areas of low infestation, the poisoned baits, harmless to humans, be distributed to interested property owners with instructions as to their use. 92 *4. A watchman be stationed at each dump to prevent unlawful dumping on Saturday afternoons. 5. An educational program through the usual publicity channels desig- nated to enlist the attention of the public in earing for minor problems about their own premises, be insti- tuted. *6. At least three “Exterminators” be added to the staff of the Health Department, and one Senior “Ex- terminator” be designated to plan, coordinate, and direct the activities of the entire group. Cudahy It is recommended that: 1. A trained man be employed, full time, to make inspections and en- force ordinance No. 250. 2. Steps be taken to eliminate the rat infestation on the dump. *3. The present dump and face be covered with soil and in the future be used only for the disposal of trash. *4. The sanitary land fill method be used for the disposal of garbage. South Milwaukee It is recommended that: 1. Such arrangement be made as to insure adequate collection of gar- bage from commercial places with- out interfering with proper collec- tion from residences. i. Milk Sanitation It is recommended that: *1. The citizens and health officials concerned and the milk interest in- volved, advocate adequate and uni- form requirements throughout the county, and over-all control of sani- tation by the Wisconsin State De- partment of Health. To this end, the adoption of the Standard Milk Ordinance approved by the Ameri- can Public Health Association, is recommended, 2. To accomplish uniformity in en- forcement, one of the following or- ganizations be established — (given in order of preference). a. A city-county health depart- ment so that adequate pay can be the means of securing highly qual- ified personnel and so that one ordinance and one enforcement procedure applies to all. b. A county health department ex- clusive of the City of Milwaukee. c. Such consolidation of health de- partments as will be necessary to establish population groups of not less than 50,000. *3. Pending the accomplishment of recommendation Number 2, the City of Milwaukee and the City of West Allis adopt the Milk Ordinance and Code recommended by the Wisconsin State Board of Health. Personnel for its enforcement should be em- ployed at the time of adoption but official ratings and rating announce- ments should not be made until one year after the passage of the or- dinance. #4. The grading of milk on the basis of milk fat (butterfat) be abolished immediately. #5, The low ratings of dairy farms and pasteurization plants in com- parison with the nationally recog- nized standards indicate the need for prompt action to correct the wide- spread deficiency in safeguards to the health of consumers. j. Swimming Pools and Bathing Beaches Bathing Beaches It is recommended that: *1. Arrangements be made for a well-planned and executed study of the contamination of the water of the beaches, including the Kletzsch Beach. 2. The study of the lake beaches in- clude a well-coordinated investiga- tion of the effects of wind direction and intensity, currents, rainfall, wet weather overflow from relief sewers, bathing loads, and by-passing at the Jones Island Plant. 3. A study be made of the effect of chlorination of the effluent from the Jones Island Plant. 4. This study include the effects up- on the quality of the water at the various municipal water intakes. Swimming Pools *1. In view of substandard design observed in a number of instances, the design features of swimming pools in Milwaukee and Milwaukee County, including the park pools, be more adequately controlled by authorities having jurisdiction. #2. Since the findings of the Survey in a representative sample of the total pools indicate inadequate sani- tary control and lack of qualified swimming pool operators, a compre- hensive program for correcting these conditions be adopted both in the City of Milwaukee and in the county. *3. Care be given to prevent over- loads in the pools. 4. Systematic courses of in-service training for pool operators be in- stituted by the City Health Depart- ment for pools in Milwaukee and by the appropriate authorities for those outside the city. k. Atmospheric Pollution It is recommended that: 1. As soon as the second set of five inspectors is trained, the third set of five be employed. It is believed that this staffing would not be inconsis- tent with the staffing in cities with comparable problems, such as St. Louis. 2. The activity be expanded to in- clude all atmospheric pollution as soon as the availability of personnel permits. 3. In due time there be transferred from the Department of Building Inspection and Safety Engineering to the County Department of Smoke Control the functions of boiler in- spection and engineer licensing, as these are related to smoke control problems, 1. Housing Permanent (Milwaukee) Since the recommendations con- tained in a recent report on housing in Milwaukee are based on carefully analyzed factual evidence resulting from routine housing inspections by the City Health Department, and cover the subject adequately, their repetition is not necessary. (See “Blight Elimination and Urban Re- development in Milwaukee,” June 1948.) Temporary Housing (Trailer Camps) It is recommended that: *1. The State Department of Health establish minimum rules and regula- tions to serve as a guide to trailer camp layout, equipment, mainte- nance, and operation. *2, Local ordinances based upon the foregoing rules and regulations specifically set forth: a. The required proportion of sanitary facilities to trailer units. b. The conditions under which water supplies may be approved or prohibited, with specifications for periodic testing of water samples. 93 c. Requirements for sewage and waste disposal. *3. Trailer camps be inspected at least annually by the local health agency having jurisdiction, and that this duty be performed by persons technically trained in general sani- tation. m. Refuse (Garbage, Ashes, Rubbish) Milwaukee It is recommended that; 1. The position of Chief Supervisor of Garbage Collection be re-estab- lished, and that the present staff of eight supervisors be reduced to sev- en. 2. If and when provisions are made for a chief supervisor, he assume full responsibility for coordinating all factors in connection with the collection of garbage. *3. In order to reduce long hauls and to relieve the increasing load upon the present plant, plans be made promptly for locating a site for an additional incinerator, which should be constructed in the near future. *4. The present incinerator be over- hauled. 5. Collection records be established and changed, when necessary, so as to keep a crew of designated loaders occupied for a full eight hours per day, and that the collection crews be limited to two collectors to each collection vehicle. *6. A study be made to determine the extent to which basement col- lection service increases the total cost of collection. If found exces- sive, this service should be elimi- nated. 7. Further consideration be given to the question of purchasing mod- ern equipment for ash and rubbish collection (see the committee report to the Board of Estimates, January 1948) in accordance with unresolved questions raised at that time, one of which was the desirability of col- lection at fifteen-day instead of thirty-day intervals at an additional estimated cost (1947) of $4.00 per family per year. *8. The collection of rubbish and ashes which is now done on a ward basis be changed to a district basis to harmonize with the collection of garbage, thus preventing a con- siderable duplication of effort, equipment, and material. 9. In accordance with the foregoing, the ward offices be eventually closed and integrated with the services of the Bureau of Street Sanitation on a district basis. 10. Since additional dumping space will be required within the next year or two, provisions be made to insure that adequate dump sites, located at strategic points, are al- ways available even though this should require purchasing land sev- eral years in advance of the actual needs. Suburban Areas In the full text of the report, rec- ommendations are attached to the study of each suburban unit. To detail them here would involve mo- notonous repetition. Disposal meth- ods include open dumps, covered dumps, and incinerators. In one in- stance a sanitary land fill project is ready for operation. In most in- stances the small population in- volved makes the overhead expense for satisfactory disposal procedures too great for practical purposes. For this reason, the outstanding recom- mendations are: *1. That adjacent communities in groups as large as practicable form sanitary districts for the communal collection and disposal of garbage, ashes, and rubbish. *2. That disposal be either by in- cinerator or sanitary land fill. *3. That pending such developments all dumps in which garbage in any form is deposited, be regularly cov- ered with earth or other suitable material to eliminate rat infestation and fly breeding. 94