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ally, without such service to follow up those who leave your institutions, the benefits derived from treament are all too often sacrificed and your best efforts made of no avail. One person in each county alert to the needs of these individuals and regularly on the job, if properly trained and otherwise qualified, not only represents the help she can give with her hands alone but likewise is the key to the intelligent cooperation of the patient's family and of the community.

If this contention is sound then the superintendents are in an excellent position to know which local communities have effective organization and qualified leadership in their local welfare work. Just as Doctor Scarborough can tell which communities have physicians who are alert to detect the early symptoms of tuberculosis and firm in insisting on treatment while there is yet hope, you have detected which communities are using your institution merely as a place in which to hide away some poor victim whose remaining value to society is only the warning to be taken from his hopelessness and which communities are turning to you for a finer kind of constructive service.

Your respective institutions are vantage points as it were from which you can view the social tendencies of various communities. The differences in the problems they send you give a perspective frequently that is lacking to even the most observing members of the local group itself.

The State Conference of Social Workers is trying hard to induce each county to engage at least one trained worker. The success of the so-called "Iowa Plan" by which county boards of supervisors and private organizations pool their resources, has greatly stimulated this movement. Here is where we believe and hope that you individually will find opportunity to make the lessons learned from your observations count. The case that ends in a disaster which some such service might easily have prevented, should not be allowed to go unnoticed by those in responsibility in such community or county. It is equally important to point out the happy results of effective work. Is it too much to ask that the superintendent of each state institution consciously measure and in some proper way, give back from time to time to leaders in each county your observations of their successes and failures as revealed in the condition of the individuals sent and resent to you.

If it is not beyond the scope of this conference a resolution adopted here urging and commending the employment of a trained social worker in each county should prove a most valuable aid.

Humans are particularly loathe to be controlled by law, if the attempted control seeks to modify or curb those activities which we choose to call charitable. Every foster parent thinks just enough of him or herself apparently to be quite convinced

that he or she is bestowing a great blessing by consenting to adopt some poor helpless babe. One feebleminded, hopelessly incompetent and not altogether moral foster mother was never the less quite genuinely philanthropic in spirit, I am sure, when she quickly volunteered and accepted the burden of raising the little one, who by his miraculous escape from the accident that killed his parents, was presumably intended for something better. There are many adoptions however that are not so frankly and truly conceived in a feeling of charity toward the child. A young girl recently appeared in a juvenile court. She had been a foster child only a few years but in that time her chief foster parent had been on one side or the other in three divorce trials. We detest the man who wishes to adopt a child in order to profit by that child's work. Should we have any more sympathy for the woman who seeks through the adoption of a baby to cement the fast breaking ties between herself and husband. We do not claim to know what the exact solution is, but with these sort of cases all too common, we feel it is in order to urge that a state law which permits of any person adopting an innocent, helpless baby without even the formality of a hearing is far too inadequate.

The third proposition was that the child placing practices and institutions of this state should be studied. Studied is not just the word, but what I have in mind to throw out for whatever value it may have as a suggestion is not what you would call an inspection, a survey or supervision, and I am conscious that this board has under the law, very full powers in the latter direction with these institutions. What I have in mind is more of a cooperatve undertaking than any of the above terms suggest. The study I would propose is a self study to be made of these institutions by the institutions themselves. The study to be initiated, guided and followed up however, by this board itself.

Not a few reports received in recent months indicate that some of the placement work done by institutions incorporated and supported for that work are little better than some of the chance adoptions referred to earlier in this paper. Well known standards of child placing we would judge, have not in recent years been strictly adhered to in Iowa. Feebleminded children have been given out for adoption. Unfit applicants for children have been allowed to take babies from institutions either through failure to investigate the applicant or through poor judgment as to who is fit. Children reported as improperly cared for in their new homes have gone weeks without attention and in one case we are told the excuse was that the placement worker was also the financial agent of the institution and had not been able to collect enough money to make the admittedly needed visit to the charge.

Now in spite of these reports I would imagine one would find those in charge of these private child placing institutions quite as anxious as anyone to do their work as it should be done. An investigation would possibly reveal a reasonably high average grade of work.

These institutions are by law expected and I presume they do report annually to this board concerning the

Number of children cared for

Number received first time

Number returned from families
Number placed in homes

Number deceased

Number returned to friends

Number placed in state institutions

Number, name and number of months of the children attending school.

Receipts and disbursements

Amount spent for salaries

Amount for other expenses

Amount spent for land, buildings and investments; and,

"No child shall be committed to any institution which shall not have filed a satisfactory report for the calender year last preceding."

The intent of this law would seem to be to give this board power not only to protect these homeless children from any abuse or neglect but also power to insist on reasonable minimum standards of placement work. This may be too liberal an interpretation, but our proposal is not one involving force but rather cordial cooperation.

The annual reports of these institutions are required in January. Why not invite the superintendent of each institution, and there are at least four or more in the state, to bring his report in person to a one day conference in which this board or your representatives would sit. Let each superintendent tell what his or her institution has done and answer such questions as may occur to you or the other superintendents about his work. Such a conference might properly consider

1 Investigation made of the foster home before child is placed 2 Conditions in which children are accepted

3 Examination and study of child before given out for placement-physical, mental

4 Probation period

5 How the unmarried mother is dealt with. Responsibilities of illegitimate child's father

6 Financial problems of institution

Money raising methods

Cost of raising funds

Such a conference has merit not only because of the help it might give the board in connection with your work of supervision but also because of the lessons the institutions themselves would learn from each other and teamwork would develop.

NEWER STEPS IN THE PREVENTION OF DIPHTHERIA

IN THE STATE INSTITUTIONS.

M. R. French, M. D., Assistant State Epidemiologist,
University of Iowa, Iowa City, Iowa.

The importance of diphtheria as one of the contagious causes of death is clearly shown in the mortality statistics for 1920 for the United States registration area. Among contagious diseases, diphtheria ranks fourth with a death rate of 15.3 per 100,000 of population; tuberculosis comes first with a death rate of 100.8 per 100,000; pneumonia second with a rate of 82.7; and influenza third, with a rate of 71.0.(1)

But even with this high death rate from diptheria it seems very low in comparison to the rate in pre-antitoxin days. In 1890 in the United States registration area the death rate was given as 116.5 per 100,000 of populaton. Following the introduction of antitoxin in 1895 the death rate fell from 116.5 to 43.3 per 100,000 in 1900; 21.4 in 1910 and 16.5 in 1917.(1) This latter fall is undoubtedly due, not only to the early use of antitoxin but also to better laboratory facilities. From 1917 to 1920, however, in this United States registration area, the death rate has not fallen. In fact the rate has increased slightly. In 1918, the rate was 13.9; in 1919, 14.7; and in 1920, 15.3.(1)

Thus antitoxin and better laboratory facilities for the detection of cases and carriers has very materially reduced the death rate to a certain minimum. Below this minimum, it seems to be very difficult to lower these figures unless we use different methods than we have in the past. This is due to the fact that diphtheria is an insidious disease. The child in the home and in the school has a mild sore throat which does not cause him much inconvenience. Thus several days elapse after the child has a beginning of the sore throat before the doctor is called, and by then it is frequently too late for the antitoxin to have its full effect for the toxin has had an opportunity of fastening itself to the nerve structures and heart. Further, diphtheria has appeared these past few years in communities in which there has been no diph theria for fifteen or twenty years. Not expecting and not recognizing the disease, parents and even sometimes physicians have delayed giving antitoxin. As a temporary measure the culturing, examining of all exposed and the isolating of carriers and suspicious cases has very effectively stopped an epidemic in schools

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