THE Centre is an instrument devised to throw up health from a sample of the populace, as a separator throws up cream from milk. This book has in the main dealt with the appearance of health as it is beginning to come to the surface. The large residue of ‘not health’ has been dealt with only in the last chapter and in the first two sections of chapter 6.
The day to day work of the Staff however is necessarily determined by the nature of the total content of the Centre membership. It is not our concern to treat disorder, but that disorder should be removed is a necessary preliminary to the cultivation of health. So it comes about that we are in continuous contact with every type of therapeutic agency willing to deal with members recommended by us for treatment. In this way the Centre has been the means, not only of referring many of its members to the appropriate source of treatment for their physical disorders at the earliest moment they are detectable by a trained diagnostician, but also of putting them in touch with public and other auxiliary services with the existence of and means of approach to which they were often ignorant: e.g. the Ivory Cross, the Hospital almoner, the Charity Organisation Society, etc. In this way many families have been saved much waste of time and needless anxiety as well as much protracted ill health.
But there has also fallen upon the Staff the responsibility for dealing with a wide borderland of conditions never hitherto systematically encountered by any therapeutic agency, and for which consequently no diagnostic or therapeutic provision at present exists. Often, too, where provision of this kind does exist, the circumstances in which it is procurable are such as needlessly to interrupt the daily life and work of the individual. This is something to which he will not submit—and which would be detrimental to his health were he to do so. The individual, as we have shown elsewhere, [Biologists in Search of Material, p. 78 et seq.] from the youngest to the oldest, seeks to maintain himself to the last minute in his social situation, however poor that be. Even at the cost of considerable suffering, men and women will not “give in” until they must. The Health Centre is the first and only organisation that openly conspires with the individual so to sustain himself in his society, while at the same time taking deliberate measures for the elimination of his disorders—even the most trivial. This of course at once wins the individual’s confidence and co-operation, but in the present circumstances in which the therapeutic agencies are not yet organised for the reception of disorder of those not manifesting the symptoms [In medical terminology a “symptom” is what the patient complains of; a “sign” that which the doctor finds wrong.] – of physical or social disability, it also throws onto the Staff much work for the reception of which in the future the therapeutic departments will be organised.
There are many instances in which, from the point of view of the cultivation of health, it appears important to eliminate some minor disorder or abnormal tendency, but where to the therapist the disorder seems to be so trivial as to have no importance, or on the other hand to be so intangible that it is beyond his scope with the instruments and circumstances at present at his disposal. As time goes forward these difficulties will solve themselves, for were the therapeutic agencies to be consistently supplied with the early case, which at present does not reach them, they would undoubtedly devise an organisation to suit its needs.
A second factor of importance in determining the balance of work of the Centre’s staff is the fact that the longer the duration of the Centre’s influence in the cultivation of the health of its member-families, the greater will be the body of health among them. So year by year there must inevitably be a consistent shift in the consultative work of the Staff, away from the interruptions caused by the necessity of eliminating disorder, towards the elaboration of technique for the cultivation of health.
Of whom does the Staff who carry out this work consist? For the 1,200 or more families with whom we have been in contact in the past four and a half years, there have been working five biologists, three or four with medical training and experience —senior and junior doctors; one or two with a science training, acting as curators of the instruments of health; one bio-chemist with assistant, a certified Sister midwife, a receptionist, two nursery supervisors, a cafeteria manager, a general floor manager, a secretary, and students of biology attached as occasiondemanded to various members of the Staff. All except students are whole time workers present daily from 2—10.30 p.m., Sundays excluded.
Five days a week, Saturday evenings included, the periodic health overhauls go forward from 2 to 10 p.m., by appointment at the convenience of the member-families. Daily all the equipment of the Centre is available for all its members. It has been a strenuous four and a half years for the Staff confronted with entirely new material and having to approach that material with a new outlook. Sustaining the routine of examination alone demanded organisation and the evolution of a technique of approach, which was exacting. To those medically trained, the discipline required to concentrate on health in the presence of such a wealth of new material of clinical interest was rigorous. It often implied a unique clinical opportunity personally to be foregone. But perhaps the most difficult task of all has been to refrain from following the many lines of special research, clinical as well as biological, that unsought have opened up, constituting an ever-present temptation which in the beginning had to be resolutely resisted. Our first necessity was to work out the general lines of procedure essential to a health organisation, and to learn the type of approach suited to health practice. Only now are we beginning to be ready to inaugurate within the Centre special researches, the material for which is ripening with such abundant promise in many directions: in medicine, in welfare of every sort, eugenics, psychology, education of the family and of the child, economics of the family ; and above all in the nature of health and its cultivation.
A review of any week’s work by the Staff of the Centre will disclose the range of material covered in their routine. It will be found that they have handled [See Appendix IX. Financial and Administrative.] work which in the ordinary circumstances of present-day administration is carried out— usually at a later period in the history of the individual—by a wide range of public and charitable services. The following is a list of activities both cultural and corrective covered by the Centre for its member-families.
Therapeutic
- Marriage Advisory Bureau
- Mothers’ Clinic (diagnosis only in the Centre, with personal reference to source of therapy)
- Child Guidance Clinic
- School Care Committee work
- Poor Man’s Lawyer
- Hospital Almoning
- Hospital Follow-up, including all forms of after-care for all members discharged from medical care
- Rehabilitation Clinic
Welfare and Educational
- Ante-natal Clinic
- Post-natal Clinic
- Birth Control Clinic
- Infant Welfare Clinic
- Care of the Toddler
- Nursery School
- Immunisation Centre
- Medical Inspections of the Schoolchild
- Vocational Guidance
- Sex instruction of adolescents
- Girls’ and Boys’ Clubs
- Youth Centres
- Sports’ Clubs and Recreational Clubs of all sorts
- “Keep Fit” and Gymnastic Classes
- Adult Cultural Education : Music, Debates, Drama, any classes or lectures desired by the members
- Citizens’ Advice Bureau
- Holiday Organisations
- Outings and Expeditions of every sort
- The Public House
- The Billiard Hall
- The Dance Hall
- Social Gatherings
For the carrying out of all these activities the Centre organisation has been found to be peculiarly well adapted for the following reasons :—
- The Centre being a family organisation, and its varied activities being carried on in such a way that they convert all situations into material for the self-education of its members, both the family life and the social environment in which the family moves is being continuously enriched. Working not in an admonitory, and not in a palliative fashion, the Centre is thus a local cultural (i.e. developmental) factor in family life.
- Since the Centre is the families’ own Club— of which its Staff are the servants —the members suffer no patronage, no loss of prestige, no sense of inferiority and no undesirable publicity in gaining information, advice or help of whatever sort they may be in need. As the services of the Centre are arranged to serve the family in its leisure, use of them incurs no loss of time, nor financial loss concurrent with loss of time.
- Since the Staff of the Centre come automatically into possession of exact information about each member of the family, the main content of which is necessary for the carrying out of any of the above activities, no time is lost in difficulties of approach, nor in gaining the confidence of families, before appropriate measures can be taken to meet adverse circumstances as they arise. More important still, the Staff often being in a position to know of the needs of the members before they themselves become aware of them, can throw a ‘spotlight’ of knowledge on to the path ahead, while concurrently providing raw material the use of which is likely to further the development of the family; and where health is absent, the Centre may be able to forestall and prevent the occurrence of disease and certainly prevent its chronicity.
- The very existence of the Centre affords an influence operating continuously to change for its member-families the environment out of which the majority of their disorders have sprung. Its power to counter disorder is therefore, radical.
- Where the Centre has been obliged to operate as a corrective agency, its member-families, on being relieved of disorder which tends inevitably to separate or encyst them in society, find themselves already embedded in a cultural milieu into which their re-absorption is easy and natural.
- The Centre is statesmanlike in constitution, for through its operation it enhances the capacity of its member-families to acquire knowledge and experience and hence to take responsible action for themselves.
- The Centre is basically economic in operation, for it cultivates human potentiality and forestalls disorder which hinders expression of his potentiality. It is cultural, not curative; radical, not palliative in method.
- The Centre, in the presence of an adequate wage for the worker, is financially equitable and well-founded. It proffers goods and services elsewhere unobtainable by its members, the consumption of which is highly desirable alike to the members and for the community ; and the purchase of which affords an opportunity for the exercise of responsible and progressively discriminative action on the part of the family and the individuals who go to make it up. The Centre being so constituted as ultimately to be sustainable by membership subscriptions,[See Appendix IX. Financial and Administrative.] is in strong contrast to the prevailing trend of affairs in which the State or charitable societies themselves assume for the public the responsibility for spending, and for which function these agencies are increasingly driven to set up extensive, dissociated administrations, all too often in an ad hoc fashion. By thus shouldering the responsibility of the individual, these provisions are un-wittingly depriving the family of one of the primary chances for expression of the health and virility of its members. The Centre—one single organisation—meets in the course of its ordinary routine the needs now partially met by a large and growing number of specialist organisations, many of them overlapping and none of them accurately articulated one with another.
Throughout this narrative, we have seen how the Centre organisation fulfils in abundant measure the family’s needs for knowledge and for action in all the phases of its growth: as for example in ante-natal care and infant welfare, in biochemical, medical and social inspection of the school child, in the health overhaul and vocational guidance of the adolescent, in education of the parents; and above all in the opportunities it offers to the young couple at the time of courtship and mating. We have also seen the advantageous position in which the biologist is placed for carrying out these duties where periodic health overhaul of the whole family is the basis of his or her approach to every individual; where opportunity to see the individual in action in the freedom of his leisure is added to knowledge gained in the consulting room ; and where the instruments for the promotion of health are continuously at the disposal of both the biologist-cultivator and the family. It is incidental, but none the less striking for that, that these conditions, necessary for the cultivation of Health, fulfil abundantly the optimum conditions desired by the therapist—medical, social and psychological alike.
In illustration of this administrative issue let us take as an example Child Welfare. In the Centre we cannot be said to do ‘Child Welfare’, for as we have described in chapter 9, we approach the child through the family, both mother and father being implicated in all action vis-à-vis the infant.
Now, useful as the Child Welfare Service has proved for the prevention of sickness and mortality, it is at a hopeless disadvantage for the cultivation of health. Not only does it deal with the infant as an isolated unit, but in many instances it is not even in contact with the mother during, nor is charged with the care of, the most crucial phases of differentiation, namely early foetal life and the first few days after birth. Its primary aim— that of the cultivation of health—may thus well be a lost cause before it can begin!
There will of course always be the sick child, for whom clinics will always be a necessity. But the Infant ‘Clinic’ as it at present exists is an anachronism. It is not a clinic for the sick—for its doctors, and with some justification, are not permitted to treat the infant if sick, but must refer it to a clinician. Nor is it a ‘health organisation’, for it has ho instruments for the cultivation of health, and is content to work under the disability of dealing with the infant as an entity dissociated from the natural mechanism for nurture—the family. How could the horticulturalist cultivate his plant if his procedure were strictly limited to the care of the bud as it opened? All he could do would be to apply insecticides and powders to preserve it from the depredations of its enemies: that is, to cure its infestations. The position of the Infant Welfare worker is but little better.
In all too many cases the Infant Welfare Clinics have no contact at all with the family before the birth of the child, and have to rely on house to house visits of the Health Visitor to ensure the mother’s attendance. Where Infant Welfare and Maternity services are carried on as separate organisations with separate staff, these visits are made for the first time after birth of the child. [The law provides that they shall not be made till the midwife leaves; i.e. after the 14th day !] The mother comes at her leisure—three to six weeks later—when the first steps in the ‘birth weaning’ have all too often become but a series of blind stumbles, ending, often before arrival at the Clinic, in abandonment of breast-feeding and in the gathering chronicity of those puerperal ailments of the mother regarded as minor and therefore all too often disregarded.
It must be noted that if at the ‘nesting’ period the dwelling is to be kept inviolate, which, as we have shown, is instinctive and necessary for function, all educative factors concerning the hygiene of the nest, etc., must be undertaken before birth; for, whether well or badly wrought, from the biological point of view the nest can only be made worse by intrusion of that which is foreign and non-specific, when it has become the seat of functioning. So that any form of organised visitation of the family by strangers during these early weeks is to be deplored. A little boy’s finger in a bird’s nest may lead to the abandonment of six eggs and the making of a new nest and a new effort at egg laying. Too early handling of a rat’s young may lead her to eat them. The human mother so interfered with is liable to eat her child—spiritually.
It is well known and universally deplored that the Infant Welfare Organisation has difficulty in retaining its hold on the infant that is not sick; while all deplore the fact that attendances fall away by the end of the first year and the growing child is then lost sight of. The scope of the organisation and its appeal are too limited.
There is one more point: and one no less important. All organisations to maintain their appeal and value to the community must allow of the progressive development of the craft of those employed within them. What of the Infant Welfare practitioner [Although the attendances of infants at Welfare Clinics appear high, the figures are in fact misleading, for they are arrived at by dividing the total attendances of all infants by the number of infants attending. Thus where some attend regularly, many may have attended but once during the whole period of infancy.] He or she, trained in Hospital upon the sick child, has in the majority of cases never been in contact with a child not sick till taking up Welfare work. Thus, initially without special experience, it is at her job that she must learn all she knows. But there, armed with nothing but a stethoscope and a weighing machine, she is cut off from all the scientific instruments of her profession and is bereft of a laboratory for routine or research purposes—a primary essential to all scientific practice. She is so overburdened with work that she must attend almost exclusively to the most disordered and has but little time to give to cultivation of the healthy; she has no commission to devise apparatus or instruments proper to the cultivation of health, and in many cases has not even a nursery at her disposal and under her scientific direction, to which to refer either infants or mothers needing education or scope for development—even as a preventive measure for impending difficulties clearly foreseen. The terms of reference of her post forbid her to treat the mother, bound up though the mother is with the infant, and—unless out of hours—-she has no opportunity of knowing the father.
Last of all—specialist though she is by calling in Infant Welfare —she has no place in nor authority over the care of the infant in the Maternity Home, which is under the control of an obstetrician who is not a specialist in infant care. Indeed, so poor is the co-ordination of medical work in this field that the Child Welfare Officer does not as a routine receive the courtesy of official information as to what has befallen either infant or mother during confinement, indissolubly linked though they are at this period.
Thus bereft of suitable equipment and circumstances, and equally shorn of a proper professional status, how can we expect progress from the doctor in this field? As for research, the possibilities are indeed remote. The organisation—as Child Welfare workers, medical and lay, fully realise—is not comprehensive enough to allow of rational handling of the work it is designed to do—namely the cultivation of health. A club for familes such as the Centre, on the other hand, fulfils each need of all concerned with the care of the infant.
Let us take one or two other examples showing how the service rendered by some of the special agencies listed above are met by the Centre organisation. The conduct of Child Guidance affords a good example. In the Pioneer Health Centre there automatically accumulate in the dossier of each child :—
(1) Health records of the individual which include :—
- ante-natal and post-natal records up to school age;
- periodic health overhaul at not more than six-monthly intervals after he reaches school;
- running observations on his physical, mental and social aptitudes as they have developed spontaneously in the freedom of his leisure.
(2) Records of his family (parents and brothers and sisters) from the medical, social and functional aspects.
The basic information necessary is thus already at hand, and from the previous personal observations of the person whose duty it is to deal with the child. Still more important perhaps, once the nature of the disorder is diagnosed, there are at hand instruments and social situations, all of which are at the disposal of the biologist for the early rehabilitation of the child; and it must not be forgotten that this includes a situation in which the rest of the family take their part; they are therefore as open to influence as is the child himself. Lastly, instead of having to congregate a difficult child with other difficult children in the process of being cured, in the Centre the child is already in his place among a preponderance of normal children and in a mixed society which includes people of all ages—in itself a health promoting factor, inducive of social ‘order’.
The first person to admit the need for (1) intimate contact with the family of the difficult child, and (2) a means of modifying the environmental conditions of that family, is the Child Guidance practitioner. Apart from the Centre these necessary conditions have however proved to be among those most difficult to achieve.
Let us take as another illustration of a provision recognised by the clinician as necessary but hitherto inadequately met: namely the ‘follow-up’ after all sorts of institutional treatment. On discharge from costly treatment of a highly efficient and elaborate technical order such as surgical operation or the care of fevers, the patient, debilitated from sickness and inaction, is returned home. Illness has probably drained the family purse, anxiety has worn down its resistance. It is into such a home atmosphere that the invalid is returned, cured of his illness, but nevertheless still a victim of the debility resulting from it.
As a member of the Centre he straightway receives, not a medical examination, but a health overhaul. His depleted reserves are attended to, his physiological capacity assessed. Thus armed with knowledge of his condition, he now finds at his disposal the instruments of the Centre and its society to draw upon for his convalescence. In this way the skill that has been so lavishly provided for the care of his illness in Hospital is enabled to bear maximum fruit in a quick recovery of health. Meanwhile the spirits of the patient and of his family are continuously sustained and refreshed, and the retreat from society that comes so commonly with ill health in the family, is avoided.
Many a child returns from the Fever Hospital debilitated, only to crush its nose against the window pane of the front parlour for weeks of ineffectual convalescence. Its parents all too often are in complete ignorance as to what happened to it while in Hospital, its reserves are depleted and its minor ailments go unattended. Many a heart case or healing fracture remains stationary for weeks, lack of knowledge having engendered— in the individual or in his parents—the fear of bringing a once injured organ or limb into active use on return home. How invaluable, for example, it is at such times to have at hand a swimming bath—and under supervision—for the after-care of this type of case.
Preventive measures in general fall no less easily within the Centre organisation. Take for example immunisation against infections. In the early months of the Centre’s work, measles broke out in a neighbouring school. A mother who had a child at that school asked for an appointment to see the doctor for a few minutes. She had heard that children could now be protected against measles and wanted to know if her boy could ‘be done’, and if it would be wise to have her baby done too. Could the Centre do it for her? The medical staff had been waiting for just such a question. Willingly. An appointment was made and the mother brought her two children. Afterwards she had tea in the Cafeteria and there friends gathered round her to hear what she had been doing upstairs. Could they have their children protected too? A stream of enquiries reaches the Receptionist. If they have young children at the same school, appointments are made for them; if not, they are told that since this immunisation is not of long duration, it is inadvisable to have it done unless their children are directly exposed to infection, in which case they should come at once. They understand. Perhaps as they leave the Consulting Room it is time to fetch their babies from the Nursery; there the gossip spreads; more mothers hear; all begin to want their children protected too if there is any danger. No posters are necessary; no persuasive lectures; only a free seeping of information throughout the society of the Centre and there is stirred a growing sense of the family’s responsibility for the nurture and care of its own children. The Centre has aroused an ‘appetite’ for parental action and has avoided the necessity for persuasion or coercion, the use of which so often engenders reaction and militate against progress.
Immunisation against smallpox, diphtheria, whooping cough, scarlet fever, septic infections and many anaphylactic conditions are all carried out in the Centre, the desire for them arising in the same topical way or through knowledge spread by gossip among the members. It should be noted in this connection that where the immunising procedure is a well-established one, the cost of the material is always made known to the family (for the purposes of education) but the cost of the service is regarded as covered by the family subscription; the net cost of the material is paid by the family—and ungrudgingly. In the case of vaccination or immunisation against diphtheria, all our members were in a position to choose whether it should be done in the Centre or, without cost to them by the public services. In the case of diphtheria, the total cost of immunisation with subsequent Schick testing was 2s. 6d. per child when shared by several families. The cost of vaccination was 9d. for one infant, 4d. when shared by two. To reduce this cost to the minimum it is thus in many cases necessary that groups of families should share the material. The finding of friends, or the meeting of mothers not known before, to form a group of a suitable size, is in itself a factor helping to spread both the knowledge of and the desire for immunisation. In the Centre every incident like this affords a possibility of a new social contact, thus tending to social integration, and to social education.
There are among the objects covered by the list given in the early part of this chapter, several of which impinge on the married woman and mother. There is nowhere outside the Centre any cultural organisation—with the exception of the Women’s Institutes and Townswomen’s Guilds— which is centred about her, to encourage and foster her education as a home builder. Still less are there any centred on the family as the natural instrument of growth and development. The Centre is the only organisation, so far as we know, which operates exclusively on the family, and which does so acting at all points topically for the education of the family as a whole—father, mother and children simultaneously.
Usually to enjoy facilities such as the Centre offers, the individuals of a family have to scatter in different directions over the town, while almost all are too far away for the mother to use them with any regularity. But where, as in the Centre, so many facilities are centralised, all are brought within reach of the whole family. It is necessary to stress the fact that the Centre affords a local medium of society easily penetrated by the mother, for only in such a way can she day by day draw knowledge and experience to knead into the life of the home as the primitive woman kneaded the dough that nourished her family. Unless such experience and knowledge can reach the mother, the experience of each individual of the family cannot be transmuted into and become an integral and live part of the home.
In a household where there are young children, the rhythm of the mother’s day is set unalterably by school attendance with its consequent journeys to and fro, alternating with meal times, preparation of the children for bed, etc. Into this framework she fits her domestic work and within it finds her necessarily scattered leisure. When the father’s working hours are such that his return to the evening meal, even at a late hour, is regular, the family have the advantage of some leisure together. But often there are conditions over which the family have no control; for example in many cases the man’s work is in shifts, changing every week, so that the varying times alter his meals and sleeping periods and so fragment the working programme and curtail the leisure hours of the whole family. But an hour snatched here and there is available, so that only some nearby provision, that is to say some provision that lies in the path of her daily comings and goings, can meet the housewife’s needs. Yet the less time there is, how much the more necessary is some local provision for refreshment and for re-creation of body, mind and spirit. The Centre fulfils this need, however unusual the circumstances of the daily routine of each family.
The effect upon the members of the family of this centralisation of the family life around the mother and her welding or digesting influence upon material so garnered into the home, is obvious to us as observers in the Centre. It is equally obvious that in those relatively few cases where the mother cannot or does not use the Centre herself, the activities of the rest of that family in the building fail to become integrated into a social whole. It follows that nothing but some local provision serving for the daily leisure activities of the whole family can produce the integration of modern society, and that it must be centred within the ambit of the mother’s excursion—for as we have seen, though it is parenthood which creates, it is womanhood that must gestate and bring that which is created to viability.