It was not clearly appreciated that the war program for the care of sick and disabled could, by no means, be converted into an adequate and satisfactory system of hospitals for the care of sick and disabled persons under peace conditions. At all events, no money was appropriated for purposes of constructing hospital facilities until March 4, 1921.
It is highly significant at the present time to note that the needs foreshadowed in this public document have, since the date of its publication, been more or less verified by subsequent experiences.
Making due allowances for discrepancies, which might have been expected, and for developments, which could not have been readily foreseen, it may be truthfully said that this document indicated quite clearly and more or less accurately the hospital needs for the care of sick and disabled ex-service men and women, if these patients were to receive the character of medical service which, in the judgment of the best medical minds, was necessary for their restoration to health and which could not be satisfactorily given in other than suitably constructed institutions.
Leaving aside these considerations, it was apparent that, when the Public Health Service was charged with responsibility,it was immediately necessary to meet the urgent demands suddenly created by the termination of the war.
The Public Health Service, in the manner indicated above, attempted, therefore, to formulate and put into execution a temporary program for the purpose of meeting immediate needs, leaving a permanent program to be developed in accordance with the appropriations and legislation.
Without going into any more detail, it will suffice to state in very general terms the work which the Public Health Service has done in this connection and which it is still doing.
Since the inception of the work, it has created a hospital system of considerable magnitude, and is now operating some 68 hospitals, with a total bed capacity of over 21,000, and expects, within the more or less near future, to open additional hospitals and increase present facilities by something less than 5,000 additional beds.
This Service now has under its care about 13,500 veterans of the World War in its hospitals. In addition to this, it is also caring for 3,000 to 4,000 Federal beneficiaries, with whose care and treatment it has long been charged, making a total of nearly 17,000 hospital patients under its care at the present time.
In the development of this hospital system, the Public Health Service has divided its hospitals into three large groups, namely; hospitals for general medical and surgical cases, for cases of tuberculosis, and for cases of neuropsychiatry. It has been unable to develop this system of hospitals with the uniformity desirable under the circumstances, and has, therefore, found difficulty in meeting the needs of those suffering from neuropsychiatric and tuberculous disorders. This demand, however, has of late been far more adequately met, especially with regard to tuberculosis.
In addition to the development of its hospital system, the Public Health Service, soon after assuming its responsibilities in this work, created what was designated as the District Supervisors’ organization. The United States was divided into fourteen districts and, in some large center of population in each of these districts, there was established a district headquarters, with a sub-district organization reaching out even to the individual counties.
This organisation constituted a decentralizing agency, and, as such, served a most useful and important function, not only in the work of the Public Health Service, but also in the work of the War Risk Insurance Bureau. This entire organization, which had grown enormously, was transferred to the Bureau of War RiskInsurance in April, 1921, with its complete personnel. It is now operated by the U. S. Veterans’ Bureau as its decentralizing agency and is still performing a necessary and important function in the work of that Bureau.
It was also necessary to create a greatly extended purveying service for supplying the necessary equipment, etc., to the hospital system which had been inaugurated. The Purveying Service has grown enormously and, at the present time, is not only purveying to the hospitals of this Service, but is also rendering assistance to the U. S. Veterans’ Bureau in purveying for its offices and its medical facilities.
The creation of an Inspection Service also became a necessity, in order that the hospitals of this Service might be kept under constant surveillance, and that all complaints might be carefully investigated. This Inspection Service has now been reduced somewhat, but still is functioning satisfactorily and has also rendered a great deal of assistance to the U. S. Veterans’ Bureau in making certain inspections for that Bureau.
In addition to these matters, the Public Health Service also began the creation of a large system of out-patient dispensaries for the care of veterans of the World War and developed this work considerably. Up to recently, it had in operation some 58 of these dispensaries, many of them equipped and staffed for all forms of out-patient diagnosis and treatment.
The development of this dispensary system was a matter of supreme importance in furnishing the medical examinations of veterans required for the purpose of establishing their compensation ratings. This entire Service, as stated, is about to be turned over to the U. S. Veterans’ Bureau and will, in future, be operated by them.
In carrying out all of this work, the Public Health Service has, of necessity, been obliged to assemble a large personnel. The personnel at the present time is somewhat less than it has been previously, by reason of the transfer of certain activities to the U. S. Veterans’ Bureau, but, with the anticipated opening of many new hospitals and the increase of its facilities, this personnel must, of necessity, slowly increase.
At the present time, the Public Health Service has in this work about 1,700 medical officers, not including attending specialists. Of these, about 950 are officers of the Reserve Corps. A Dental Corps has been created and numbers, at the present time, about 180 dental officers. A corps of female nurses has been assembled and numbers, at the present time, about 1,800.A Reconstruction Service has been formed and numbers, at the present time, about 580 reconstruction aides. A Dietetic Service has been organized and numbers about 165 trained dietitians. These figures will give some idea of the large personnel necessary in the performance of this work.
It is difficult to draw distinctions between the various classes of personnel, but it may perhaps be said in general terms, at the present time, that the most difficult qualified personnel to secure is the medical officer. The Public Health Service was peculiarly fortunate in assembling a large Reserve Corps. At the close of the war, many medical men who had been in the military forces were demobilized. Finding themselves somewhat adrift, and having broken completely old associations, they were inclined, if opportunity offered, to continue in the Government service. A special appeal was made to these men by the Public Health Service and inducements were offered to them to accept service in the care of disabled discharged veterans. As a result, the Public Health Service was able to assemble a much larger number of reserve officers than could have been done under any other circumstances.
It has been a matter of great difficulty to maintain among these officers the necessary morale, by reason of the difficult circumstances and conditions under which they are employed. Having only a limited and somewhat uncertain tenure of office, with many uncertainties as to their future, it is worthy of note that they, nevertheless, have, given to the Government a service which could not easily have been secured from any other source. They have shown a fine spirit in the performance of this duty, and, as much as any set of men assembled under such conditions and circumstances, have delivered a service the quality of which is comparatively high. The retention of their services seems to me a matter of importance.
From the inception of this work up to date (Jan. 16, 1922), there have been cared for in hospital by this Service about 245,000 veterans, who have been furnished a total of about 12,831,000 hospital relief days. Also, about 1,945,000 outpatient treatments have been given and a total of over 1,427,000 medical examinations have been made. Many special services of various kinds have been rendered. For example; about 175,000 patients have been given dental treatment. Several thousand patients are being given occupational therapy and several thousand patients given physiotherapy every week. Prosthetic appliances of various kinds have been furnished to thousands of patients.
The important matter of medical social service in its hospitals has not been neglected by the Public Health Service. In cooperation with the American Red Cross, there has been organized an efficient medical social service, which has administered to the needs of the discharged disabled soldiers and sailors. Theseactivities of the American Red Cross have been supplanted by many other agencies, including the American Legion, Knights of Columbus, Jewish Welfare Society, and others. All of these agencies have rendered valuable assistance in the prosecution of this important phase of the work.
The Public Health Service accepted a share in the responsibility for the care of discharged and disabled ex-service men, with a full comprehension of the privilege which had been conferred. It has taken a pride in attempting to give to disabled ex-service men the very best service possible. While its ideals have not always been realized, it has, nevertheless, I believe, always treated the ex-service man with consideration and given him good professional service. It is my endeavor that the character of this service shall continue to improve, and I believe that it does improve constantly. No effort will be spared to render the very best service possible under the circumstances and conditions imposed.
Just what the future will hold for the Public Health Service in this work, it is now impossible to say. It appears, however, that the Public Health Service for sometime to come will be one of the designated agencies for furnishing hospital care and treatment to beneficiaries of the U. S. Veterans’ Bureau. This responsibility of supplying hospital facilities, with all that is implied, will be as adequately met as possible. The Public Health Service at the present time is operating a number of hospitals which, from many standpoints, are not suitable to the purpose to which they have been put. To attempt to operate hospitals in unsuitable buildings, unsuitably located, subjects the Public Health Service to unmerited criticism, but, since these facilities are needed for a time, it will be necessary to continue such places in operation. It is not possible, under such circumstances, to render the highest type of service, but every effort will be made to render the best service possible.
With the construction which is now going on, under appropriations which have been made available by Congress, it is anticipated that, in the more or less near future, it may be possible for the Public Health Service to close some of its unsuitable plants and open others of a far more satisfactory character. This will relieve the present situation a great deal and will do much to obviate the criticism which has been made against the National Government because it has not supplied suitable hospital facilities for the care of men who have given so much to their country.
In conclusion, it seems appropriate to say that the Public Health Service, in all of this work, has realized fully the necessity for the most complete and cordial cooperation with other governmental agencies engaged in it. It has been a firmpolicy of the Public Health Service to stimulate an attitude of cooperation on the part of all of its employees. It is a matter of peculiar satisfaction at this time to say that the Public Health Service feels that, in the present Director of the Veterans’ Bureau, it is receiving from him a most cordial support in this policy of cooperation and the relationships which exist between these two Bureaus daily grow better, as they must if the work is to be properly accomplished.
It is also to be noted in this connection that the recent creation of the Federal Board of Hospitalization has added to the administrative machinery a piece of co-operating mechanism, which will, undoubtedly, do much to stabilize and coordinate, as well as standardize, many necessary things, which, up to this time, have been carried on more or less independently. A governing body of this character, which can lay down broad policies, influencing all of the official agencies engaged in this work, must of necessity be in a position to subserve a very useful purpose. The sympathetic consideration and support of this body should have a fine moral effect.”
GENERAL SAWYER: “Representing General Wood we have Colonel Mattison.”
COLONEL MATTISON read the following article prepared by General Wood: relative to the N.H.D.V.S. and its Relation to the World War Veteran:
“Of all the various agencies utilized by the Federal Government in caring for disabled men of the World War, the National Home for D.V.S. is probably the oldest in this line of work, dating back over fifty years in its care for disabled soldiers. Immediately after the close of the Civil War, the necessity for some organization of the government to care for the many thousand disabled soldiers of that war became apparent, and in 1866, by act of Congress, the National Home for Disabled Volunteer Soldiers came into existence with a Board of Managers selected by Congress to carry out the purposes of this Act. Prior to this, several of the States, civic and benevolent organizations had taken up the work locally in many parts of the country, but the creation of a National Board superseded the local work and for quite a number of years prior to the time that State homes were established by various States the burden of caring for disabled veterans of the Civil War fell on the National Military Home.
The first Home established was located at Dayton, Ohio and was known as the Central Branch, but as the necessities of the question developed, other branch Homes were established by Congress until at present there are ten different institutions under the control of the Board of Managers, scattered from Maine to California. But as the Civil War was practically a war between sections of the country, all the Homes, with the exception of the one at Johnson City, Tennessee, are located either in the North or onthe extreme Northern border of the South. For example the Home at Hampton, Virginia.
Membership in the Home was originally confined to disabled soldiers of the Civil War, but gradually as the need developed, this privilege was extended to soldiers of the Mexican War of 1846, the Indian campaigns, the Spanish American War, and the Philippine service, so that by the year 1917 when the World War occurred, practically all disabled soldiers who had served in any of the wars of the Republic, were eligible to membership in the Home. The high tide of membership in the Home was in 1906 when over twenty one thousand disabled soldiers were members of the various Branches. After the peak of the load had been reached there was quite a decided downward curve in membership owing to the advancing years and heavy death rate among the soldiers of the Civil War, so that by 1917 the membership had decreased to about thirteen thousand men, and there were in the various branch Homes many thousand vacant beds, both in barracks and in hospitals.
In this connection, attention is called to the fact that the Home functioned in a two fold capacity. It furnished hospital service to the man who actually needed such attention and it also furnished domiciliary service to men who were disabled and prevented from taking care of themselves in the active competition of life but who were not actually patients. This latter service is called our domiciliary service and is a service that probably will increase very materially in its scope with the passage of time, as men who have served in the World War, owing to disability will find themselves unable to meet the active competition of the world outside and will therefore need this domiciliary service in a very acute way.
By the Act of October 6, 1917, eligibility in the Soldiers’ Home was given to men who had served in the World War, on exactly the same terms and conditions as it had been given to the veterans of the other wars, and therefore today the disabled soldiers of the World War stand in exactly the same position in their rights to care and treatment in the National Home as does the soldiers of the Civil, or Spanish American Wars. But few men of the World War had taken advantage of this privilege prior to the year 1920 when the Sundry Civil Bill for the F. Y. 1921 gave authority to the Director of the Bureau of War Risk Insurance, now the Director of the U. S. Veterans’ Bureau, to make allotments to the Board of Managers of the National Military Home for alterations and improvements of existing facilities to meet the demand of hospitalization from the Bureau of War Risk Insurance. Such changes were thought necessary as a large amount of space available was barrack space which while satisfactory for domiciliary service, was not satisfactory for hospital service.
Acting in accordance with the desires of Congress, as shown in this bill, the Board of Managers at once entered upon an energetic campaign of construction to prepare their plants for this work. Conferences were held with the Director of the Bureau of War Risk Insurance, and the statement made by him that the greatest need of the Bureau of War Risk Insurance at that time was for tuberculosis and neuro-psychiatric beds. To meet this need, and to grant to the fullest the wish of segregation on the part of the World War men, two branch Homes were set aside and their domiciliary and hospital population moved to other branch Homes, and acting under the advice of the most competent experts, the Board could find, the branch at Johnson City, Tennessee was changed into a tuberculosis sanatorium, and the branch at Marion, Indiana was changed into a neuro-psychiatric sanatorium.
In addition to the complete change of two branch Homes, numerous and extensive improvements and alterations were made at a majority of the other Homes so that the fullest cooperation might be given to the Bureau of War Risk Insurance in its great work, and today outside of the Home at Hampton, Virginia, and the one at Danville, Illinois, which have been practically set aside for the older class of veterans, adequate facilities have been prepared for the hospitalisation of such soldiers of the World War as may be assigned to them for hospitalization.
But in this connection especial attention must be called to one very peculiar and unique feature of the service furnished by the National Military Home, and that is the fact that under the law, the Home must care for the victims of peace as well as the victims of war and furthermore, that the gates of any branch Home are open to any disabled soldier of the World War and that for admission, it is not necessary that the disabled soldier be sent there by the U. S. Veterans’ Bureau or any other organization. If he presents himself with his honorable discharge and the medical examination shows disability, under the law the Home must take care of him as long as such disability exists, this whether the disability be one of war or one of peace. To give a concrete example, if a World War soldier presents himself at any branch Home with a leg or arm amputated, under the law, the Home must take care of him whether he lost the limb in the Argonne or in a saw mill, and this feature is one that I think should be carefully considered because it leads up to the question spoken of above, of domiciliary care. Now a man with a leg gone is naturally crippled in the battle of life and cannot compete on equal terms in almost all professions or trades, but still when the operation is completed and the wound healed, he does not require hospital treatment but comes under the domiciliary class, and Icannot help but feel that there are probably many hundred of cases along this line of disability which if transferred from the active hospitals of other branches of the service to the National Military Home for domiciliary care, will lighten the load very materially of hospitals where active curative work is being done, and increase the number of beds available for active hospital work, and at the same time give the domiciliary case the best of care and attention.
This brief summary of the relation of the National Military Home to disabled soldiers of the World War, leads one to the inevitable conclusion that the work of the Home in caring for these disabled soldiers is one that will increase from year to year and if the results of the Civil War can be relied upon, the peak in caring for these men will not be reached for twenty years, possibly thirty would be a more correct estimate of the time. In other words while it is probable that the hospital peak will be reached by 1923 or 1924, and then fall off, the domiciliary load is one that will grow from year to year and become more and more important as time goes by.
In conclusion, speaking for the National Military Home, I wish to state that the relations existing between the former head of the Bureau of War Risk Insurance, Col. R. G. Cholmeley-Jones, and the present Director of the U. S. Veterans’ Bureau, Col. C. R, Forbes, have in every way been most pleasant and cooperative and every request made by the Home for allotments and assistance in this work has been most generously and promptly met.”
GENERAL SAWYER: “I have pleasure in introducing Dr. A. White, Secretary of the Board of Hospitalization, who will address you on the subject of “the Neuro-Psychiatric Case and How to Meet its Requirements”.”
DR. WHITE:
“The neuropsychiatry problem which the World War created and presented to the medical personnel of the various branches of the Government for solution, may be advantageously considered in three parts.
The first part of the problem consisted of dealing with the conditions which developed in our armies during the war, more particularly those conditions which developed as a result of the stresses of actual service, particularly, of actual fighting. This large, and as you well know, very heterogenous group, in some mysterious way came to be labelled with the diagnosis of “shell shock”, a term which neuro-psychiatrically was most unfortunate, and which continues its vexatious existence.
This group of cases, while a very heterogenous one, consisted largely and perhaps most characteristically, of a multiplicity of typesof conversion hysteria, cut aside from any attempt to diagnose in detail the various forms that “shell shock” took, it is sufficient to say that this group as a whole was a group of acute psychoses developed under the severest of stresses of service conditions and that when these stresses were relieved, and particularly after the signing of the Armistice, these patients got well and to all intents and purposes this group as a whole ceased to exist and so is not today one of our problems.
The second group is the group of what I shall call the ordinary State hospital type of psychosis. This includes the type of individual that we ordinarily find in State hospitals, that has always been recognized, that is usually called “insane”, and that for the most part was discovered by the army rather than created by war conditions, although it must be recognized that a certain number in this group might, under the ordinary circumstances of life, have remained stable, at least much longer than they did. However, there is nothing unusual or extraordinary or unfamiliar in this group to the average physician of State hospital experience.
With regard to the treatment of this group, however, it should be said that the great stimulus which came to psychiatry because of the war came because the country discovered, and was astounded by the discovery, that it had distributed throughout the length and breadth of its population a vastly greater proportion of defective and mentally ill individuals than it had the remotest dream of. Because of this stimulus which psychiatry received, the matter of treatment has received very much more intensive thought with the net result that there are today more well recognized agencies for dealing with this class of patients than ever before. Very briefly these agencies may be considered under the following heads, some of which of course are not only well known and well recognized, but have been used for many years, whereas others that are perhaps equally well recognized have only received wide application recently.
Thefirstof these agencies, perhaps, is the application of the general principles of medicine and surgery to the treatment of the sick individual. In other words, the patient’s general health becomes a problem for inquiry and appropriate consideration, irrespective of his mental state, on the general theory that physical health is at least the best condition precedent for undertaking a restoration to mental equilibrium.
Thesecondof these agencies is the complement of the first, and is best designated under the general term of psycho-therapy and consists in the recognition of the mental disease as such irrespective of whether there can be found any physical foundation for it or not, and on the basis of such recognition endeavors to deal with it as a thing in itself. In passing I may say that theoretically the best results would come if these two agencies could work hand in hand each with sufficient understanding of the other.
Thethirdagency, which has been very much broadened in its activities in recent years, I may designate as the social agency. It recognizes implicitly at least, if not consciously, that mental disease at any rate the kind of mental disease included in the second group, the so-called “insane” is a disorder of the individual as a member of the social group and that it manifests itself largely by disturbances of his relation to his fellows, and therefore it becomes a legitimate therapeutic endeavor to attempt a readjustment of these relationships. To this end the social agency has been developed in many directions. In the first place, we have amusements. The simpler amusements may be called, speaking from the point of view of the patient, the passive variety,—the type of amusement that is brought to the patient, such as theatrical performances, moving pictures, and the like, whereas the second type of amusement, which is more advanced and more valuable, is the type in which the patient himself takes part, such for example as theatrical performances in which he is a performer, musical programs, in which he plays or sings. Then there is the group which is not after all very widely separated from the amusement group and yet is somewhat different, and that is the group which we might term athletic activities and which demand upon the part of the patient some initiative. These range all the way from the simplest activities, which are imitative in nature, such as calisthenics under the instruction of the athletic director, to mass games, where a large group of patients are all engaged together in a common purpose, such as push ball, to games of contest requiring not only initiative but a relatively high degree of efficiency, such as the tug-of-war and the various types of races and stunts, boxing and wrestling, and which are from time to time advantageously staged on a field day and receive the added stimulus of an audience. In addition to such activities as the above there are also many minor ones of a similar nature, the principle of which, however, is the same,—the social give-and-take of patient between ward and ward, the instruction in such things as folk-dances, and the like.
Thefourthagency, which has been very largely developed recently, but which has always been used, is the agency of work. This has been applied in approximately three ways. The first of these is known as diversional occupation and comprises practically the whole field of what is thought of by many as occupational therapy. The activities in this field consist of such work as basket weaving, leather tooling, bead stringing, rug weaving, and a thousand other similar activities. The object of this activity is to assist in the re-direction of the patient’s interests, to turn them away from infantile and regressive objects, and to project them again into the outer world of reality. Then there is the industrial type of work therapy in which the patient is carried still further along the line of personal initiative and given an opportunity to do creative work which is at the same time useful and which helps him to keep in form pending the time of his ultimate discharge from the hospital. And finally, there is the vocational education work, which undertakes definitely and systematically to give a man training in some specific direction which he canutilize, after he leaves the institution, and which will have a definite economic value. For this latter work of vocational training there is needed such psychological advice and assistance which will at least prevent the wastage of time and effort upon unprofitable or impossible tasks, whereas the vocational psychologist cannot by any rule-of-thumb-tests tell that a man will make a success in this or that direction, he can tell within reasonable limits that a certain patient cannot profitably undertake a certain type of training, that his capacities do not measure up to the minimum requirements that would make success possible. In this way the work of vocational education for the neuropsychiatric case can be narrowed down so that it can be applied more intensively and more effectively to selected groups that can be reasonably assumed to be good risks.
Thefifthagency, which can be advantageously brought to bear upon the neuropsychiatric case, is the agency for extra-mural social adjustment, and the personnel consists of the psychiatric social worker. With her help the patient discharged from the hospital can have the maximum amount of assistance for relating him again with the problem of self-support and self-sufficiency. She, through her study of his family situation, his economic status, his industrial placement and social contacts can assist to these ends.
The third group of neuropsychiatry cases is like the second,—a group that has always been with us, but unlike the second it is a group that never before has been systematically hospitalized. It is the group of what might broadly be termed borderland states, comprising all sorts of types of defective, delinquent, psychopathic, neurotic, and mildly psychotic individuals. Whereas they perhaps present no new problems when one is speaking from the platform of neuropsychiatry, they do present a distinctly new group of problems from the standpoint of hospitalization. Here all the agencies which have been described in connection with the second group need to be brought into action, but beyond them there needs to be a definite intensive study of methods for the new hospital problems involved. I mention only one aspect of the problem because it is one which has forced itself repeatedly upon the attention of hospital authorities and that is the need for an intelligent, and I may say, a therapeutic utilization of discipline in dealing with these cases, in this group there very probably are contained a reasonable number of individuals of unusual equipment, who, if our ingenuity and our breadth of vision are great enough, may perhaps be saved for some work of more than ordinary usefulness.
One of the medical agencies which it is contemplated to bring to bear upon this third group of neuropsychiatry cases is the dispensary because it is recognized that there is actual danger in hospitalizing a certain proportion of this group, and therefore it is much better to deal with them as ambulant cases. They can be dealt with in the dispensaries which are equipped not only to take care of them, but for all other medical and surgical conditions, and so will get the verybest possible attention. There should, however, be connected with these dispensaries, especially the larger ones in the more densely populated districts, a psychiatrist with psychotherapeutic training who should have a psychiatric social worker to help him. If there are enough patients to warrant it perhaps additional assistance might be needed.
And finally, I would emphasize that in this great scheme, which contemplates the hospitalization of from ten to fifteen thousand neuropsychiatric cases of the general type above referred to there should be included all of the armamentarium for scientific research and all of the opportunity for individual endeavor and initiative which is calculated to bring the brighter professional minds to bear upon the subject and to illuminate it with the light of their genius. In order that such results may be effected as promptly as may be, and with the highest possible efficiency, I believe there should be established a training center for neuro-psychiatrists where our younger men, who are recently graduated from our medical colleges, and who have the inclination to specialize in this branch of medicine, can fit themselves in a minimum period of time to take it up as their life work. And that this result may be accomplished I think it important that in extending an invitation to the younger medical men to enter this branch of the service that it should be possible to give them some assurance of permanency in their respective jobs.”
GENERAL SAWYER: “The subject with which Dr. White has dealt is so important that it will have more consideration later in the program, as you will notice.
It is quite necessary in the operation of all affairs with which Americans or even any of the human family deal, to have somebody who knows something of the legislative procedure that is necessary to the conduct of their affairs.
Honorable Charles H. Burke was added to the Hospitalization Board for two reasons: first, because he does represent in his great family many hospitals, the services of many doctors, likewise of many nurses. He therefore comes to us, being a Congressman of long experience, as a man who can deal with the subject partly from a professional aspect or view of the matter, and again with a thorough and complete understanding of the legal side of the affairs with which we are dealing.
So I have great and special pleasure this morning in presenting to you the Honorable Charles H. Burke, Commissioner of Indian Affairs, who will address you briefly on the statutory regulations affecting the hospitalization of the World War Veteran.”
BURKE: “Mr. Chairman, fellow members, ladies and gentlemen:
I think in the introduction of General Sawyer I learned for the first time how it happened that I was accorded the honor and the privilege of being a member of an organisation made up of such a distinguished membership as is this Board, barring your humble servant.
It would hardly be expected, after listening to these discussions by these eminent experts in their particular lines, that I would undertake to say anything along the scientific side of this proposition, and I am going to be rather general in what I state in the short time I shall talk to you.
Government activities can only exist by reason of the law, and so it will be proper to consider perhaps or discuss briefly the application of the law with reference to the activities that are being conducted, of which you, each of you, are a part.
The responsibility for whatever the Government may do in this or any other matter rests largely upon the Congress. I have hastily gone through the legislation that has been enacted in the last few years with reference to taking care of and providing for the ex-service men, and during the war for their dependents, and for those who might become incapacitated or disabled from any cause. There has been much legislation, demonstrating that the Congress is keenly alive to the importance of the situation. There has been one act after another, and hardly an act but what has been amended within a very short time after its enactment.
The recent law is what is known as the Sweet Bill, the law under which we are now operating. Within the memory of many who are here present the appropriations for all purposes of the Government were under a billion dollars, and there is being and is appropriated at the present time nearly half of that amount for the purpose of caring for the hospitalization, etc. of these ex-service men. Am I correct, Colonel Forbes, in the amount of money that is being appropriated? It is a vast and large sum of money, and it is the duty of those charged with the responsibility of expending that money to see that we get a hundred cents’ value for every dollar that has been appropriated. This requires economy and efficiency, and this gathering and this organization which General Sawyer is the chairman, was created for the purpose of getting better results from the moneys that are appropriated by the Congress; and you, each and every one of you, have been brought here, as I understand, for the purpose of coming in closer contact with those who are charged with the responsibility, in the first instance, of administering the expenditure of this large sum of money; and you owe to this responsibility exactly the same responsibility as does Colonel Forbes or anyone else occupying a higher station than you may occupy.
Therefore, I am confident and I am certain that when this conference shall have concluded, every person that has come here will go back to his respective place where his duty requires him, with a better understanding and with a more determined disposition to try and render better service and get really more for the money that is being expended for the purpose for which it is being expended.
Speaking of legislation, we shall undoubtedly require considerably more legislation because, as I have stated, in the short time since this subject was first taken up by Congress think of the progress that has been made.
As I understand, in 1919 the Public Health Service were hospitalizing something like two thousand persons. General Sawyer stated here today that we are now caring for twenty-two thousand; and I think it has been stated—and it is generally considered—that the maximum will soon be thirty-two thousand. So you see that it is more than likely that we are going to have to have additional legislation and more appropriation; and I may say to you generally that I have that confidence in the American people—I have that confidence in the Congress of the United States—to know that there need be no uncertainty nor hesitation on any one’s part with reference to what may be done to provide for caring properly for these dependents and these ex-service men who are entitled to every consideration.
I believe, as the result possibly of this conference, it may be brought to the attention of this Board that there is some legislation amending the so-called Sweet Bill. I think Colonel Forbes, as the head of the Veterans’ Bureau, has already discovered and suggested some very necessary amendments to the law, and I have no doubt that he will be able to secure those additions to the law. It looks now as if we may have to provide for additional hospitals by the enactment of further appropriations of money. It will not be done unless it is necessary, but I am sure if it is necessary that adequate provision will be made and made promptly by the Congress.
One of the policies of this administration is coordination and cooperation, and endeavor to avoid duplication in administrative matters; and if there is a bureau charged with a certain responsibility and with certain duties to perform, if it may be possible for them to do what may be under the jurisdiction of another bureau, to centralize and have this work done by one rather than two; and so in the work of coordination in the administration of this particular activity there has been a great saving. The Public Health Service, I believe, makes certain provision and takes care of certain persons at the request of the war Veterans’ Bureau and vice versa. I think it has been said,—if it is true it ought to be corrected,—that when the Veterans’ Bureau takes care of patients for the Public Health Service, there has been no provision made for reimbursing the Veterans’ Bureau. That will undoubtedly be taken care of by Congress, either by increasing the appropriation for the Veterans’ Bureau, or providing that when they render service for the Public Health Service, the Public Health will reimburse them for such moneys as they may expend.
Now one of the things that I want to particularly bring to your attention, and to perhaps admonish you, in the two or three minutes I have left, is to remember, as I stated at the outset, that governmental activities exist only by authority of the law, and that we must keep within the law; and remember, if there are some things in connection with your duties that are not operating just as you would have them, that they cannot be changed without changing existing law. The responsibility for the law is upon the Congress of the United States. The responsibility for this great undertaking is upon the Congress of the United States, and if you have not sufficient money to properly take care of these men, the responsibility is not yours; the responsibility is upon the Congress.
It is your duty;—it is our duty to bring to the attention of the Congress the money that is necessary in order to properly handle this subject. Then it is for the Congress to say whether or not that amount will be appropriated. Under this present administration, those of us who are in Bureau positions have been admonished that we must keep our expenditures within the appropriations, and we have had brought to our attention the statutes upon this subject. I am going to read them to you for your information, and I want to say to you who may have charge of an institution and have had a certain allotment of funds for a given period, that it is up to you to see that your expenditures do not exceed that allotment. If you have not sufficient money to do what you feel you ought to do, you must reduce your expenditures for the time being, regardless of its effect upon the service, because under the law you have no right to create a deficiency or incur any liability on the part of the Government in advance of an authorization and an appropriation therefor.
I want to call your attention to the statutes on this subject because they are being brought to our attention not only by the President and the head of the Bureau of the Budget, but by the Congress; and so I want you people to understand that we are expected to follow the law.
That, ladies and gentlemen, is the law; and so I want to impress upon you that you so conduct your institutions that you will keep within the limit of the allotment that has been made for your institution; and if you have not sufficient money, then bring it to the attention of the head of the Veterans’ Bureau or someone else connected with the administration. They will consider it, and if it shall seem that more money is necessary they will not only recommend it, but I think I can say for the Congress that the Congress will generously respond.
I congratulate this conference upon its start. I hope that there may be a general discussion,—that those who have come from long distances will tell their experiences and make suggestions with reference to anything that will improve this service; and I am very certain that when the conference shall conclude on its last day it will adjourn with a feeling that the time has been well spent, and that in the future we are going to profit, and profit materially, as to the result of what may be done in this conference and by it.”
GENERAL SAWYER: “Fellow workers, I certainly hope that this introduction this morning has given you two things; first, that it has given you the impression that the men engaged at the head of the affairs of this Government in this subject are capable, worthy men. I hope it will have given you the same inspiration that I carry away this morning,—to go on with this conference and with your work after you leave here more earnestly if possible, more sincerely if you may, and certainly with more determination to bring about the results we all have in mind.
This morning you have heard the various members of the Board of Hospitalization make their addresses, brief of course as they have been and in many instances not entirely fair to them, considering the subjects they have to handle; but they have done as well as time will admit.
This afternoon this conference, under the chairmanship of Colonel Forbes will take up a special subject or two, and will then go into the matter of the general discussion of the affairs as they have been presented today. We want you to feel that we are here to listen as you have listened this morning; and so we are going to ask each one of you to participate in the discussions. We want this to be an active meeting, of men in motion, so that when this conference does close we may have the satisfaction that has been expressed here by the Commissioner of Indian Affairs.”
General Sawyer asked that, upon adjournment, the members of the Conference assemble outside the building in order that a group photograph might be made.