The principal features of such care are:

1. Public-health nurses.

2. Accessible hospital care and medical attention.

3. Teaching and practical demonstrations for mothers of the hygiene of maternity and infancy and of the household arts essential to the well-being of mother and child.

4. Accessible consultation centers or well-children's clinics for the periodical examination of young children in order to secure their most vigorous development.

It will be seen that such a program involves more than medical and nursing care. For example, the State university extension divisions and departments of home economics are already doing excellent pioneer work and can greatly assist the plan. The public libraries, especially those in smaller towns and the traveling libraries, are already undertaking an educational function in the careful distribution of pamphlets and literature for mothers.

Such a partnership between the Government and the States already serves agriculture through the Smith-Lever Law, already serves vocational training through the Smith-Hughes Law, and is creating through the joint work of the Government and the States a new and cleansing knowledge of social hygiene, and is slowly removing the isolation of the remote ranch and farm family by the good-roads act. On exactly the same plan of Federal aid stimulating and standardizing State and local activities, the well-being of mother and child, a basic national economy, may be secured.

In this connection Australian parliamentary reports of 1917 are of interest. For the last seven years the Australian Commonwealth has allowed for each living birth the sum of $25, and the acceptance of this allowance is general. Yet the report on infant mortality submitted to the Australian Parliament in June, 1917, by the committee concerning the causes of death and invalidity in the Commonwealth strongly urges the adoption of a general scheme of practical measures, such as are in force in New Zealand and elsewhere, as a means of lessening the infant mortality rate. In August, 1917, the same committee submitted a report on maternal mortality in childbirth. Figures are given to show that, although there was a decrease in the death rate after the introduction of the maternity bonuses, this decrease was not so great as it had been during the preceding years. The report concluded with the following paragraph:

Speaking generally, your committee is of the opinion that much greater benefit could be obtained from the large sum of money spent annually than is being obtained under the present system, and that as the wastage of life and the damage to health now occurring in connection with childbearing is due to the ignorance of the mother and lack of skilled care, such improvement should be sought in two directions:

(1) The provision of every facility for pregnant women to obtain skilled advice before the confinement occurs.

(2) The provision of trained attention by a properly qualified and properly supervised midwife or nurse during the lying-in period.

The exact method by which the latter of these highly necessary measures is to be accomplished should be a matter for further earnest consideration. Information is necessary concerning the causes of illness as well as the causes of death among women during confinement. With the economic aspects

Since October 10, 1912.

of the direct payment to women of cash bonus, your committee is concerned only in so far as the health and lives of the women are affected.

In the opinion of your committee, however, there is imperative need for the immediate extension of existing facilities for pregnant women to obtain skilled advice concerning their health before their confinement, and the Commonwealth Government might well provide financial assistance to enable women's hospitals and similar institutions to inaugurate or extend such branches of their activity, and might even undertake the provision of such facilities in places where they are as yet nonexistent. The return to the community would almost certainly more than compensate for the expenditure involved.

When the matter is carefully examined, it becomes clear that only a plan of public cooperation making generally accessible instruction in public-health nursing, and medical and hospital care offers the safeguards of life and vigor which are needed.

The experience of England seems to show that a general measure of such character as that outlined above is absolutely essential in a country of modern standards of health and comfort even when health insurance with maternity benefits is in operation. In many other European countries such measures exist. In these countries, as in England, experience indicates the need of basic governmental responsibility for maternity and infancy.

The health-insurance law of the United Kingdom went into operation in 1911. It provides a benefit of $7.50 upon the birth of a child for the wife of an insured man and double that sum if the wife herself is insured and the wife of an insured man.

Yet since the insurance law went into effect two measures have been passed by Parliament permitting grants in aid to sanitary districts for the protection of maternity and infancy. The second was passed in August, 1918, and sanctions increased expenditures. It specifies the objects for which funds may be spent and is clearly an expression of a belief that no provision already in existence is adequate.

As applied to the United States, it may be said with certainty that any public provision for safeguarding maternity and infancy must be universal. It must afford a dignified service which can be utilized with the same self-respect with which the mother sends an older child to the public school. It must not be compulsory.

CHILDREN IN THE ISLAND POSSESSIONS.

For the past seven years the bureau has been occupied with investigations of "matters pertaining to the welfare of children and child life" in continental United States. In the first year of its existence it was asked by the then Secretary of War to make reports upon the children of the islands under the protection of the United States; but the resources of the bureau have never permitted this expansion. Various considerations, however, urge study at this time of the needs of those children who are indeed legally under the protection of the United States, yet who are so far removed from American observation that comparatively little is known of them. Especial attention is called to the children of Porto Rico and of the Virgin Islands.

1 Maternity Benefit Systems in Certain Foreign Countries. H. J. Harris. U. S. Department of Labor, Children's Bureau, Legal Series No. 3, 1919.

THE VIRGIN ISLANDS.

The Virgin Islands were purchased from Denmark in 1917 and an act passed by Congress provided a temporary government for them. Little can be presented as to living conditions in the Virgin Islands; but, thanks to the census taken by the United States Census Bureau in 1917, certain facts are available which are recognized as indicative of the degree of well-being enjoyed by a people.

1. Population. The population of the Virgin Islands in 1917 was 26,051, of whom 7,321 were under 14 years of age. At the date of the last Danish census in 1911 it was 27,086. This shows a decrease of 4 per cent in the six intervening years. The excess of deaths over births and the excess of emigration over immigration are submitted by the census as explaining a decline in population which has been general since 1835, when the population was 43,178.

2. Illiteracy. In 1917 it was found that 24.9 per cent of the population 10 years of age and over was illiterate. The proportion of illiteracy in continental United States, the purchasing country, was 7.7 per cent in 1910, a rate known to be alarming; and of Denmark, the selling country, 0.2 per cent, according to latest available figures for that country which give the rate for 1907.

3. Infant mortality.-The rate of infant mortality is not given in the printed census report; but the text contains this statement:

The present high infant mortality rate probably is accounted for mainly by the fact that most of the parents are poor and dependent on their daily wages for a meager livelihood; by the fact that 58.7 per cent of the married women and women living with their husbands by mutual consent were engaged in gainful occupations in 1917, a large proportion of them as field laborers

4. Women gainfully employed. The proportion of the women of the Virgin Islands of different age groups gainfully employed are as follows:

The proportion of mothers in each group employed is not stated, but since not less than 63.7 per cent of every age group of women between 16 and 45 are employed, clearly the mothers of young children are largely included among those who work for pay.

It is plain that under the four heads enumerated a depressed level of existence is revealed. While many factors chiefly economic are involved in the decline of these islands, it is believed that a careful study of the conditions surrounding the mothers and children would be of material aid in proposing methods of securing more satisfactory living conditions."

PORTO RICO.

1. Population. According to the census of 1910, the population totaled 1,118,012, representing an increase of 17.3 per cent in 11 years. Of this number, 893,392, or 79.9 per cent, were living in rural

areas, while only 224,620, or 20.1 per cent, were recorded as living in cities and towns. This indicates that the problems which affect rural communities are the problems which affect, to a great extent, the entire island.

At the time of this census the density of the population per square mile for the size of the island was more than ten times as great as that for the United States proper.

2. Illiteracy. In 1910, the percentage of illiteracy for all classes 10 years of age and over, for both sexes, was 66.5 per cent, or practically two-thirds of the population of that age. This showed an improvement over 1899, when for the same classes it was 79.6 per cent. In that year (1899) the percentage of illiteracy for all children between 10 and 14 years of age was 82.1 per cent; in 1910 this dropped to 49.2 per cent. Despite this improvement, the rate is alarmingly high when we compare the figures for another island possession, Hawaii, for 1910, where the percentage of illiteracy between 10 and 14 years of age is only 3.2, and for the age group between 15 and 19 years, only 13 per cent, as compared with 59 per cent for Porto Rico. 3. Infant mortality. In comparison with the United States, France, Germany, England, and Sweden, Porto Rico represents a very high birth rate. But this is accompanied by a high infant death

rate.

In 1916-17, the infant death rate was 199.0; in 1917-18 it was reduced to 173.4.

4. Delinquent and neglected children.-The report of the Governor of Porto Rico for 1918 states that the reform school is still overcrowded, owing partly to the large demands made for space for boys. under control by the juvenile courts. Some improvements and enlargements have been made since 1917. The average number of boys in the school for 1917-18 was 156, but the number has very lately reached 200, which is the maximum capacity of the school, yet this is not sufficient for the need.

From January 1, 1917, to June 30, 1918, 452 children came before the juvenile courts. More than half never attended school, and of those who did very few had passed the fourth grade; 77 were homeless.

The most serious drawback to the effectiveness of the juvenile court law has been the lack of adequate facilities to take proper care of the delinquent children. The minimum needs, according to the governor's report, are a temporary detention home for each juvenile court, a separate home for delinquent children, and an institution to care for the abandoned children. This statement is corroborated by the following:1

According to the last report of the insular chief of police, it is estimated that there are in the island of Porto Rico at the present time about 10,000 homeless children under 12 years of age who live by whatever means they are able, many of them begging or stealing, and most of them having no permanent lodging place, sleeping at night in boxes or on doorsteps, or wherever they happen to find a lodging place secure from the rain. These children are for the most part deserted and abandoned children of illegimate parentage, or orphan children whose parents have left no provision for their care and education, and they constitute a fertile soil for the implanting of criminal tendencies and are ready material for older people of criminal habits.

Fleagle, Fred K.: Social Problems in Porto Rico, p. 32.

INTENSIVE STUDIES NEEDED OF ECONOMIC ASPECTS OF CHILD WELFARE.

The discussion at the child-welfare conferences served to emphasize what the work of Children's Year and the regular work of the Children's Bureau has already indicated-that child welfare is a national, even international, problem of first magnitude, and that the economic aspects of the problem are now most urgent. It was stated at the conferences, for instance, by Dr. William R. P. Emerson, that about one-third of all American children of preschool and school age are malnourished, and that this condition makes it impossible for the schools to reach reasonable standards of achievement; and that 20 to 40 per cent of those graduating from elementary schools are physically unfit.1

Dr. Thomas D. Wood said that it was well known that "threefourths of the 22,000,000 school children in the United States have health defects which are actually or potentially injurious to them as prospective citizens of the Republic"; and that "at least 4,500,000 are suffering from malnutrition." He estimates that among the children with health defects there are 5,000,000 with defective eyes and from 11,000,000 to 16,000,000 with defective teeth.2

This alarming testimony from physicians is further added to by the well-known economist, Prof. William F. Ogburn. In his studies. made for the Bureau of Labor Statistics of the United States Department of Labor, Prof. Ogburn estimated that while the food actually consumed by a child in a Philadelphia working-class family during the first 16 years of life would cost $1,750, a family was actually able to expend only $718 in buying the child's food. The difference between those figures, according to Prof. Ogburn, indicates the economies and adjustments made in the family budget, and also suggests the reason for the malnutrition described by physicians and dietitians. But, as he points out, his studies do not "concern the question of what a child ought to have in order to be reared properly." "This is a most important question," he goes on to say, "and no doubt others will develop it." 3

"Poverty is not the most important cause of this serious barrier to health development," says Dr. Thomas D. Wood; but although ignorance undoubtedly is responsible for a good deal of unhygienic living, it should not be forgotten that "there is a certain minimum. income below which not all the intelligence in the world can purchase an adequate diet. It must be remembered, too, that it is poverty in a host of cases which is the real cause of ignorance." Special investigations in three American cities made by the Children's Bureau indicate the extent to which infants are underfed because of the advance in prices of food. In 1918, in Baltimore, of 728 children between 2 and 7 years of age only 29 per cent were having fresh milk to drink, as against 60 per cent the previous year; in Washington more than half of those between 2 and 7 years studied by the public-health

1 Standards of Child Welfare: A report of the Children's Bureau conferences, May and June, 1919. Children's Bureau Publication No. 60, page 238.

2 Standards of Child Welfare: A report of the Children's Bureau conferences, May and June, 1919. Children's Bureau Publication No. 60, pages 248 and 250.

Ibid., p. 29.

4 Ibid., p. 250.

What is Malnutrition? Children's Year Follow-up Series No. 1, by Lydia Roberts. Bureau Publication No. 59, page 11.