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To give or not to give out-door relief is the first and greatest problem in municipal charity. Shall the city undertake to provide provisions, fuel, clothing, rent, and other necessaries to needy families in their own homes, in addition to maintaining hospitals, almshouses, and other institutions; or shall it limit its activities to the latter function, leaving the assistance of the poor in their homes to organized charities, churches, and benevolent individuals? The problem is not a new one; in fact, it has been discussed at greater length than probably any other phase of municipal charity. Extended experience has been had by large cities on both sides of the question. The fact that several of the largest cities in the country have given no out-door relief for a quarter of a century, and that it is the impression and belief that the poor in those cities are as well cared for as in the cities giving out-door relief, may be said to have shown beyond question the practicability of abolishing public out-door relief in large cities. Those who favor the continuation of public out-door relief in the few large cities in which it still persists -- Chicago, Boston, and Buffalo -- would doubtless claim that in New York the absence of out-door relief, while probably a good in itself, has led to other evils, notably the sending of large numbers of children to institutions. The fact that the absence of out-door relief in other large cities -- Philadelphia, Baltimore, Washington, and others -- has not led to this result indicates that other factors must be regarded as primarily responsible for the large proportion of destitute children in New York City. The question of public out-door relief in large cities in this country was ably presented to the National Conference of Charities in 1900 by Mr. Frederick Almy, secretary of the Charity Organization Society of Buffalo. The experience of American cities during the three and a half years since the date of Mr. Almy's paper tends to strengthen the position of those who favor the abolition of public out-door relief in large cities. During this period no city which had discontinued public out-door relief has re-established it. Societies, churches, and individuals seem to have proved their ability to meet the situation in different cities and under varying conditions, not perfectly, but certainly as well as it is met by public action. Each year which passes without the resumption of public out-door relief in any large American city strengthens the argument for its abolition in the small number of large cities in which it still exists.

It is interesting to note that although the past three years have shown a very marked swing of the pendulum towards a more general recognition of the important part which material relief must play in the help of needy families in their homes, this fact has not in any locality, so far as we know, led to even a discussion of the question of the resumption of general public out-door relief. It has led charitable societies to strengthen their relief departments, seek new sources of income for relief purposes, give larger amounts, and yet it has not in any case led to an agitation for the return" of what was once the well-nigh universal custom of public out-door relief in all our cities, large and small, as well as in rural districts.

The few years that have elapsed since Mr. Almy's paper was written have, moreover, served to accentuate the very great advantage of this division of the field as between public and private charity. The responsibility for the adequate relief of needy families has been more keenly felt, and this has strengthened the societies and agencies established for such work. Municipalities have fewer but more definite responsibilities, and have improved the management and material condition of their hospitals and almshouses.

The trend of the past decade in regard to public out-door relief in American cities is all the more interesting by reason of the recent ominous increase in dependency in London. The London Spectator, of January 2, 1904, devotes a leading editorial, under the caption of "The Rising Tide of Pauperism," to the extremely serious recent increase in the number of both out-door and in-door paupers in the Metropolitan district, the figures on Christmas day, 1903, being higher than for any corresponding date since 1871.

II.

We may place as second in the present problems of municipal charity, because of its important bearing upon all phases of the situation, the question of dealing with able-bodied persons, casual lodgers, tramps, vagrants, etc.

In former years we heard much about "able-bodied paupers." We hear the term but seldom nowadays, because most of the class who formerly were able-bodied paupers are now able-bodied prisoners. Able-bodied pauperism is a misnomer. So long as able-bodied persons were admitted to almshouses upon application and upon their own declaration of destitution, or even, as in some cases, committed by magistrates to almshouses for definite terms, the almshouse necessarily took on more or less of a correctional character. It is not too much to say that at the present time in cities whose municipal charity is generally considered as well administered, no able-bodied persons are admitted to almshouses or to any other charitable institution for extended care. Whatever else should or should not be done for able-bodied persons who declare themselves destitute and unable to find work, there is general belief that they should in the first instance be admitted to a lodging-house for temporary shelter. Under the plan which prevails in New York City and which seems to stand the test of experience, all able-bodied persons applying for assistance, whether temporary or permanent, are sent to the Municipal Lodging-House. The most evident features of this institution are enforced bathing and cleanliness, fumigation of clothing, and in general sanitary conditions and regulations. Still more important, however, from a social point of view, are the careful questioning of each lodger as to his recent employer, previous residence, length of time in city, etc., and the paid force of investigators who, on the following day, visit these references for the purpose of ascertaining the facts so far as possible as to the character, habits, and circumstances of the lodger. A large number of the lodgers come only once or twice. Those who come three times or more and who by investigation have been found to be tramps or vagrants, or who have given false references, or have been disorderly in the lodging-house, or seem to be "suspicious characters," are taken before magistrates for commitment as vagrants, and if the magistrate is convinced that such course is proper are sent to the workhouse, a correctional institution. The officials of the lodging-house must make out a case to the satisfaction of the magistrate.

The comparatively small number of lodgers who come three times or more and who upon investigation appear to be men who are not of the tramp or vagrant class, but are temporarily out of employment, are allowed to come to the lodging-house for a somewhat longer period. Quite a proportion find temporary employment at low wages in the city institutions, others succeed in finding private employment. Recently an arrangement has been effected with the Charity Organization Society by which men of this class are supplied by the lodging-house with wood-yard tickets, enabling them to earn enough each day at the Charity Organization Society wood-yard to pay for lodgings and meals and leaving them a considerable part of the day for further effort to find employment.

The New York City Lodging-House has no "work test." Experience has led most of those familiar with its workings to believe that the investigation made by its visitors and the possibility of commitment have been much more satisfactory in determining the future treatment of the lodgers than a work test would have been.

III.

The third problem in municipal charities may be stated thus: What should be the standard of clothing, food, and care in the municipal almshouse? Shall it have the regime of the prison, or shall it be a hospital, or is it possible to make it a home? If it is to be a home, how far can it be made comfortable, clean, sanitary, and how varied can the food be and how good the clothing, without making it "too attractive"? The answer to these questions is being found in the solution of the second problem stated above. The elimination of the able-bodied element from the almshouse, together with the segregation of certain classes of defectives now commonly sent to State institutions, is making the almshouse a home for the aged and infirm, or at least a place where none but the aged and infirm are cared for, and which should be homelike. If the applications are carefully investigated, so that only those who are actually unable to earn a livelihood and whose immediate relatives are actually unable to maintain them, and who are unable to do any regular and ordinary work, are allowed to enter the institution, the danger of its becoming "attractive" is minimized. We can all assent to higher standards of care, better food, better clothing, and a more comfortable place for the really infirm, incurable, and senile than we would favor if able-bodied were also to share in such provision. (1)

One of the first facts in the situation to be recognized is that the population of a home for the aged and infirm in a large city is a very diversified population. It has little homogeneity, aside from the two facts of physical disability and destitution. It represents many nationalities, many religions, many previous occupations, and many different standards of life. It includes all varieties of disease that afflict the aged, and in all degrees. It represents all attitudes towards its caretaker -- the city. It is a little city in itself. It will, if left to itself, and if its circumstances permit, break up into many smaller groups on lines of nationality, tastes, and character. This suggests the lines along which the administration, to be successful, should be directed. The buildings should be so constructed and the labor so directed as to allow some opportunity for natural groupings, and in particular so as to allow each inmate, able to do even a little work, to do that which he is most able to do. While there will be no able-bodied element in our almshouse population if it is thoroughly investigated and wisely judged upon admission, there will also be comparatively few who are absolutely helpless. The man who can do only half a day's work by working all day, the man who can only work half of each day, the man who has the use of hands but who walks with great difficulty or not at all, -- all these, with hundreds of others, are as certainly debarred from participation in the ordinary industrial life of the community as though they were absolutely helpless. Yet very many of them can do some work, can contribute in some degree towards the orderly operation of the institution in which they are cared for or towards the production of some article required in that or some other city institution. While considerable progress has been made in utilizing the labor of some of the inmates of our large municipal almshouses, much remains to be accomplished in this direction. Greater resourcefulness than is usually found in an institution of this class is required, however, for devising and carrying to success further efforts of this character.

In every large population of the aged and infirm, acute illness, accidents, or conditions requiring surgical operations will continually develop. The hospital ward is a necessary adjunct of the almshouse. And if there are included as hospital patients those suffering from incurable diseases which permit long years of life, the hospital portion becomes a large factor. At the New York City Home for the Aged and Infirm, from one-quarter to one-third of the entire population are cared for in buildings known as hospitals and organized so far as practicable on a hospital basis. The diseases are of such a character that it is difficult, if not impossible, to maintain training-schools for nurses. It is not that the patients are objectionable or that the diseases are objectionable, but that they do not afford sufficient opportunities for the care of acute illness or acute surgical conditions. The same reason makes it difficult to secure a satisfactory medical service; the great majority of cases have but little interest or "value" to the ordinary practitioner. To provide graduated nurses in any considerable number is impossible because of the great expense involved. The more usual course is to employ untrained nurses of about the class who ordinarily go into domestic service and to employ one or more skilled supervising nurses who are graduates of training-schools.

It is interesting to note that one of the charges seriously made against the trustees of pauper institutions in the city of Boston is that they have maintained a training-school for nurses and have spent too much money on operating-room furniture. If the trustees have been able to establish an efficient training-school for nurses in the almshouse hospital, they should receive general and warm commendation for having devised a plan for securing the best quality of nursing at the lowest cost. The training-school for nurses is the most economical plan ever devised for caring efficiently for the sick in large hospitals. If, by the establishment of the training-school and by providing hospital operating-room furniture and other necessary facilities for medical and surgical work, the trustees of the pauper institutions of the city of Boston have succeeded in securing efficient nursing and high-grade medical and surgical service for the hospital portion of their population, they have measurably solved one of the most difficult problems in municipal charitable administration, long recognized as such, both here and abroad.

IV.

Aside from the hospital portion of the home for the aged and infirm, every large municipal department of charities finds it necessary to maintain hospitals for the care and treatment of the sick, both accident and acute cases and those of a more chronic character. A problem arises as to the proper standards of administration of municipal hospitals: Shall they be as good as the best, or shall they, in view of the fact that they care only for the destitute, many of whom have become such probably through their own faults, be conducted on a simpler and less expensive plan? Who has not heard the wise citizen, the sage doctor of philosophy, or the head of a wealthy church, in visiting a public hospital, remark under his breath, but apparently with misgiving, that the patients are receiving better food and clothing, and withal are more comfortable and are living under more sanitary and cleanly surroundings than they did in their own homes? The implication seems to be that the patients are getting better than they deserve, or that it is hardly fair for the citizens to be called upon to do so much at public expense for this purpose, or that in some way the social structure is involved in serious though vague danger in thus forcing higher standards of living upon this class of people. Never were there more shallow attempts at reasoning nor a more thoroughly uncharitable attitude. As has been well said, the best occupation of the sick man is getting well -- best not merely for him, but for his family, for the city which otherwise continues to contribute to his support in a hospital, and for the community of which he otherwise remains a non-productive member and a burden. There can be only one rational, only one truly charitable standard for the administration of public hospitals: they should be equal to the best, so far as essentials are concerned. Nothing that will contribute to recovery is too expensive to be economical. We can omit ornamental features, but in the essentials of sanitation, cleanliness, medicines and surgical facilities, clothing, and, above all, a plentiful supply of food, well cooked and well served, there should be no scrimping. These conditions not only conduce to the early cure of the patients, but exert a marked educational influence, and raise the standards of life of all who become for a time the subjects of city care.

V.

Recent advances in medical science have made the care of consumptives one of the serious problems in municipal charity administration. Municipal hospitals and almshouses have always sheltered large numbers of consumptives, but the knowledge of the communicability of the disease in all stages and the curability of some cases in the earlier stages changes radically the nature of the problem. It is no longer simply a question of providing shelter, food, and clothing for a given number of unfortunates; it has become a question of such care for these sufferers as will protect the other patients and inmates of the city institutions from infection, will extend to the consumptives all the opportunities and advantages which modern science suggests for their N improvement, if not for their cure, and will make the hospital for consumptives a large factor in the substantial eradication of the "white plague" from our large cities -- an end towards which some of our municipalities are beginning consciously to direct their enormous powers. So great has been the education of public opinion very recently in this matter that it seems almost impossible that less than two years ago hundreds of consumptives were still cared for in the general wards of public hospitals in New York City, that other hundreds were in wards devoted to this disease but in the same buildings as medical and surgical wards, and that many others were left to wander about the streets of the city spreading infection and with no place to which they could turn with certainty of admission and care for any period of time. The segregation of consumptives from other patients in the hospitals of New York City during the last two years, the establishment in the hospital devoted to their care of most of the features which have been successful in sanatoria for consumptives in other States and cities, and the set purpose, carried into effect, to turn away no consumptives asking for care, and to discharge no one from the Hospital for Consumptives, unless for serious misconduct, except upon his own urgent request or as substantially cured, have been considered the most important achievement of the Charities Department during the Low administration. The example set by New York and other cities (New York was not the first to move in the matter, though it has probably carried its plan into effect more thoroughly than any other city) should be the adoption of similar measures in the charities departments of all the large municipalities of the country. It is not necessary to wait for the construction of expensive permanent buildings; tent-cottages or temporary wooden structures are probably better suited to the purpose, in that they afford better opportunities for the fresh-air treatment, are much less expensive at least for the original outlay, and, what is perhaps of greater importance, can be made available with very little delay. The tent-cottages, of which there are twelve at the Tuberculosis Infirmary of the Department of Public Charities, on Blackwells Island, accommodating about one hundred and forty patients, were modelled after a design by Dr. Holmes, of Denver. (2)

Since the health departments of large cities have begun to classify tuberculosis as a communicable disease and to require all cases of tuberculosis coming to the notice of physicians or hospitals to be reported to such departments, a new question has arisen as to whether the management of the hospitals for tuberculosis should be placed under the Department of Health, as is the case with hospitals for smallpox, diphtheria, scarlet fever, and measles. As a matter of fact, many of the diseases which contribute most largely to the census of municipal hospitals are being found to be communicable, though not in the ordinary sense contagious. Pneumonia, influenza, typhoid fever, and many other diseases would fall within this latter classification, as also leprosy, certain skin diseases, certain eye diseases, and the venereal diseases. It has never been suggested that all these diseases should be transferred to the Department of Health, and it is the opinion of the writer that it is not desirable that they should be. Their proper care and treatment does not demand the unusual precautions which are requisite in hospitals for the treatment of the strictly contagious diseases. There is also, in the writer's opinion, grave danger that the burdening of the Health Department with the administration of large series of hospitals for infectious diseases would almost inevitably result in impairing the efficiency of the work of that department in those important lines that directly affect the health of the entire community, such as the protection of food supplies, especially milk and fruit, the protection of the water supply, the medical examination of school children, etc.

It is very important, however, that the Health and Charities Departments should work in complete co-operation and harmony, and that the Health Department should always be able to refer to the Department of Charities, for care in its hospital, cases of tuberculosis which come to its notice and whose circumstances and habits are such as to conduce to the spread of the disease. It may be that the Health Department should exercise its jurisdiction to the extent of requiring the retention at the hospital of the Charities Department of cases of tuberculosis who may wish to be discharged but whose circumstances are such that proper home care is out of the question, and who would spread the disease by frequenting lodging-houses, parks, and other public places, particularly those who cannot be made to take proper measures for the destruction of their sputum.

While the question of change of climate and change to a great altitude is considered much less important than formerly, it is likely that but few cities can find within their limits the proper location for a sanatorium for incipient or only moderately advanced cases of tuberculosis. Pure air, attractive surroundings, and opportunity for moderate exercise in suitable cases are not likely to be found in or in the immediate neighborhood of large cities. These municipalities should therefore be given statutory authority to locate sanatoria for consumptives outside their corporate limits. Such authority was conferred upon cities of the first class in the State of New York several years ago, but later legislation so hampered the exercise of this power, by requiring the consents of so many local authorities, that it is doubtful whether such sanatoria can be established without change of legislation. The authorities of New York City have the matter under consideration, and considerable examination as to available sites has already been made. If the city makes reasonable effort to proceed and finds itself unable to secure a suitable site by reason of local opposition, it cannot be doubted that the law will be changed.

VI.

Municipal charity administration, in common with other branches of municipal action, has always before it the problem as to what constitutes the most effective method of administration, an unpaid board whose membership changes but slowly, or a salaried commissioner, with definite term or subject to removal by the mayor. History is being made rapidly on this question. In 1897 the city institutions of Boston were removed from the jurisdiction of one paid officer, and placed under the jurisdiction of three boards of trustees, each board consisting of seven members, serving without salary. The best-known municipal hospital in New York City, -- Bellevue, -- with its three tributary institutions, was placed on February 1, 1902, under a newly appointed board of trustees, seven in number, serving without salary, the term of one member expiring each year. The objects sought to be obtained by this change were the elimination of partisan influences in the hospital, the establishment of continuity of policy in its management, and the securing of higher standards of efficiency in all branches of its service than had theretofore obtained. It was not claimed that such a board would be more effective than one official giving his entire time to his duties if that official were in all respects qualified for his position and assured of a reasonable tenure of office, but it was contended that the mutations of municipal politics in New York City were such that an appointment of the right kind of person for commissioner was to be regarded as a happy accident which might happen once in a great while, rather than as the usual type of municipal administration of this department.

As Commissioner of Public Charities, the writer was an ex officio member of the Board of Trustees of Bellevue and Allied Hospitals during the first two years of its existence, but his part in the work of that board was so inconsiderable, owing to the pressure of his duties as Commissioner, that he may speak of the work of the board without violating the dictates of propriety.

In a word, the new board of trustees has laid deep and secure the foundations of a new and regenerate Bellevue Hospital, not only in its physical aspects, but in its management and in its spirit. There is every reason to believe that this board will succeed in placing the hospitals under its jurisdiction on a par with the best hospitals of the country, and that its work will soon receive that same confidence and commendation on the part of the public, and be as much a matter of municipal pride, as is the case with the Boston City Hospital and the Boston Public Library. To do this the board must maintain with each successive administration such relations as will enable it to secure liberal appropriations, both for maintenance and for permanent improvements. It must be able to withstand the insidious efforts which will doubtless appear in all sorts of unlooked-for places and will be felt through many unsuspected channels, once more to reinstate favoritism and make the hospital an adjunct to a political organization.

It is to be hoped that the Bellevue board will not be called upon to pass through all the experiences which have befallen the trustees of the pauper institutions of the city of Boston. In the writer's opinion, no one who has even a moderate acquaintance with their work can deny that great improvements have been effected by this board and that the institutions under its jurisdiction have been vastly improved and have been much more humanely managed and are far more creditable to the city of Boston than was the case under the former system. Yet we have recently seen this board subjected to a series of plausible charges, brought by one of its own members, with the assistance of certain disaffected employees of the board. These charges were, after investigation, placed by the board itself before the mayor, with the request that he order an investigation. The investigation was undertaken by a committee of the Common Council of the city of Boston, which, after a long inquiry, brought in a majority report (the committee dividing on strict party lines), which was characterized editorially by the Boston Herald of December 4, 1903, as "deserving no more confidence than the verdict of a bribed jury." The same authority states that the investigation was undertaken for the purpose of securing the abolition of the board of trustees and the re-establishment of a single paid commissioner.

A partisan majority of the committee finds certain of the charges against the board sustained, and, without suggesting in what way a change in administration would remedy the conditions which they think they find to exist, recommends that the legislature abolish the board of trustees and provide for the appointment of one salaried commissioner. It does not seem likely that this recommendation will meet with much favor at the hands of the legislature of the State of Massachusetts, especially as the minority of the committee finds every charge against the trustees unfounded. The incident is significant, however, in showing the persistency of the influences which would subordinate public charities to political considerations.

It is not for the writer to speak of the administration of the Department of Public Charities during the past two years under a salaried commissioner who had had previous and extended experience in dealing with charitable questions and who was already familiar with its institutions, nor to attempt to compare the rate of change for better or for worse in the Charities Department during the past two years with any preceding period, nor to attempt to guess as to the extent to which whatever charges were made during the past two years will be continued under a different administration. All this will enter into the history of this question, which, as stated above, is making rapidly, and on the basis of which something more nearly approaching a consensus of opinion should be reached within the next decade as to the best form of administration for municipal charities. Greater than all the problems of the department and underlying all of them is the greater problem of securing efficient, disinterested administration.

Homer Folks,

Secretary New York State Charities Aid Association; Commissioner of Public Charities of New York City, 1902-1904.