Mr. NELSON. My question was, have you supported the previous measures seeking this same end?

Doctor FREEMAN. Yes.

The CHAIRMAN. We are very much obliged to you, Doctor Freeman. We will now hear Mrs. Dunbar.

STATEMENT OF SAIDIE ORR DUNBAR, CHAIRMAN OF PUBLIC WELFARE AND PUBLIC HEALTH, GENERAL FEDERATION OF WOMEN'S CLUBS

Mrs. DUNBAR. Mr. Chairman and gentlemen, I appear here as the chairman of the Public Welfare and Public Health of the General Federation of Women's Clubs, and as a substitute for our chairman of legislation, Mrs. Charles Free. Because of death in her family she could not attend, for which we are very sorry. Because I am substituting for her, I have a series of notes before me.

The General Federation of Women's Clubs is the largest woman's organization in the world to-day. It is a confederation of many clubs, organized for many purposes. Some, no doubt, are not directly interested in matters of legislation, but all have a potential interest in health and welfare legislation. It is impossible for the chairman of any organization, or a department or division of that organization, to claim she is speaking for the entire membership, but as chairman of public welfare and the acting chairman of public health, I can present to you the opinion of many of our active workers.

The General Federation of Women's Clubs has faithfully supported the maternity and infancy legislation. This is true of Federal legislation, such as our support of the Sheppard-Towner Act. We have, in general conventions, indorsed the infancy and maternity appropriation bills. We have likewise given support and actively worked for State boards of health and their appropriation bills, particularly their matched funds for the development of State bureaus of child hygiene, or bureaus of infancy and maternity. Likewise we have cooperated with lesser units of official health agencies in order to bring this program down to the community.

While doing this there has been a growing consciousness of the need for more organized community health machinery. The value of our health services depends very largely on the degree of local support and participation, the demands for and the willingness of the local community to maintain permanent service.

For nearly 20 years I have worked as a layworker in public health, in a rural State and with a voluntary State association. I have been associated, however, with the workers of official health agencies and with most of the national associations. I have lived on the frontier line and have watched the application of our present day health measures and the promotion of community health programs. In fact, I have had the privilege of sharing in the development of those more or less in a large area. Without any hesitation whatever I can say to the members of this committee that our best health work is done in those communities that have the full-time county health units.

The health units throughout the United States have not come about by magic. It takes organization work and money to maintain such programs. They come from a realization of the importance of health and from a willingness to pay for such services. There has been, as you know, a program of State and Federal subsidy to counties that were interested in and willing to try out the county health unit plan. In my estimation this has been very successful. At least I can speak from accurate knowledge of my own State and from reports of other States.

In Oregon, for instance, we faced a crucial test this past fall. Six full-time county units had reached the last year of outside financial subsidy. They could continue only if they appropriated the full amount, $10,000 or more. In spite of depression, in spite of antitaxation propaganda, the entire six counties voted the full

amount.

I believe in the demonstration plan. For many years to come it will be necessary to combine all forces within the State and community. The establishment of relationships, the building of permanent health programs remains, therefore, a challenge to both volunteer and official agencies.

The General Federation believes that volunteer health agencies should work in harmony with official agencies, that we should promote our health activities in the full knowledge of official agencies. We believe that we can aid by interpreting the official agency to the community and further aid through the creation and molding of public opinion favorable to organized health services.

We agree with the statement of President Hoover that the time has now come when we should accept a personal responsibility for health comparable to the sense of responsibility we now feel for education. This can only come about as we actively participate in the local health program. The permanent value of such health programs, including intensive, continuous health services for our rural counties depends in a very large measure upon the development of similar services within the State departments of health that they may prove personal services in the areas that have neither the basis of taxation nor the concentration of population to make them self-sufficient.

Therefore, as far as the administration of the General Federation of Women's Clubs is concerned, we wish you to know that we have offered our services to the Government of our country and desire to cooperate with its various departments. In this particular matter we wish to go on record as in favor of the principles of H. R. 12995— the Cooper bill of June 16, 1930. This bill had not yet been introduced when our last biennial convention met in Denver, but in anticipation of such form of legislation, that is, legislation promoting infancy and maternity, as well as county health units, we adopted unanimously the following resolution:

Whereas the General Federation of Women's Clubs is in accord with the belief that there is a definite need for the further systematic development of public health work in the United States, and

Whereas it is our belief that the development of official local health organizations through which child hygiene and other health activities can be most economically and effectively conducted is a proper function of Federal and State Governments, and

Whereas it appears consistent with good administration that there should be cooperation between the Federal health agencies, the United States Chil

dren's Bureau and the United States Public Health Service in their respective fields, and official State and local health agencies toward this end, and

Whereas there is a most pressing need for additional Federal cooperation and support, including financial assistance in the further development of efficient State and local health service; their assistance having for its primary object the stimulation of a larger sense of local responsibility for public health work; therefore be it

Resolved, That the General Federation of Women's Clubs endorse these principles, as well as the work of the United States Public Health Service, other Federal health agencies, and the United States Children's Bureau for the further development and strengthening of State, local and county health activities and the work for maternal and infant hygiene.

It is our hope, therefore, that in consideration of the bills now before you, you will find it possible to incorporate in your final recommendations and legislation, the principles of continuing the important work of infancy and maternity and the development of local health units for the prevention of disease and the promotion of health among our rural population.

The CHAIRMAN. Are there any questions?

Mr. BURTNESS. Mrs. Dunbar, in view of the fact that you have had practical and personal experience in this field, would you mind giving us a picture as to just the organization that will be set up locally, in the local divisions, in the event of the passage of this bill? Just the practical set-up in a county, for instance, as contemplated by those of you who are supporting this legislation?

Mrs. DUNBAR. There are some counties in the rural States where such machinery would have to be contemplated somewhere in the State board of health; in other words, they would have to so strengthen the State board of health that it should carry definite responsibilities for personal service in those areas, until the time when those counties could financially subsidize themselves in whole or in part. Please note, gentlemen, that in many of the rural western States particularly we have practically no health machinery. We have a county court of three members, a judge, who is not a legal judge, as you know, a man elected to serve as county judge in civil affairs, and two commissioners. They constitute the county board of health. You may have practically no county physician or health officer. You may have a man subject to call who may be paid on a fee system. You may have a man who is paid $40 a year, which is not unusual at all. He does not feel any responsibility for the development of the health program or health consciousness of the people. Now, then, in such an area as that, when you have a county as large as the State of Connecticut, with less than 4,000 people in it, you can understand that there is not so much the personal application there, except in times of stress. That leadership, then, will come from State-wide agencies, that maintain staffs who visit that territory, plus the personal members of the State board of health that go in. Mr. BURTNESS. Just what do they do?

Mrs. DUNBAR. For instance, we will take the county

Mr. BURNTESS (interposing). I am quite familiar with the general situation, but what I am trying to get is a picture of the change that will come about with the enactment of this bill.

Mrs. DUNBAR. All right, I will draw from my imaginational experience a county that has just about twice the size of the State of Connecticut and has less than 5,000 people in it. Every member of the State health agency, past member, goes in and reports first,

as is the custom, to the State health officers and says, "We are entering Blank County. Is there something definite that we may do?" The health officer then may assign some definite responsibility. If the worker is a public-health nurse, she will do actual case work, as well as teaching. If the worker is a member of the health educational department, she will do that type of work. She may be a teacher before the institute. She may have to speak before the women's clubs or the parent-teachers' association; she may carry with her literature on maternity and hygiene in the State board of health; she may enroll the mothers in the maternity letters from the State bureau on maternity and infancy; she may have conferences with the county judge and the county health officers. If she is a nurse, she will do individual case work. All the time she enters the county as a health teacher, and we do that, particularly those of us who represent voluntary agencies, and then when we get into the professional field a doctor from the State board of health, an epidemiologist or bacteriologist, as is necessary in a case of epidemic, will do direct case work and personal contact.

Then we have adopted another program that works very successfully through the cooperation of State boards of health and voluntary agencies of the medical profession. We are all the time trying to raise the standard of medical relationship of the community in this way. If we have a fine expert, who is an expert in one line, the medical men of the county will be called together to confer with him on that. If they wish to use him as a consultant in clinic service, a temporary clinic will be set up. The State board of health will send out workers regularly to various sections of that county or that State for clinical purposes. We may establish a sort of a temporary dispensary in which we all pool the money and establish a health center in which the lay workers and the professional workers may come for the purpose of meeting the patients or for consultation.

Mr. BURTNESS. Your remarks so far in response to my question have been directed largely to the sparsely settled, poorer counties. Mrs. DUNBAR. Yes, sir.

Mr. BURTNESS. Now, what would be the set-up in the more densely populated counties, for instance in a good agricultural State, counties which can afford to cooperate, and so on? What is the practical setup there?

Doctor McCORMACK. You mean what would be the set-up where you have a full-time health department?

Mr. BURTNESS. Yes.

Mrs. DUNBAR. If you mean where we have a full-time health unit, which consists of a full-time physician, at least two full-time nurses, a clerk in the office, and offices, it is more or less a matter of the standardization of work and stimulation and extension of services. Now, you will find that that health unit, which is a service unit for the whole State, which is up to your State board of health and to State-wide health agencies-we will take tuberculosis, for example for a special consultant to come there and do special work in an intensive way, which can easily be done because they have so much more machinery. It is in standardization of work, in promotion and stimulation, more than it is in the personal contact.

On the other hand, they may call workers from State boards of health or State agencies for an intensive campaign.

Does that answer the question?

Mr. BURTNESS. I think so.

Mr. GARBER. Are you familiar with the administrative provisions of both the Senate and the House bill?

Mrs. DUNBAR. Fairly so-only as a lay student could be.

Mr. GARBER. Are they, in your judgment, sufficient to properly safeguard against any duplication of services?

Mrs. DUNBAR: I believe, sir, that any operation of infancy and maternity acts in the past, and in the development of full-time county health unit work, we are doing away with duplication very largely. Please know that the personnel in the larger rural States is limited. We all know each other very closely; we know each other's program more intimately, probably, than in the more intensively organized States where they have a larger personnel and more money and more machinery and all that sort of thing, and there is a better giveand-take policy as to responsibility for the opportunity of service, and I believe there is very little duplication. I know that the voluntary agencies that have their own funds seek, first, to know definitely whether service is maintained by the State board of health and the State health agencies, and then build their program accordingly and say: "Will the work that we can do, or may do,-will that support and promote your program?" We are working on a demonstration plan and idea, to promote the official health agency.

Mr. GARBER. Would not a health demonstration include a children's demonstration in any State?

Mrs. DUNBAR. Yes, sir.

Mr. GARBER. Now then, if there were not some provision, would there not be duplication in holding two demonstrations where one would suffice?

Mrs. DUNBAR. You have very little chance of that now because your child health demonstration you are referring to the Children's Bureau through the official health agency, if that machinery exists. We all do that. That is our policy.

Mr. NELSON. In that controversy, which I understand exists as to the supervision under which this work of maternity and childhood hygiene should be administered, what position has your organization taken?

Mrs. DUNBAR. I do not speak for an organization that has a membership of two and a half million; I only speak for the leadership of the departments that are concentrating their study on this question. Our opinion is this: In the last analysis infancy and maternity is a part of the general health program. Its exact interrelation to that

Mr. NELSON (interposing). Will you tell me what position those that you represent took in that controversy?

Mrs. DUNBAR. Yes; we believe that in the last analysis maternity and infancy is a part of the general public health program. We believe that you can not promote your very best public-health program or infancy and maternity program except in its relationship to the whole. I think that the bureau has given that a great deal of consideration and thought. You can not think of maternity and infancy